Trying to Destroy Healthcare the Ostrich Way

Copyright: <a href='https://www.123rf.com/profile_andreykuzmin'>andreykuzmin / 123RF Stock Photo</a>Ostriches reportedly stick their heads in a hole if they see something they fear. If they can’t see it, then it must have gone away. President Trump, with most republicans lawmakers going along, is trying that same tactic on the public. Despite 7 years of promises, and multiple attempts, Republicans have been unsuccessful overturning the Affordable Care Act, otherwise know as ObamaCare. So Trump has been doing everything he can to destroy it, with the hopes that it will wither and die, then he can blame Democrats on it’s demise, claiming it was bad legislation. This despite not having a good alternative.

One of the efforts have been to keep people from signing up for coverage for next year. The Trump administration has cut the advertising budget by 90%, shortened the enrollment window, and will close the site on some Sundays for, “maintenance.” They figure that if people can’t see it, they will think it must not be there.

Well sign up just started. If you don’t otherwise have coverage, such as through work, sign up right away, while you still can.  You must sign up by 12/15/17. Don’t wait until the last minute as you might not be able to get on the site. Don’t be scared off by reports of premiums going up. Although true, subsidies also go up per the law, and it costs nothing to find out what it would cost for coverage. Go to healthcare.gov.

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Regulators Asleep at the Wheel

Recently the Federal Railroad Administration and Federal Motor Carrier Safety Administration said they would no longer continue pursuing regulations requiring testing for sleep apnea in truck drivers and train engineers.

Sleep apnea is a condition where, in the most common form, the airway is partially blocked during sleep. This leads to daytime sleepiness, increasing the risk of accidents, plus is otherwise hazardous to patient’s health if untreated.  The National Transportation Board determined that a 2013 train derailment that killed 4 and injured 59 was a result of undiagnosed sleep apnea. According to the railroad Metro-North in the New York City suburbs, 11.6% of it’s train engineers have sleep apnea.

Screening involves an overnight sleep test.  We require our pilots to get tests for drug use. Why would we not want to test truck drivers and train engineers for a common problem that is just as dangerous? It’s part of President Donald Trump’s campaign to cut federal regulations. Although some regulations are excessive, this is not one of them. What’s next, repealing seat belt and motorcycle helmet laws?

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Politicians Playing Doctor

Recently the British baby Charlie Gard has been in the news. Unfortunately he was born with a rare disorder called Infantile Onset Encephalomyopathic Mitochondrial DNA Depletion Syndrome. The parents of the 11-month-old boy have been in a court battle with the London Hospital caring for him since October. The hospital obtained a court order to remove the boy from life support as the doctors treating him said his condition was terminal and that treatment would just cause the boy additional distress.

The parents have held up hope for an experimental treatment with nucleosides a U.S. doctor has offered, even though he had not examined the patient. In fact no person or animal with Charlie’s condition had ever received the treatment. Reportedly 9 patients with a related disease had some improvement with the treatment.

President Trump weighed in:

Recently Republican House Congressmen Brad Wenstrup (Ohio) and Trent Franks (Arizona) said they would introduce a bill to give Charlie permanent residency in the United States so he can travel for the experimental therapy.

I sympathize with the parents. It’s awful to see your children with serious illness. However sometimes stopping care really is the best thing to do. The US doctor reportedly said a 10% improvement in strength was possible. But that’s the same as saying you can go from lifting 10 lbs to being able to lift 11 lbs. It’s just not going to make a significant difference.

I also believe in research studies. In fact close to 20 years ago I had a patient with a different neurological disorder who could not be removed from a ventilator. I received FDA approval to administer an experimental treatment. It may have helped – they did get off the ventilator, but they died not that much later. That drug had preliminary treatments in animals, then in humans.

If our politicians were really that concerned about the health of an infant in another country, maybe they would accept refugees from countries such as Syria, where innocent people have been in terrible conditions. Their chances of improvement would practically be guaranteed. Unfortunately for Charlie, that’s just not realistic.

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Exploring Cuba – Part 2

In my prior post, I discussed a trip I made to Cuba in December. In this second part I will focus on some medical aspects.

