Got them Blog-Post Commenting Blues?

Okay, several people have mentioned to me that they are having trouble commenting on the blog. That the process seems unnecessarily complicated.

Well, actually it is. But for a good reason. All these steps have been put into the Commenting process to keep automated spamming software from clogging blogs worldwide. (Had any spam e-mails lately? The same folks that send you that junk would love to fill up blogs with the same stuff.) So "Commenting" may be a bit annoying to begin with, but once you get the hang of it, it's really not too bad. And it really does make a lot of sense -- once you understand the spamming threat.

So here's the steps again to publish a "Comment" -- including a note as to where most people are probably getting hung up!

1. Click on the word "Comments" at the bottom of the posting where you'd like to leave a message. This opens up a "Post a Comment" box with three actions you need to perform -- in the right order!
2. Write what you want to say inside the box, and please write your name at the end of this message. (Just so I know who you are!)
3. Don't try to "Post Comment" yet!! There's one more thing you have to do!! I think this is the step where most people get confused. Just breathe deeply and have confidence in your work. And trust me.
4. Directly under your Comment, there is a "Comment as: Select Profile" line. You need to fill this in for the anti-spamming reason stated above. If you click the little check box next to "Select Profile," you will be offered several choices. The easy one is "Anonymous" -- which is okay to select, since you've already told me (and the rest of our blogosphere) who you are at the end of your message.
5. Okay, now you can click on "Post Comment." When you do this, a "Word Verification" box opens up, showing a string of letters written in a wavy typeface. (You and I can read these letters, but the automated spamming software can't. So this step is an important security feature -- not just an annoyance.) Re-enter the wavy letters in the box provided.
6. Then, just click "Finish." And you're done. And you're an official blogging wizard!! Doesn't that feel good?

Reclaiming my Life

Some day soon, I want to tell you about the Angel in the Sandwich Shop who found me sobbing over a grilled chicken pita, but not right now. Right now, I want to tell you about some advice she gave me:

In our conversation, she said: "Randy, there are lots of things you should do in order to fight your cancer successfully. But every bit as important, there is something you need to be. You need to be who you truly are. You need to be Randy now more than ever in your life. Who are you really? And what does that mean you have to do? Then do that!!"

And one consequence of this conversation was the following realization: For the first couple of weeks after my surgery -- back when I was sleeping 16 hours a day -- I would evaluate any potential activity based on this question: "Do I feel up to doing this?" A perfectly sensible question at the time.

But I had been hanging on to this question for too long. And framing my activities by thinking about my limitations had diminished me. I had started defining myself more and more in terms of my disease.

And here's the kicker: by becoming not much more than my disease, I cut myself off from all the love, the caring, the prayers, the compassion, that you, Dear Reader, have been sending my way. I started seeing all your good wishes framed by "Well, all that is quite nice, but I'm still sick. And I might die from this illness."

And what my Angel in the Sandwich Shop helped me see was that I needed to change my question from: "Am I up to doing this?" to "Is there any reason why I shouldn't do this?" And there is an immense gulf between these two questions. Believe it!

The internal transformation has been huge. I feel that am no longer The Patient. I am Randy Lyons again. The juggler -- and the guy who runs the jugglers club. The mighty dinosaur hunter and dinosaur lecturer. The loving spouse. The good friend. The best brother and son that I know how to be. The human being enthusiastically drinking in all that life can offer me.

Medical Update -- 5/27/09

(Gentle reader, the following information is the best understanding I can get about what's going on with me. Your comments are encouraged.)

My healing from surgery is just about done, so it's time to make a decision about what happens next. I got the news yesterday afternoon that the Pathologist at Johns Hopkins confirmed the analysis by the Chester County Hospital Pathologist that the cancer was a metastatic cancer (that means that it can travel from one place to another) in my parotid salivary gland. And I am informed that this is an aggressive form of cancer. This information helped me reach the conclusion mentioned at the end of this write-up.

As mentioned in the 5/23 posting, there is some disagreement about the best way to proceed among the doctors I'm working with, a discrepancy because of two different facets to the cancer:

On one hand, there may be some residual primary tumor in the salivary gland, and some doctors I've talked with say that you should surgically remove the entire parotid as a first step. This would, however, delay chemotherapy and radiology until the new surgery heals up. (Because radiology can undo the healing process and cause considerable difficulties in the process.) One radiologist tells me that the healing would take from 4 to 6 weeks. Another tells me that 2 to 3 weeks would be sufficient. In either case, cancer cells will continue to spread around my body -- settling almost anywhere -- and begin to grow. Something like 7 of the 30-odd lymph nodes that were removed recently had cancer cells in them, so clearly there is spreading going on even as you read this.

The other approach is to start chemotherapy as soon as possible in an effort to eliminate the cancer cells that have traveled away from the primary site. And to start radiology as soon as possible to deal with any residual primary tumor that may remain in the parotid.

An unidentifiable mass -- roughly 1/4 inch -- showed up on the MRI, which may be tumor or may be an inflamed lymph node. There's no way to tell. I am informed that the radiology should be able to "take care" (my term) of this mass if it is tumor, but I must admit I'm not sure whether "taking care" of this means just stopping it from spreading or actually making it shrink and possibly disappear.

After a month of treatment in this second approach, I would undergo a second MRI to see if the mass is smaller, unchanged, or larger.

So Step 1, you remove the parotid gland to provide some assurance in the local area or you go after the stuff that's spreading all around and then concentrate on whatever may be left in the parotid gland.

And I've chosen this second option. To start radiology and chemo as quickly as possible. The initial bump on my neck was discovered in late January and, to date, nothing has been done to address the potential spread of the disease.

It took a long while for me to understand that there are no right and wrong answers to this dilemma as to how to proceed. Both approaches might yield complete success. Or neither approach might do so. The cancer is unusual enough that no one can give an answer with any assurance.

So the right answer is the one that feels best to me, and that's what I've chosen to do.

I am deeply grateful for your continued prayers and best wishes.

Medical Update - 5/23/09

Gentle readers, I haven't blogged much about my medical status recently and I feel I should tell you why:

I have the great privilege of having outstanding medical personnel working on my behalf. At the moment, however, there is some disagreement among these folks as to the best way to proceed from here. More surgery? Maybe. Chemotherapy and radiology as quickly as possible? Maybe. But these two approaches may be mutually exclusive.

