|Name Of Column
||Settling Some Ashes
||News & Events
||Michael E. Kupferman, MD
||“Doc, my TEP is leaking. What can you do?”
||Am I Feeding the Wolf
||Why do you use (or not use) a base plate?
||The Silent Scream
|My Neck of the Woods
||The Presence of Angels
|The Speechless Poet
||Len A Hynds
||A Pair of Brown Boots
||Prose & Poetry
|Bits, Bytes & No Butts!
|| Windows 10 Settling and Here Comes Apple
INDEX AND LINKS TO EACH ISSUE MAY BE FOUND AT: http://webwhispers.org/news/WotWIndex.asp
Settling Some Ashes
I needed to make some plans for my future resting place so that my son would not have to be making decisions based on guesswork at what should be one of the worst times of his life. Losing his mother had BETTER be one of the worst times or being haunted by her might take that priority. I had made the “cremation” decision a long time ago but where would my ashes go? At one point I had said sprinkle the ashes on the lake where we had a little fishing cabin. That cabin is long gone and the fish up there will have to wait for someone else to nibble on.
I knew that my ex-husband, my son’s father, had a burial of his ashes in his parent’s grave, and my son suggested that I might want something similar. I wasn’t sure how this was handled by the cemeteries or even what it was called but surely the big cemetery (pardon me, Memorial Park) in Florida, where my parents are buried, would know.
I could understand the benefits and simplicity of making arrangements where my parents and a large number of aunts and uncles are buried rather than start over with family in another city or cemetery. This made good sense as I am an only child and have no close relations anywhere else.
Actually, I liked the idea as much as you ever like the idea of dealing with dying, passing on, or just fading away and at least my son would be able to bring just one bouquet for me and his grandparents! This whole thing seemed to be a money saving, practical, idea but I had no idea what to ask for.
So a month after that, I was in Florida visiting my cousin and I suggested we spend the day at the cemetery. I wanted digital photos of all of the graves and I wanted to stop in the office to find out what they say about this arrangement I would like to make.
As soon as I asked the receptionist about arranging for my ashes to be placed, scattered or left at my parents graves, she smiled brightly and I thought I saw a very small $ sign come up in each eyeball as she said, “Oh, you want a Second Right of Inurnment.” So it had a name. Later, I found there were other Second Rights, such as Interment and Entombment.
When the sales lady (excuse me, counselor) appeared, I was about to learn a whole new bunch of words, most of which were acceptable but there were a couple that I already knew, I kept to myself. They started with looking up the gravesites and getting a map to mark locations, also noting when my parents were buried and when the lots were purchased. The lots had been bought 50 years ago when old rules still applied and I had become the sole owner of the lots, which made things a lot easier for me and I didn’t have to buy any space. I had the feeling that the Second Right might have been removed from the standard contract during more recent years. Also, being an only child, no one else had any rights. Siblings would have had to sign for me to be able to plan this Inurnment.
Since I live in Alabama and would be cremated in that state, the cremation price was not figured in. However, Florida has a law that a vault is necessary to be buried in a grave. It’s called an urn vault (concrete, abt 12” x 12”, $150) and the urn (starting at $195), which holds the ashes is placed inside the vault before burial (opening and closing of the grave, $550). I said, I’ll take one urn vault, one opening and closing, scratch the urn. I think we can find a cigar box. Found out later there was supposed to be another $50 for installing the vault in the open hole but they forgot to charge me for it. Did they get the extra money when they notified me of this, after I got home? I had already bought the swamp in Florida and I wasn’t about to pay for the alligator. I told them my son had a strong back, he could shove the little vault into the hole for $50 and they decided it wasn’t really fair to charge me after the contract was signed.
So I called my son and said, “What exactly happened with your dad?” He said, “We got to the cemetery with Dad’s ashes in a cardboard box. A guy came out of the office with a shovel, moved some sod, dug a hole, dropped the box in, filled the hole, replaced the sod and left.” It was $200 or $300 total charge. OK, in ten plus years, rates go up. From Illinois to Florida, rates go up. So maybe $700 wasn’t too bad a deal. Besides, where else was I going to find parents to be buried with?
You might think that it would be a lot easier just to scatter the ashes in the breeze. Maybe, if they don’t catch you! There is a section called the Scatter Garden where you may let your dear departed join everyone else’s dear departed….for a fee. Or, perhaps you could drift out to sea in a boat and throw ashes to the wind, being very careful of which way the wind is blowing at the time but you have to rent a boat and probably someone to run it! Well, my cousin was with me and she had arranged for the burial at sea for her late husband just last year and made arrangements for herself at the same time. $1,000 each for this sea service and your survivors don’t even get a boat ride! They don’t allow them to go along. Talk about being lost at sea!
My cousin said if she had known prior to signing that contract that for $700 each, she could have been placed there with her parents and all of our folks, she would have done that. At least her children and grandchildren would know where to find her. Her husband’s parents are there at the same cemetery.
With Second Right of Inurnment papers being drawn up, I was to stop back the next day, but there was one more decision I had to make before then. It is 3AM and I’m awake. Is this what I want to do? Yes, I am very comfortable with this idea and the amount of money it costs is actually not that bad for the peace of mind and having it all settled. So I rolled over, gave a sigh, and started to drift off. Wait! I’ve been saying 'parents' grave. That is not the way they look at it. It is your mother’s grave or your father’s grave and you have to pick one. I have to choose between my parents. OK, simple, I tell myself, I was a Daddy’s girl so I would have my ashes placed in his grave. Mom and Dad wouldn’t know, anyway….or would they? I can’t take that chance. If they did know, my mother would have her feelings hurt! All right, let’s think about it the other way. My ashes could go in my mother’s grave. That’s better. My dad would understand that…. Peace. Sleep was on the way.
Since I owned the rights to both graves, I had them draw up papers giving the Second Right for the other grave to my son. I could do that since he has no brothers or sisters to sign. It is really simple when an only child has an only child. He may or may not need it or choose to use it, but I thought I’d pave the way. Pave… Reminds me of the one foot square concrete box for $150!
I told the other larys there in FL, that I visited the next two days, about what I had done. None had heard of it. None of my friends had heard of it. It is entirely possible that you have a Second Right to existing gravesites and would not have to purchase cemetery lots. Or maybe you can leave a Second Right to a child. Perhaps spouses may choose to share a gravesite, even if they already own more than one. They can always be left to your children.