When my patients ask about foreign travel where there may be health concerns, I usually direct them to the CDC site. It’s also where I go to check for my own travel, though I look at the more detailed Clinician view.  To start off it recommends typhoid vaccination.  You have a choice of the oral or injected. The oral is a live virus that is taken every other day for 4 doses, starting 12 days before potential exposure. It gives better immunity, but should not be taken by people with a suppressed immune system, such as those on steroids. The injected form is a non-live vaccine, a single injection taken at least 2 weeks before potential exposure. The injected form is harder to find, and even pharmacies that carry it may need to order it in advance. The injection is more expensive, and neither vaccine is usually covered by one’s health insurance. There are other vaccines recommended, but typhoid was the only one I needed.

Cuba has mosquitoes that may carry Dengue Fever, and more recently Zika. I chose to travel in December because it was outside hurricane season, it was the cooler time of the year, and there are less mosquitoes around that time. Cuba does a better job than many other countries controlling mosquitoes, but I was still cautious. Due to the cost, they don’t use insecticides to fumigate buildings, but rather burn oil, as can be seen in the photo above. We checked in to one place not long after they had done their weekly spray, and had to wait 30 minutes for smoke to stop poring out the window! I sprayed much of our clothes with permethrin spray, and applied DEET to exposed skin, especially in the evening when the mosquitoes are more apt to bite.  I texted PLAN to 855-255-5606 to get periodic updates from the CDC about Zika before the trip.

Food is generally safe to eat, but we avoided street food. The tap water is not safe, however. We mostly depended on bottled water and avoided ice except at a few restaurants and bars that filtered their own water. Bottled water is kind of pricey at times. The best deals are on large (3-4 liter bottles) that you can find sometimes in stores. They often cost the same price or less than a one liter bottle that is more readily found. I also brought along a SteriPEN which sterilizes water with ultraviolet light. I didn’t have enough experience to trust it completely to replace buying bottled water, but used it to sterilize water to rinse our toothbrushes, and would have used it if we didn’t have bottled water. I also recommend bringing Imodium, and an antibiotic from your physician for traveler’s diarrhea. I’d also bring some toilet paper. Many public toilets often didn’t have any, or  you’d get a small amount from an attendant after giving a tip.

Bring sunscreen. It’s not easy to find places that sell it in Cuba, and it’s expensive.

Months before my trip I tried to arrange to visit a hospital. It so happened that the fiancée of a Cuban in the travel industry who helped with some of the arrangements was an anesthesiology resident. He told me that he would love to show me his hospital, but that unfortunately the government required a 30-50 dollar payment, despite the fact that I said I would be bringing some medical supplies. He also said I would not be allowed to tour the medical school due to, “national security!” After I arrived we talked a number of times, and ultimately he could not get government approval for me to see his hospital, even though he said everyone at the hospital wanted me to come. He said the only exceptions they made were for those with an educational visa, coming to teach basically, and even then they needed at least 3 months notice.

Although I could not tour the hospital, I had some long conversations with that doctor and learned a lot about their system. All things considered, the Cuban doctors are apparently pretty good, but they are particularly hampered by old equipment and lack of medications and supplies. The anesthesiology resident showed me photos of anesthesia equipment they currently use that are from the 1980’s. He said they don’t have air scrubbers in the operating rooms, so sometimes everyone gets sleepy!  He told me about a colleague of his who was working with a nurse anesthetist. She let her go home early because she wasn’t feeling well. Later she had to intubate a pregnant patient. Unfortunately it didn’t go well and the patient suffered brain damage. During a subsequent investigation the government argued that had she not let the nurse anesthetist go home early, maybe the patient wouldn’t have died because she would have had additional help. She was sentenced to 12-15 years in prison, and even if she gets out after 5-7 years for good behavior, she won’t be allowed to be a doctor anymore! Because physicians are held responsible for a bad outcome, Jehovah’s Witness patients are told they can’t refuse blood if needed, though they do take measures to minimize the need. Doctors are paid poorly (the resident said after he finished he would make 80 CUC (about $80) a month), often less than taxi drivers. It’s very difficult for specialists to be allowed to leave the country, even on vacation, for fear they won’t come back. If they go on medical missions they are paid better than usual, but they only pay them the bare minimum while they are abroad to encourage them to return home after the mission. I was surprised to learn that they are fairly tolerant in terms of LBGT, in part due to Raúl Castro’s daughter, and they even have doctors who do sex reassignment surgery to change gender.

