Tap, Tap, Tap... the White Cane Arrives...

Right now my cane is folded and
in my purse more than it is
 straight and in front of me.

It was morning and my husband had invented an errand to get himself out of the house – I was just a bit crabby and beside myself. The White Cane Lady was supposed to arrive at 10, and I was increasingly anxious as the moment approached.  I positioned myself in the hallway so I could look out the front window through the slats in the shutters, without being seen from the street. I waited and waited. Right on time she drove up. No cane in sight. She went to the trunk of her car, rummaged around a bit and pulled out what I instantly knew was a folded-up cane in a plastic wrapper. My heart was pounding.  Being presented with a white cane was going to be a life-altering event, something akin to being pinned with a Scarlet “A,” only worse.

I went to the door and let the WC Lady in. “I’m very, very anxious,” I said. Not missing a beat and ignoring any hesitation that I had, she said  “Let me show you how to open it.” Out of the plastic, she held on to the top part of the cane and said “hold it close and upright so you don’t hit anybody with it.” She let it go and poof it was 44 inches long. Just like one of those those self-erecting tent poles. “Now, you try,” she said.  It took a couple of times, but I managed.  She showed me how to hold it - like you would a golf club with the index finger on the outside pointed downward. I did ask her if I should be wearing sunglasses and she said no, they only do that on TV.

For the next hour and a half or so, I was too absorbed to be anxious. The cane becomes your vision from the waist down, the WC Lady explained. It’s not a crutch or a substitute, but rather an extension of your senses.

She showed me how to store the cane in the car when it is extended. We drove (she drove, not me) to the supermarket, and I learned how to get out of the car with the cane. In the store, I walked up and down the aisles, looking straight ahead, not down at my feet.  It makes perfect sense. I’ve been bumping into things for some time; I realize now that it was because I was looking down and not in front of me.  

I started seeing with my ears too.  I learned that the aisles with canned goods are quieter than the ones with boxes of sugar and cake mix. I learned to listen for the sound of a cart coming towards me and going away from me.  Somehow, carrying the cane helped sharpen all my senses.

I had a problem getting used to the rhythm of walking with the cane. It takes some practice. With the left foot out, you move the cane out to the right side to protect the right side of the body with the next step.  Right foot forward, move the cane left. Left foot forward, move the cane right. Tap, tap, tap. All I could think of is line dancing and I don’t do that well, or the cha-cha-cha and I don’t do that well either. I did practice coming to the end of an aisle and “bumping” the cane into the dairy section. I started to get the hang of it, but it will take practice.

When we left the market, it was time to cross the street and get back to the car. At the crosswalk, we stopped and listened. To a truck, an idling car, a moving car, no cars. If I’m not crossing the street, I learned not to look at the street. Because of the cane, drivers, will or should be anticipating my next move. If I’m not crossing, I don’t want to act like I am. Phew, this was hard work.  I couldn’t imagine how young Helen Keller did this with both no vision and no hearing.

When I got home, I realized that I wasn’t feeling sorry for myself any longer, that I had paid the utmost attention to my lesson and that I had learned quite a bit. It’s true: this wasn’t just about waving a white cane, it was very much about listening and becoming aware of the environment.

The WC Lady came back a few days later. This time we went to the light rail station. I learned how to go up and down steps and cross the train tracks. Using the cane I found holes near the tracks that could have tripped me. At the ticket machine I went to put in money for the full fare and the WC Lady stopped me. I was now qualified for the disabled fare, she advised.

Hmmm… I immediately wondered if there was a disability fare on the commuter train between Baltimore and Washington DC.  (And there is, by the way. From now on, my roundtrip ticket to DC is 6 bucks and not 12!)

The light rail came and I used the cane to find and navigate the steps.  We sat down and other passengers started to talk with us. How odd. I had a white cane and I was laughing. We rode to the airport, and along the way, my teacher was pointing out different things to me – I became aware of the number of stops we traveled.  She noticed the inconsistency of the person announcing the stops. She asked if I could identify and use the STOP request button, which is really a tape. Talk about feeling like you are all thumbs!

When we arrived at the airport station, she watched me get off the train. Sweep the cane more to your left, she said. Cover the space in front of you to approximate the width of at least your shoulders. Don’t be so robotic, she said. I noticed the change in texture where the sidewalk met the door jamb, and then felt the waxed slickness of the airport floor.  

