daVinci total November 2010 - Hystersisters Hysterectomy Article

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daVinci total November 2010

daVinci total November 2010

From the da Vinci Hysterectomy Stories Articles List

HysterSisters Articles

Options to Hysterectomy
Pre-Op Hysterectomy
Post-Op Hysterectomy
Hormone and Menopause
Intimacy after Hysterectomy
Pelvic Floor
Fitness after Hysterectomy
GYN Cancer
Grief and Loss
Endometriosis
Uterine Fibroids
Hysterectomy Stories
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Background: I am 47 years old and have two teenagers. I never had what doctors consider regular periods. Over the past few years, my periods got longer and heavier. After a couple of months of bleeding more than not during the Fall, and some whopping gushers, I sought medical intervention. A pathology report after a D&C suggested a hysterectomy was necessary due to complex hyperplasia and suspected adenomyosis. My surgeon does about three daVinci hysterectomies per week. I was scheduled for a date about five weeks in the future. I was terrified. I’d never had surgery before. I’d only ever had local anesthesia when getting stitches.

During my labors, I had received Nubane and an ineffective shot of Demerol. To me, you go to a hospital to leave with a baby. You don’t go to a hospital to leave without some parts which have, apparently, gone bad. I’ll say it again: I was terrified. Would I even survive the surgery? Do people survive surgery? At that point, I was skeptical. This was personal and it involved me!

I read HysterSisters like a hungry woman. I couldn’t get enough information – although a lot of what I read was more for vaginal- and abdominal-hysterectomy patients and I didn’t realize that it wouldn’t pertain to me quite as closely. I loved the posts where women told what they liked about how they felt after the operation, what went well for them, what was the best surprise, etc. I posted my questions. I read nearly every day. I felt much, much better knowing what I learned. Yes, I now agree with the Sisters who say the waiting (and the uncertainty, at that point) is the worst part!

My Sisters taught me to plan for the future. The pessimistic side of me had to plan for the worst. I spend grueling hours assessing what was important to me and writing my own obituary. I wrote letters (to be opened in the event of my demise) to my husband, my teens and my parents. Oddly, doing so gave me a sense of control and made me feel a little better about the situation. So if you are like me, write those letters! You can happily shred them later.

Because the holidays were coming, I made a pumpkin pie and froze it. I doubled nearly every dinner I made and froze some for “after” for my family. I put up the holiday decorations, assembled the tree, moved the outdoor items into position (hidden behind a bush so people driving by wouldn’t think I was far too early) and sent my holiday email to family and friends. It was challenging but I made my gift lists, bought the items and even wrapped them (while listening to carols) on a Saturday as my date at this castle was drawing near.

I accepted a date for Thanksgiving (less than two weeks after my surgery) to eat turkey at the neighbor’s house. I didn’t think I would be up to traveling 2.5 hours in the car (including some bumpy roads) for the usual family gathering. As it turned out, that meal was a nice change of scenery. However, sitting for about 70 minutes at the table, then in the living room to be social, was very tiring! I left as quickly as I could without seeming rude.

I bought food items that would be easy for my family to prepare (frozen, easy, pantry items) and stocked my pantry. I labeled my cabinets using Post It notes and a big Sharpie so any volunteers working in my kitchen could find the necessary items.

Pre-op appointment: Not nearly as worrisome as I had feared. Because it is a large teaching hospital, it was regimented – stops at the laboratory for a blood draw, a chest x-ray, an EKG (took 10 minutes), the clinic for people with other medical issues (to manage my high blood pressure during surgery, which ultimately meant not taking my usual, daily diuretic the morning of surgery) and then the educational consultation with the nursing staff. That’s where I learned about “pleasantly lemon-flavored” magnesium citrate that I was to use for bowel prep – and would have to purchase myself at Wal-Mart for $1.12.

I had packed for the hospital with advice from the HysterSisters in mind. I would wear the hospital’s gown (and let them do the laundry when it got dirty). I took a small plastic basket with a scoop-like handle to contain my lip balm, pencil/notebook, sore throat lozenges, glasses’ case and cell phone. I took along my own little pillow and a small blanket. Although I had my toothbrush and hairbrush, I used neither. I took a decorated plastic bowl and two bags of candies. I shared those with the staff – then left the remainder at the nurse’s desk on my way home. Items I wish I had packed include a small bottle of hand sanitizer (early on, you won’t want to walk to the bathroom simply to wash your hands) and a small clock.