Many Cubans rely on natural formulations, such as herbs, they call ‘green medicine,’ due to cost or personal preference. The anesthesiologist told me that for a man to get a prescription for Viagra (sildenafil) he has to see his primary care doctor, a urologist, and a psychiatrist. Once they get a prescription, though, they are basically assured of getting it indefinitely. He said many patients research their condition and tell their doctors what prescription they want, and they often comply.

One of the most dangerous things in Cuba are the cars. They are famed for their old cars, many of which look fabulous, but they lack safety features, such as seat belts and airbags. In fact we were in a car accident. We hired a car and driver for 6 days through a contact in the travel industry in Havana. He was probably around 60-years-old, and reportedly one of their best drivers. He was very nice, funny, and knowledgeable, and arrived to pick us up in a pretty new Chinese car, a BYD (Build Your Dream). On the first day as we were driving, while my wife and daughter were sleeping in the back, the car started drifting to the left. I grabbed the steering wheel, noting the driver had fallen asleep. He quickly awakened, pulled the car to the side of the road, and got out to stretch. He came back in and apologized, saying he had gotten up early to pick the car up. The next day he said that actually he hadn’t slept well because he had witnessed a teenager, who was not paying attention listening to music, hit by a car the day before.

In the middle of the car trip I met with the doctor I mentioned above and told him about the incident. I wondered if he might have sleep apnea, though the driver had said he had never had such a problem.  He said that they don’t test for sleep apnea because they don’t have CPAP machines to treat it.

The rest of the road trip went fine until the final day. Once again my wife and daughter were sleeping in the backseat when the driver fell asleep again. This time he swerved too quickly for me to reach the wheel. We hit a guard rail, damaging the front end and side mirror and puncturing two tires. The driver said he did not know why he fell asleep and that he had been well rested. One theory I came up with is the possibility of carbon monoxide poisoning from a leak in the exhaust system. Our driver obtained another car and driver for us, who brought us back to Havana.

No one was serious injured, but my wife was seated behind the driver and her left elbow hurt immediately afterward. Back in Havana we went to a clinic that caters to foreign visitors. X-rays showed no fracture.  She was given a skinny piece of gauze to use for an arm sling (she had been using my belt up until that point). When it came time to leave they said we owed 100 CUC (about $100).

Boarding Pass

 

Cuba requires one to have medical insurance to visit the country, and they add $25 to the price of each airline ticket to cover it. Delta Airlines said to show the boarding pass if needed as proof of insurance. I showed the boarding pass, but they said it wasn’t good because it said AeroMexico on the top. I pointed out that below that is said that it was operated by Delta Airlines. They said they would have to investigate it. They gave no indication how long it would take, and given that it was the evening I didn’t think they would get an answer that night. I eventually gave up, paying the money so we could get her passport back and leave. I wrote Delta Airlines and explained the situation, sending them copies of the boarding pass and the medical bill. We were on something like their 4th commercial flight to Cuba, so I figured they would be eager to work out any glitches. I was wrong. Besides some email exchanges, they called twice at 7 am. When I pointed out the early hour I was told it was 10 am on the East coast. You would think an international airlines understood the concept of time zones! In any case, ultimately I was told we, “..must request a refund of the insurance premium directly with the Cuban insurance provider.” Really? They expect their customers to request a refund from the Cuban government?! All I was asking for was the approximately $100 I paid for the clinic. Not the taxi ride there and back, the medical costs after we got home, to say nothing of pain and suffering. Imagine someone of lesser means ended up needing much more care and being told the insurance they thought covered them didn’t. That might keep people from choosing to visit Cuba, at least on Delta Airlines.

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Exploring Cuba – Part 1

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If you travel because you like to see different cultures and experience things you usually don’t, Cuba is a good place to go. For Americans Cuba has been kind of like forbidden fruit. I thought it was a good time to go as it recently became easier, and I wanted to see the country before it gets changed too much by hordes of tourists.

Although they do have beautiful beaches, as an American you can’t currently legally go there just to stay at a beach resort. You have to declare which category you are traveling under, and tourism is not one of them. Most people choose the people-to-people category. When I went last month with my wife and daughter, I chose the journalism category, as I have a blog and photography site, but in practice, I think it’s rare that anyone actually checks. That could change with the incoming administration, though. In this article I’ll get into some of the details of the trip, for those interested in going.

