"Prostate Cancer: The Journey!"

In my Blog post "A Quick Update on Wednesday, 28 October", I had listed 18 stages of my Journey as I visualized it. Now there are 15 stages. Before getting started, I thought it would be useful to set the stage for all these posts by sharing my context for the Journey.  While most recipients of my emails know me well and know how old I am and know about my lifestyle, it is possible that there may be persons who come to this Blog via referrals who do not know me.  Therefore, I felt it important to share who I am and the relevant aspects of my family health history at the time this Journey began.  In this manner, each reader can adapt the information to the context of their own situation.

I was born March,1940, making me 4 months short of 70.  I have always been in good health except for varicose veins and cataracts.  I've had surgery to correct both and will have surgery again on my right leg.  Varicose veins are a continuing battle, but that is another story.  For many decades, I have watched what I eat, being vegetarian at times, and currently on a gluten, casein and soy free diet as a result of treatments by Dr. Richard Nuzzi ( http://www.drnuzzi.com/index.html ) .  I take nutritional supplements and three homeopathic remedies prescribed by Dr. Nuzzi to maintain good health and to strengthen my immune system.

I am 6' 1" and weigh 155 lbs.  My favorite exercise is cycling averaging between 4,000 to 5,000 miles a year.  After arriving in Colorado three years ago, we all learned how to ski.  We ski almost every weekend during the ski season and during the week, I cycle, weather permitting.  My resting heart rate is between 38 and 45.  I am still able to get my heart rate up to around 170 when working hard on my bike.  That is 20 heart beats higher than the theoretical maximum for my age.   Next Summer, my nephew Chris and I are planning on climbing Mt. Whitney in California.

Men lean as I am, who eat right and exercise, are considered to be at lower risk of many diseases including varicose veins and prostate cancer.  I have both, so there go the benefits of study statistics and trends.  No one is immune. Regarding family history, my father died of colon cancer at age 84 in 1988. Longevity is a part of our family history. In August of 2008 we celebrated our mother's 95th birthday.  She died exactly two months later of natural causes.    My brother Ed (71), who lives in California, was diagnosed with prostate cancer in 2001 when he was 63.  He underwent a very successful radical prostatectomy performed by an excellent surgeon at USC, Dr. Gary Lieskovsky, via conventional surgery.  He's been cancer free since then and has PSA tests every six months.  Ed and I have two younger brothers who live in Argentina.  Stephen is 65 and suffers from Post-Polio Syndrome.  Richie is 59 and has to watch his blood pressure. There is no other family history of cancer.  I figured that while my father had colon cancer and my brother prostate cancer, based on the history of our entire family, I still had a pretty good chance of staying clear of cancer.  It is quite plausible that my father did have prostate cancer first and after that colon cancer, but we'll never know for sure.  In any case, I was mistaken. 

Now on to the Journey which only God knows how it will end.  Fifteen stages have been posted up to  and including my trip back home to Colorado from New York.

The Story

At the end of June, Keith and I embarked on a car trip to Texas, where Corey joined us for the trip to South Lake Tahoe via Hoover Dam and Las Vegas.  After a few days of travel, I experienced an unusual discomfort in my groin area.  I had never experienced such discomfort, so I had no idea whether I had something that would go away, a urinary tract infection, prostatitis or who knows what else.  It did not seem to affect my normal bodily functions, but with time the symptoms of discomfort grew to be more and more uncomfortable.  Over the years, I had learned to listen to my body and realized that something was wrong.  I immediately thought about prostate cancer, but realized that most of the time, prostate cancer has no symptoms.  So, my inclination was to dismiss cancer as a probable cause of my discomfort.  By the time we arrived back home in Colorado on July 12, after three weeks on the road and 4,700 miles of driving by car, the discomfort at times was so great that I could not sleep.

On Monday, July 13, I immediately called my primary care physician, Dr.Michael Robertson's office.  The office scheduler wanted to give me an appointment for a couple of weeks out.  I mentioned that I was having urinary tract problems and she immediately slotted me in for Friday, July 17. I also made an appointment to see Dr. Nuzzi.  This was the beginning of a three month process that led to my surgery in New York.  