Earlier in the week, I had trimmed my finger- and toe-nails so hospital germs wouldn’t have anywhere to hide. I shaved my legs, too, since I knew I wouldn’t be reaching to do that for a few weeks.

Wednesday: My coworkers had a party for me, complete with anatomic graphics (uterus, Fallopian tubes and ovaries) on a cake. I enjoyed roast turkey, baked beans, stuffing and chocolate cupcakes for dinner. I drank milk – because it is not on the approved bowel-prep list, too. I figured this big meal would be cleared out from inside me during bowel prep.

Bowel Prep (Thursday): On the day of bowel prep, I was up at 4 a.m. I bathed the dog, ran some errands in the morning and cleaned house. I looked at my stomach in the mirror, wondering what it will look like “after.” I kept surprisingly busy despite my liquid diet. I treated myself to pineapple juice (strained) and Jello for breakfast. At lunch, I had delicious vegetable broth (who knew something so simple could be that tasty?) and two cups of orange Jello. By suppertime, I was bored by the liquid options in front of me. No liquids or food after midnight.

Oh, yes, you want to know about the bowel prep. Well, it didn’t work like everyone had told me it would. I had prepared the bathroom as the Sisters recommend: Vaseline, wet wipes with aloe, two rolls of toilet paper, puzzle book, newspaper, Nintendo DS, cold water and Gatorade. I had even tilted a TV toward the bathroom and moved an arm chair into the bedroom!

I would say bowel prep almost didn’t work at all! I drank the mag citrate in two big glugs and a final, small sip - and waited. I immediately drank cold water to banish the taste. I sat in a chair within a few feet of the bathroom. Nothing happened. 45 minutes later, still no activity. The hospital called to inform me of the time of my surgery tomorrow: 7 a.m., report at 5:30 a.m. (as anticipated but previously unconfirmed). So, I took a nap. Three hours of blissful sleep. I figured I probably wouldn’t sleep well in the hospital so why not take advantage of this opportunity? When I woke up, my stomach made a few gurgling noises but nothing else happened. I finally decided to call the doctor’s office 15 minutes before they were to close for the day and ask “What now?” I certainly didn’t want my surgery to be postponed due to the lack of expected results from the mag citrate. It took the office 30 minutes to return my call. By that point, I had been to the bathroom to move my bowels twice. I doubt I was “fully cleaned out” but it was diarrheal.

When the doctor’s office talked to me, they said that not all surgeons require bowel prep before daVinci (which I knew from my fellow Sisters) and that, in fact, it probably won’t be on their list of required preparations in the near future! I suspect it is one of the many medical interventions that is done and has long been done – but really isn’t needed. [More about others of those I was to encounter later…]

The night before (Thursday): I was diligent about following the instructions to shower, then use the Hibiclens cleansing wipes (which make you sticky, until they dry in about 2-3 minutes) from the doctor then changed into a clean nightgown and crawled into a bed made with clean sheets. I didn’t even let the dog sleep there (like usual) because of the possibility for germs.

Going to the Castle on Friday: I woke up after a less-than-restful night’s sleep when the alarm went off at 4:05 a.m. I had my approved single sip of water and took my thyroid medicine. My period started – for the very last time Menstruation made absolutely no difference to the surgery (whereas a positive pregnancy test would have, but they didn’t tell me how).

In the chilly morning air, I wore bikini panties, socks, generously-sized sweat pants and a big-shirt. I wore slip-on shoes. I wore those same items going home.

My husband and I arrived for the surgical check-in at 5:30 a.m. We had barely sat down in the waiting room when we were called. Let the preparations begin! It was a long, narrow room and there was lots of activity in the hallway/waiting area nearby. There were two doors (one was propped open most of the time) to the hallway, and another two doors on the other side of the room (which I had been told by a friend went to the operating rooms). The room had a sink, a TV/VCR/cart (which I surmised was for patient education – but I was wrong, apparently), two chairs, a few cabinets – and the hospital bed looming at one end, IV hooks from the ceiling, a curtain, the usual. There was a bathroom around the corner, in the main hallway. There was a locked medication room across the hall. I watched lots of people enter and leave it, always using their ID cards to swipe for entry.

