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Tuesday 18 September 2018

HOSPITAL IN FULL BY FIONA CUMMINGS @FionaPefi


Good day Bloggets. So, are you sitting comfortably? My story shall begin. I should be sleeping now, but I can’t. at least I have had something to eat my third attempt to eat since Wednesday.

 

As I wrote yesterday, my Husband was rushed to hospital with me driven by our Son. We went to accident and emergency. Going along the car park, weaving in and out of tightly parked cars, I was angrily shocked just how many cars there were at that time of morning.

 

Our Son is great at describing how to go in between for example mirrors of parked cars. Steps and so on.

 

All three of us got in those rotating doors. Into the hospital. Remember the days when hospitals smelled like, well, hospitals?

 

Pure coffee fragrance hit us.  Along with the warmth from the heating, though it’s not winter yet.

 

So, I remembered this part from when I came once by myself. You turn left but in the meanwhile, there are pillars all over the place. Got to reception, gave my Husbands details and we were sent to another apartment. It’s like a maize. Our boy found it and we took a seat. By this point I just felt so sad for Hub as he was in enormous pain. And BW as it was his day off.  He’d up most mornings at 4.30 am for work, a day off normally means for him a lay in. not that day. So, I told him that he could go but to inform the receptionist, who by the way, was out of that large room, and along another very long corridor, through two sets of doors. Turn right and again avoid the pillars as well as the cleaners mop and bucket.

 

Our Son was wanting to stay, but we insisted he left. Not wanting to spoil his day. He left, and returned.

“I’m not allowed to leave you.””

What?

“The lady said I had to wait with you until you see the first person.””

Em, excuse me, but who are the parents receptionist? Patronising? I was not impressed.

 

We didn’t have long to wait, about half an hour. BW left and incurred a parking fee which we knew he would get..

 

I wonder if in other countries do you have to pay to park?

 

I guess they have to make their money from somewhere.

 

As you may know, our NHS is all free. And after my experience this past few days, it’s so true, you get what you pay for!

 

A lady took Hub away to do something, not sure what. Brought him back. By this point he was in more pain. 8 out of ten. Ten being the highest amount of pain and 1 being the lowest.

 

Then we were taken to a room. I put my hand on Hubs shoulder and followed. Not easy I can tell you. We couldn’t take our dogs as they wouldn’t really guide as they hadn’t been told the routes obviously. And then came the blood test.

 

Well, the nurse couldn’t find a vein. She tried the other arm. No, and then the hand, nothing, and the hand again and then the other hand twice. Poor thing was like a pin cushion.

 

And then he started to pass out. Oh, gosh. She went and got a Doctor. He came put something in his hand and then the needle. Straight away, if Doctors can do that, why can’t nurses?

 

And then Hub was taken on a bed wheeled away to another room. I was anxious. How would I get to the next room? Thank goodness a lady came to my rescue. Not sure if she was a nurse, care assistant doctor cleaner or cook. I didn’t care, I got to my honey.

 

So, he had his first X-ray. Then the long wait. Reading up on Google, we were convinced it was Appendicitis. He had every single symptom. Well, but two.

 

By now the pain was getting worse, so they administrated pain relief.

 

It was so awful to hear him in agony. He had so many tests I thought I had been through everything in my last operation, but no, Hub topped that. He had tests on parts I never knew he had.

 

Another room, another X-ray, this time on his chest as that shows up the top of his stomach more.

 

Another long wait. Now he was in his worst pain. (Just find out what is wrong and treat him please?)

 

By this point he had seven different people seeing him and so far, in seven different rooms, five of them I had to follow and the last one of the days, a room where he got more blood took and other tests of bodily fluids. Four different voices came in and out of that room. Sounds, that is all we can rely on in situations like this.

 

I was really starting to panic by now as they didn’t have a clue what was wrong with him. They didn’t believe it was his appendix.

 

We waited in a cubical. Just a curtain between us and the corridor.

 

Every conversation was heard between Doctors other staff and patients.

 

Voices asked questions. To us or the neighbours? It was not discreet at all.

 

And then a man said we are going to take you to a ward. Was he talking with us? Yes. But if you can’t see, it’s not always obvious who you are speaking with.

 

Well banging sounds could be heard as a wheelchair was getting prepared.

 

In the next cubical was a daughter and Mother. She was a funny old soul.