Thoughts That May Help Others

It is important to "listen to your body" and avoid dismissing symptoms rationalizing that it is something that will go away.  We are our own best symptom detectors.  Without drawing conclusions on diagnosis, keep track of what is happening and know when something is going on that is not "normal."  Don't hesitate to see your doctor when you observe unusual body symptoms.  Dismissing symptoms out of fear or denial does not make them go away.  Share your symptoms with your spouse or other trusted member(s) of your family.  It is a great relief not to keep a secret and the person with whom you share your symptoms will encourage you to get yourself checked out. 

The Story

Getting to an initial diagnosis took from July 17 to the end of August and it involved 5 visits to doctors, two DRE (Direct Rectal Exams) and two PSA (Prostate-Specific Antigen)  tests.  The results of this process were not totally conclusive, though strongly pointed to serious prostate problems.  My first PSA test score was 3.8 compared to a baseline of 1.7.  Both Dr. Robertson and my urologist Dr. Ali Sarram said this rise in PSA was a concern, but it did not necessarily point only to cancer.

The DRE screenings confirmed that I did not have an enlarged prostate, so BPH (Benign Prostatic Hyperplasia) could be discounted.  (Visit http://www.roboticoncology.com/benign-prostatic-hyperplasia/  for more information on BPH.)

In view of the symptoms I described in my blog post of Stage 1, a possible diagnosis was prostatitis. 
(Visit http://www.johnshopkinshealthalerts.com/alerts/enlarged_prostate/JohnsHopkinsEnlargedProstateHealthAlert_3163-1.html ).  I was prescribed two rounds of antibiotics and one round of anti-inflammatory.  However, after about 8 weeks following my first exam in July, the second PSA test result shot up to 4.7. Such a rapid rise is what is called PSA Velocity and it was reason for serious concern and quick action beyond treatment for possible prostatitis. 

My urologist scheduled me for a prostate biopsy on September 11.  At this point, of course I was alarmed, but I did not panic.  Neither doctor could give me a conclusive diagnosis, so I did not even bother to ask.  All I could do is speculate, hope for the best and be prepared for the worst.  I shared my results with family and friends and was open with them about the possibilities.  This really helped me cope with the uncertainty and sleep at night.  Now I had to get ready for the next stage:  A biopsy.

During this nearly six week period leading to the decision to have a biopsy, I investigated as much as I could about prostate disorders, urinary tract problems and anything that could possibly link to the symptoms I was experiencing.  Everything led me to prostatitis.  However, I had this nagging suspicion that there was more to this story and the biopsy would give me the answer.

By the way, in the midst of this process, I also had a colonoscopy, clearing me of any colon problems and sonar imaging of my legs to determine the extent of my varicose vein problems, which will require surgery again on my right leg.  It was a busy time.

Thoughts That May Be Of Help To Others

When going through a long process of diagnosis, there are a lot of uncertainties.  There are times when all one can do is wait and prepare for the next step.  It is good however to understand the end game plan to the extent this is possible, without letting emotions go overboard.  For example, my diagnostic process was leading me to either prostatitis, cancer or both.  While I still did not know for sure which way this was going to go, I had a pretty good idea of what I was prepared to do with either eventuality.  This was my way of removing uncertainty and have some semblance of peace of mind.  I had a game plan!!

The Story

I received a brochure from my urologist, Dr. Ali Sarram, explaining the biopsy procedure.  I also went to the Internet to search for more information about a prostate biopsy. 
Johns Hopkins has a good description of the procedure, so I will not go into the details you can learn by visiting  http://www.johnshopkinshealthalerts.com/reports/pdfs/JHHAGuideToYourProstateBiopsy.pdf .  Also visit http://www.righthealth.com/topic/Prostate_Biopsy . 

My prostate biopsy was scheduled for Friday, September 11.  I was nervous about the procedure, but all information indicated that it would be a short procedure and cause minor discomfort.  One of the most important steps was the pre-biopsy preparation which started the night before.  I made sure to diligently follow the instructions. 

Contrary to all the information about this procedure causing minor discomfort, it was one of the most uncomfortable and painful experiences I ever had.  Twelve small tissue samples (cores) were taken from my prostate and every time a core was taken, it felt like I was being shot inside my body.  I recovered  pretty quickly from the pain and even joked with Dr. Sarram right after the biopsy that I was going to go home and go on a 50 mile bike ride.