I was prepared to answer the same questions over and over (when did I last eat, what did I eat, anything to drink?). However, I didn’t have to repeat myself like the parrot I envisioned! I was asked to provide urine for a pregnancy test (the first time, I didn’t produce enough – but after another hour, I did), blood was drawn again (to type and cross-match in case a transfusion was necessary) and I got to use the cleansing wipes (again), with the help of my husband. The nurse put the TED anti-thrombosis stockings on me. All of these steps were quite quick – but the waiting between steps got to be a bit stressful. It was probably 20 minutes of tasks expanded into about 110 minutes of time. That gave me time to be concerned, shed a few more tears and feel sorry for myself.

I met the CRNA (anesthesia professional) who was very, very good at putting me at east. I felt the best when she said that she would only stick me once (prior to being unconscious) to start just one IV. That’s the first time I sat on the bed/gurney looming at the end of the room. She also promised that she would stay with me every minute – from the pre-op room through the entire operation. I felt really good about her. Her supervisor, an anesthesiologist, came in. He told me that he would be “roaming’ through several ORs that morning and would be available if he were needed to assist with me. [As far as I know, he wasn’t needed and she did an excellent job. Huge relief.]

Going to the OR: I was wheeled off to the operating room about 7:20 a.m. The hallway was noticeably cold, just like some Sisters told me it would be (keeps the germs away). I asked to see the robot (it was pointed out as being “over there” under a big drape, to keep it sterile). There were several people busy in the room – but my doctor wasn’t there. The staff asked me to move over, onto the daVinci operating table. I do not remember it seeming narrow. I do not know whether I had my arms flayed out on restraint rests (in a Christ-like fashion), but I do not think I did. What I do remember is that the table seemed to have a part near my shoulders that was bean-bag like! If you are familiar with those novelty pillows with a very thin polyester covering and very small foam-like “beans” inside…it felt like that. [I later learned from one of the port assistants that those beans then have the air sucked out of them and become “cement-like” during the operation. This prevents the patient from shifting. It also puts a lot of your weight on your shoulders for several hours. So if your shoulders are a bit sore, this might be why!]

My kind CRNA asked me to start breathing the “regular oxygen.” I wasn’t asked to count backwards – and I had my eyes closed, so I didn’t even see the mask. I remember that I muttered something about my family and loving my pets – then…

Waking up in the PACU/recovery room: I was groggy but the nurse told me that my surgery was done. I didn’t feel any pain. It was hard to open my eyes – I later learned that was due to puffy face and eyes (from the inclined table during the operation). I think I dozed a lot in the recovery room. I think I might have been rude to the nurse; my mouth was so horribly dry. I asked for ice chips or water and she said I had to wait until I was in my own room. I complained and said I was promised that I could have something watery in recovery! I was in the recovery room about two hours (that’s on the long side of “normal”). The surgeon had spoken to may waiting family and friends around 11:15 am. It was 1:15 pm when I was moved to the surgical gynecology-oncology ward. I was “parked” in the hallway for about another 30 minutes while a room was found (cleaned?) for me. It was worth the wait – it was one of only two single rooms on the ward.

The nurses came in to ask questions, ask my level of pain, hook up my IV bag, attach the catheter bed to the bedside, install the leg-inflater cuffs which began their 15 second cycles of inflating/deflating/waiting, move the rolling bedside stand beside me, give me the TV control (hardly what I wanted or needed) and, finally, fill the Styrofoam pitcher and put water in a cup for me! Delicious, refreshing water. Finally. Even though I was drinking it through a straw (which adds to gassiness), I was drinking.

I dozed on and off until about 3 pm. Around that time, I was talking and making sense with my husband. Around 4 pm, my elder teen stopped by to visit and stayed for an hour. At 6:30, I was given a Percocet. An IV drip was still being used but I do not know what it was. I drank lime Kool-Aid. I drank milk. My husband went home to have dinner with the family. I was served scrambled eggs for supper –and ate some. At 6:35 pm, the surgeon came for a visit. He told me it went well and that he would do rounds around 8-9 a.m. with his entire team. The CRNA visited, as did the port doctor.

I took a nap from 7-8:20 pm. Then someone took my vital signs. Then the shift change happened. The nurse brought me what seemed like an entire pharmacy of drugs I was commanded to take because it is “routine”: Pepcid AC, GasX, a heparin shot. Blood was drawn again. Then she wanted to prick my finger for a blood glucose test – which I questioned. There was a brief exchange about do I have diabetes (no) and don’t I have this done regularly (no, never before in my life) before the staff person reviewed her written instructions and concluded she was in the wrong room!