 

Her daughter was in so much pain and was groaning and the lady told her “Shush!””

She groaned again, she had fallen off a horse and broke her ribs. Her Mother continued in a sharp tone.

“Shush. I said. Stop being ridiculous. I know you are in pain, but anyone would think you were given birth.””

 

Reminded me of my time in hospital last time. My friend was with me. I had tears coming down my face and she told me to stop being a coward…. So, caring these people seriously. I would guess that someone somewhere was walking around with parts of their heart inside of them.

 

Okay, we were off. Oh my he walked so fast.

Explaining again as he was off, I have to hold onto something as I can’t see. He told me to grab the handle of the wheelchair. Well, this guy was in rehearsal for the next Olympics. He ran, I wouldn’t care, the sounds that were coming from his mouth, he was the one who needed the wheel chair.

 

 

I thought he was going to have a heart attack.

 

I thought I was going to have to pay money to the hospital for damages. Well doors that were supposed to be kept open I was closing and doors that were closed I was leaving open. I never knew just how much stuff a hospital has. Surely things could just get stolen? Mind you not sure why anyone would want to steal from what I was rearranging.

 

There were plates of metal sticking out from the walls, bookshelves and trollies. Just mess everywhere. I’m sure really clean, but what a mess.

 

I think I took a couple of staff out or were they visitors, may be patients? I just know I knocked into them and oops they were there and then they weren’t.

 

Well the guy didn’t stop to see if they were OK and I knew if I stopped he would be long gone.

 

Few at last. A lift. Thank goodness. Again, I wasn’t even aware I was in a lift as the building was spinning around.

 

I knew I was in  one only when I heard the doors closing. Then they opened and hang in there Fifi we are off again.

 

Through double doors, single doors around corners. Have you ever tried following someone blind folded? You are unaware they are going to turn a corner until they do. Suddenly you have to tell your body it’s going the other way.

 

And no warning of stopping. Whoosh. We have stopped. And then off zooming along again. Oh no, that was another trolley.

 

I didn’t hear a smashing crashing sound

That’s good.

 

At last words are spoken. Something to do with where they are putting Hub.

 

My head was in a swirly Wizz

 

There was a chair next to a window. Of course, I didn’t know it was a window until I felt it. There was no heat or draft from it.

 

And a bed to my right. Hub lay on that and before he knew how to say I’m hurting… he found buttons. My Husband and tech go hand in hand.

 

He said he wanted to make the bed go up. I advised him not to as I said he could push something that would send him into next week.

 

Did he listen? Well he was then sitting up and said it helped his pain.

 

And then he lay back and back up again. He just couldn’t put himself in a comfortable place.

 

Well, we waited. And waited. And then we waited some more. He was waiting for more pain killers. I wanted to get cross but where would that get you?

 

At last he got his fluid through his drip. The staff were really lovely, but how many? He saw another eight different members of staff. Most of them asking his next of Kin and my contact number. If they wanted to call me during the night, could they? and then the floor was to be done.

 So, a cleaner came and mopped.

 

More paperwork. More questions to answer which we already had answered on the forth paper we answered.

 

By this point Hub was worse. And then another person. More questions repeating everything. Well when they asked the new question? (Are you religious just if we need to get someone) em, a priest? Oh, God.

 

Was he going to die? What was wrong with him?

 

More really intrusive nasty things done to him. And after eight hours, he needed the toilet. He had been shown the button to press for a nurse. Haha, good stuff, poor people had been pushing that button for about half an hour and no one came.

 

Hub thought if he got out of bed, they may see him. It was then I was ready to totally cry. Why can’t I help my poor love to the toilet? Oh, there are times I don’t like being blind and then there are times I hate it.

 

I felt so dam helpless.

 After half an hour a person came, again, a cleaner nurse, care assistant? Who knows as far as we know, could have been a visitor. They told him when he needed help back to his bed to pull the cord.

He did. Fifteen minutes later, no one had come. Thank goodness a patient’s wife came for him. Bless her.

 

By this point Hub was a mess with pure exhaustion. He stood for so long. He lay on his bed and said he needed more pain killers.

 

I heard a voice, “Please can you get my Husband his pain killers?”” the voice came back. Yes, sure love. Well few, I had asked a member of staff and not the lady with the mop or trolley with cups of hot drinks.