I went home after the biopsy and slept for 5 hours.  My body was in shock.  I realized days after the biopsy that perhaps there might be quite variation in pain tolerance and sensitivity to the anesthetic that may have been the reason why the biopsy procedure was so painful.  Fortunately, I won't have to have this done again.

Thoughts That May Be Of Help To Others

A prostate biopsy may not seem like a big deal, but it should be taken seriously.  Five key points:  1)  Make sure that it is really necessary.  Get a second opinion if you have any doubts.  2)  If you can get a referral of someone who's had a biopsy with your doctor, check it out.  3) It is very important to follow exactly the pre-biopsy preparation instructions.  4) Discuss with your doctor the pain issue prior to the procedure.  I don't wish my experience on anyone.  5) Ask when you can expect to receive the biopsy results.

Another thing that did not occur to me until after receiving the biopsy report,  ask your urologist what laboratory is going to do the pathology and issue the report.  Your doctor can comment about their reliability and competence.  In my case. Bostwick Laboratories performed the pathology and issued the report.  Dr. Sarram reassured me that they are one of the top laboratories in the country.  If you have any doubts, check them out.  Not all laboratories are equal. The biopsy cores are preserved so that if there are any doubts, they can be examined by another laboratory.

The Story

After the biopsy, I continued to prepare for the worst while still expecting the best.  I spent many hours on the Internet researching prostate cancer and treatment options, just in case the biopsy results were positive for cancer.  While I was anxious to get the results, I knew that it could take as long as a week.  On Wednesday afternoon, September 16, I was driving out of our local shopping center parking lot with Keith when I received a call from Dr. Sarram.  He did not beat around the bush.  He had received the biopsy results and the prostate was cancerous.  Immediately after giving me the bad news, he told me that there was good news:  the Gleason scores were on the low side. (See more on this below.)

I did not crash my car, but I admit that it took a lot to pull myself together and deal with the news while driving.  Based on the research I had done the previous days, I asked Dr. Sarram whether there was any doubt about the results and whether we should get a second opinion on the biopsy results.  He responded that there was no doubt about the results and we should schedule a consultation to decide on course of treatment.  The next day I called Dr. Sarram's office and asked them to fax me a copy of the biopsy report.  The consultation with Dr. Sarram was scheduled for Wednesday, September 23.  This meant that I had one week on my own to deal with the news and biopsy results without talking with Dr. Sarram.  I received a copy of the biopsy report on Thursday, September 17.

The biopsy report was very comprehensive and easy to understand.  The first two pages (see attached Biopsy Report pages 1 and 2)  were the biopsy report,  including a description of each of the 12 cores taken, a prostate biopsy map showing exactly where the cores were taken on the prostate and which ones were cancerous, a photomicrograph showing a diseased cell and the Gleason scores of each diseased core.
Five of the twelve cores were cancerous with four having a Gleason score of 3 + 3 = 6 and one with a Gleason score of 4 + 3 = 7.  These scores, as Dr. Sarram indicated, were still on the "good news" side.  Anything higher would have been of more serious concern.  Visit http://www.johnshopkinshealthalerts.com/alerts/prostate_disorders/JohnsHopkinsHealthAlertsProstateDisorders_3137-1.html for a good explanation of the Gleason behind the Gleason Score.

The last two pages of the report called "Patient Empowerment Report" provided a review of the results from a patient's perspective and plenty of advice on next steps, including many links to helpful Internet sites such as www.prostatecancerinfolink.net , www.prostatecancerinfolink.ning.com , www.cancer.gov , www.cancer.org .  (See attached Biopsy Report pages 3 and 4)

I had no doubt that the diagnosis of prostate cancer was conclusive.  It was time to move on to the next stage, investigating treatment options.

Thoughts That May Be Of Help To Others

I thought Dr. Sarram did the best he could to give me the bad news and also the good news.   I did the same when sharing the information with my family.  Giving some good news along with the bad created a picture of hope, rather than hopelessness.

It is very helpful to have all homework done prior to receiving the results of a biopsy.  I could have done better.  Knowing beforehand what to expect removes uncertainty and makes it easier, albeit not easy, to deal with the reality of the situation, no matter how good or bad.

A Caution: Keep in mind that while a pathology of specimens is a scientific process, the reporting of results in terms of a score such as Gleason is subjective.  The actual condition of disease could be better or worse than the biopsy report indicates.  I will comment more on this when reporting on the post-surgery biopsy results.