We flew from Seatac to Miami airport and stayed at the Miami International Airport Hotel, conveniently in the terminal, saving time to catch the early morning flight to Havana on Delta Airlines. We obtained our visa when we checked in, paying $25 for each one. That’s part of the reason they tell you to check in 3 hours early.

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Although you will see plenty of places that accept credit cards, including MasterCard and Visa, they do not accept American credit or debit cards. Thus you have to carry cash. There are two currencies, the Cuban Convertible Peso (CUC), which is about equal to a US dollar, and the Cuban Peso (CUP), mainly used by locals, and about 24 CUP equals 1 CUC. The official rate is used everywhere, except for the black market. You will pay about 3% to change you money to CUC and 3% to change it back, but if it’s US dollars they tack on an extra 10% as punishment for our embargo. I converted my dollars to Canadian dollars first, saving about 7% (saving 10% not converting from US currency, but paying 3% for converting it to Canadian). When I left Cuba I converted the relatively little CUC I had left to Euro, as I plan to go there later in the year.  You can convert money at the airport and at banks, but the later often had lines out the door. Major hotels often will convert money, but some require that you stay there. Most places did not give a receipt.

Except for one night, we only stayed at places we booked through Airbnb. One place was basically a guest suite connected to a beautiful large house with friendly hosts, and a very nice breakfast for an additional 5 CUC per person. Another place was really a hotel that they were using Airbnb for bookings. One was from an older couple that owned a few apartments and rented out a couple of them. Having to deal with just cash was a little nerve wracking. I carried a fairly large sum in a money belt most of the trip. I never worried about being robbed, but it was uncomfortable in the heat. Even more concerning was worrying about the possibility that I might run out of money. The first couple of days was more expensive than I anticipated and I contacted a cousin that by coincidence was arriving in Havana a week later than us. She brought me some money as a loan. I never ended up needing it, but it did provide peace of mind.  A big advantage of Airbnb is that you pay that in advance, so you do not need to bring money for your lodging. At a couple of the places they incidentally did offer to exchange dollars to CUC at better than the official rate, though probably not quite as good as if you exchanged using Euro or Canadian dollars. I didn’t use them, and you have to be careful, but I would have over standing in line at a bank. I advise you to convert a little more than what you think you will need for your entire trip, and carry emergency money in your native currency that you would only change if needed.

For the three of us, I rightfully worried about getting around with lots of luggage. We limited ourselves to one carry on luggage without any full check in size luggage. Particularly as I was bringing some medical supplies (more on that later), and anything you might need but can’t count on being able to buy there, space was at a premium. One thing I did was to buy two pairs of quick drying ExOfficio underwear, and Sea to Summit Lite Line clothesline to hang it up on.

It just so happened that we arrived in Havana the day Fidel Castro was buried in Santiago de Cuba. Raúl Castro declared a 9 day mourning period after Fidel died, banning public music and sales of alcohol. It was not followed completely, but it was certainly more subdued when we first arrived. They have 9 or so TV channels, and during the mourning period they played revolutionary type programming, such as black and white videos (or dramas?) of soldiers fighting in the jungle. As one Cuban told me, it was interesting, but not for 9 days.

We went on our own, not part of a tour, though I worked with a Cuban tourist guide someone introduced me to before the trip. She made suggestions to the itinerary I made, and helped me hire a car and driver for 6 days. One of the travel changes I made at her suggestion was to cancel a fight to Baracoa on the other end of the island. I hadn’t realized that it had been badly damaged by Hurricane Matthew. In addition, the only airline that flies there, Cubana de Aviación, is notorious for bad service. When I made the flight reservations I had to enter all our contact and passport information. To my chagrin the email confirmation included all of the details! I emailed them about my concerns about identity theft, but they never responded.

One of the other things our guide did was to make many restaurant reservations for us, which was surprisingly often necessary.  When it comes to restaurants, there are two kinds: state owned, and private. The latter were only allowed less than 3 years ago. They are generally more expensive, but better quality. We ate at a few of the state owned places. Although the buildings were often beautiful, the food quality was often lacking, serving such things as canned green beans.  In Havana, restaurants we particularly liked included La Guarida, San Cristóbal Paladar, Doña Eutimia, El Cocinero, Atelier, and Paladar Vistamar. In Cienfuegos Las Mamparas was quite cheap and pretty good food. In the Viñales Valley Finca Agroecologica El Paraiso was amazing.