And as of last Thursday, there seems to be a new question as to the proper pathological interpretation of the biopsy slides from my big-deal neck operation of several weeks ago. And the treatment options change markedly with the interpretation of the slides...

While this uncertainty produces a certain level of anxiety, I am glad that we have a week or two left in my recuperation-from-surgery period so we can get it straightened out. So my actual path towards medical healing is not being slowed down drastically -- and we have this time to make sure we proceed in the best way possible.

So I would tell you more about what's going on and what's planned, but I might well have to post something considerably different the very next day.

Thank you all again for caring and loving and praying. And for sharing your thoughts by "Commenting" in my blog. It's delightful to think that your words are being carried to so many people that you don't know -- but I'm sure you would like a lot if you knew them... Kind of a great big verbal "get acquainted" barbecue. Without the messy sauce...

Finding Hope and Peace in an MRI Machine

Yesterday's "next step" in finding out exactly what's going on in my neck -- and where -- was an MRI (or "magnetic resonance imaging") scan at Johns Hopkins Hospital. We had it done there because their machinery was probably more state-of-the-art than that at our local Chester County Hospital.

Now, I had been through a CT scan and a PET scan already on this journey, so the idea of laying down on another table which then rolled inside another large doughnut-shaped contrivance for the MRI felt like it would be no big deal. Been there twice. No prob.

Ah, well.

I lay down on the table and positioned my head in a holding device, which didn't feel that cool. Then the technician and her assistant placed towels on either side of my head to keep it entirely immobilized -- which started a considerable feeling of claustrophobia. Then, they placed a mask (think Hannibal Lechter and you're not far off) over my face -- so close that it brushed against my chin. Okay, now we have a serious problem in the works. Then the table, the head-holding device, the Hannibal mask and me -- we all rolled into the tube together.

Nope. Sorry. Won't work. I didn't last 5 seconds in the tube before I pressed the "Get Me Out of Here!" button that I had been holding. And the table rolled back out of the doughnut.

(Dear reader, I hope it's clear that the only reason for my needing to wear the mask was the area of my body being imaged. If you have an MRI scheduled for your chest or arm or somesuch, the mask will not be part of the procedure. So you can breathe normally again.)

The technician and assistant took the mask off and sat me up. Rubbed my shoulders and held my hand. I asked if a sedative might be available, and was told no. I then nodded my head towards a closed closet door and asked if there might be some Jack Daniels' available there. The assistant (whose name was Sam) smiled as she shook her head no, but the two of us had to explain the reference to the technician, who spoke with a strong Eastern-European accent and might not have been in the US for all that long. Jack Daniels' we explained: whiskey.

The technician explained that I didn't need any whiskey (or "vhiskey," as she pronounced it) since I had already had a Margarita that morning. Because, she explained, "That is my name. Margarita!" And the three of us laughed.

As I lay down for a second try at the MRI and had the mask refitted, Margarita held my hand and told me, "I will hold your hand as long as you need me to. When you are ready to start, just let go of my hand." I was rolled into the tube and held her hand for maybe 15 or 20 seconds. Then let go. She also told me that I should keep my eyes closed. Which was a great suggestion delivered just the right way. Not: "Don't open your eyes." (which is a negative thing) but: "Keep your eyes closed." (which is a positive thing).

Anyway, as I let go of Margarita's hand and shortly thereafter heard the door close (meaning I was alone in the room), the panic started to come back.

But I kept my eyes closed. And the thought occurred to me, "Diane wants me to lie still." (Diane is a classmate at the Full Spectrum School, which I mean to blog about sometime soon.) And that worked! For several seconds after that, the panic subsided completely and I felt my body relaxing. When the panic started to build again, I thought "Lori wants me to lie still." (Lori being another classmate.) And pretty soon, I started through the entire class list: "Dawn wants me to lie still." "Hal wants me to lie still." and so on. I spent several minutes going back over the class list to make sure I hadn't missed anybody.

Then I started in on my juggling group: "Jack wants me to lie still." "Travis wants me to lie still."

After 10 or 12 jugglers, I started in on my Quaker Meeting: "Marina wants me to lie still." "AnnaMarie wants me to lie still."

(During my previous scan -- the PET scan -- I managed to get through the experience by just remembering that there were a lot of people who cared so much about me and wanted me to get well. But the MRI mask made this approach ineffective. The claustrophobia was lurking just much too close. I needed names and faces of individuals I could visualize to make things work.)

After a bit, Margarita let me know by way of a speaker system in the head-holding device that I was 20 minutes into the procedure -- halfway home!! I started in on the teachers and staff at West Chester Friends School: "Teacher Dottie wants me to lie still." "Teacher Matt wants me to lie still."

Now, I still knew that if I opened my eyes, all this good work would be lost -- that I would likely panic, need to be rolled out and we would have to start over again from the top. And this helped me stave off the curiosity of "What would happen if I just squinted a bit?" No, Randy. Don't go there!!!

Remarkably soon -- it seemed -- the procedure was over, and Margarita and Sam(who had also a huge help in calming me down after the first anxiety attack and prepping me for the retry) were rolling me out of the doughnut and telling me what a marvelous job I had done.

As I sat up, I told Margarita how helpful her comment about not needing whiskey had been, and she smiled. (She told me she was from Ukraine, and I told her her accent was lovely. Then she smiled again. I was probably also smiling. I forget.)

Yesterdy, I did something that I didn't think possible. I did it with the support of the Hopkins staff -- and the recollection of all the love and caring that is aimed in my direction from so many wonderful people.

Love. It's a powerful thing, dear reader. A powerful thing.

Wordplay

Have you noticed that the words "meditation" and "medication" differ only by a single letter?

Hmmm?

Clarity

Earlier today, I was recalling the telephone call I got from Dr. Chuma several weeks ago informing me that the pathology report on the original lymph node removed from my neck had come back positive for cancer.

Dr. Chuma -- who I'm sure has had to make this type of call on many occasions in the past -- just moved quickly through the facts that he felt I needed to know and start dealing with. No sugar coating. No "I'm sure everything will turn out okay." However much I wanted to hear him say that, it really wouldn't help since it wasn't true.

I had expected the pathology to come back negative -- that the lump he removed in surgery was simply a harmless sebaceous cyst like the half dozen I've had located here and there around my body. Which made the information he was giving me all the more unbelievable, surreal, impossible.