Click here to download:

Biopsy Report Page 1.pdf (747 KB)

Click here to download:

Biopsy Report Page 2.pdf (546 KB)

Click here to download:

Biopsy Report Page 3.pdf (664 KB)

Click here to download:

Biopsy Report Page 4.pdf (666 KB)

The Story

I am going to relate in this Stage the story of how the caring and compassionate actions of a few and faith in God can have life-saving consequences. The story is a bit lengthy, but I hope worth reading.  This story demonstrates that arriving at a treatment decision and selection of a doctor requires extensive "homework," a willingness to communicate with any and all family and friends who may be able to help, gracious acceptance of all the thoughts and prayers coming my way, and ultimately staying open to God's miracles.

 I had one week before my consultation appointment with my urologist, Dr. Sarram.  Since I already had done a considerable amount of homework, I had a pretty good idea of treatment options.  What I did not know is how the biopsy results best fit any of the available treatment options.  The first thing I did is call my brother Ed in California.  (See his cancer history in Stage 0: Context for "Prostate Cancer: The Journey.")  Ed gave me Dr. Lieskovsky's phone number at USC and I immediately called to find out whether Dr. Lieskovsky was still in practice.  Dr. Lieskovsky's nurse confirmed that he was still performing radical prostatectomies as he was back in 2001.  In view of Ed's very successful experience,  I had a fall back position should no better options materialize. 

Significant advances had been made in both radical surgery techniques and in radiotherapy since 2001.   I was curious about the surgical advances made over the last few years using robotics.  On Monday, September 21, I was looking at Facebook and noticed that a friend, Jody Schoger, in Texas was soliciting donations for a LiveStrong Foundation bike ride.  I emailed her with a copy to her husband Steve to let her know about my diagnosis. Both Steve and Jody are cancer survivors and I figured that they may have some insights into cancer treatment options based on their own experiences at M.D. Anderson in Houston and the many connections in the cancer battling community.  On Tuesday morning, September 22, Jody wrote that her brother underwent robotic prostatectomy in Des Moines and that she had sent out via Twitter a call for information among all her cancer warrior contacts.  On Tuesday afternoon,  Jody confirmed that she had sent out a general query to her cancer fighting community.  No more than 20 minutes later, Jody wrote:

"I found what you needed immediately on Twitter from my incredible network.  You will find the surgeon to read about at http://www.roboticoncology.com/
Best of all, if you call any survivors please talk to Lynn Lane at cell/txt: 917.744.1818.  He messaged me and asked that you call him.  He is 43, and a wonderful man both Steve and I met. I rode Tour de Pink w/him.  He has an awesome surgeon and will tell you everything you want to know, plus.  I thoroughly encourage you to talk with him. Jody"

I called Lynn Lane on Wednesday morning, September 23, the same day I was scheduled to meet with my urologist, Dr. Sarram.  My conversation with Lynn was pivotal in leading to a decision to go for a robotic prostatectomy.   Lynn was passionate about Dr. Samadi in New York, who performed his surgery.  Following our conversation, Lynn emailed Dr. Samadi with my information.  In the meantime, Alicia and I met with Dr. Sarram on Wednesday afternoon.  Our 90 minute session with Dr. Sarram was very informative.  Dr. Sarram explained the biopsy results and superimposed the data on a nomograph to predict the stage of my cancer.  Dr. Sarram's assessment was that my cancer was at Stage 1/borderline Stage 2.  Following this systematic review of all the data, Dr. Sarram made his recommendation for treatment:  Surprise - Robotic Prostatectomy.  I then mentioned to Dr. Sarram that I had independently come to the same conclusion and that I had the name of a top notch doctor in New York who has performed over 2,000 of these surgeries.  Dr. Sarram mentioned that he also performs the same surgery using the same robotic technology - da Vinci.  I asked him about his experience with robotic prostatectomies.  He said that he had performed about 300 of such surgeries.  I felt confident that Dr. Sarram could successfully perform the surgery and I was not keen on having to travel to New York.  I felt confident that having robotic surgery with Dr. Sarram would be successful.  I asked for referrals of former patients and all three referrals gave Dr. Sarram glowing reports. 