Second Rights are going to become very common if the next generatioon know about them and it makes a great deal of sense. You might check the actual cemetery website to see what their rules are.
(I wrote this in 2004 but it is still valid. Second Rights need to be checked out.)
“Doc, my TEP is leaking. What can you do?”
Michael E. Kupferman, MD Department of Head & Neck Surgery MD
Anderson Cancer Center Houston, TX, 77096
Trachea-esophageal punctures have dramatically improved the function and quality of life of patients after laryngectomy by providing them with a hands-free method of intelligible communication. In this article, we will describe some of the issues related to trachea-esophageal punctures and how these problems can be managed.
What are the options for voice restoration after a laryngectomy (voice box removal)?
Patients with advanced or recurrent cancers of the larynx are often managed with removal of the larynx, or voice box. The loss of voice decreases quality of life and, thus, restoration of vocal production is of high priority in this population. Voice rehabilitation after a laryngectomy is complex, and a number of options are possible, including an electrolarynx, esophageal speech and a trachea-esophageal puncture. Most surgeons currently utilize the TEP to re-introduce voice function in patients after laryngectomy.
What is the optimal solution for voice restoration after surgery?
The gold standard in alaryngeal speech production is tracheoesophageal puncture (TEP), which can be performed either at the time of surgery or a few months after treatment has been completed. This approach provides serviceable and satisfactory vocal function after laryngectomy in the vast majority of patients, with a success rate that ranges between 80 and 92 percent.
What is the major complication after TEP placement?
Despite the high success rate, TEP also has several associated complications, one of which is fistula enlargement, which can occur in upwards of 30% of patients. With the Voice Prosthesis (VP) unable to occlude the enlarged fistula, aspiration and leakage will occur, and may lead to poor voice function, hygienic issues and pneumonia.
Who is at risk for developing an enlarged and leaking TEP?
A number of risk factors have been identified, including: radiotherapy; malnourishment; diabetes; reflux; smoking; esophageal stricture; hypothyroidism; among others. The increasing utilization of radiotherapy as the main treatment for many larynx cancers today may account for the rising incidence of this problem. Radiation therapy to the neck leads to impaired wound healing, fibrosis and swallowing abnormalities which may predispose to TEP enlargement.
What are the possible strategies for dealing with the leaking TEP?
The management of a leaking and enlarged TEP site is complex and strategies include: surgical closure; surgical reconstruction; and customized prostheses. Closing the enlarged TEP resolves the aspiration problem, but also results in the loss of voice production thus negatively impacting quality of life. An approach that we have found great success with has been a minimally-invasive injection into the puncture site to decrease the diameter size. This allows a more secure fit for the prosthesis.
How is this performed?
At our institution, patients with TEPs are evaluated during liquid swallows to assess for the precise area of leakage. The speech pathologist then selects and fits the VP based on the unique presentation of each patient that will optimally fit the puncture site. Once this is completed, the puncture site is analyzed by the surgeon to determine optimal placement of the injections. Usually, this is performed at 4-5 locations to shrink the size of the site in a uniform fashion. No anesthetic is necessary for this procedure, and all patients tolerate it well. Once the injection is completed, the voice prosthesis is replaced, and the patient is allowed to resume speaking within 1-2 days.
How successful is an injection into the TEP site?
In our experience, injection around the leaking TEP can improve leakage for almost 6 months. The procedure is less effective in patients with a history of radiation before their laryngectomy. Many patients will require a second injection, as the injected material is temporary.
-Ang, K. K. , and A. S. Shiu. "General principles of radiation therapy for cancer of the head and neck. In: Myers EN, Suen JY, Myers HN, Hanna EYN, eds. Cancer of the Head and Neck. Philadelphia, PA: Saunders, 2003:717-735." Print.
-Boscolo-Rizzo, P., et al. "Long-term results with tracheoesophageal voice prosthesis: primary versus secondary TEP." Eur Arch Otorhinolaryngol 265.1 (2008): 73-7. Print.
-Calder, N., C. MacAndie, and F. MacGregor. "Tracheoesophageal voice prostheses complications in north Glasgow." J Laryngol Otol 120.6 (2006): 487- 91. Print.
-Cheng, E., et al. "Outcomes of primary and secondary tracheoesophageal puncture: a 16-year retrospective analysis." Ear Nose Throat J 85.4 (2006): 262, 64-7. Print.
-Hutcheson, K. A., et al. "Enlarged tracheoesophageal puncture after total laryngectomy: a systematic review and meta-analysis." Head Neck 33.1 (2011): 20-30. Print.
-Hutcheson, K. A., et al. "Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy." Head Neck (2011). Print.
-LeBert, B., et al. "Secondary tracheoesophageal puncture with in-office transnasal esophagoscopy." Arch Otolaryngol Head Neck Surg 135.12 (2009): 1190-4. Print.
-Makitie, A. A., et al. "Postlaryngectomy voice restoration using a voice prosthesis: a single institution's ten-year experience." Ann Otol Rhinol Laryngol 112.12 (2003): 1007-10. Print.
-Op de Coul, B. M., et al. "A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single Institution's experience with consistent application of provox indwelling voice prostheses." Arch Otolaryngol Head Neck Surg -126.11 (2000): 1320-8. Print.
-Seshamani, M., et al. "Cymetra injections to treat leakage around a tracheoesophageal puncture." ORL J -Otorhinolaryngol Relat Spec 68.3 (2006): 146-8. Print.
-Shuaib, SW. , et al. "Minimally-Invasive Approach for the Management of the Leaking TEP." Laryngoscope In Press (2011). Print.
Am I Feeding the Wolf?
Not sure why exactly but I’ve just been feeling cranky for a while now. At first I blamed everyone else for being such jerks but eventually I had to admit that the problem lies closer to home. Part of it is that time seems to be just flying by at record speed and try as I might I cannot seize, savor, “carpe” every precious moment. Summer was perfect here in Maine but it went by in a flash and now the girls (my grand-daughters) are back in school and I don’t know how that happened. They are growing up so fast and I am growing old even faster, if that is possible. I KNOW that some of my emotional turmoil has to do with my Dad’s death in January. It was not unexpected, of course at his age but losing a parent is still tough even when you are getting old yourself! The cliché “confronting one’s mortality” has become rudely real in the last year. Surprisingly, more so than when I learned I had cancer 15 years ago. I guess I still thought I was invincible …. silly youngster that I was.