As I paced the floor with my telphone in my ear, hearing these totally incredible words, my mind racing to figure out what really going on (since this couldn't be true!), a remarkable thing happened:

I felt there was a mist forming over my head -- maybe 2 or 3 feet above me. And after forming, it descended ever so slowly until it touched me, and then it proceeded to move down the length of my body. And the parts of me that it touched were transformed.

As it moved down my body, a great deal of pettiness and silly or stupid ambitions, false beliefs and useless fixations, were washed away. (You know how, when you're taking a shower, you soap up outside the water stream, then step under the shower head and the soap forms a cascade as it rinses off your body? It felt like that, but this was a non-physical -- a metaphysical/spiritual -- rinsing.)

I lost track of Dr. Chuma's words as he was speaking, but that wasn't a problem. I knew that I would have other occasions soon to get all the medical information I needed from him.

But this feeling of being cleansed I knew to be a special blessing that I should experience as fully as I could. So I tried to relax into the feeling of goodwill and peace that the mist brought with it. I felt that, if I could hold onto the feeling -- the clarity -- that this mist imparted to me forever, that I would move beyond the vicissitudes of life forever. Maybe to become the rightful self that we all have in store for us -- that lives inside of each and every one of us. Waiting for release.

I can't tell you which stupid ambitions were washed away. Or which useless fixations no longer have a hold on me. That's not really the point.

And, at the moment, as I try to keep up with my doctors' visits and the medical information I'm working to absorb and the decisions I'm being asked to make, that wonderful feeling of being cleansed seems remote.

But not gone.

Orchid Update #2

Given the recent bout of chilly and/or windy weather, Deb and I have been taking our orchid plant (see previous "Orchid" postings) in and out fairly frequently. Out for the sunshine -- in for protection. Several times a day on occasion.

And it occurred to me today that we might as well give the plant a name. We've named a considerable number of objects around our house, including our GPS (whose name is "Mildred"), and the plant has become special to both of us.

So I asked Deb: "What would you think about giving a name to the orchid?"

And she responded immediately: "Blanche. It's been Blanche since it first showed up here."

(For those of you without a dictionary handy, let me explain that the word "blanche" derives from the French and that derives from the Latin. And it means "white." And given the stunningly white blossoms that the plant produces, the name is entirely appropriate. Deb knows these sorts of things without resorting to a dictionary. It's one of her many appealing qualities.)

So there you have it.

My Dick Cheney Smile

There are a few residual physical effects from my big-deal surgery on May 5th. And most of those effects are gradually decreasing with time. For the first time since the surgery, I can contemplate being back to my pre-operation self functionality totally. (However, Dr. Chuma tells me that the feeling in my left ear lobe is likely never to return -- and that if my wife has a habit of nibbling on that ear lobe, she may have to transfer her attention to the other one. I am not making this up.)

Anyway, one of the ongoing issues is my "Dick Cheney Smile" (my term). The nerve or nerves that activate the muscle(s) which retract the left hand corner of my lower lip have not been functioning since the operation. So when I smile big, the lower right corner of my lip behaves properly and opens the lip, but the lower left corner just sits there. So my lower lip just cuts a diagonal across the bottom of my face. So the smile looks much more like a sneer. Like several recent politicians we've seen holding national office, including you-know-who.

Since I'm normally laughing loudly when this "DCS syndrome" occurs, I don't think anyone nearby is offended or will confuse me with you-know-who.

(But I want to assure everyone out there that my delightful boyish grin is fully available at all times and totally unaffected by the aforementioned nerve issue.)

It's been annoying when, for example, I try to eat toast. I have to reach up underneath the toast to pull the lip out of the way before I chomp down or else.

But given the gravity of the issues we're dealing with here, this is like sooooo small. And I had resigned myself to doing the "pulling the lip" trick for the duration, but maybe I don't have to. Just this morning, lying in bed, I believe I started to feel some control coming back in this area. (Dr. Chuma said that was likely to happen, but until it does, you always have that question: am I stuck with this?)

I've never had surgery anywhere near this involved and extensive. So all my previous understandings about recovery times are not all that helpful for this experience. So it has been a blessing in many ways to have this gradual return of functionality over the last twelve days:

While I understand that that I still have cancer cells in my body (which chemotherapy and radiology treatment should start to eliminate in weeks upcoming), I have today gained a new understanding and appreciation for the immense well of healing that my body is prepared to provide for me.

The Quakers out there may recall George Fox's revelation about "A Ocean of Darkness/an Ocean of Light." Yes, it feels like that...

I'll keep you posted.

Orchid Update

(In case you haven't read the posting, "A Confluence of Orchids," you may want to take this opportunity to do so now. The following information makes more sense with that as a background. In terms of metaphor. If you just want to know about the flowers and don't care much for metaphor, then please feel free to read on.)

I am happy to report that the magnificent orchid plant that my family sent me post-surgery is doing fine. Actually, a lot better than fine. It has, in the last 48 hours, produced two new blossoms -- one on each stem of the plant. And they are both as beautiful as the eight blossoms that were in bloom when the plant was delivered. And all of them continue to be wonderful.

Thought you might want to know...

Going Good

So it's Saturday morning and I'm at the gym for the regularly scheduled session of the Turks Head Jugglers. There's a dozen jugglers here -- all of whom I know. Most of whom I haven't seen in over a month. Everyone (except me) is practicing hard. And everyone (including me) is having great fun. The music is a bit too loud, of course. And there's nowhere else on earth that I would rather be.

Around 9:45, Ellen comes sailing in and sees me sitting on the floor, smiling, sipping coffee. She almost yells at me:

"What are you doing here? You should be home blogging!! You're falling behind. Get that thing up-to-date!"

Love comes in many different forms.

Have you noticed?

Staples in my (Skinny) Neck

Some of you may be puzzled, appalled or just plain grossed out at the idea of 25 metal staples holding together a suture on your neck. Or anywhere else for that matter. "Why," you may find yourself asking, "don't you just stitch things back together with good old-fashioned black thread? Why the shiny hardware?" (And by the way, photos of my shiny hardware are available. Did I already mention that?)

And yes, I've been asking myself the same question for about a week or so. And now that they're safely (and painlessly!) removed, the answer -- or at least an answer -- occurred to me. In the shower. Gently bathing the place where the staples used to be. (I haven't had a chance to talk this topic over with Dr. Chuma, who put them in in the first place. We've got other topics of greater urgency. But I like my answer!)

So, here's a chance to put on your virtual surgical gown and gloves and ask youself "Why would I staple this area rather than stitch it?"