 

After over nine hours, he saw the Doctor. Less than a minute with him. When he left, we were as confused as we were at the start of the day. It just happened so fast.

 

Basically, he wasn’t getting out. They didn’t know what was wrong with him.

 

All the tests came back perfect.

 

But his two X-rays showed up something they didn’t understand. Oh. My. God. Of course, I went there. Straight to cancer.

 

In the morning the following day, he was to have a CT scan to see exactly what it was.

 

Just a sleepless night to come. And then our BW came in. oh, gosh, he was so proud to announce. In front of the whole ward. He had brought about £900 worth of Hubs tech, just to entertain him. Well firstly Hub was in no state to be entertained. Then out came a huge tub. Oh, bless him, he’d made his Dad a Lasagne. Even bringing a fork. Well the lady we had just filled in form number 751 with, had told us not to have anything valuable. And Hub wasn’t allowed any food.

 

Then he brought out two apples, two bags of crisps, and two chocolate bars. Oh, but the best was a bottle of beer…. Huge one. And he even remembered a bottle opener.

 

And then came the clothes he brought, everything that was so needed. And a soap bag with a comb in because bless BW he said his Dad likes to brush his hair… Poor Hub didn’t care by that point if he lost all of his hair.

 

He was so happy to show us the really jazzy shorts Hub had that he brought in…. I’m thinking along with being in total shock about the beer, em, he’s off on holiday soon, Hub best hang onto his shorts, or they will go the journey.

 

Luckily BW had spent all but two hours with the dogs but it was really time I got home to be with them. As already The Little Fella was showing signs of stress he wasn’t with his Daddy.

 

We repacked the bag bless him he even brought Hubs tablets for his eye pains. Not that he takes them much these days.

 

I kissed my darling night night and left. I was totally exhausted. I wanted to return that very next morning. I asked the Sister when I could come she replied visiting time was 1 pm. I did the long walk with BW. Around the corners but he was a much better guide than the porter.

 

I got out into the air. Burst into tears. My Son was so loving. I was there all day I didn’t know what was wrong with Hub and I was worried sick.

 

I know just how difficult it is being blind in hospital. It’s pure hell. Especially if you are on a ward.

 

As I got home, LF and Waggatail knew something was up. My Son told me to sit down. I didn’t want to I wanted to keep busy. No, he told me to sit. He had made my dinner.

He’s a great cook.

But something went very wrong.

The V words.

No, not very delicious, not vegetarian, but vegan.

 

Oh, my goodness. I couldn’t eat it. It was disgusting.

He cooked noodles in coconut oil. Gross. And then he fed me on a plate this revolting tough stringy horribleness. I tried to put some in my mouth but no way I could chew it.

 

It’s the new stuff that looks like raw meat. With blood. Why? Apparently, it’s to get people who eat meat try it. No. don’t. I am not saying I would rather you ate a cow or chicken, but either eat the veg that would come with it or starve, rather than eat that stuff.

 

At least Quorn tastes nice. Ish.

 

I felt sick. As noodles did the slow waltz inside of my mouth, I gulped down the cups of tea he made me. Two. And I needed those.

 

Sham came and we chatted for a while. She tried to calm me down. She failed but she was really nice about it.

 

At 1 am I went to bed. No sleep all night nor Hub he and I text each other. He said his pain was getting worse. A ten. He said more that made me cry. I was so upset I couldn’t be with him.

 

He was there for me when I was last in hospital, but it was a private hospital we paid for it. Our very kind friends gifted me with some money too as you can imagine a week in a private hospital was very expensive. But Hub was there. And now he is in I can’t be with him.

 

Next morning, I was up at half six. I just busied myself until Sham came and took me to hospital. She was great. BW was at work. So, I could only spend four hours with Hub.

 

He was much worse. We saw the Doctor. He said he still doesn’t know what is wrong with Hub. Oh, my goodness. I had to ask. I had been searching the internet all night.

“Doctor, could my Husband have cancer?””

 

His answer wasn’t what I wanted to hear.

 

So, after asking the Doctor that question that had been on our minds for two days. Could Hub have cancer? The answer was. “We are not ruling that out.”” And that was after a pause. Oh gosh, I wanted to hear.   “Oh, no, if he had cancer, his bloods would not be normal. And they are fine.”” But no.