So back to the cranky bit, I had to ask myself just what the h@#$ was bothering me. I don’t really know the answer but I DID remember this article I wrote way back in February of 2009 that got a lot of positive response and it still resonates for me. Am puzzled why that big old bad wolf has come lurking again but I need to stop feeding him, that’s for sure.
I would love to hear how you all deal with the wolves at your door ….suspect we all have them from time to time.
Feeding the Wolf
During the recent celebrations surrounding the inauguration of Barak Obama, one speaker referenced this legend and I have been haunted ever since by its powerful message.
An old Cherokee is teaching his grandson about life. "A fight is going on inside me," he said to the boy.
"It is a terrible fight and it is between two wolves. One is evil - he is anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority, and ego." He continued, "The other is good - he is joy, peace, love, hope, serenity, humility, kindness, benevolence, empathy, generosity, truth, compassion, and faith. The same fight is going on inside you - and inside every other person, too."
The grandson thought about it for a minute and then asked his grandfather, "Which wolf will win?"
The old Cherokee simply replied, "The one you feed."
Whether we labor on the international stage where old grievances and new realities clash like Titans threatening the lives of hundreds of thousands lesser mortals or simply muddle around our daily lives trying to play the hand we have been dealt, this is food for thought.
Who will we feed?
It has been my experience that the evil wolf is very seductive- even charming sometimes, and quick to share the spoils of his feast with you…at first. It feels good sometimes to lash out at the weak, blame someone else for your failures, gloat in your successes, delight in someone else’s misfortune. It is one of the oldest (and cheapest) tricks in the book…make yourself look better by making someone else look bad. I loathe admitting it, but I am guilty and I suspect, unfortunately, that just about everybody I have ever met has fed THAT wolf more than once. That does not make it right and, unfortunately, as most of us learn, it begets a very hungry and unruly wolf. It would have been so much better had we never fed the thing, because it keeps coming back and it is a bully. It will haunt us, whispering, “Remember how good it felt to rip and tear and destroy.”
The good wolf, on the other hand, is just not as compelling and glamorous (by the way, the word glamour originally referred to the aura cast by a magic spell). The good wolf sounds like a very earnest Boy Scout and, frankly, I don’t think he is a very persuasive salesman. It is just not all that much fun to be good, sometimes. There is a much more immediate reward in gossip than there is in forbearance. Even the words are more exciting. Poor good wolf. He doesn’t stand a chance.
It is surprising he ever prevails, but he does, time and time again…and every time we feed him with kindness, courage and dignity his nasty twin slinks just a little bit further away from our door.
Recently a friend commented on the difference between my writings early on in this journey and now. He is so right. In the beginning, I was angry and fearful…defensive and wary. I didn’t realize it, but I was just trying to survive. Cancer is a pack of evil wolves at your door. I fought fire with fire sometimes, in those days. I had many good wolves too, vying for my attention and when I couldn’t feed them properly, others did that for me, to ensure they would keep coming back. They did, thankfully…the bad wolves are still out there and occasionally try to slink back for a handout of sloth or bitter self-pity but it’s slim pickings most days.
The good wolf is a hard taskmaster, despite its humble demeanor - reproachful wolf eyes will keep you awake nights - but there is no better companion than a happy well fed good wolf.
It seems a simple thing to feed the good wolf rather than the bad. I think we all know it is the right thing to do, but it is so hard sometimes to choose hope over despair, compassion over scorn, joy over bitterness, and love over hate. It really is that simple. We are the fortunate ones in this battle. We chose life over death and we prevailed.
Here’s to keeping the evil wolf at bay.
Why do you use (or not use) a base plate?
John Hendrix – Savannah, GA
This is a good question. I for one was not even told about a Lary Button after my surgery. I had my surgery at MD Anderson in Houston. I find it strange I was not told of all my options. I take that back, I was given many options…….different types of base plates. I have questions I really need to ask my SLP and doctor about the button. My stoma is not perfectly round which may or may not be the reason I was not given the option or it could be that the edge around my stoma is sensitive and will bleed very easily. I will say that I am able to wear a base plate 3-5 days at a time. Could probably go longer but do not think it healthy for the skin. I sometimes get some skin irritation around the stoma, but I will take the base plate off, wash around it, put some cream on it my doctor prescribes, and let the fresh air get to it for a couple of hours, clears it right up. I will be interested to hear the thoughts and reasons of others for wearing or not wearing.
Ronald Gresham – Chicago, IL
I use a baseplate because of the irregular shape of my stoma, and a lary button doesn't fit. And it is so difficult for me to talk with a lary tube.
Sharon Severini - Waterbury CT.
Happy Fall all, I use a baseplate for my HME! I have been using the Bloom Singer contour adhesive housing (oval) from InHealth and through donations since Jan 2013. I have to use a housing/baseplate because my TEP is too close to the stoma. My SLP says for me to use a lary tube with an HME holder. Oh well, I get a good 2-3 days out of these by using skin tac or prep and a little liquid adhesive.. Have used Atos brand also thanks to donations! I also will add that I wash out HME cartridges when I need to due to insurance.
Christo Slatton – Bullhead City, AZ
First off I do use a base plate. The "hole" in my neck (as I so affectionately call it) is on the large side and is "oval" in shape. This prevents me from using a much preferred "Lary button" effectively. I have tried just about everything out there to get a button to hold a seal with no luck. It either blows the seal or the whole button blows out within a few minutes. I can actually put the HME into the hole without a baseplate and it fits pretty good. My SLP nearly fainted when I showed her that trick. I wish I had her reaction on video; it was pretty funny. Needless to say I am forbidden to ever place an HME near my neck without a base plate installed. And that's why I use a base plate.
Ed Chapman – West Richland, WA
I wear a base plate during the day with an HME or "hands free". Then most nights I wear a lary button. If I wear the button with a HME I can't press on the HME to voice as the button presses against my TEP (even the shortest button) and trachea. It not only occludes the TEP but hurts. If I wear a button with the "hands free" I just blow the button out. I've tried straps and the Velcro hooks but it still manages to come out. So the base plate is best for me.
I have also tried different base plates and have found the In-Health Tru-Seal oval shaped works best for my neck. The new Atos "hands free" unit works best for me. I wasn't able to successfully use either the Blom-Singer or the old style Atos hands free units, for one reason or another.