Tell you what, I'll give you ummm.... 2 minutes if you want to consider the question, then I'll tell you what I think. Okay? Ready? Go!

......

Bink!! Time's up! Come up with anything?

Did you figure out that installing a stitch puts thread above the incision -- but also directly underneath the incision? And that when the stitch thread is removed a week or so later, that the removal opens up a "mini-tunnel" directly across the incision site? The site that most needs healing? And is most vulnerable to infection?

But that a staple does not penetrate underneath the incision, so that the entire wound area can start to heal completely and immediately right after the surgery is done? And that there is no new exposure of sub-dermal tissue at the wound site when the staples are removed?

Didja? Well, that was my answer!

(If you've got a better one, please leave a comment to that effect. Let's get this figured out!!)

Medical Update -- 5/13/09

(I will try to keep this short but informative, as Deb and I have a meeting in Philadelphia at the U of P Hospital with one of their primary head/neck cancer guys early tomorrow.)

After the first surgery (to remove the first lymph node for biopsy), the evidence seemed pretty clear that we were dealing with a fairly run-of-the-mill cancer. One that has an extensive clinical history, and standard protocols for treatment. (Now, this is me talking and I may have to correct this statement in a future posting. But that's my understanding right now.)

After this surgery (to remove a considerably larger set of tissues), this is not the case. My cancer is an unusual condition called "high-grade salivary duct carcinoma with micropapillary pattern." Please don't ask me to explain any of that -- but please feel free to "Comment" on it if you know something about it.

Since this condition is unusual, the medical history is not nearly as complete, and Dr. Chuma is helping to set up a series of meetings with doctors who will have much more information to provide -- and recommendations for future treatment.

So this is good news sandwiched in the bad news: not a lot of people know much about this, so we can call in some high-level experts to help us out because they will be interested in the case!! So we've got the beginnings of a plan.

And the next logical step in the treatment is radiation therapy, which can't start until the tissue that's left in the area of the excision heals thoroughly. For which Dr. Chuma is allocating a month. So we've got the beginnings of a plan with time to invest in making sure the plan is thoroughly worked out.

I believe Dr. Chuma said he's pretty sure he removed all of the primary tumor site, which means that what's left over is (in his words) "microscopic particles" of malignant tissue which are contained in a relatively small area. (Once again, please note that all of this is subject to change without notice. We're all working to clarify this picture!)

Many thanks to all of you for your interest in and your caring about my journey. I don't believe any of you -- unless you've walked this path yourself -- can understand how immensely your love and compassion strengthen me.

My Skinny Neck

By this point in our saga, dear Reader, Deb and I have visited Dr. Chuma (my E/N/T guy and lead doctor in my healing journey) 5 or 6 times. And that's not counting our two dates in the Operating Room. And on every occasion I have come to like him, admire him, and trust him even more.

And on every single visit, (except the two in the Operating Room), he has mentioned my skinny neck. Mentioned it with admiration and appreciation. (Truth be told, I was a little concerned about getting "old man's turkey neck" syndrome, but read on!)

Originally, I thought he was simply pointing out how much easier it is to operate on a neck that is not layered in... umm, how to put this politely... layered in excess tissue.

In other words, I thought he was saying that my skinny neck made it easier for him to find what he was looking for as a surgeon and to work around areas containing nerves, large blood vessels, and other critical features that he needed to stay away from. All of which is a good thing.

But during today's visit (which I will blog about this evening), an even more crucial element in my well-being came to light. Something I had missed:

Twoards the end of our visit, I extolled the virtues once again of Dr. Johnson, the wonderful GP who first noticed the bump on the side of my neck and decided to pay attention to it. Without her alertness, I might still have that original bump and, thinking that it was likely a cyst or something else benign, told myself for weeks or months that I really ought to get that looked at some day. Which would mean that none of this discovery process would even have started.

At the end of my little speech about Dr. Johnson, Dr. Chuma said, in effect, "What allowed her to find and be concerned about that bump was the fact that your neck is skinny. Hidden inside a heavier neck, that bump might not have been noticed even by her."

Geez. The things you wind up being deeply grateful for...

Medical Update -- 5/12/09

Well, tomorrow (Wednesday the 13th) promises to be a big day. I see my E/N/T doc at 8:10 AM, and he's promised to take the 25 staples out of the left side of my neck. (This seems to be the way one closes a large incision, as opposed to stitching closed a small one.) For the last week that part of my anatomy has looked like an unfortunate cross between a cheap sci-fi flick "special effect," an ill-planned effort at goth glory, and an exhibit at a medical convention. (BTW, got photos if you want 'em...)

The healing has gone extremely well, and the doc (who was also the surgeon) said the other day that the incision looks "fantastic." Still, I am sooooo looking forward to this! I will have the option of sleeping on my left side as well as my right side for the first time in a week.

Also, by then, Dr. Chuma should have the biopsy reports back from the tissue samples he removed last Tuesday, so we should be able to start planning the next steps in my treatment. In just a few words, he could lift my spirits immensely or simply reset my resignation to staying with the course -- "putting one foot in front of the other."

So your thoughts and prayers are invited tonight and tomorrow morning. I will post what happens at our visit as soon as I can.

Porch Lessons

Deb and I live in a lovely house in West Chester that's recently turned 100 years old. And our block is lined with other houses much like ours. An architect friend called this "the most beautiful block in West Chester." We sort of lucked into owning this place, but that's a long story to tell some other time.

Like so many houses of a century ago, the front of ours is graced by a lovely porch. The porch faces south, which means that, sitting out there at sunrise sipping tea, you can watch the dawn break off to the left. And sitting out there at sunset sipping sherry, you can watch the day end off to the right. And day or night, there's almost always a gentle breeze...

(Before proceeding, you might want to try clicking on the above photo. Depending on the software in your computer, the picture may expand to full size. It's really kind of nice. And you can get back to this blog posting by clicking on the "Back" arrow at the top left corner of your screen.)

Looking at the photo, you can see several bird feeders suspended under the porch roof. (The birds appreciate these feeding stations when it rains or snows!) You can also see the three pieces of purch furniture (a rocker, a table and a chair) that inhabit the porch from early April to early November, thereabouts.