There was no one in the international section of the airport so we chose to practice on the escalator there. Up and down the escalator we went. I held the bottom of the cane against the second step up in front of me. When I no longer felt a step, I knew I was at the top of the landing. Wait until you feel the little bump, and then step off.

Coming down the escalator, I reversed the procedure. When the tip of the cane hits the bottom of the escalator, wait for the bump and step off. I went up and down many times. And people were getting very confused watching me go up and down. My guide walked away once and I was all alone going up and down, up and down the escalator with my eyes looking straight ahead. Even I was ready to laugh!

We walked over to a more crowded section of the airport and I deliberately stood with the cane, smack dab in the middle of travelers.  One person with a ton of luggage walked directly towards me all the while looking up at an arrival/departure board. I had to duck and dodge to avoid a major collision. We walked around some more and a few people politely moved out of my path. We went to my problem area, the pesky escalators with the inconsistently placed yellow stripes, and we/I practiced more. Feeling quite good about my excursion, we went back to the light rail station and came home. It was obvious to the others on the train that I was “in training” and it was all ok.

The next morning, my husband and I went out for a walk and I took my cane to practice. Cane to the left, right foot forward; cane to the right, left foot forward. Again, and again. When you sweep to the left, the distance between the cane and the left foot is greater than the distance between the cane and the right foot. The left foot is going to go where the cane just swept.  The whole idea is to check out the space where you are about to walk. Got it?

All right, so my training wasn’t so bad. I felt very safe and secure with the WC Lady. I even felt empowered. My husband even commented that I seemed to be paying more attention to my surroundings, which was true; normally I’m lost in thought. Can’t do that any more.

WC Lady and I plan one more visit. We are going to go on the commuter train to DC, take the DC metro and walk to work. In the meantime, I am on my own.

I began to carry the cane with me everywhere I went -- to work, when traveling, and doing errands. But I carried it folded up, in my purse. I was just too afraid to take it out and use it. A crazy fear, but a big one.  Afraid of being looked at, of being vulnerable, of being pitied… you know, the Scarlet “A” thing.

I took it to DC one day and bravely opened it before I got off the train. I figured I’d try it out walking the platform in Union Station and on Metro. I was very self-conscious. I didn’t notice any difference. At the airport, most people had been very polite and considerate. Here, they ignored me, bumped into me, and on the metro, not one person even thought to offer me a seat. It’s very hard carry a brief case, a white cane and hold on to a pole to maintain balance. I was not a happy camper! At least I tried.

I went to New York and went out to dinner with my work colleagues. When we left the restaurant, it was pitch black and I was in totally unfamiliar territory with a couple of blocks to walk. If ever there was a time to use the cane, this was it, but I just couldn’t. I still couldn’t use the cane in front of people that I knew. That old Scarlet “A” again. I said out loud that I wasn’t comfortable walking. My colleagues became uncomfortable. One asked if I wanted his arm. “No.” “Carol, are you ok?” “Yes,” I said.  It was a long walk back to my friend’s apartment. What was this stubbornness all about?

The next day I went to the train station with my friends. Their train left before mine. It was 5:30 pm on a Friday afternoon and the place was mobbed.  Waiting for a train at Penn Station in New York is something like a rugby scrum. Everyone clusters around the big board that lists the departure gate numbers. They don’t announce the gate until just a few minutes before departure, at which time a huge mob rushes to the gate. This time the white cane helped, but not in the way you might expect.

I took out the cane, opened it, held it close to me but made it very visible, and approached the information desk. “I can’t read the board. Can you tell me what gate the 6:00 pm Acela will leave from?” The clerk did a double take; they’re never supposed to give out the gate number before it’s announced, but seeing the white cane, he said quietly, “Go stand by Gate 9.”  So I walked over to the Gate 9, sweeping the space in front of me.

And that was just the beginning of the good things the white cane did. Once I was at Gate 9, people took notice, and several asked if they could help. Someone carried my luggage down the escalator for me, and that allowed me to focus on the steps. I swept (left… right… left…) my way to the train, got on and took a seat. I left the cane open and visible and had it leaning on the seat beside me. My seat-mate was very friendly, and we chatted off and on. About an hour in to the trip, she asked if I wanted something to drink. Yes, that would be lovely and I tried to give her some money. No she said and returned with a diet coke. We had a delightful talk – I extolled the virtues of Apple for all of its accessibility options, only to learn that she worked for Microsoft!