Around 11 pm, I went for my first walk! Less than 12 hours after my surgery finished, I was walking with a nurse at my side, catheter bag and IV pole trailing. I only made it as far as the hallway and asked to turn around – but it was momentous for me.

I had been waiting for the Percocet to do something for the discomfort but it didn’t. The night nurse gave me a list of other (heavy-hitting) pain options. Eventually, I asked for and received ibuprofen. That was the perfect solution for me!

Feeling better, I started writing more notes – and noticed my swollen fingers. The scar from stitches I had in one finger a couple of months earlier felt stretched! It’s probably a good thing I didn’t have a mirror to see my own swollen face and eyes.

Saturday (the day after my surgery): At 12:10 a.m., my vital signs were recorded again. My catheter bag was emptied. At 1:05 a.m., I walked to the nurses’ station and back. It was much more comfortable to walk that second time!

I slept until 3:45 a.m. Then I felt like I had gas to pass. Uncomfortable feeling – one I knew I would encounter. My blood pressure was 102/50 and my temperature was 37 degrees C. My cheeks felt flushed.

The patient in the next room died around 4:30 a.m. Understandably, this took considerable staff time so I was unable to go for another walk until 6:30. Breakfast arrived – then I passed my first gas just before the 7 a.m. shift change.

The nurse came to remove my catheter at 8 am. It was simple. Yes, it felt a bit odd but wouldn’t be called painful. Three seconds of discomfort, I’d say.

The doctors came on their rounds and declared I could go home. That happened at 10:38 a.m. (a very important moment to me!). Unfortunately, the discharge paperwork took just short of three hours. While waiting, we watched a football game. I used the toilet for the second time and ordered/received/ate lunch.

Around 1:30, I was riding in a wheelchair to the parking ramp. I stopped at the nurses’ station and left the candy bowl and its remaining contents.

What I later figured out is that when the approval for discharge happened, all pain medication ceased. That might be fine – except that the wait for the three pages of “discharge instructions” took three hours. [Frustratingly, there was nothing except my most recent vital signs on those discharge instructions that could not have been printed at the end of September when I was told a daVinci hysterectomy was in my future.]

This lack of ibuprofen resulted in the most pain of my entire surgery/recovery. Getting into the car (a sedan which suddenly seemed low to the ground) wasn’t simple. I had the small pillow to put between my swelly belly and the shoulder/seat- belt. The seams in the parking ramp’s floor were jolting. Riding in the car just a handful of miles was surprisingly unpleasant. Getting out of the car at home caused me to grimace, whimper and cry. Walking up the stairs to the second-floor bedroom felt like a rod was being shoved up my anus. I rate this painful time (perhaps 25 minutes total) an 8. That’s painful!!

However, I was relieved and delighted to be home and heading to my own bed, where no one takes vital signs regularly or sticks me with a need four times daily. It was important to me to shower with antibacterial soap and get any “hospital germs” off me. I put on my own nightgown (no spotting or bleeding, so no need for uncomfortable underwear) and got into my own bed.

Finding a comfortable position was impossible. I ended up on my back with two pillows under my head. I am a stomach-sleeper. I could not rest on my side. I certainly could not think of resting on my stomach! With ibuprofen and our family dog beside me to keep my warm, I slept from 3:15 – 5 pm.

Thoughtful neighbors brought hot beef soup for supper, which my family enjoyed. I had pineapple juice. I went to the bathroom painlessly although I did notice the toilet was a lot lower than the ones in the hospital!

On a visit to the bathroom, I discovered a small length of black thread (from the surgical stitches?) and a tiny blood clot (half the size of my smallest fingernail). This was the only discharge I had, which was a good thing. Due to my incisions, I preferred to wear flannel nightgowns with no underwear (and did, at every opportunity, for another six weeks).

I was walking hunched over like a C-section mom. My cheeks were flushed nearly all day. My husband developed a schedule for my ibuprofen, stool softener, GasX and regular daily medication. I did feel some gas pain in my shoulder and under my right breast/ribs but it improved gradually, after the abundant flatulence and burping.

I sat in a chair to watch “Wheel of Fortune” in the bedroom. Regular ibuprofen kept my pain at the level of 1 or 2. Re-positioning myself in bed really made me aware of the discomfort. Otherwise, I felt okay.