 

The CT scan would tell what was wrong. So, why not give that on day one? This was late into day two. We were promised the scan yesterday, and tonight he hadn’t even had it.

 

My brother in law called me up and I handed the phone after I spoke with him to Hub.

Hub put his best strongest voice on. He just won’t admit his true feelings. As soon as my BIL said goodbye, reassuring me he is there if I need him. Hub went back into himself. He kept telling me he was scared and was so pleased he had me and our Son. He knew how good BW had been we are a tiny family but have so much love between us. I said he was going to be fine, but left wondering.

 

I had to leave the hospital at that point, knowing my Husband was worse that day than the day before and still no diagnosis. They were just pumping stuff into him all the time. Day and night. Pain killers mainly.

 

The two days on the wards were not good as it brought back memories of our Mums and my Dad. Hospitals are just not nice. And I struggle with them for so many reasons, but to see Hub so sad was awful. And I had to leave him.

 

I came home, Sham had made me some food. She told me I had to eat it. What with her and my bestie telling me to eat, anyone would think I needed to put on weight!

 

Hub and I text all night to each other. He was so close but so far.

 

I kept saying have you had your CT scan yet. He kept replying no.

 

Well I looked up so much on Google that night again, I couldn’t open my eyes by this point. 48 hours almost without sleep. I  certainly realised that searches on line, just scares you.

 

I then started to look up private hospitals. And I was serious I was going to get Hub out of that hospital and bring him to a private one.

 

Half six this morning, no scan still. I was furious. But one good bit of news was that Hub seemed to be a bit better during the night, though totally exhausted.

 

They were injecting him with goodness knows what and giving him things through his tube in his hand.

 

He had to wear surgical stockings and have those dreadful injections in his stomach. So, plenty to do during the night, no time to sleep.

 

6 30 am. I called his ward. Confirmed who I was and asked knowing the answer. Had he had his scan? No. well, then she told me he may get it tomorrow. Sunday. Em, no. so I kind of lost it in a polite way. Trying to keep calm. Basically, telling her they were messing him about. And I was going to get him home today and take him to a private hospital where he would get the correct treatment. The noise in that hospital was just awful. But I will say it was clean and the staff for example care assistance nurses and cleaners, were all so lovely.

 

Doctors? Well, when they are learning all what they have to learn at University, they should add an additional lesson in and it’s called in the other’s shoes.

 

One thing I did notice this visit to our hospitals, was how everyone like Doctors surgeons and so on all shook our hand.

 

Within an hour and a half of me putting down the phone from the sister, Hub told me he felt so much better… he was lasting much longer without painkillers. Apparently, during the night, they were feeding him loads of antibiotics. In their terms, they flushed him out twice.

 

He was told before nine this morning he was allowed food. For the first time in three days. Great, no operation. But at that point, Hub thought he was going to be asked to return for more tests later on.

 

And me, well I was still thinking of the dreadful big C.

 

All morning my friends were continuing to call me by phone. Bless them. Trix and the Like man were so lovely the Like man was going to come through. As was Hubs brother. But by 11 this morning Hub called me and said he was about to go for his scan and then they were going to let him home.

 

How? I mean, he still was relying on pain killers and we didn’t have a diagnosis.

 

I kept myself busy, speaking with my friend on my Alexa box. Changed our bed and put out freshly new washed towels.

 

I sorted out our dogs, cleaned the floor washed the clothes to hopefully welcome my love home.

 

I got the dogs and took them for a walk with my friend. My heart was flat. My soul was torn and I just felt so angry. All that night though I was in bed, I was looking up so much that messed with my mind.

 

Sham came in the house and into the kitchen. She brought her dinner and started to cook.

She made me homemade soup. it was lovely though, though I am a little odd eating other people’s food, as I do wonder how clean they are? But the thought what she did was so lovely. And I won’t forget that.

 

During that night was so silent, I had awful thoughts. What will I do if he dies? I can’t even remember where we put important things. Who would do all our tech stuff? As for the bills? I can’t even work our complicated TV. Hang on, I would not even want to watch TV or bother ever again with anything tech. I would exist.

 

I felt sad for the elderly men on the ward. One gent broke down and cried every time his family came to visit. Then after five seconds, he was so happy and joking. Just very emotional bless him and the other one in his eighties, had no visitors as his wife was in a wheelchair and didn’t get far out of the house.