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When people think of Cuba, they think about old cars. There are many American cars from the 1950’s, quite a few Russian Lada cars, plenty of Chinese and other cars. Cars are very expensive (it can be the same as a house there), and most everyone with a car is also a mechanic. You have to be to keep the cars running. Our driver said that a particular 7 person Hyundai van was popular for giving group tours, and a used one, if you could get it, cost 140,000 CUC!

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It was common to see people on horseback or in horse drawn carriages, particularly outside of Havana. I even saw two using the inside passing lane on the highway!

After a couple of days in Havana, we drove to Cienfuegos, stopping at the Giron Museum (Museo Giron) by the Bay of Pigs, and the Cueva de los Peces (Cave of Fishes). We passed by areas where the farmers spread their rice on the the edge of the road to dry, then would sweep it up at the end of the day, then repeat it for about 6 days to totally dry the rice.

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Cienfuegos is a nice port city that has a French influence. Outside the usual tourist things there, we toured a cemetery, where a couple of boys rode up on a donkey. We visited a botanical garden. We also took a day trip to El Nicho waterfalls, and another to Trinidad.

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Trinidad, also a UNESCO World Heritage site, is a charming cobblestone paved town. It’s reportedly often the hottest part of Cuba, and even in December it was pretty warm.

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We left Cienfuegos to drive to Santa Clara where we saw the town and the Che Guevera Monument. From there we drove to quiet but lovely town of Remedios to spend the night.

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Next it was on to the Santa Maria Cayo (key). The road there reminded me of driving to the Florida Keys. We spent 1/2 a day at the Lasterrazas resort. As I said earlier, technically you can’t go to Cuba just to take a beach vacation as a US citizen. It was just a small fraction of our trip not only for that reason, but because that wasn’t what I wanted out of a trip to Cuba, though I know many others could spend their whole time there.

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We then drove back to Havana, where we stayed the rest of the trip, except for a day trip the following day to the town of Pinar Del Río, where we toured a cigar factory,  then on to the Viñales Valley where we gorged ourselves over lunch at the amazing Finca Agroecologica El Paraiso.  We saw a couple of sites, including the tacky Mural de la Prehistoria.

Our driver said the Pinar Del Rio province, where they grow a lot of tobacco, is called the Valley of the Fools. He told the story of Pedro Perez. Before a race he was invited to answer a question for a prize. The announcer said, “OK Pedro, how much is 2 plus 2?”  “6,” he replied. The crowd roared, “Give him another chance. Give him another chance.”  The announcer said, “Ok Pedro, I’ll give you another chance. How much is 2 plus 2?”  Pedro scratched his head and thought about it and said, “5.” Again the crowd yelled, “Give him another chance. Give him another chance.” The announcer said, “This is your last chance, so think carefully, Pedro. I asked you how much is 2 plus 2. First you said 6, then you said 5, so what is your answer?” “4,” said Pedro. The crowd shouted, “Give him another chance. Give him another chance.”

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Back in Havana we took a trip to the outskirts to see Hemingway’s estate. Our taxi driver gave us a tour, though you will get a lot more information if you take an official tour (I listened in on some of them).

As a communist economy, mixed with a little capitalism, there are some strange things when it comes to prices. Taxi drivers often make more than doctors. Natural gas in Havana is cheap. Our driver said the prior month it cost him 25 cents. Because that’s the same price as a box of matches, some people leave their stoves on all the time.

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Dogs run wild in many places. They were never threatening and most seemed well fed. Although some people have them as pets, many are on their own.

The Cuban people are often critical of their government, when asked in private, though proud of some of their achievements, such as medical care and literacy. To thumb their nose at communism, many cars have Apple stickers on them. Kids may sing America from West Side Story in front of the neighborhood commander.

Cuba has a vibrant music scene. We enjoyed some of it, but missed a lot because we couldn’t stay up late enough.

There is no longer a limit on importing cigars or rum for personal use. At the airport I decided to buy two more bottles of rum, one dark, and one white, plus some honey, at the duty free shop. When we arrived at Atlanta we had to pick up our luggage then turn it back in to go to Seatac before going back through security. One of the workers there said clear bottles were not a problem going through the x-rays in security, but he recommended taking out dark bottles and putting it in our luggage. I showed the duty free bag and he said to put the dark rum and honey in my bag but the clear bottle could go in my carry on. I didn’t have room to check all of it in, and I questioned whether it was really ok to open the duty free bag. He said it was no problem at that point and to trust him. I shouldn’t have. When I made it to security they saw the clear bottle and said it couldn’t go through since the duty free bag had been opened. I was told I could go back to check it in (but my suitcase was long since gone) or throw it away. I didn’t ask if I could just drink it on the spot!