After considering how painful walking up the stairs was, I decided I would not walk down them for a week. I wouldn’t choose a car ride any sooner, either, I concluded.

Day 2: I was able to sleep on each side, using a pillow or blanket to rest on. I slept for about 7 hours overnight. I woke up at 4 am so I watched a holiday movie on TV from 4-6 a.m. I took several walks around the upstairs rooms. Getting out of the wing chair is easier than other chairs because it has arms to use to lift myself. I ate 6 bites of oatmeal and was full. Took a noontime nap. Took an afternoon nap. It is getting easier to get out of bed. Still taking ibuprofen. I am still wearing the TED stockings (as instructed). They roll down – and my big toe sticks out of the hole. Annoying. Calls and guests made it a very busy day. I use a pillow to cough. I also learned not to read the funny sections of Readers Digest because it isn’t comfortable to laugh! Pain level: 0-2.

Day 3: First bowel movement around 1 a.m.! Slept about 7 hours but I was uncomfortable and had hoped to sleep more. Napped a lot. Still taking my temperature twice daily; it remains normal. I think I will get bored of this routine eventually. Pain level: 1.

It took me about three days to dare to look at my own incisions (besides the glimpse I caught in the mirror after showering each day). There are four, in a fairly straight line slightly above and to the sides of my belly button.
Somehow that isn’t where I thought they would be – I had the idea they would form an inverted V from my belly button downward!

Bowel movements are tricky. The whole “waking up” of the digestive tract is slow, gassy and noisy (at times). The surprise for me was a quivering and painful feeling in my anus – like I needed to use the toilet but with no result.

Day 4: Getting out of bed is even easier. I was told that I now “hop right up.” I am no longer walking like I had a C-section. I slept about 6 hours at night. I took a morning shower, washed my hair and used the hairdryer. That tired me and I napped for 2.5 hours. Gas/shoulder pain has now gone way. Molly Maids came for their initial cleaning of my house. I ate an entire slice of bread and a cup of stew. Taking less ibuprofen now (3 times per day, 400 mg per dose). I haven’t weighed this little in years. Noticeable absence of dreams I can remember. My incisions are just beginning to get itchy as they heal. Pain level: 1

Day 5: Incisions are really itching – and I am not touching them. Guests, phone calls, naps continue. The blurry vision I experienced in the hospital when reading something up close is now gone. Pain level: 1

Day 6: No ibuprofen, GasX nor stool softener today. Napped 3 hours in the afternoon. My temperature remains normal. I feel like I do get tired easily. I ate Mexican casserole (delivered by a friend) but there were no stomach repercussions. My appetite is normal again. Pain level: ½

Day 7: Finally, I have dreams again when sleeping. Had some shoulder pain/flatulence this evening. Slept sort of on my left side. Resting on my right side continues to be uncomfortable (that’s where my least-well-healing incision is). “I feel well.” No nap, no pain meds. Pain level: ½ (just a couple of twinges and the shoulder pain in the evening)

Day 8: Laughing hard is less painful and getting out of bed rarely gives me a brief twinge of pain anymore. My discharge instructions say I can stop wearing the TED stockings after a week. However, they keep my legs warm and I kind of like them.

Day 9: It is getting more comfortable to rest and recline on my right side – but I still cannot sleep on my right side. I finally decided to go downstairs to the main level of our house – and it wasn’t painful at all! I went up and down the stairs about five more times today.

Day 10: Digestive tract is still a bit slow and I get a few cramping sensations. Feeling like I need to have a BM but do not. I went outdoors with the dog for the first time (three minutes total). I didn’t leave the deck.

Day 11: Housework begins! I unloaded the dishwasher, swept some crumbs into a pile, washed dishes and did 2 small loads of laundry (no hauling or carrying, however). Pain is only the cramping sensation from not having a BM. I’ve increased fiber intake, more juice and stool softener.

Day 12: I woke up sleeping, sort of, on my stomach! This is great. My incisions look fine; three look better than the far right one but even it is okay. Taking the Colace (stool softener) is the key. Am still wearing TED stockings. I wrote nearly 25 thank you notes – and walked them to the end of the driveway to put them in the mailbox. This was my first outing since coming home.