That same evening, I emailed Lynn Lane about the results of my meeting with Dr. Sarram and that I preferred to have the surgery in Colorado.  Early Thursday morning, I received an email from Dr. Samadi in New York and also a response from Lynn in Houston.   It was a full court press from both for me to go to New York.  I was conflicted.  Lynn wrote that this was a once in a lifetime chance and that I should go with the best.  Dr. Samadi was very kind and confident that he could take good care of me.   I was blessed with what I thought were two good options.  I struggled with my two options Wednesday night and throughout Thursday afternoon when I received a phone call from New York.  It was Dr. Samadi.  This phone call clinched it.  Dr. Samadi was both passionate and compassionate.  I asked myself: why would a top doctor in New York, if not the country, call someone he had never met unless he really cared.  The decision was made.  I was going to have a robotic assisted prostatectomy by Dr. Samadi in New York City.  Wow, what a decision.   What was left for me to do was talk with Dr. Sarram.  I was only able to reach his nurse and informed her of my decision.  I'm sure Dr. Sarram was disappointed, but I had to make a decision which was in my best interest and not worry about how others may feel.  (Click on the link below to view Dr. Samadi's very informative web site: Robotic Prostatectomy & da Vinci Robotic Surgery - Information

Thoughts That May Be Of Help To Others

This stage in the journey may not be the most painful, but certainly the most difficult.  The information on the Internet is overwhelming. As Steve Schoger wrote, "just doing a search under "Prostate Cancer Treatment" yields 6 million links!!"  Making contact with family and friends who may have first-hand experience can be very helpful in narrowing the options to a very few best.  I've included relevant links in the Journey Stages as a way of facilitating the search for information.

It is important to have a process in mind on how to get to a decision.  However, it is also important to stay flexible and open to all the possibilities that arise.  In the midst of a serious health crisis, it is very empowering to be in charge, yet allow God to be in control.  

The Story

Getting ready for surgery may not be difficult, but it certainly is tedious.  In my case, it not only involved getting all the testing done and filling out all the forms for both doctor and hospital, but it involved planning a trip to New York and a sufficiently long stay for safe travel back home.  I wrote in Stage 5 about being in charge of the process.  This stage is no different.  Surgery was scheduled for Wednesday, October 21 at Mount Sinai Medical Center in Manhattan.  I had just under one month to get everything ready.  I viewed this Stage as a project and I was the Project Manager.   I quickly became acquainted with Dr. Samadi's office staff, principally Vickie Frank, Administrative Manager, Ana Beras, Scheduler and Helen Petruzzelli, Clinical Nurse.  After receiving all the instructions from Dr. Samadi's staff and requirements from Mount Sinai Medical Center,  I visited my primary care physician, Dr. Robertson and we got to work on conducting all the required tests .  Everyone on the Colorado and New York side were very cooperative and helpful in getting everything done on time.  We finished with only a couple of days to spare.  It is such a blessing to be able to "work" with Dr. Samadi and Dr. Robertson and their staffs on a personal basis, 

The only glitch in the process was my treadmill stress test.  The first treadmill stress test was halted at 140 bpm because the technician noticed an abnormality in the readout.  The cardiologist, Dr. Fuenzalida,  informed me that the abnormality could be a blockage of one of the small arteries feeding the heart.  He recommended a heart catheterization to obtain a conclusive diagnosis.  He said that if in the process he found a blockage, he would insert a stint.  I was more disturbed by this news than when I found out about my prostate cancer.  I told the cardiologist that I had a similar experience with an apparent abnormality three years ago when preparing for varicose vein surgery.  Back then, a nuclear imaging stress test was performed and I was cleared.  I made arrangements to have the results from the cardiologist in The Woodlands, Texas forwarded to Dr. Fuenzalida.  After reviewing the results of this test,  Dr.Fuenzalida canceled the heart catheterization procedure and instead opted for a treadmill stress echo cardiogram. In this test, they confidently took me up to 160 bpm and fortunately this test cleared me for surgery.  Thank you God!!!

The week of surgery was Fall Break in school, so Keith go with Alicia and me to New York.  For me it was going to be sort of a home coming since I lived in New York in the 1960's.   For Alicia and Keith, it was going to be a first.  They have never been to New York.   I was happy that they were coming along and had an opportunity to sightsee, visit museums and go to shows while I was having surgery and recovering.  It turned a trip that in a way I was dreading into a trip I was excited about for them.