Back safely in Baltimore, I got off the train, still using the cane, and swept my way over to hop in the car and go home with my husband.

A couple days later, I was in the airport awaiting a flight to a conference in Las Vegas.  I was using the cane. I was standing in the Southwest boarding line when I heard a familiar voice and discovered an old friend standing right behind me. He already knew about my eyes and had always been sympathetic, but as soon as I realized he was there, I folded up the cane and put it away.

In Vegas, it would have been great to walk up to a Roulette or Blackjack table with the cane, but I didn’t. I only used the cane once – when I went to see the Lion King by myself. I needed to ask the usher to help me find my seat. And I did take and use a portable illuminated magnifier to read the PlayBill.

Finally, the other night I was in DC with some folks who had read the earlier entries to the blog. Several were interested, and asked questions. I had the cane with me but it was folded up, though it was visible sticking out of my purse. I’m not sure why, but even though I’ve been thoroughly “outed” (by myself, mostly), it is still difficult to actually use the cane in the presence of people I know. Sometime I take it out and show people how it’s used, but then I fold it up and put it away again.  The urge not to be different is a powerful instinct.  This new existence will take some time to get used to.

My world crashes and then comes up again...

Illuminated Portable Magnifier

I left Dr. Low Vision’s office, went home and ordered three different magnifiers: a portable one, a standing one and some spectacle clip-ons that could be used over my regular glasses. It took about 3 days for them all to arrive. The two magnifiers were illuminated and worked well enough, but it’s awfully hard to read a story when only the left side, or the right side, or the middle of a paragraph appears in your field of vision.  You really have to get used to moving the magnifier around.

Good idea, but not for me!

I was so excited when the clip-ons arrived. I opened that package immediately; I had the beadwork ready to try them out. What a let-down!  The plastic lenses weren’t any better than the stuff I already had.  I was starting to wonder if all this effort would be worthwhile after all.

A few days went by, and I received a call from a rehab counselor from the Division of Rehab Services. She said she had a referral from Dr. Low Vision, and that I needed to complete some paperwork. Then we would set up an appointment and get moving with the evaluations. She mentioned an “O and M” evaluation and I said “What’s that?”  Ms. Bureaucrat said “Oh, to see if you need a white cane.”

Major meltdown!  “Who said I need a white cane?” I asked in a high voice that was getting higher by the minute. “I don’t need that! “ Ms. Bureaucrat said that Dr. Low Vision had ordered it and that I should talk with her.  I said I would. Nevertheless, we set up an appointment. All I really wanted was the machine that would allow me to do my beadwork. I hadn’t bargained for a white cane!

I stomped around the house for a few days and was very unhappy about this white cane business.  What did I say or do that made Dr. Low Vision think I needed a cane? Finally, I decided to send her an email.  My question, in milder form, was basically “how dare you refer me for an evaluation that includes a white cane?”  And her answer right back was “When I asked about your comfort getting around in dark or unfamiliar areas, you indicated a bit of uncertainty…” And then, in typical Dr. Low Vision style, she said, “there is a lot more to a mobility eval than the white cane. There are other tricks the O&M (orientation and mobility) person can teach you.”

Ok, I thought. But I still stomped around some more. The seriousness of my visual impairment was sinking in. Maybe I did need a white cane and maybe this eye thing was more serious than I thought. In my opinion, I could still see well enough for most things; the idea that I was so nearly blind as to require a white cane was not just shocking, it was – well, sort of insulting. My self-image was under attack, and I did a lot of stomping around and venting my resentment.

A week later, my husband and I drove to Annapolis again, this time to meet with the Rehab Counselor. She explained that DORS (Division of Rehabilitation Services) was a service available to all Marylanders.  I explained that I was working and made a decent salary. Doesn’t matter, she said. The purpose is to keep me working. The evaluations and recommendations are available to all Marylanders regardless of income.  She asked a billion questions (later, my husband would say she was “thorough”) and said she would gather the information to determine the degree of my disability. In the meantime she would set me up with a rehab team, including a specialist in orientation and mobility.