Day 13 (Thanksgiving): Woke up mostly on my stomach. I felt some occasional cramping sensations (a BM would help relieve this) and, rarely, gas. Showering and dressing before going to the next door neighbor’s before 1:10 pm seemed like a lot to do! I enjoyed my afternoon sitting at their Thanksgiving table (while my husband and kids drove to family 2 hours away). An hour at the table and then two hours sitting on the sofa being social exhausted me. I definitely walk slowly.

Day 14: I had a cramping pain in my anus, so I need to have a BM. I think this is really my only remaining bothersome symptom. I got off the sofa, felt dizzy – and fainted! I woke up a minute or so later (I knew from the clock on the TV) a bit confused until I figured it out. Pain level = 0 (except for the BM cramping)

Day 15: Felt light-headed again when getting out of bed. Now I sit on the edge of the bed to be sure I am okay before walking. Slept 8 hours. No pain. Taking stool softener two times per day. On this day, I went for my first drive. I drove about 25 miles each direction to visit family. Driving was not a problem at all although I kept my small pillow between my belly and the lap- and seat- belt.

Day 17 (first post-surgery appointment): Of course, I drove myself to the hospital (the handful of miles that it is). My incisions look good. Now, about that final pathology report…it was rather unexpected: my uterus was cancerous. Slow-growing and caught early (something the D&C, pap smears and CA 125 blood test didn’t notice). There was a lengthy discussion of the pathology report and their recommendations for ongoing follow-up care.

Next appointment (11 weeks post-surgery): The joy of an internal exam – and possibly getting the okay for sexual relations, baths, swimming pools and hot tubs?

My biggest reliefs: I survived. Seriously, I wasn’t sure that would happen for me! I had no need for a transfusion because I lost so little blood (just about 1/8 of a cup!!). I had my total hysterectomy in the modern era with daVinci.

Most irksome things I wasn’t previously aware of: Not being given ice chips or water in the recovery room (my mouth was so dry!); the hospital routines (blood drawn twice daily, heparin shots twice daily); staff in my room every 30 minutes during the night (except the span when the elderly lady passed away).

Most surprising: discomfort of riding over the seams in the parking ramp and roads on the way home, discomfort of walking up the stairs at home; how quickly I concluded this has all been worth it [that might have happened when I was emptying an entire bathroom drawer of no-longer-needed pads (some enormous – and insufficient), pantiliners, “sacrificial” (stained but serviceable) underwear, etc.].

Beware phone calls from doctors: Even before my first post-op appointment, the doctor’s fellow phoned me about the final pathology report (apparently, when this hospital bothers to call you, it isn’t good: first, suspicious stuff in the D&C, now uterine cancer – AFTER the surgeon told everybody in the waiting room “no cancer was found.”)

The cost: For those of you who have the nagging question “What is this going to cost?” my bills total right around $28,000. I believe this is the bulk of my bills for the preliminary appointment with the surgeon, pre-op appointment/tests/radiology and other fees, hospital stay (including professional fees, room/board for one night) and the actual daVinci surgery. That does not include my check-up at 11 weeks (or anything in the future). If you are curious, perhaps this number will give you some vague idea. [My totally uneducated and random guess was $70,000 - so I was very glad to have been wrong.]

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Clifford Rogers, M.D. The Everett Clinic, Dept. of Surgery and Gynecology 1330 Rockefeller Ave, Suite 120 Everett WA 98201 425 339 5424	Terry Grogg, M.D. 4461 S Broadway Suite 200 Suite 200 Grove City OH 43123 614-875-0444	Kym Boyman, M.D. 1775 Williston Rd., Ste. 110 South Burlington VT 05403 802-735-1252
Aarathi Cholkeri-Singh, M.D. 120 Osler Drive Ste. 100 Napeville IL 60540 630-428-2229	Jennifer Fuson, M.D. 1720 Nicholasville Road Suite 702 Lexington KY 40503 859-264-8811	John Lenihan, M.D. 314 ML King Jr. Way Suite 104 Tacoma WA 98465 253-403-5432
Debra Richardson, M.D. Gynecological Oncology Clinic - SW Med 2201 Inwood Road Suite 106 Dallas TX 75390 214-645-4673	Jonathan Y Song, M.D. 2455 Dean St. Suite A St. Charles IL 60175 (630) 513-9160	Gretchen Makai, M.D. 4735 Ogletown Stanton Rd MAP II, Ste 2103 Christiana Care Health System Newark DE 19713 302-623-4410

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