The hedge you see on the right separates the front edge of the porch from our small front yard -- and it does a wonderful job of masking us from neighbors and passers-by: we can hear them and see them, but we remain invisible to them. And the birds love to bounce through the hedge or just sit deep inside the hedge and chat. Usually with themselves, sometimes with each other, and -- on special occasions -- they chat with us.

One of the best days of the year for Deb occurs in the early spring when I bring the porch furniture out of the baesement, hose it off, and place it as you see it in the photo. I've made it a habit to bring it out when she's off running errands or somesuch, so that it's a surprise when she returns home and sees it sitting in its rightful place. I believe she sees this as the official end of winter.

It's not unusual for Deb to spend an hour or two in the early morning sitting out there -- reading, meditating, listening to the birds, waiting for the sun to rise. And equally likely that she will spend an hour or two just before bedtime out there as well. She has always understood the gifts that the porch has to offer.

The reason that I'm writing about this in my health blog is that I have "lost" the porch over the last several years. Sure, I would occasionally sit out there with Deb because I know she enjoys having me out there with her -- but that's the point: I'm sitting out there with Deb and for her as opposed to being on the porch for myself whether Deb is out there or not.

And it's just occurred to me over the last several days -- when I've been sitting out on the porch by myself reading a murder mystery, listening to the birds (and also our human neighbors), being refreshed by the breeze, sipping tea -- how different it is to be totally there because you want to be there and you're soaking in the sounds, the sights, the peace and quiet of this lovely place as opposed to doing a favor for someone you love. I started doing this sitting-and-reading act because I'm really not physically ready to do much else. But now, I'm sitting, reading, and truly being on the porch.

And all this started me thinking about how quick we are to pass over the simple, familiar pleasures of life -- often the ones that nourish us the most -- in favor of the new, the exciting, the different. We spread our branches farther out as opposed to planting our roots even deeper.

Yin and yang: both are important and each needs the balance of the other.

So here's another gift of my illness and my recuperation: I have my porch back. And maybe an important piece of myself came along with it.

And, if you're ever in the neighborhood, please stop by and spend a little time on the porch with us.

What I'm Learning

One of the unexpected rewards of this process (above and beyond the outpouring of compassion and prayers that has been so evident and so helpful to me) is gaining the wisdom of insight and personal experience that so many of you have shared. There are ways to make this journey more difficult and other ways to make it less so. I want to list as much of this wisdom as I can in this posting -- in case you find yourself in need of it or know someone else who may profit by it.

Please revisit this posting from time to time, as I plan to update it on a now-and-then basis. And for goodness sakes, please feel free to add comments of your own to this list!!

1. From Nancy Bernardez: "You must not let your head completely take over this topic. Stay grounded, meditate, and remember the divinity that is within you. Allow Deb to fulfill the role she designates for herself; she will know exactly what to do for you and you will never be alone in this. Set your ego aside and accept everything that is offered by all of us who love you and are praying for your speedy and complete recovery. Remember: breathe, meditate, and find the meaning in the message."

2. From Emily Seay: "Probably the worst part of cancer is the not knowing. There is a phrase we use [here at Johns Hopkins Hospital]: 'tolerating ambiguity.' It can be exquisitely painful. Often worse than any physical pain the cancer and/or treatments can throw at you. The upside of this situation is not only that you've had excellent health, you have devoted yourself to spiritual and psychological training which will benefit you in ways you cannot yet imagine. Your intellect, organizational skills, choice of mate, Sagittarian sun sign, etc. etc. all bode extremely well for a positive outcome. I believe your natural optimism will cary you through some dark hours, but you can also remind yourself, that when you are chosen to walk this path, it is yours, and it will offer you gifts as well as lessons that few of us will experience..."

3. From Kathy and Bill Siddons: "Recovery is more than a mending of the body. It is an easing of the mind, a calming of the heart, and a healing of the spirit."

4. From Lisa Lapp: "A strong opinion I have developed about cancer treatment since working at Fox Chase, and then experiencing life and seeing cancer in friends and others since then, is that the only way to treat cancer is very, very aggressively -- and at the best possible clinical facility for your particular diagnosis. And with a treatment plan that is both comprehensive (all disciplines woven together) and thoroughly specific to your case. And with a heightened awareness of all new and trial treatments that may be available. And with lots of questions, at every step."

5. From Barbara Siddons: "Remember that recovery from anesthesia and surgery is a process and not an event -- take time!!"

6. From Sherry Vardaro: "When you know the moment is right, close your eyes and visualize putting your trust in 'somthing or someone else,' whether it be the doctors, nurses, a family member, the universe, God or all who want to care for you right now. The act of trusting and visualizing yourself passing on any remnants of control to another will relieve you of the burden of holding the belief that you have control -- which is only an illusion and won't serve you well."

7. From Frank Barch: "While it's important to choose the right doctor and medical facility for your surgery, it's even more important to select the right doctor and medical facility for your follow-up work. That is where most of the decisions about healing and future treatment are made."

8. From Allison Prettyman: "If you decide to blog about this, don't make it simply an updated medical report. Use the opportunity to share what you are feeling and where you are right now with all those that love you and care for you."

9. From Jean-Marie Barch: "Choosing the right medical facility is not necessarily finding the most advanced facility. The right facility for you is the one where you feel most comfortable and where you place the most trust."

10. From Randy Lyons: "Getting a second opinion may not change any of your decisions about treatment options. But it may provide you with much-needed comfort and confidence in your medical team and the decisions you've reached together. As your journey unfolds, you should be able to look back at those decisions and those people and feel good about them."

11. From Chris Smith: "Unfortunately, hospitals are very noisy places at all times of the day and night. I have not endured surgery, but have had to stay over [at Jefferson Hospital] in empty rooms during heavy snowstorms. I had NO physical discomfort to deal with, but could not sleep with all the noise! And by the way, there is no regulation that says you have to keep your [hospital room] door open..."

12. From Sharon Smith: "Those little cells are working to reconstruct you as I type. I can just picture them, wearing construction hats, saying, 'C'mon guys! Let's heal this one up! We'll get paid double time if we work overtime!' I imagine it's more the blue-collar-type cells that do all the dirty work of healing and reconstruction after a major trauma. It's the more academic-type cells that enjoy the restful, meditative parts of healing. I wish you, and all your tiny little cellular beings, good luck in the healing process!"