 

My friends were telling me not to be so negative. He would be OK.

 

Well he had the scan and thank my angels, parents I prayed to and nature, he has a really bad infection that is in his blood. His intestine is too small so there is a block and that was the mass. Oh, gosh. Relief. But how did he get this infection? I learned that you don’t catch it… But with his intestine being small, he could have complications in the future.

 

Well I learned that the fluids they gave Hub were antibiotics. He had his CT scan which he said wasn’t a nice experience but at least by then he was starting to feel better. All results came back good apart from saying he had blood poison. As well as an infection caused by the fact he had this small intestine which he would have had since birth.

So, he learned by pm he was coming home. Oh, I found it hard to believe I still wondered if he would by this point. But the best thing his pain had gone from 8 out of 10 being ten being the worst to 3. Wow, so the antibiotics were working.    

 

Our friends brought him home. I stayed with the dogs. At last my baby was back where he belongs. He was weak but stayed awake for our Son to return from work. BW was so relieved to see his Dad back too. He got a shower, then fell fast asleep.

 

They sent him home without pills as they said they flushed him twice overnight so he is free of infection now. but it could come back.

And if it does, it’s a private operation for sure. I can’t go through that hell tunnel again.

 

Well I’m just starting to come down from the past few days of emotions. Yesterday morning Hub held me and I just cried. I was so full of pain what could have happened. People say stop thinking of the negative, well I say if only they knew my life. They reply. “Yeah I have had it bad too.”” As I say, if only they knew my past!

 

It was so difficult yesterday to keep him sitting down. He is still weak and in pain and his skin is like a pin cushion. He found two new puncture marks yesterday on his wrist he never knew he had. But to be honest the last day I visited him, he was out of it most of the day. And during the night, they did all sorts to him. Including two lots of flushing out with antibiotics. He has been told it’s best that he doesn’t eat red meat… Result. So, it’s chicken and fish from now on and to be honest that will be better for him for so many reasons.

 

His voice is back to normal now and after the shock of what happened to him he’s seems to just be happier being well, fitter as my goodness, he had a full medical. They did every test possible.

 

I just got very frustrated as everything was so very slow. If he had the CT scan on day one, they would have known what was going on. He could have been out on day two rather than the evening of three. It would have saved us two full day and nights of stress. So much worry. It was only yesterday Hub let me know that he was scared for his life. He thought he was going the same way as his poor lovely Mum. As did I. Bless her for months she was visiting hospitals and they never knew what was wrong with her. It was such a short time before she died when we learned she had cancer. Sadly, she had a lot of stress towards the end of her life and I am sure that didn’t help.

 

But thank God he’s OK. My heart is burning. I’m exhausted, but I’m so grateful to our maker and eventually the NHS for helping him. It was the attitude that annoyed me. It was like just whatever. Tomorrow. And I have no patience! But it was just seeing him so very ill. And waiting hours to learn what was happening next. And when next came, it didn’t happen. But he’s home and all is well that ends well. How much this cost the NHS? Goodness knows. How much did it cost us? Nothing. Totally free. But observing everything over the past few days I felt myself getting so wound up. The staff work such long hours. 13. As for Junior Doctors, much more than that. As for nurses and care assistants, the pay is absolutely shocking. You can earn more as   a shop assistant who are not in charge of the wellbeing of people’s lives. And it seemed like the left hand didn’t know what the right hand was doing. Too many cooks spoil the broth. By the time they worked over nine hours, all the paper work they had to do. It’s dangerous working longer. Peoples buzzers/buttons were going all the time, it took on average fifteen minutes after Hub pressed his button for anyone to come out, only to learn that something he needed was missing or they only had one of them on that ward or they would have to get another member of staff to do whatever. So, taking another ten or fifteen minutes for that to happen.