So as the old saying goes we are all different if not it would be a awfully dull world. Fortunately all the companies that produce our products realize this and they have given us many options.
Mike Cohn - Wheeling, Il.
10/13/10 (Almost my 5th birthday)
I need to push out quite a bit of air to voice and my SLP wasn't even sure if I was going to be able to speak with my TEP, but I persevered.
At first I used a Barton-Mayo button to hold an HME. As things in and around my neck kept healing and changing (kind of like a new house settling) I began to get quite a bit of air escaping around the button and added a Kapitex gel to help seal it which helped for a while. Eventually even that leaked air and that is when I switched over to baseplates. It took some trial and error to find the best mix and brands for me, but I believe that at the moment, I have. I have tried to use a hands free device with the baseplate, but I still have push out more air than they can handle. That was too bad, as with my sales job, I had to speak all day and a hands free would have been a great tool, but I had no problem being understood with the HME. Since my very recent retirement, I find the baseplate/HME combo or even just a foam pad over the stoma more than efficient these days.
John Zimdars – Ft. Myers, FL
What other ways are there to hold a HME?
Richard Crum – Jeffersonville, IN
I was 45 years old when I had my total laryngectomy. I was still working with 3 children and I needed to continue working. I learned how to use a hands free valve using base plates and I have been using a base plate ever since. They work for me.
John Haedtler – Espanola, NM
I have worn a Base plate 99% of my Laryngectomy life (coming up on 14 years now). I was taught from day one of the benefits of the HME! I also use the buttons, but I’m not able to wear them full time as my stoma expands and allows the button to fly out.
For me the Blom-Singer Tracheostomy Valve Housing has worked the best and the cost is minimal. With the Adhesive Tape Discs. My daily cost is less than 50 cents a day! And the Humifilter holder with replaceable foam filters, equals about 16 cents a day. So after buying the housings my daily cost runs about 66 cents.
I am one of the fortunate ones that has had almost NO post-surgical problems. So I try my best to speak to new patients and let them know that;, One, they are not alone while going through all of this, and, two, life is great!
Carl Strand - Mystic CT
February 10, 1993
I began wearing an InHealth / Blom Singer large base plate 22 years ago with a hands free valve. I went through the pretty normal learning curve relative to keeping a seal. At one point I looked a bit at the Barton-Mayo button, but my speech pathologist and I agreed that it probably would not seal well in my stoma.
So, I have continued to wear the InHealth base plate ever since. There was a short period when the PVC base plate was discontinued in favor of a silicon base plate, but then both options became available and I returned to the PVC.
I have tried the disposable housings at various times, but they just do not work well for me. They seemed to irritate my skin and the seal did not last.
The major problem with a reusable base plate is Medicare's insistence that it can be used for 45 days and they will only reimburse two every 60 days. I use one for 15 days before replacing it, so I absorb the modest cost of the ones that Medicare will not cover. The minor problem is that InHealth has problems supplying orders since their computer "improvements".
Mohan Raj – Bangalore, India
Due to a bit of surgical error, I presume, my Stoma is far too low between the collar bones Base plates will not be leak proof. I am not able to use them though I have plenty of them. I am not able to use the Hands Free, though I have one, simply because I cannot stick it in a leak proof base plate!
The only solution, I am told is to is undergo a surgery to correct the Stoma location. Move it further up. The risks, in my view, far outweigh the gains.
Over the years I am quite happy the way it is. No cumbersome procedures involving chemicals around the stoma such as skin preps, adhesives, skin cleaners and so on. The cloth bib is as good if not better for me than the so called HME. I have used a cloth bib for the last five years and I find it simple, hygienic, cost effective and totally trouble free.
For the little I talk, I do not miss my Hands free!
Jack Kehler - Ozark, AL
As a still relatively new lary, please tell me what a Barton Mayo or lary button is. And why wouldn't the Dr or SLP say something to me about those? Thanks.
Julius Akemu – Nigeria
Am a neck breather from Nigeria and I did my surgery in India in 2014, Here in Nigeria we don't have access to all these accessories. How do we purchase all this accessories?
Pete Meuleveld – Salem, OR
Like some others, my stoma shape does not make for a good fit and seal for a lary button. So I use a baseplate 24-7 and the seal gives me a good consistent speaking voice. When using a finger or thumb over an open stoma, I would have to wiggle it around for a good seal. The cassette is quick and easy to occlude and the baseplate usually lasts about 4-5 days. Works for me.
Alzie Kirksey- Hollywood, FL
I had my surgery 7-16-2010. No one never told me about a lary button that will hold the HME button. I use the base plate. Give me more information.
Gereald Hughes – Houston, TX
I'm new here. lary since 2/14... All experiences have been via the V.A. hospital and I have nothing but praise for them here in Houston.
I was in the Philippines when I woke up one morning gasping for breath. A tumor was discovered on my larynx and I had an emergency tracheostomy and headed ASAP to Houston. Upon arrival, I went from the plane straight to the V.A. hospital. However, they did little post op indoctrination and info sharing. I have relied on the internet.
So, now, I simply use a foam filter most of the time. I happen to love them. Yeah, I get plugs but not so bad as to be intolerable. I have a routine where on Saturdays, I go to bed with a lary tube/ HME. I do it to avoid stenosis...and it seems to work so far.
I enjoy NOT wearing a tube, but the foam does come off if you're talking a lot. I sometimes resort to 2-way tape to augment the adhesive. I've heard about the lary button and wonder if it is something that I would use.
Thomas Mosser – Bethlehem, PA
Aug 13, 2014
My response to the lary button. It is great and does serve the purpose, however you need to be very careful with its use. The other night when I was inserting the lary button I had the unpleasant experience of having it sucked into my stoma. Not a pleasant experience and I am in panic mode. A trip to the emergency room and then the operating room where the ENT physician on call removed it thankfully without any problem.
I use the base plates and dispose of them when the seal breaks. I usually am good for two days and sometimes if the seal is really good 3 days. It is the price that we have to pay. I am a proponent of anything that will help us since the base plates do make my skin red and I have to give it a day or two rest so I now go to my lary tube and have been hesitate to use the lary button because of my recent experience and do not want a return trip to the emergency and operating room.
Also I was told that you should not sleep with the lary button and now I believe it is for you not to have it get sucked into your stoma. I use esophageal speech to communicate and I am thrilled that I have been fortunate to be able to use it. Still learning and practicing the use of it.