13. From Emily Dickinson [by way of our neice, Emily Seay]:

"'Hope' is the thing with feathers ---

That perches in the soul ---

And sings the tune without the words ---

And never stops --- at all ---"

14. From Martha Seay: "Living with cancer is like living on a roller coaster. When you get an 'all-clear' set of tests, you rise to the top -- and stay there for a couple of months. But the week or so before the next battery of tests, you get anxious all over again and try to prepare yourself for possible bad news. Another 'all-clear' report puts you back on top. A 'not-so-good' report just increases the anxiety. A 'we-may-have-a-problem' report plunges you all the way to the bottom. You live like that even after years of 'all-clear' tests. That's just how it is."

15. From Bala Krishnaraj [my flute teacher]: "Be happy -- and everything else will follow."

16. From Anthony Paino [Dinosaur curator at the Academy of Natural Sciences. He'd like to see me back in the prep lab soon...]: "I have to tell you this whole 'illness' thing sounds like a dodge. If you didn't want to volunteer for Bugfest '09, all you really had to say was 'no.' Haven't you heard of the therapeutic value of mad, screaming children [whom one finds frequently in the halls of the Academy...]? Isn't it exposure to insane ten-year-olds the method that those people in Tibet have used to live well into their 100's? Wait, no. I think that was yogurt."

The Gift of Hearos

(Before we begin, let me assure you that the word "Hearos" in the title both is and is not a typo. Explanation to follow.)

Last Tuesday (the day of my surgery) and the following Wednesday were two of the most miserable days I have ever spent. I don't blame the hospital or my care-givers this, but that's the case. It went like this:

In those 48 hours, my only food intake was two small forkfuls of scrambled eggs and an equal amount of gelatin. I simply couldn't interest my body in eating the food it was craving. I was woozy and exhausted from the surgery and the variety of drugs administered before, during, and afterwards. I was pinned to my bed by the saline drip coming into my right arm and the two drains installed in the left side of my neck. I desperately needed sleep, but was continually awakened by medical staff and passers-by in the hallway who seemed to have forgotten that there were sick people nearby. (My roommate turned on his television, until he determined it was a problem for me, and then switched to earphones. God bless him...)

In short, I was hungry and couldn't eat. I wanted to get up and move around for old time's sake and couldn't budge. I wanted to sleep but was continually reawakened with testing for vital signs, questions about how I felt and chatter from the hallway.

Things finally calmed down after midnight. There was silence from the hallway and a greatly reduced traffic through the room. At this point, though, the most exasperating and unexpected annoyance came into play: my automated drip-control machine. This device deliverdd a controlled amount of saline solution and dextrose plus whatever antibiotics and/or steroids my care called for at the time. Down out of the hanging plastic bags, through the machine, then into my arm. You've seen this on medical TV shows, right?

The machine had a ten-second cycle of "whirrr....click" on and on through the night -- thereby assuring that I would not get any sleep at all. During the day, the machine's noise had been masked by all the other noises going on, but now in the relative peace and quiet, its monotonous "whirrr....click" song seemed to get louder as the night wore on.

Now, I'm into ear plugs in a big way. Never travel without them and even use them for sleeping at home. But the foam-style plugs that I brought with me didn't baffle any of the "whirrr....click" noise in the slightest. Wrong acoustic frequency, I suppose. Knowing this, I had called Deb earlier that evening and asked her to purchase and bring over some Flent's Ear Stopples -- the ultimate in noise blocking ear plugs -- which I had always felt would shut out the sound of an F-18 fighter plane taking off. But the Flent's Ear Stopples did not reduce the "whirrr....click" noise at all either. Didn't touch it.

This infernal machine was located maybe two feet from my head and, consequently, two feet from my uselessly plugged ears. I found myself counting "whirrr....click's." I started timing the cadence. I began examining the machine's control panel and asking myself "would I survive until the morning if I just turned this off for a few hours and didn't tell anyone?" (I decided against pursuing this idea -- but it was tempting...)

The control panel had a "Silence" button. I took a chance and pressed it. The machine responded with yet another "whirrr....click." I asked the night nurse if there was a trick to silencing the "whirrr....click" using the button. She seemed surprised: "Oh, goodness no. That button only turns off the alarm. It doesn't affect the 'whirrr....click' at all." Silly me.

(Two things to note at this point in the narrative. First, dear reader, do not expect to get any rest in a hospital bed. It might happen. Eventually. But get yourself fully rested before you're scheduled for a hospital stay. And feel free to write and thank me for this advice when you get home!! Second, I was later told that the steroids that I was taking intravenously tend to make one more jittery and sensitive than normal. And maybe this was a large part of my problem with the "whirrr....click" machine. I hope never to be able to test this theory, as I hope never to meet another "whirrr....click" machine in this lifetime or any other.)

Around 4:00 AM, I asked the nurse if she could push the machine around the corner towards the bathroom by stretching out the tubes that connected the machine to my arm. Get it away from my head. And ears. She said of course she could -- and then did so. She then wrapped a towel around the machine which -- will wonders never cease? -- silenced the "whirrr....click"!! The silence was complete and oh-so-welcome. And oh-so-short. Along about 6:00 AM, the day's regular routine started up again and the chance for an extended sleep was gone.

A remarkable number of people that next day decided that the door to my room needed to be open for a remarkable number of reasons. My roommate's bed had some sort of problem, and there were maintenance guys lifting things and pounding things and climbing ladders and comparing notes about what was wrong with the bed. Nurses and doctors drifted in and out -- and several of them woke me up to introduce themselves. Meals that I couldn't bear looking at were delivered and taken away. A hospital volunteer woke me to ask if I wanted a newspaper to read -- and how was my stay going? A lady with a clipboard stopped in to ask if I wanted to continue my television service. (I said no.) I signed papers that were thrust in front of me. I have no idea what the papers were about, but I hoped that by signing away anything or everything I own that I might be left alone for a couple of hours' rest. It didn't work.

For hours, I kept pressing my "Nurse Call" button and asking whoever answered to please come and close the door. Again. Please. Soemone always came and closed the door, but someone else would show up 10 minutes later, do something in the room and leave without shutting the door behind them. Again. This may be hospital regulations. I don't know.

Once when calling yet again to have the door closed, the nurse asked if was there a problem. I nearly sobbed as I said, "Please, I'm just trying to get a little sleep here."

Okay, here come the Hearos.

My roommate was visited often by (I guess) his wife, and the two of them were as thoughtful as one could possibly hope for. Like Deb, she had focused her day on taking care of her husband and doing whatever she could to make him comfortable. Like Deb, this involved staying for an hour or so, then leaving, then coming back a few hours later.