You can see more of my photos here. In my next post I’ll discuss some health and medical issues regarding Cuba.

 

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Presidential Politics and Influenza Vaccinations

Recently a patient of mine expressed frustration with the presidential campaign, saying the other side wouldn’t listen to facts and just believed what they wanted to believe.

Knowing that she had repeatedly refused to get a flu shot, I asked her in that case if she’d like to get one, given that scientific studies have shown that the benefit outweighs the risk for most people. Although she hesitated, I unfortunately could not convince her.

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ICD-10 Keeps Getting More Painful

As I previously discussed,  a year ago we transitioned from the disease classification ICD-9 to ICD-10. That has been painful, but they keep making tweaks that require more work.

I guess the powers that be decided that more than 155,000 diagnoses were not enough when they recently changed many diabetes diagnoses (a day or two ago, at least, my organization implemented the latest edition). Now it’s no longer sufficient to say that someone has Type 2 Diabetes Mellitus with Diabetic Neuropathy [E11.40], for example, but I now have to specify in addition whether it’s with or without long term insulin use, or if it’s unspecified. That means all my carefully constructed Problem Lists on my patients no longer work. Every diabetic medication I reorder will have to be changed as they are associated with a diagnosis.

Across all my patients I’d estimate that’s close to 1000 changes I will need to make. Assuming it takes me 30 seconds each time (I’m probably a lot faster than most of my colleagues) that’s over 8 hours, so a full work day. Multiply that across all the primary care doctors and that’s a lot of time – about 1000 people working years! We have a shortage of primary care physicians and I think there are many better ways to spend our time.

I typed “type 2 diabetes mellitus” into my electronic medical record. I eventually scrolled to the bottom to see a message that there were 3158 diagnoses loaded, but that the results had been limited due to it being a common phrase! Many of these were synonyms, and one can save favorites, but I think it’s ludicrous that we have so many codes for just one disease. Those who promulgated moving to ICD-10 claimed the higher specificity would lead to all kind of advantages by being more precise, but in reality physicians can’t spend all day just to pick a diagnoses and they are going to pick something close that will satisfy the billing system. For many diagnoses you can’t even get precise agreement. There are various codes for uncontrolled diabetes, for example, but if you ask different doctors what that means, you’ll get different answers.

Patients with diabetes have to suffer from complications of their disease, increased medical costs, and being stuck more often for blood or injections. It’s too bad their physicians have to suffer more as well.

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Remote Globe Puppy

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The New York times just ran a story about how Mongolia uses a system for their mail where each address consists of three words. A clever British start-up company What3Words divided a map of the world into 57 trillion pieces, each 9 square meters (about 10 x 10 feet), and assigned a 3 word combination to each one.

I checked the address of my office, and it’s crowned.tamed.raced. Given that each address takes up such a small area, I honed in on the map to where the actual rooms in my building are. Here are some of the address I came up with: remote.globe.puppy, patio.thin.ropes, living.quit.exit, castle.lofts.roses, famous.learns.cheek, and minds.agent.former.

I would say that as a geriatrician, living.quit.exit is a pretty good description of what I do, but from a marketing perspective, I’d have to go with remote.globe.puppy.

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Let’s be Clear on ClariSpray

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Bayer, the maker of Claritin, has a new product, ClariSpray. This is a good product, but with a confusing name. It has nothing to do with Claritin, other than they are both used for allergies (allergic rhinitis).

It’s actually fluticasone nasal spray, the same ingredient as Flonase, a prescription product, but now available over-the-counter.

Their website does takes pains to explain this, but there are some things things they don’t mention. They don’t say how it compares with Flonase or Nasacort. Although there are slight differences, and some people may prefer one over the other, they are basically similar, and just a matter of personal preference. Bayer’s website also doesn’t tell you that you shouldn’t take ClariSpray if you are taking Flonase or Nasocort, or one of the other nasal steroid sprays only available by prescription.

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Healthy Snacks

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I was pleasantly surprised to see this sign at the edge of the produce department. Good job, Fred Meyer!!

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