Susan Bolt, MSP, CCC-SLP
As a speech pathologist, many of our patients could not use lary buttons due to the shape of the stoma; they couldn't get a good fit or keep them in place. Others simply found them to be uncomfortable. Of course, just as many couldn't find a base plate that worked for them. A few found success with lary tubes designed to hold HMEs, but again, getting a good seal depended upon a round stoma. Side note: I was at a conference not long ago
where a surgeon was talking about the "ideal" stoma being u-shaped, and all of the SLPs in the audience immediately retorted, "But then you can't use a button!"
Dennis Rutter – Granite City, IL
Why I use baseplates. While many of you can use the "button", I cannot use them I have tried over the last 3 years many times, but it causes my stoma to bleed around the edges. My doctor said I will probably never get used to it. I keep trying, as I would love to avoid the expense of the baseplates. I do use the Flexiderm and I get 3 -4 days out of one baseplate. So I guess I am lucky in that aspect! So, that is why I wear baseplates.
Madlyn Walton – Irvington, NY
Did not know till now that lary buttons could hold HME. Tell me more about this please.
Maggie Scott – Dauphin, MB, Canada
I have tried to use different types and sizes of 'buttons' but I am unable to as the size of my stoma is too large. The largest button they make is 18mm which is too small for me.
I would love to be able to use one because as you say, it would be a lot cheaper.
Instead, I try to make the base plate last as long as possible. It lasts between 2-5 days for me depending on how much I talk, exercise, shower, etc.
Jerry Shoul – Joppa, MD
I would love to use a button, tried it but the shape of my stoma won't hold the button in place.
Moira Daly , SLP - South Burlington, VT
The use of a LaryButton requires a fairly round stoma with a firm lip to retain the button in place...for some, it is difficult to find a button that fits because of size or shape of the stoma. Also, as stomas shrink so too do they enlarge such that the button may no longer be self-retaining in the stoma if with prolonged use the stoma starts to enlarge. LaryClips or a tube holder can sometimes be used to help hold it in place...but again, not all stomas are suited to a button or some just don't tolerate it...adhesive baseplates are thus a terrific option for many.
Linda Palucci – Kissimmee, FL
I was never able to use a base plate. No matter what I did, it would not stay on me for more than a short time, less than an hour. As soon as I started talking, it would come loose. Finally I gave it up and just cover my stoma with my pointer finger, on my left hand. I slide it under my scarf, been doing this for about 13 years. Works for me, I have a very good voice this way.
Jim Culbertson – Corpus Crist, TX
I use a base plate for my HME because it is convenient. I find the Flexiderm base plate will stay in place for 24 hours and makes the TEP easy to use. I recently returned from working overseas for a week at an altitude of 8000 feet with no problem TEP usage.
Malcolm Babb - Chesterfield, UK
I use a baseplate because my stoma is large and irregular in shape. This has meant I have never looked at a button as a solution and also occlusion is problematic. A table tennis ball is a good way to occlude my stoma for valve speech but is hardly convenient!
Just as important to me is that when I (rarely) use a foam or fabric stoma cover I find that mucous gets where I don't want it.I have to use glue to get a good seal for a reasonable length of time and am fortunate I don't get problems with the skin to which the baseplate adheres.
I had my operation in 2002, at the time baseplates were becoming more "fashionable". I cannot see me changing my chosen solution for covering the stoma, it works well for me.
David Kinkead - Peoria, AZ
I use a baseplate because of an irregular stoma. I can't get a lary button or lary tube to stay without ties around my neck. I do not want to wear the ties so I use the baseplate. Even with the baseplate, because of the shape of my stoma, I have a lot of trouble using my TEP to talk. The base plates, and I've tried several, will not give me a seal that lasts. At the IAL convention this year I had several SLP's work on me to try to get a good seal. We tried different baseplate so and even lary buttons to no avail. Thank goodness for good insurance so the baseplates do not cost a whole lot but I don't feel I have a choice
Joe McGoff - Houston, Texas
My total laryngectomy required a surgical procedure called a double flap. For those of you unfamiliar with this procedure it involves taking an arm, thigh or leg muscle and using it for extensive reconstruction of the throat when a large amount of tissue is required to be removed. This procedure left the exterior surface of my throat slightly disfigured. I tried numerous base plates from various manufacturers. None would adhere for any length of time to the skin surface immediately around the stoma. The best I could tell all the base plates required a fairly symmetrical surface in order to achieve and maintain adequate adhesion throughout the day. The ENT surgeon knew this was a possibility and when creating the stoma left a slightly raised rim around the stoma entrance which permits me to use only a lary button in which I insert the HME or hands free device. Since I am unable to use base plates I have no idea whether I get as good a seal or not. For the most part people usually have very positive comments on the quality of my TEP voice. What I do know is I do not have to bear the expense of purchasing the base plates, adhesives, cleaning solutions and spend an inordinate amount of time each day applying and removing the base plates. Should anyone have any questions I will try an answer them.
Davina Cook - Detroit, MI
I was told that my stoma was not a good shape for a lary button. The baseplates work well when glued because I worked in a sweaty factory. Finally had to order 30 a month because 1 every 2 days wasn't good enough.
Debbie Deaton – Cincinnati, OH
I started using base plates when I was first able to talk again. I hated them!! They would only last about 10 minutes before heavy mucus would break the seal and then I could not talk. After putting up with this for many months, my slp finally said, let’s put holes in your lary tube. Well, that worked immediately!! Why, did she wait so long to do this? It was very expensive buying all the base plates only to have them fail, not to mention the toll it took on my nerves and feeling of self-worth.
I have not used base plates since that day and I never plan to use them again. I wear my lary tube 24/7, only take it out to clean it and that works fine for me. I would suggest this method of talking over the expense and failure of base plates any day!!
Ed Kuszajewski – New Stanton, PA
Hello Webbies. Regarding the baseplate issue I don't use them because of the shape of my neck since surgery. I could never get a good seal and they would not stay in place very long. So I am still using the bib style cover and my finger to be able to speak. At some point I intend to try the button. Good question. It may help some of us try new methods to speak. Stay well everyone!
Thank you for your submissions. Edits are used for length, clarity and to keep comments on subject of the month.
Staff of Speaking Out
The Silent Scream.
Yesterday I discovered a very useful feature of laryngectomy. When caught by a storm of frustration, fury and rage we can scream and bellow and roar without disturbing a soul! I can’t imagine how it’s taken me two years to discover this – I’m obviously a slow learner!
