Sep 21 2016 - Socket 101

I am having to learn more and more about prosthetic socket design.

Socket design deals with the interface between carbon fiber/titanium, and the soft squishy parts. It is nowhere near as interesting to me as the bio-mechanical or electronic knees.

While socket design and building, is the less "sexy" part of prosthetic wear, it has the distinction of being the most important.
A comfortable, pain free socket will be worn all day.
An uncomfortable or painful socket will get little use.
I would more likely wear a good socket with a broomstick on the bottom, than I would wear a million Rand bionic leg that fit poorly.

A well designed bionic knee may be used by thousands of people, but because every stump is different, every socket must also be different. A prosthetic knee is science and technology. Designing and building a good prosthetic socket, is art.

For trans femur amputations, the shorter the femur, the less stump to attach a socket to. Every inch shorter the femur is cut, means almost 10% more energy required to walk on a prosthesis. That is one reason the Paralympics classification system can not ever work. Every stump is a different length.
All the top T-42 athletes (Amputation above the knee) are knee dis-articulation amputees. In a knee dis-articulation, the leg is amputated between the femur, and the shin bones. No thigh muscles are cut, and the femur remains intact. This also allows the full body weight to be applied to the end of the femur.
Before my amputation surgery, the Doctor and I discussed whether it would be necessary to cut my femur. It turned out I had a suspicious growth just above and behind the knee. It was decided to cut the whole suspicious section away, and that include about 1.5 inches of femur. This left me with a shortened femur, but a relative long, shortened femur. That extra length means more leverage in stump movement, and more area to attach a socket on to.

 There are basically three different socket design theories. Most sockets are a combination of all three designs:

1. Plug socket. This is what the peg leg pirates wore. Basically a cup that the stump fits into. Most of the body weight is supported not on the end of the stump, but on the fat around the top of the thigh. My last adjustable, socket with all the holes was like this. Usually plug sockets are held on to the stump with belts and straps.

2. Ischial containment socket. When you sit for a long time on a hard surface, (like stadium bleachers) discomfort comes from the pelvis bone pushing on the skin and muscles against the bench. This part of the pelvis that you sit on, is called the Ischial bone. An Ischial containment socket makes a small cup like platform on the top of the socket, that cups the Ischial bone. So while standing or walking, the body weight is on the Ischial bone, and not on the stump. These sockets are held on with suction between the end of the stump, and the socket. My old Texas flag socket was like this. It tried to keep all the weight off the stump, and put it onto the Ischial bone. As you can imagine, walking with the Ischial bone cupped, is not pleasant. Another uncomfortable thing with Ischial sockets is sitting down, because of the Ischial lip pushing into the thigh.

3. Quadrilateral socket.  This type of socket is sort of a square shape instead of being shaped like an oval. It tries to control and contain the movement of the femur within the stump. It puts much of the body weight on the skin and muscles of the stump. By me adding lots of thick foam pads in my last adjustable socket, I was turning a plug socket into a quadrilateral socket. These sockets are held on with suction, or vacuum.

Here is a picture comparing the Ischial socket, with the quadrilateral socket. Both are for a left stump, and the front of the stump is to the right of the picture.

You can see where I circled  the "seat" for the Ischial bone. Also see how the Quadrilateral squeezes the thigh to hold the femur from moving around.

Most modern sockets are a combination of all three types of socket designs.

Yesterday I spent a few hours at the prosthesis place. We looked at and talked about all my foam insertions in the socket that I wore over the weekend. I wore the prosthetic leg about 6 hours on Saturday, and 12 hours on Sunday. Being able to adjust the tightness was welcome when wearing it for long periods of time.
I felt more like I was wearing a crutch that fit on my stump, more than a walking prosthesis. The farthest I walked was to the mailbox, about 10 Meters. It caused no pain, but was very uncomfortable. If it was my permanent prosthesis, it would live in the closet, not on my stump.