Some time after my sobbing plea to the nurse, my roommate's wife came back into the room after running a few errands. And she stopped by my bed just long enough to drop off a package of ear plugs. Ear plugs!! The package had 14 pairs of ear plugs. Brand name? Hearos. She dropped them off and gave me this wonderful look of compassion, as if to say: "I know you're hurting, and I wish I could do more. But I hope these help."

Between that time and my discharge from the hospital there were other challenges and difficulties, but somehow, the edge had been taken off. The world had become a softer, gentler place. I kept looking at my package of Hearos -- and relaxing a bit more.

Now it's understood that the lady's Hearo ear plugs were no better at stopping sound than the pairs I had brought or the Ear Stopples that Deb had purchased for me. But that didn't matter in the slightest. What mattered was that another human being -- one with whom I had no previous dealings and who didn't owe me anything -- had heard my distress and had taken it on herself to do something about it.

Dear friends, it's the small kindnesses we offer to each other that can mean so much -- and it may not be given to you to know just how much. So when you have a chance to offer such a kindness, please don't let the opportunity slide by. Do the kind thing. It's what makes us truly human.

A Confluence of Orchids

A vitally important part of convalescence (as I'm finding out) is having the right thing or things to read. You're supposed to be spending a lot of time sitting still, and unless you're a knitter or into making chain mail or somesuch, reading is the way to go.

(My current book discusses the influence of Rene Descartes on the evolution of philosophy, science and religion in the late 17th century. And how that influence resonates in today's society in everything from creationism to stem cell research to radical Islam. It's a wonderful, well written book that I plan to finish sometime after I'm healed. But it's a bit heavy for the current need.)

The books I needed for this time and purpose are sometimes called "page turners" or "pot boilers" and murder mysteries are prominent in this category. And -- voila! -- I rediscovered that Deb and I had a collection of over a dozen Rex Stout mysteries that had been loaned to us over thirty years ago by a dear friend we lost touch with shortly after the loan. So they've been sitting on a bookshelf in our house for over thirty years and I literally haven't touched them in all that time. But they have proven to be the perfect read for now.

Rex Stout's detective is a very heavy gentleman of indiscrimintate age who never (well, hardly ever) leaves his New York brownstone house to solve a case -- or for any other reason. His name is Nero Wolfe. His assistant is a charming young man named Archie Goodwin, who meshes perfectly with his boss -- doing all the things that Wolfe refuses to do -- and the two of them have this perfectly charming chemistry. The books are set in the 1940's and 50's -- and portray New York as the wonderful town that you see in Frank Sinatra movies of that era.

Okay, now the orchids. Every day, from 9:00 to 11:00 AM and 4:00 to 6:00 PM, Nero Wolfe takes the elevator in his house to the top floor, which is a greenouse for thousands of orchids. One does not disturb Mr. Wolfe when he's with his orchids.

So, I've been lying in bed or sitting on the porch for days, transported back to this wonderful time and place and being truly amazed at the inventiveness and great good humor the books' author invests in each story. And reminded of the orchids -- whose beauty (understandably) seems beyond the capacity of Rex Stout to describe. So he doesn't even try.

Right. Now, my sister (whom I love like life itself) and the rest of my family arranged to send flowers to me when I got out of the hospital....

Anyone out there want to guess what kind of flowers she sent? I'll wait...

Okay, if you didn't say "Orchids!!" please re-read this posting. This is the punch line!!

What they selected was the most elegant flower I think I have ever seen. See picture below.

Now, I will grant you that I send Deb orchids twice a year -- once on our wedding anniversary and once again on her birthday -- but neither occasion would have prompted Martha to send me orchids for my recovery or helped me rediscover the delightful world of fictional murder.

So here you have it: My therapeutic reading. My ever-so-thoughtful family. My wonderful wife. Orchids everywhere I look.

Thought you'd like to know...

The Weather

Those of you in the Philadelphia and Baltimore areas already know this. The rest of you may want to know that the weather here over the last four days has been perfect for convalescence.

Any warmer in the afternoon and I would probably start perspiring -- an uncomfortable thought as the incisions in my neck work their way (very nicely!) down their path to healing. Any cooler in the morning or evening and I would have to cover up more completely than I would wish -- covering the wound area with clothing that could abrade the incisions.

But as it is, Deb and I have had windows open for most of the day, with the gentlest of breezes wafting through, often laden with the sweet smells of spring. Ah.

Back Home

Thank you all for your kind thoughts and prayers. There were a number of times, leading up to the procedure and now recovering from it when I felt I can "tap into" this marvelous pool of love and caring. And several times -- as described in
future posts -- when such tapping was deeply helpful.

(It turned out to be two days' recovery in the hospital rather than one, but that was not unexpected. And writing this note is just a quick episode between naps.)

The operation seems to have gone quite smoothly. (I wasn't paying much attention, truth be known.) The inscision site is completely pain free (without any pain medication!), but it's tough to swallow at the moment -- I am told, because of a tube that was down my throat for most or all of the surgery. So that should pass fairly soon.

There are a couple of relatively minor post-operative consequences to the surgery that I will relate later. (After yet another nap.)

Our decision to have the operation done locally by Dr. Chuma feels completely justified -- many of the nurses and medical staff said approving things about the appearance of incision site. And it was so nice that Deb could have friends around her for the surgery and aftermath and dash back and forth to the house to get stuff done and retrieve a few things that I asked for. Things that wouldn't have been possible, say, at Johns Hopkins.

The biopsy samples are off to the lab and results should be available in a few days. The site of the primary tumor is still unknown, but the biopsy samples may help point the way to the culprit.

I understand more clearly now that this operation was merely a step in clearing this cancer -- a huge one, no doubt, but only one. We knew going into this surgery that the material removed from my neck would be unlikely to include the actual primary tumor, but that the amount and location of any cancerous cells found in this area would help in planning the next step.

There will be decisions made in the hunt for the tumor, and radiation applied to zap it. So there is still much road ahead.

I will never adequately be able to tell you how much your writing, your calling, your texting, and most of all your thoughts and prayers have meant to me. I hope you will stay with me on this journey until it reaches its joyful end.

Schedule for Surgery and Stay-Over

Just got word from the hospital: my surgery is scheduled to start at 12:30PM tomorrow (that is, Tuesday May 5). And Dr. Chuma has informed me previously that it should last roughly two hours. Any and all supportive thoughts and prayers -- then or now or later -- are gratefully accepted.