I discovered this new bit of emotional armour while I was visiting a close friend in hospital. She has depression and is suffering a relapse. It’s a tough time for both of us. Much of the time she is either rehashing unhappy memories, despairing at the rotten stuff going on in the world, criticising her nearest and dearest or worrying about whatever might go wrong in the future. Then suddenly the veil of misery lifts and she is ‘herself’ again – smiling and friendly and apologising for having been so miserable. I feel relieved, thinking the worst has passed, that she’s on the mend. Then next day, her downcast eyes barely flicker when I say ‘hello’. The ‘Black Dog’ has her in his grip again.
I’m an avid fan of mindfulness, so at some level, I can be open to all this. Mindfulness asks you to bring your full attention to whatever is calling your attention, relaxing as best you can with it all. One moment you’re listening to someone talking, the next you’re aware of an emotional reaction welling up inside you, a moment later an itchy toe is all you can think about. This challenges the judgements we make about familiar situations e.g. “This is wonderful” …‘She’s impossible’ …. etc. These judgements shut down our ability to see situations in a more rounded way. And so we get caught, again and again, in familiar patterns of behaviour. For some of us, that might mean trying too hard to please others and then getting hurt when our efforts aren’t appreciated, For others it might mean flying off the handle too easily and then cringing in memory of the harsh words we spoke.
When we’re being mindful, the judgements are only part of the picture. A very influential part, but we’re also conscious of our emotions as well as all the sights and sounds and itchy toes. This can somehow jolt us out of our usual pattern. Life begins to take new turns.
I’ve seen how this simple practice of just tuning into the detail of present experience can make profound changes for the better, so I’m basically a mindfulness addict! But expecting mindfulness to make life perfectly smooth is unrealistic. So I’ve also learned a modicum of patience over the years, as well as less destructive ways of dealing with misery. Which brings me back to my new discovery – the silent laryngectomee scream.
The other day, when I walked into my friend’s room, she didn’t respond to my initial ‘hello’, but slowly lifted her eyes to mine. I read anger and disgust in her look, and her first words were to criticise my appearance. “Oh-oh” I thought, but I was in confident mood and didn’t feel too troubled. I answered her in good spirit, saying I didn’t think I looked all that bad. Gradually she cheered up but later, just as she was leaving the room to have her tea with the other patients, she requested that I wear different clothes the next time I called.
Something inside me snapped. My habitual reaction in the face of anger is either to appease or to withdraw in a sulk. The urge to sulk won out – I glared after her with all the spite I could summon and banged the door with venom. I was in a tizzy, wanting to tear her hair out! I needed to let off steam – but how to do this without getting myself labelled as a lunatic? That’s when I realised I could scream and shout to my heart’s content without making even a decibel of noise! I visualised her standing in front of me and launched myself into a full fury. I pounded the air where she stood, roared into her face, screamed into her ears, bellowed all the insults I could think of. After a while I felt the rage draining out of me and even began to laugh at the whole situation.
With the worst of my anger abated I could think a bit more clearly. I sent a text to two close friends to help unburden myself and feel more supported. When she came back I told her how hurt I had been by her remark. It didn’t work, in the sense that we ended up having a bitter row and me leaving in a huff. I sat in my car for an hour, fuming and giggling by turns. Also regretting some hurtful words I had spoken. I decided to follow the old adage: “Don’t let the sun go down on your anger” and went back to apologise for my part in our quarrel. She wasn’t in her room so I just left a note.
Going in to see her today I was apprehensive to say the least. I had resolved to be friendly but knew my anger was ready to rear up again at any excuse, and feared this would bring us down the same dead-end as yesterday. Luckily, her mood was good and although we didn’t dare bring up the subject of our quarrel, the afternoon was quite a happy one for both of us.
I suppose this (getting hurt, quarrelling, apologising, getting over it) is part and parcel of any close friendship, particularly when one or other of you is going through a tough time. Although I dread dealing with depression, I try to see this as an opportunity to learn more patience, let go of habits of appeasing and sulking, and try instead to find the courage to be honest about my own needs for respect and care. And, of course, to learn the art of forgiveness. To forgive myself for my shortcomings, and likewise to forgive her for hers. Forgiveness is key to friendship – and often a major challenge.
But at least now I have another crutch as I stumble along the rocky road from blind fury to forgiveness: the silent scream. Thanks Lary!
Presence of Angels
Life IS beautiful!
For all its lacerating turns and devastating losses, for all its hardships, anxieties and pain, it is still an amazing ride! This is a piece of my life, the story of how I came to lose my voice and the journey back into having something to say –the mulling observations of a passenger in an unanticipated journey. I hope it can be of use to some, entertainment to others – and that it’ll help explain to my friends, present and future, why I “speak funny.”
A confrontation with cancer can quite thoroughly kick out one’s stuffin’s. Of all the challenges I’ve faced, this fight has been, by far, the hardest. It is aptly called a battle, and we survivors are not much different from other veterans: crisscrossed by scars, burned, filled with toxins, mutilated. Until that time when medical advances present reliable cures without side effects, fighting cancer also means bearing the marks of combat.
But there is another side effect to be had: character. At the risk of sounding trite and corny, there is much truth in the saying “Si no mata, engorda”, a maxim widely used in Argentina (if it does not kill you, it’ll fatten you up, or in its American version “that which does not kill you makes you stronger”).
I’ve seen such amazing valor among those who I’ve met along the way! Witnessed so much kindness, patience, and strength! So much service to others, so much resolution to cheerfully “go on and make it”! Would I rather not have had the lesson and missed out on the learning? Probably. But, this is what came my way, might as well make lemonade!
• I talk less, I observe (and listen) more
• I can no longer sing, but I’m returning to writing
• I cannot do public presentations, but I can be an even sharper strategist
• I cannot yell back – so I have a big incentive to hone in diplomacy!
• I no longer have a beautiful body, but, hey! What was I expecting? Even without the surgeries, age would have shoved its unforgiving agenda against my bones and skin and probably taken along with it my determination to make up for those losses with more subtle and far more beautiful virtues.
I’m not saying “bring it on!” At this point, that would be beyond stupid. But, having landed in this place for the time being, the plan is to open my stand and serve up something a bit tart but mostly, I hope, refreshing.