 

The private hospital I was in some years ago, The Spire hospital, was incredible. I pushed the button and within a minute someone came. They had an amazing policy where by no one waited longer than a minute and a half for someone to come to you and it didn’t matter who. It was whoever was closest to the person needing help. So, whether it be the cleaner, porter or consultant, nurse or cook, Doctor or receptionist, someone came out. And dealt with what you needed or got someone who could help more. And even then, you never waited. It was such a nice environment and you felt as a patient and visitor so relaxed and safe. I didn’t feel Hub was safe there though the staff like the nurses and so on were really lovely, it just didn’t have a relaxed feel probably because they were so tired so stressed themselves. But we paid nothing. Thanks tour wonderful NHS. It just totally needs revaluating and people who work for the NHS need to feel more special. More valued and receive more money. May be give the specialists less money? Managers slightly less money? I’m not talking loads but if they took may be a couple of thousand pounds per year from each of them, and put that towards the staff who are earning £8 per hour? Or make it a nicer place to work by offering less hours, and benefits to encourage people to work for them. If staff are happy, patients will be happier, visitors will be much happier and happy hospitals will happen. More effect things will get done and the slow process will be no longer and surely beds will become free for the next person because things will just get resolved faster. Getting better is sometimes all in the mind. If you have confidence in your carers, your mind will heal your body. Obviously in most cases, it takes medicine. This was the case for my Husband. But he was so afraid as was I because we just didn’t have any faith in what was happening. And even now, I still feel like I can’t totally relax because I’m just wondering did they get the diagnoses correct. As one evening at half six, the consultant didn’t have a clue what was wrong with Hub. That night at eleven they started giving him medication through a drip and the next day, he was told at nine he would be released as they knew what was wrong, it would just have to be clarified with a CT scan. And he was home that night. So, from not having a clue, to knowing within four and a bit hour. Within that time, he had no other tests, so how did they know? See what I mean?

 

On Saturday I was so frustrated and wanted Hub to have his CT scan. He had been promised for two days. That morning I was told that it could be the next day he would get it. That would be three days.  I called a private hospital called the Nuffield. I learned today as they don’t answer your enquiry by email until the weekend is over, that he would have to be referred by our GP. Oh, my, if that is the case, would we have to wait to see our GP? Three weeks before that could happen?  That doesn’t fill me with confidence. I thought you could just turn up. Or at least book over the phone your appointment? I’m sure that is what we did for me? And it took two days to do that. From the phone call to me getting admitted. So why not for the Nuffield? Unless you can ask your GP to call them or email them to refer you and you don’t need to see your GP first? Something I need to look into, unless you know and can let me know?

 

I just know unless you get a room to yourself, hospitals are so very unfriendly for those of us who are blind. In most cases a blind patient will be visited by their sighted spouse, or the other way on, I guess it’s rarer to have two blind people, but we do exist…

 

Guide Dog staff kindly offered to give me mobility training around the ward. But I said it wouldn’t be worth it, as by the time I learned that, he would be moving ward, and he did just that. Also, you can’t really learn where the new trolley is going to be or a chair with a new visitor will be in the ward. And there are tables at the end of most people’s beds. Hub in his second ward on his last day, learned himself where the toilet was, because he was at the very start of the ward just near the toilet. But he said every time he got out of bed, he knew people were just looking at him. It’s awful. It makes you feel embarrassed. But when he was ill, and he needed help to do that, I could have done so if we had a room of his own, but not on your Nelly could I dare to help him in a ward full of life…

 

His first ward was so busy too, and noisy. His second one was quite the contrary. It was like a blooming morgue.

 

So, life back to normal with the knowledge that we really have to take more care of ourselves. We can’t get away with things as we get older. I mean, Hub has learned that he has a small intestine and it’s so narrow that food has got stuck and caused blood poison. Surely, he’s had that narrow intestine all of his life? why now? is it his age? Old so and so. Haha.

 

Finally thank you all for your support. Louise, Rob, Hanz, Trix, Like, JB, J, B, Pip, Sham and our darling Son. Thanks to all my readers too. You have all been so kind. Terry and Carrie-Ann thanks so much. Thanks for your shares too I hope somewhere along the line, this blog may go towards some kind of help in hospitals for those who are blind. Even if it’s not training but understanding a little more. I mean just some of the comments we had were.

“Can I pull your curtains to block out the sun as it will blind you…””

“Do you wear glasses?””

No, I’m blind.

“Did you drive in?””

No as I said I’m blind.

“Do you work?””

Yes. I’m an area manager!

“Really? Wow!””

Why wow? Hahaha. Blind people can be clever. We can work you know? But I guess the best one was

“Would you like me to show you how to work your reading light?””

With love.

 

© Fiona Cummings

 

        

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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