Ugh, the white cane thing again.  I was defensive again. I’m not disabled, I can drive! I can just imagine driving into a parking lot and then getting out of the driver’s side with a white cane! She then told me that people with visual impairment do this all the time. They use their canes to test depth and changes in the terrain, especially in low-light conditions.

We left her office and went home to await the rehab visits.  My first appointment was with the dreaded White Cane Lady. She came to the house and we sat in the living room. She asked me questions – I told her I had problems getting around in dark and unfamiliar places.  My commute to Washington is hard – maneuvering around all the people on the train platforms.  Once I get on an escalator, I hold on for dear life.  We talked about the yellow strips on escalator steps, and how they are often misplaced.  Curbs can be tricky, as can almost any terrain that is uneven. Airports where the floors are shiny can be tricky. She measured me for a cane and we made two more appointments.

My next visit was from a computer guy. He came to the house and we/he adjusted my laptop and iPad to enable all of the accessibility features. The Mac is even more amazing than I thought. In addition to the zoom in and zoom outs, you can change contrast, font size, colors, etc., etc. It will also read the dropdown menus aloud to you. And the iPad has special zoom features too. We made another appointment so I could try out a variety of the CCTVs, the special camera machines that really, I MEAN REALLY, enlarge print. After the tech left, I felt very enabled!

These are phenomenal for stringing beads
and also for hiding the ends of yarn
when changing colors

My third visit was from a rehab specialist who knew all about special gizmos and gadgets. She had quite a goodie box with her that included orange dots to mark settings on the TV remote and microwave.  You can use one of the raised dots to stick on a button, or the orange material around a dot to highlight a button. Much to my husband’s dismay, we walked all around the house marking settings on the washer, the dryer, the oven, and anything else that had a tiny number on it. She brought big-eye needles for sewing and she showed me how to use dental floss holders to use as beading needles. Brilliant!

These tools would make any beader, jeweler,
sewer happy!

She told me about some simple tricks like putting a rubber band on the shampoo bottle (to differentiate from the conditioner) or a diet soda (to differentiate from the beer), to have a special shelf in the fridge for the stuff I use all the time, and to put labels on salad dressings and other things I use. She showed me special pens (I won’t use anything else now), check writing guides, talking clocks. There are knives that help cut even slices of bread or tomato. There is something to help a person who has a visual impairment do just about everything. From this amazing catalogue, I ordered a pair of scissors and a pair of pliers that had magnifiers attached, and a combination lock that is based on directional movements rather than tiny little lines and numbers.

I was feeling pretty good again, but I was still dreading the white cane visit. I don’t want a white cane. I don’t need a white cane. I really, really, really, really don’t need a white cane. Honest.

Big, Bold and Bright...

Retinologist Number 5 referred me to Dr. Low Vision, an ophthalmologist who specializes in helping people with visual impairments.  I filled out a series of papers – questionnaires, data sheets – all in big print – and made an appointment to see her. The appointment was only a month away, but it felt like an eternity. For 15 years, I’d been grappling with my “interesting” eyes and suddenly there was a whole new dimension:  I could do something about it.   I had now acknowledged that I needed and wanted help, and I was going to get it.

On the day of the appointment, I gathered up my Kindle (I wanted the doctor to check the settings) and all my other eye paraphernalia.  Together, my husband and I drove to Annapolis.  Dr. Low Vision sees patients at several different doctors’ offices, and stays booked up well in advance. The first appointment I could get was at an Annapolis office.  We arrived a few minutes early, and were people-watching in the waiting room when we saw a 50ish woman walk in dragging two wheeled cases. She had on a comfortable long dress (like I wear) and a streak of blue in her hair. We guessed instantly that this must be her; if she’d been a patient she wouldn’t have had all the baggage, and if she’d been a drug company rep she’d have been more fashionably dressed.

Sure enough, in a few minutes the woman came out with a folder in her hand and called my name. This was Dr. Low Vision.

She had my medical record and all the pictures from Retinologist Number 5, so there were no bright lights in the eyes this time; all she had me do was read the standard eye chart. I liked her already. Within minutes, she was going through her sack of goodies and pulling out all sorts of gadgets and gizmos. “Big, bright and bold,” she said, “That’s what we’re after.” For the next hour, I was like a kid in a candy shop. I tried a variety of different magnifiers. I learned that there are lots of different kinds and that choosing the right one is almost like being fitted for glasses. I learned that I should ignore the manufacturer’s “power” rating like 3X or 4X, and look for the diopter value.  “Power” rankings are like women’s dress sizes – they vary from manufacturer to manufacturer. Diopter values are standardized across all brands, and give you a much better idea of how well they will work for you.