Down into stormy waters (so starts the nightmare)
I was diagnosed with thyroid cancer in May 2007, though I had been experiencing symptoms since early 2005. Described as “the cancer to pick, if you had to have a cancer at all,” it is relatively easy to treat: a surgery here, a radioactive iodine treatment there, the occasional external beam radiation and… a typically long and pretty much normal life to follow.
But for a few of us, things don’t turn out as simply. My cancer came back --or never left?—shortly after my first batch of treatments. It was only four months after my initial, first-ever surgery when I noticed a little bump, a diminutive Adam’s apple on my throat. One doctor said not to worry, that it was probably scarring leftover from the operation. But a second doctor wanted an MRI.
The news of cancer recurrence can be more devastating than the original diagnosis. Something about thinking you have overpowered the beast, recovered from the wounds of battle and readied yourself for futures is so kicked in the teeth when this happens, that you are left reeling.
My doctor called on a Friday night in December to tell me “I’m worried about you, Monica” and then went on to describe that the MRI showed a fairly large tumor wrapped around my trachea –that little bump I had noticed before was but the tip of something significantly larger. He felt he had to pass along the news before going out of town (fishing!) for the weekend. He did not want to leave me wondering, he said. He left me, instead, horrified, panicked, trembling, sobbing and clinging to my husband like a shipwreck in the eye of a storm, with nothing to distract me in the darkness.
And I, who have been both blessed and cursed with an incredible fertile imagination, could not shake off the mental picture of the black mass menace intent on strangling me, of it circling the rings of my breathing pipes with oblivious malice. I slept little that night – it was all nightmare.
There but for the grace of God…
The air in the waiting room at the fifth floor of the UCLA medical plaza building was thick with tension. Anxiety filled the volume of the space –like breathing jelly. The energy drew its power from the two dozen or so people waiting to see some of the top head-and-neck doctors in the country. With furrowed brows and nervous kicks and waggles, they found it hard to tap into the lift of humor, though some tried.
I, too, sat and waited and tried to focus on my reading but my mind kept popping back and forth from the book to a subjective kaleidoscope of potential and dire scenarios. I was there for a second opinion on what to do with my recurrence. I sighed – the minutes dragged on slowly. Then out of the corner of my eyes I saw a woman get up and walk to the reception counter. She must have been in her sixties, dressed all in beige, round and grandmotherly except for the fury that was barely concealed in her expression. She stood in front of the receptionist, took out an object from her purse, put it up to her neck and out came a sound that startled all eyes in her direction, as if she had suddenly blown into a kazoo that could also articulate. The sound was definitely monotone and mechanical, yet within the drone one could identify distinctive phonemes, and make up words, and derive meaning.
“Don’t gawk” I told myself. “Not polite.” I lowered my head but kept my eyes fixed – what the hell is that!? But I knew what it was: it was being an amputee, a weirdo who can no longer speak with normal voice. And it is, in my mind, one of the potential outcomes for my present condition.
When I met with the doctor and he unrolled the MRI film over the light box, I broached the subject. Without knowing the name of the condition, I described it as “what that woman has, the one in the reception area, who speaks with the squealer.” “That” he said, “is not even on the table. You are not even close to that. I think we can take care of your tumor easily. I see many worse cases all the time.”
“You mean I will be able to speak and sing, as always?” I felt my blood pressure dropping and relief flooding in balmy waves.
“Singing… I don’t know,” he replied. “Your left laryngeal nerve is highly compromised because the tumor, you see, it wraps around it. Might have to cut it. But you will be able to speak normally, for sure. No issues with that -- whatsoever. We can get you into surgery right away, I just had a cancellation for Friday.”
It was December 21st, 2007. My husband and I were planning to join the family in New York for Christmas celebrations. We looked at each other. “Shall we do it? Cancel tickets and just stay and get it over with?”
But the doctor retracted himself. “Come to think of it” he says, “let’s schedule this for January. We have time, it’s not that urgent. And it will give me the chance to run a PET/CT scan to see if there is anything else we should take out while we are in the process.” The unassuming self-confidence of the doctor, his lack of worry at my situation burst the balloon of terror and left me elated. As we came out of consultation, I looked again for the woman in the waiting room. She was no longer there and I thought, with that guilty better-than-thou strain implied in the sentiment, “there but for the Grace of God.” And we went away and had our Christmas.
White hairy angels
Surgery #2 was scheduled for January 19th, 2008 -- the run up to that day in paroxysms of fear and apprehension. It’s funny what one remembers of those moments beforehand: the sleepless hours, the drive to the hospital, the registration process, undressing and stuffing all personal items into a plastic draw-string bag, and the valiant efforts of my good-hearted husband to distract me with conversation about normal living. Or the way tiny hairs in the back of my hand shone under the light while the nurse fumbled to put in the IV until he somehow got it going, crinkled and twisted, at the base of my thumb.
This time I had completely overblown it with my freak-out: I went into the OR and not much more than an hour later I was coming to in Recovery, making a mental note to formally complain about their choice of piped-in music – heavy metal feels like nails on a chalkboard when you are waking from anesthesia. Even so, I was hugely relieved when I realized that it had gone quickly; even more when told that it had also gone well.
That afternoon I was getting onto a chair. By the next day, walking. I stood up, grabbed my IV pole, had a nurse help me suspend the drainage balls that were hanging from my neck onto some portion of my gown, and off I went for a stroll down hospital corridors.That’s when I saw him. He was beautiful, white, fluffy and serenely stretched across the bed, by the feet of a patient whose room we were passing: a huge white dog. In a hospital.
I paused, looked back in the direction, walked a few feet, returned, repeated. A dog. Really? “Yes” I was told soon after as I approached the first nurse I could find and asked about it. “We have found that dogs and pets are highly therapeutic, so we let them be with the patients. They recover faster.”
No kidding! How incredibly wonderful that western medicine is starting to acknowledge this other dimension of healing --one powered by the presence of angels.
A PAIR OF BROWN BOOTS
One night in December1953, as a 23year old policeman in Camberwell, London, I was sent by my sergeant to a Common Lodging House where an inmate had died suddenly. A doctor had been called by the warden, but was unable to issue a death certificate, as he had never seen the man before, whose name was not known. It was a case for the coroner’s officer and a subsequent post mortem.