I'm only scheduled to spend one night in the hospital, so stopping in there for a visit doesn't make a lot of sense.

I'll write more as soon as I know more.

"Commenting" on the Blog -- Revisited

Okay, a number of you sweet people have told me that you're having trouble leaving Comments on the blog. Which suggests that even more people are having this difficulty and just haven't mentioned it yet. So here's a couple of suggestions. (Please refer to last month's posting about Comments if you need a refresher for some of this):

-- rather than listing your made-up URL with one period (as in "somewhere.com") try listing it with two periods (as in "somwhere.someone.com"). This whole URL thing goes beyond my comfort and competence level, but I think this helps. It seemed to be the key to getting Deb into the system.

-- Another one of your choices for "Comment as" is "Anonymous." That way is a bit easier than posting as "Name/URL," but it displays your comment -- undestandably -- as "Anonymous," and I would love to know who you are!! So if you choose to do this Anonymous route, please embed your name within the message that you leave.

And to you very clever people who have mastered this "Comment" challenge, please feel free to Comment on this posting with suggestions, so that others can take advantage of your cleverness.

In any case, many thanks to all of you who have successfully posted Comments, to those of you who have tried to post Comments without success, and those of you who have given serious consideration to posting Comments. Thinking about all of you helps me remember that I am a part of a Healing Community, and that the love and caring we share makes the Universe a better place to be.

Second Opinion -- A Trip to Johns Hopkins

(I've been falling behind in my blogging. Sorry. It's because so many pleasant things are taking place to me and around me. It's certainly not a lack of interest or paucity of things to say...)

Anyway, last Tuesday, April 28, Deb and I drove to Baltimore for a Second Opinion discussion at Johns Hopkins Hospital about my upcoming surgery. The visit had been arranged by my wonderful sister, who works in the Radiology Department at Hopkins, ably assisted by her daughter (our niece) who is equally wonderful and is currently an oncology nurse at the same institution.

(NOTE: This confluence of need [i.e., a Second Opinion] and provision [i.e, the professional connections of my sister and niece at such a prestigious institution]is yet another example of how completely the Universe is looking out for my welfare. Of this I have no doubt.)

It was a beautiful spring day for a drive. Even I-95 seemed pleasant and bucolic in the splendid weather. We arrived at Hopkins at 10:00AM for our 1:00PM meeting, which proved to be perfect timing:

Our first job after parking the car was finding the office where we were to meet our Second Opinion doc. The Hopkins Hospital Campus is huge, with a dozen major buildings, and we wanted to make sure we could walk directly from our lunch date with Martha (my aforementioned sister) to the doc's office in good time. The hunt for the office took roughly 20 minutes, so it was good we did this pre-lunch rather than rushing around as our appointment time came close.

(On the subject of buildings, Hopkins has a large one completely dedicated to cancer research and treatment. No surprise, I guess. But just seeing the building started me thinking that maybe I should have the surgery at Hopkins rather than Chester County Hospital. My E/N/T doc back home said he would understand completely if I made such a decision, and clearly Hopkins has devoted a great deal more money and facilities to dealing with the disease. Hmmm... But read on to discover how this issue played out.)

Next task was to fill out the Patient Questionnaire that Hopkins had sent me a week beforehand. I kept meaning to fill this out back home, but you know how those things go... We filled this out in a coffee shop on-campus. Halfway through coffee and questionnaire, I called my sister to confirm our 11:00 lunch appointment. Martha said yes, she would join us at one of Hopkins' fancier dining establishments at the appointed hour.

Martha showed up exactly on time, and the three of us had a wonderful, relaxed and leisurely meal. (Martha is anxious about my welfare, and I hoped that our chat over salad and soup would allay her concerns. I think it helped...)

We parted company with Martha shortly after noon and made our way back to Dr. Christine Gourin's office. When we got there, I started filling out the other several questionnaires that were necessary to complete before we sat down with the good doctor. Finishing these meant that all the loose ends were tidied up by 1:00 -- and Dr. Gourin was ready for us just as we were ready for her.

Dr. Gourin's credentials were exactly what I was hoping for, and she was incredibly generous with her time. She spent over an hour with us, making sure that all questions were answered and our anxieties were minimized.

Dr. Gourin examined all the reports that Dr. Chuma had written and viewed the disk copies of the CT scan and PET scan that we had brought with us. She wanted the story from the very start -- and was as impressed with my GP's spotting of the potential problem as the other docs have been (as reported in previous postings). This deepened my admiration for my GP even farther, which I wasn't sure was possible.

Dr. Gourin listened attentively to my story, asking a few clarifying questions and interjecting explanations about my condition and its treatment. She described the course of action Dr. Chuma has outlined as "the Gold Standard" for treatment of this type cancer. She also confirmed that the surgery was fairly routine (inasmuch as any major surgery can be "routine") and that complications are rare and recovery and rehabilitation is usually complete.

She also suggested that I might be eligible to participate in one or more trials after the surgery. I liked that. I will be in touch with her after the results of the surgery are available to see what options I might want to pursue.

As we were leaving her office area, Dr. Gourin called after us to say: "And remember, this is a very, very curable condition!!" I liked that too. Especially the repetition of the word "very" with the added emphasis. Yay!

On our way out of the building, Deb and I sat down in yet another on-campus eatery to go over what we had heard. After ice cream and some additional note scribbling, we retrieved the car and started home.

On our way, Deb and I discussed what we had heard and how we felt. We decided that Hopkins would absolutely be the right place to have this surgery if my condition had difficult facets to it.

But since everyone we've talked to about the surgery seem in agreement that this procedure is routine, whatever advanced facilities and personnel Hopkins might have would not really benefit me. Coupled with our confidence in Chester County Hospital and Dr. Chuma, this became more than enough reason to have the surgery and follow-up work done close to home. Two miles' travel rather than eighty. This should make life as easy as possible on both Deb and me for the surgery itself and all follow-up work.

I checked this decision out with Dr. Frank Barch (an old friend, mentioned in a previous posting) and he concurred with this decision completely. His spouse (also a Dr. Barch -- she has her PhD in clinical psychology) said it best: "Sometimes, the very best facility is not at all the best place for you."

So the day was a complete success. We had a pleasant drive, a nice lunch with my sister, an extremely helpful discussion with Dr. Gourin -- and an important decision made with confidence.