I learned about sunglasses. I tried on all different colors of sunglasses, and learned for the first time that the colors were for more than just fashion. Brown lenses increase contrast, especially in overcast hazy light. Yellow increases depth perception. Gray is good for color.  Who knew?

She adjusted my Kindle. I had already changed the font to the sans serif to make it more readable, but she widened the line spacing and it made all the difference in the world.

We talked about escalators. Escalators all have a yellow stripe on each step, but about half of them have the yellow line on the inside edge, not the edge you’ll fall off if you can’t see where it is. She agreed it makes no sense. For my part, I’ve started using the elevators.

We talked about driving . . . sigh . . . and she said, “we’ll keep you driving as long as we can.” I talked about my crafts and she recommended some clip-on magnifiers. She was wonderful and had an answer for just about everything.

Mid-way through the appointment, she left the room and came back pushing a cart with a machine on it. It had a small camera and a large monitor. I looked at it and said, “I don’t need that!” She turned it on, put a newspaper crossword puzzle under it and then left the room for awhile. I started playing with the buttons and I couldn’t believe that I could read the clues and see the numbers on the little boxes. I could also put my hand under the monitor and write with a pencil.  When the doctor came back into the room, I told her I thought the machine was way cool. It would help with reading paper and print (I’m all Kindle when it comes to books), AND I could do my beadwork under it! OMG!

I suppose it was a therapy session as much as an eye appointment. Dr. Low Vision was my vision from heaven. I thought about a former neighbor who had low vision, and became completely housebound because of it.  I thought about Retinologists 1 through 4 who were so focused on my retinas that it never occurred to them there was an actual person attached to those eyeballs. Every retinologist should know about low-vision specialists, and should make it a point to tell people about all the stuff that is available. 

How do people learn all this, I wondered? I’m an expert in health care delivery and in aging and I didn’t know any of this! And then it dawned on me – most people don’t know.

Dr. Low Vision gave me a catalogue with all kinds of neat gadgets in it. She made some recommendations for me about magnifiers and also referred me for rehab services through the State of Maryland. I wasn’t quite sure what “rehab services” meant except that I was very interested in the machine that might help me continue my beadwork, and Dr. LV told me they could help with that.

I left the office with a big smile, ready for the next step of the journey. 

Six Little Words -- How are you dealing with this?

Some have asked me “How did this all start?” It started innocently enough.

About 15 years ago, my husband and I had afternoon appointments at Lenscrafters to get our eyes checked for new eyeglass prescriptions. My appointment was about a half hour before his – we each had different doctors.  Well, he was in and out with a new prescription, and I was still in the examining chair. My doctor clearly saw something in my eyes that concerned her. She called in the other docs and then at 5:00 pm on a Saturday afternoon she called the Wilmer Eye Clinic at Johns Hopkins Hospital to schedule an emergency appointment for me.

When my husband and I got there, a very nice M.D. / Ph.D. ophthalmology fellow was waiting for us. For the next five hours he put drops in my eyes, shined white lights in my eyes, took pictures of my eyes and asked me to read letters that were 20 feet away. Finally, he told us we should come back Monday morning to see the experts. We left exhausted, hungry and uninformed.

My vision was ok to me. I thought this was a very painful waste of time – much ado about nothing. Monday we went back to Wilmer and the doctors were again very interested – not in me, but my eyes! They examined and examined, conferred among themselves, told me they had diagnosed me with pattern retinal dystrophy and sent me on my way.

At that point, we switched from the shopping mall optometrist to a Wilmer ophthalmologist for our annual visits. Every year, I would go for my exam, the ophthalmologist would panic and send me back to the retinologist at Wilmer.  I would dutifully visit the retinologist, she would affirm my diagnosis and I would be on my way.  Nothing could be done about it, she said.  She was very nice, but unhelpful. Come back next year, and we’ll tell you how much more your vision has deteriorated.

Eventually that retinologist moved away and I stopped going to Wilmer. My vision started to deteriorate.  I started missing parts of words and things were especially blurry. I kept getting new glasses, always thinking that the glasses would help me see better. I love beadwork and I tried a million different magnifiers to help me. Nothing really helped.