I drove the car to Camberwell Road, where the entrance to this particular Common Lodging House was along a poorly lit alleyway, at the front of which was an old clothes and junk shop. These lodgings were licensed by the local council for the overnight accommodation of tramps and penniless young men. They were all dreadful places, and this one was no exception. I am sure that officers of the council never visited such places. This one consisted of two floors, a fairly tall building, sandwiched between warehouses, and on the upper floor was a room of toilets and wash basins; the only other room was like a small hall, that contained thirty low iron single beds, placed so close together that there was barely room to walk between them. The lower floor consisted of a grubby entrance hall, a kitchen, and a small dining room, where the tables and benches were bolted down. The room behind the kitchen was where the warden of the establishment had his private room. The whole place was dirty, gas-lit and Dickensian.
Upon my arrival the warden appeared from the kitchen, saying, "How soon can you move the body. I'm full up, and I've got people waiting for beds.", indicating with his drooping cigarette the adjacent dining room, where three tramps were fast asleep, with their heads in their arms, sprawled across the table. Above them, on a card on the wall, I read, "MUG OF TEA - SLICE OF BREAD AND DRIPPING - BED - Sixpence". I followed the swarthy, unkempt Warden, who wore a filthy apron and a string vest, up the stairs to the upper floor, the bare wooden treads thick with dust and grime. There were two gas mantles on the walls, both being broken, with a blue flame shooting out of the side of them.
We went into the sleeping room which was similarly lit, and I could see that every bed was occupied. Everybody slept fully dressed, with just one threadbare blanket covering them. There were no sheets or pillowcases. The smell in the room was awful, for a variety of reasons. The warden showed me where the body lay, and returned downstairs.
I removed the blanket covering the body, and shone my torch upon it. It was of an old tramp, a man probably in his seventies. He looked almost noble in death, and it was certainly a face of character. I thought to myself, "What an awful place to die in. You were somebody’s son once. Maybe you are a father or even a grandfather. What dreadful things have happened in your life, for you to finish up in a place like this?"
Everybody there was pretending to be asleep, with me in their midst, and I spoke to the room generally, saying, "Does anybody know his name, or if he has any family that I can contact?” There was no reply, so I started writing down his description, and then to list his pitiful belongings, when I suddenly realised that his boots were missing. I thought in disgust that they could only have been taken from his feet after he had died. I said loudly to the whole room, "His boots have been stolen, I am disgusted. You know what happens to people who steal from the dead. A curse is put upon them!"
A blanket moved exposing the face of another old tramp, who said, "He thought the world of those boots, guv'ner. We both got the same sort from the Salvation Army last week." I asked him what they were like, and he stuck a foot out from under his blanket, and on it was an almost new, light brown boot.
I went downstairs and into the street to the nearest telephone where I contacted Mr. Simpson, the undertaker, and waited outside for about ten minutes for him to arrive. Together we carried the plain wooden coffin up those awful stairs and into that dormitory. I had to get the chap out of the adjacent bed so that we could rest it on it, in order to load the corpse into it. As we carried it out of that room with difficulty, passing it over many pretending to be asleep, I said to the room in general, "I am coming back with other officers to search this place.” Of course that was not remotely possible, just wanting the thief to worry that I might. As we slid the coffin down those stairs, the warden passed us with the next sixpenny customer for the bed.
I told Mr. Simpson that I would have to take fingerprints sometime during the night, and he promised to leave the key to his mortuary under a stone. I telephoned the station stating that I was returning to get the fingerprint box, but got sent on to another assignment and it was two hours before I had a chance to get back to the station for the box. I saw a young man standing on the front steps, facing the black curved iron railings, and holding on to them with both hands. His heads was bowed and he appeared to be sobbing. I went to him, asking if he was alright, and had he been crying. He told me that he was lost. He had a look of fear on his face, but relief at seeing me. He told me that he was trying to get to a Common Lodging House called the Spike, at Peckham. When I told him there was one much nearer, he literally shuddered, and started crying again. Wondering what to do with this young man, who was acting so strangely I glanced down, and saw that he had on a pair of almost new light brown boots! I asked him if he already been at the Camberwell Lodging House that night and he nodded, clutching hold of me in fear, with his eyes wild and staring. I asked him if he had stolen those boots and crying he agreed that he had.
I asked why he was so upset, and he said, "I got out of there as soon as you left and for two hours I've been asking people how to get to Peckham, but it doesn’t matter which way I go, I always finish up on these steps, the boots are haunted." I frankly couldn’t charge him with theft, as we had no loser, and he had been punished in a strange sort of way. I drove him all the way to Peckham, and let him keep the boots as he had no others.
When I later took the fingerprints of the old gent, it may have been a trick of the light, but I could swear that he was smiling.
Windows 10 is settling down and here Comes Apple!
It has been more than a month since Windows 10 entered the picture and we have seen a dramatic decline in the updates. Now it's the Big A's (Apple) turn to make a major operating system update...in comes iOS9 for all your Apple products.
The first write-ups are coming in on this update from Apple and for the mosy part are very positive. CNET offers this review with the pro's and con's of iOS9...has Apple gone too far to please the business world at the expense of "regular" users...you can decide. They grade the bottom line as positive.
If you have an Apple phone and have not done an update to hte operating system the folks at CNET have brought in the experts to help you smoothly update your phone or iPad letting you get on with exploring the new features:
Meanwhile back on the Windows front we have help from Ed Bott in resolving some common problems folks are encountering with Windows 10. Ed is a long time Microsoft analyst and tech writer whose knowledge of the Windows products is amazing...read more of Ed's fixes here:
To answer some common questions Dave's Tips has put out a few items to help us adjust:
Have you upgraded? If you have why not share your thoughts on Windows in the Webwhispers Forum or in the Facebook group? We can all share experiences and learn from one another. Make a plan to stop in at the WW Forum or our Facebook group page for more news updates and personal exchanges.
Speaking of Facebook..one of the long asked for "Dislike" button is coming...Facebook just wants to be sure that its title is not going to imply anything mean or hateful...so as soon as they come up with a neutral title for "I think that stinks". Jason Cipriani also has a set of ideas to keep you and your privacy protected while using Facebook...
Bob Rankin does an excellent job of telling us about online grocery shopping....freah produce and meats even delivered to your door...and yes you will pay a premium but for those with no other way of getting to a grocery store this service has a lot going to it...and many happy users are making them a success. This idea was tried before but failed to take off due to unforeseen costs and localized problems ...now with a wiser group of merchants those costs and problems have been mostly overcome.
Frank in NJ
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