Yesterday Bradley took another cast impression of my stump. He wants to build a quadrilateral-ish style socket. One that tightly controls my femur. Holding it in place and immobile. My femur tends to move in an outward, (Doctors call this Abduction) sideways direction when I put weight on the stump. The movement, while not painful will result in pain after a few hundred steps.

The previous sockets that I was able to do the 5km runs in, also strongly controlled the femur, but as my stump shrunk in length, the femur was forced into the stump end, and this soon made that type of socket painful, and hurt me inside the stump end. This put me in a wheelchair for a few months.

Then we tried the Ischial containment, which helped to reduce the pain from the socket on the stump end, but was very uncomfortable.

Today I go to Bradley again to try a new socket. This one will be more of a quadrilateral design. It will tightly control the femur, and at the same time not allow the femur to press against the stump end, by supporting my weight with use of a small Ischial cup, and the fat around the top of my thigh.
I guess you could say, that this socket I'll try today is 10% Ischial, 30% Plug, and 60% Quadrilateral. It will be held on with suction.
I will have to wear a different silicone liner. This one has a soft ridge around it to seal in the suction. This liner is thinner and larger than my other one. Much easier to put on. :-)

This may look a tad phallic, if your weird. :-)

Many people confuse "suction" with "vacuum".
Suction is caused by trying to remove something, from within something, without any way for air to get inside to replace what is being removed. Vacuum is when you actively remove the air from a container.
My sockets so far have been suction. As I push the stump down into the socket, the air is squished out. The design of the liner prevents any air from getting back into the socket, so a suction is formed between the end of the stump and the socket. There is a small valve at the bottom of the socket for the release of suction and allows air back into the socket. Otherwise I could never get the socket off.
Some very expensive, modern sockets are held on with vacuum, not suction. There is a small air pump that sucks air out of the socket. This "elevated vacuum" makes the entire stump swell to the exact shape of the socket. It gives a very firm and perfect fit between the stump and the socket.
There is so much R&D needed for medical equipment, and so few actual sales, that prices for all prosthetic hardware is very high. For me to buy an elevated vacuum system, I would first need to sell my house.
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18:00
I am just back from Bradley's. My new socket feels great so far.

You can see the lip for the Ischial bone. It is about a 30% Ischial, 30% Plug, and 40% Quadrilateral.
The Ischial seat is great for standing, but rubs a bit while walking. My stump goes quite far down into the socket, but the Ischial lip stops any further going in.
I'll try it for a few weeks, then go back for a fitting. I am sure that wearing it lots will force the stump to shrink even more.

For the first time in many months, I am thinking about going to the USA I think if I had a good prosthesis that could be worn all the time, then getting around inside the RV would not be to hard. Showering would be just about impossible. I will need to do a sponge bath.
I can't wait for tomorrow when I can play with the new socket a bit.
I am excited.....
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Sept 15 2016 - New socket, Driving, Paralympics.

I spent yesterday at the prosthesis place. They built a new socket. It is a very complicated socket. Slit right down the front, and held closed tight with velcro. The velcro wasn't strong enough, so I added a big hose clamp also.

 The new socket is not as light as you would think with all the holes in it. The remaining part is thick and strong. It is made to be worn with a thick plastic fexible inner liner. Eventually the liner should be permanently attached to the socket.
One major problem we have now is that my skin sticks to the liner. Which is good to keep it on tight, but bad for putting it on. My stump pain is bad when pushing the stump down into anything. So if the liner and the socket are attached, then I would have to push very hard to slide the skin against the liner. That is what we are trying to avoid. Lubrication is a bad idea because then the stump would also slide out of the liner easily.
My previous liner was a flexible silicone sleeve that sort of lived on the stump, and was used to form a vacuum between the liner and the socket. As you can see, it would be hard to form a vacuum with all the holes in the new socket, so the vacuum is between my skin and the plastic liner, then the liner somehow attaches tightly to the socket.