Thoughts That May Be Of Help To Others

This experience reinforced the importance of taking ownership of our medical history and being well informed of all prior tests and procedures performed over the years.  You never know when information from the past may be helpful in the future.  If I had not been fully aware of the tests conducted for my surgery three years ago, I would have been subjected to an unnecessary heart catheterization.   When tests are requested for a new procedure, I always go back and check whether a prior test result could be used.  This is a good way of avoiding duplicate or unnecessary tests.  Always make sure to request copies of all reports and studies.  It is fine for your doctor to have the information on file, but there is no substitute for having all your information in your own personal medical file.

The Story

Check-In time at Mount Sinai was 10 AM on Wednesday, October 21.  The last time I had anything to eat was the Tuesday morning before flying to New York.  I had a glass of homemade smoothie with fruits and vegetables.  That was it.  I also had to stop drinking at midnight, so I was starving and thirsty.  Alicia, Keith and I took a taxi to Mount Sinai Medical Center located on the upper East side of Manhattan, right next to Central Park.   Mount Sinai is a large complex including Mount Sinai Hospital and Mount Sinai School of Medicine.  The building complex spans three Manhattan sized blocks between Madison and 5th Avenues and 98th to 101st Streets.  Our taxi dropped us off on the Madison Ave. side which was covered by construction scaffolds, so it was not clear at all where to enter.  After wandering to a few entrances, we finally found the right one and walked into this huge modern atrium connecting the School of Medicine to the Hospital.  I've never been a big fan of hospitals, but once inside, I felt comfortable.  The multi-story high atrium created an uplifting feeling as opposed to the typical claustrophobic feeling of single story hospital entrances.  This may seem unimportant, but the initial feeling walking into a building can be important in maintaining an uplifting attitude as opposed to getting depressed.

After asking a few people where to go, we worked our way up to the registration area.  The reception clerk had my name on the list (whew, thank God for that) and handed me a whole set of forms to fill out.   Fortunately I had brought my entire file with me and I showed her that I had already filled out all these forms.  She double checked and sure enough, I had no more forms to fill out.  Now that is an easy hospital check-in.

After waiting for about 30 minutes, they escorted us into a patient preparation room where they handed me a gown, robe and head cover.  Boy, was I ready for New York or what?  See picture No. 1 where I am with Alicia.  In the second picture is Keith with a surgical head cover.  He was ready to assist in the surgery.  The third picture is my interview with Dr. Gainsburg, Dr. Samadi's anesthesiologist.  An orderly came in with my ID tag and after confirming my ID, placed the tag on my wrist.  After a while another person came to take a blood sample.  What was strange about this is that this person did not bother to check my ID and I did not know what this sample was for.  I can only guess that it was to confirm my blood type in case it became necessary.

While the waiting around for things to happen can be hard, scheduling of surgery can only be an estimated time since the priority is on successfully completing surgeries and not keeping up with a time schedule.  Alicia and Keith were waiting with me and it helped to pass the time.  Around noon, Chris Kunz, Dr. Samadi's Physician Assistant for Surgery came in to explain what was going to happen next.  It was good to know what to expect next.  Then Dr. Daniel Gainsburg, the anesthesiologist, came in and conducted the patient/anesthesiologist interview to make sure that he had all the necessary information  to successfully administer anesthesia during surgery.  Both Chris Kunz and Dr. Gainsburg came across as very kind and competent.  They gave me further reassurance that I was going to be fine.  We waited a few more minutes and an orderly came in to escort me to the operating room.  I was happy that I was able to walk to the operating room instead of being wheeled in on a gurney.  it was time!  Alicia and Keith got to go out for a few hours and visit museums. 

Thoughts That May Be Of Help To Others

While I felt kind of silly carrying around with my medical file, it came in handy at hospital check-in.  Without my file, I would have had to fill out a whole new set of forms.  Now, my file goes with me to all doctor visits.

  I've always heard that selecting an anesthesiologist is as important as selecting a surgeon.  However in reality, this is not practical.  I believe that once the surgeon is selected, it is reasonable to depend on the surgeon to team up with an anesthesiologist who he or she trusts.  It did help to meet the anesthesiologist prior to entering the operating room and have a conversation to create a good comfort and trust level.  I appreciated the visits of both Chris Kunz and Dr. Gainsburg
  

     

Click here to download:

STAGE_8_HOSPITAL_CHECK-IN.zip (1344 KB)