I started seeing a new retinologist and it was a horrible experience. I went into the waiting room and there were probably 50 people waiting. After waiting an hour, I was called by a technician who gave me drops, then called by another one who took pictures,  then was shuffled into an exam room where I waited for the doc. He came in, shined light in my eyes and was out the door before I could ask a question. I figured he saw maybe 200 patients a day – a real Medicare factory. I went back twice and then gave up.

Because the retinologists had a doomsday attitude, so did I.

Last year, my opthalmologist encouraged me strongly to go back to the retinologist. I said I wouldn’t go back to the old one and so he gave me the name of a new one. Retinologist Number 5, I’ll call him.

My husband came with me. It was a smaller office. I was seen on time. Number 5 examined my eyes and showed me the pictures. He showed me the blind spots and told me that I had a two- to ten-year window of progression. Then he asked,  “How are you dealing with this?”

No one had ever asked me that before. I was completely taken aback. Instantly, I blurted out “I’m fine.” He then softly said “When you are ready, I have someone who can help you.”

Six months later I went back for another visit. Short wait, lights in the eyes, pictures. No change, Number 5 said. And then those words again: “How are you dealing with this?” This time it wasn’t a surprise. With tears in my eyes, I said “Not very well.”  I didn’t tell him, but I had signed up to go my annual beading convention and I wasn’t taking any classes where I would have to work with small beads. I couldn’t see them any more.

I had also washed my hair with hand lotion a few times. I misread an airplane reservation for my husband and he missed his flight. I had stumbled on an escalator at a subway stop, and banged up a knee. I was beginning to feel very uncomfortable getting around in Washington.  I found myself making up reasons not to go places if I had to drive – even familiar places. The highway signs didn’t say the same things that they used to.

So this time, when Number 5 asked that piercing question, I said I was ready.

Pattern Retinal Dystrophy or Multiple Scotomas

What I see with my right eye

So, what is my vision like?  Fortunately I have two eyes and one is significantly better than the other. I have multiple scotomas in both eyes but the right one is much worse. Scotoma are blind spots on the macula. The macula is the part of the retina that permits central vision, what you focus on and what you want to see. Imagine looking at a person’s face and seeing only a grayish blur. My left eye compensates some, but it distorts the upper right corner of what I see. When I look at a street sign with both eyes, I simply can’t see some of the letters. Lombard becomes Lombd.  My brain compensates some: Cradle Rock becomes Candle Rock. When I take an eye test I can’t see all of the big E; when we move down a few lines, I can’t see all of the letters.  I have to move my head around to find the letters and even then it’s hard to tell what belongs where. Straight lines become squiggly. Going down an escalator with all those silvery metal lines is really scary. There is little depth perception. Reading is a blurry mess. I’s, X’s, H’s, M’s and N’s get mixed up. R’s, S’s, B’s P’s and D’s do too. Threading a needle at 62 years of age is really hard; with blind spots, it’s just about impossible.

Right now, there are no cures or fixes. What I have is genetic.  My dad had it and some of my siblings do too. It is similar to the dry form of macular degeneration. Glasses don’t help - you can’t correct what you can’t see. My right eye corrected is 20/120. The other eye is 20/60. You need anywhere between 20/50 and 20/70 depending on the state in at least one eye to drive. So, I pass that test. BUT, I oly drive in the daytime, in good weather conditions and where I know where I am going, and not dependent on street signs.

There is test that you can take to see if you have “macula issues.” Close or cover one eye, and stare at black dot on the Amsler grid. If all the lines stay straight and perpendicular, you’re good to go.  If you see some curvy lines on the chart, time to go to the eye doctor. Check both eyes! A sudden change from straight to curvy can mean development of “wet” macular degeneration – a leak or bleed under the macula. This can actually be helped – all the more reason to go to the eye doc immediately if it happens.

Amsler Grid to Test Eyes

There is an excellent app for the iPad and iPhone called Macula Tester. it allows you to test your eyes by marking the curvy areas, take a picture and track your the progress. 

These are the blind spots in my eyes.

So, this is my story. My eyes don’t capture everything, especially in dim light.  This is a form of “low-vision.” Magnifiers help, but they don’t fill in for the blind spots.  BUT, with the right doctor and resources ...