This afternoon, I went for a short shopping walk in the local shop. I needed food. The whole apparatus was very uncomfortable. There was no pain, but the intense desire to remove the leg right there in the store was hard to resist. With no way to securely attach the liner to the socket, the liner was sometimes loose. In the store, reaching for garbage bags, the socket and leg fell off. The liner was still on tight, so I was able to put the socket back on. But it never got on tight enough again to walk on. It was like I had a crutch on my hip. I sort of shuffled the rest of the way through the store to the car. I didn't get some of the stuff I needed.

Tonight I am cutting pieces of foam to fit inside the socket to make it more comfortable

Bradley gave me many types, and thicknesses of foam.
The next big thing is to get the socket and liner to stay together. Some sort of clamp or snap, or something.
I don't see anyway to "not", put the liner on before inserting it into the socket.
My stump didn't pain me today, but right now it is not feeling very pleasant. It is funny to me to be so uncomfortable, without real pain. I fear it takes strain in ways, I hadn't thought about.
 But with all the problems, I was able to do my shopping on my own. A big step for me.

After a few days of playing with the foam to make the socket more comfortable, I think they will build a new socket similar to this one, but with extra thick carbon fiber where I now have the pads.
--

The driving school collected me this morning at 04:45.
We went to the Traffic department test center. I was 12th in line. Before they opened at 08:00 there must have been 5 hundred people in the line.
I did my eye test, and then paid lots of money, and got a date to take the learners exam. 28 Sept at 10:00.
 I have 13 days to study. If I pass the learners exam, then the next day I will go and book a date for the driving test.
I talked to some of the guys there. One was going to take his driving test today...for the third time. He booked 3 weeks before. After his flunks, he had to re-book. Once was a wait of 5 weeks between tests. He first booked his learners test in mid June. 3 Months and 6 full days of testing. What a waste of human time.

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I have been watching the Paralympics. One of the largest Prosthetic makers "Otto Bock" does charitable emergency repairs of prosthetics at the Paralympics. So far this year:

Repairs by equipment
Wheelchairs: 2245
Prosthetics: 348
Orthotics: 134
Repairs by Sport
Athletics: 385
Wheelchair Basketball: 258
Wheelchair Tennis: 163
Powerlifting: 140
Swimming: 122
Total Games repairs so far: 2727

They talked about how the Paralympics is becoming all about technology, science, and electronics.

If a prosthesis becomes an essential part of who you are, then it would be part of what makes you, you. Biology alone will no longer define a human being.

Nerves transmit muscle signals at 119 meters per second.
Nerves transmit pain signals at a very slow .6 meters per second.
Nerves transmit touch signals at 76 meters per second.
What if you had a brain interface that detected a thought for a muscle movement, changed that signal into an electric signal, and sent that signal to a muscle via wires at almost the speed of light. You could have reflexes that are thousands of times faster than a normal human. Tennis anyone?

What if you had a system (like a SCUBA system re-breather) that could inject oxygenated blood cells directly into your blood stream. You could hold your breath for hours.

What if your artificial heart had a boost function to speed up the flow of blood throughout the body.

What if you had a helmet that could measure brain functions, and could generate these function. An athlete could then use this to stop pain signals. Professional football players would love that.

A fancy prosthetic electronic knee could evolve into a leg system...into a lower body system, into a complete body system. So a completely paralyzed person could be an athlete...or a super athlete.

 Now blind people "drive" to the shops in driver-less cars. Putting the same electronics on the head, could allow a blind person to walk to the store unaided.

Soon a blind, paralyzed person will be able to kick ass in ping pong.
Pure biological people will be severely disadvantaged in the near future.

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Sep 12 2016 - Dying Friendships

I am growing apart from many of my good friends. The things that we once had in common, are fading away. I blame myself, and the fact that I have such a lack of commitment, and a short attention span.
"Always tired of things that are, and want the strange and new."

At various times in my life I have learned and understood electronic OpAmps. The last time was a few years ago. Now I need to know about OpAmps for a project I want to build. But I have forgotten all about them. Do I want to spend many hours of my life, to learn something "again", that I won't use for another few years, and I will have forgotten by the time I need it again?
At various times in my life I have learned and understood DNSSEC.
At various times in my life I have learned and understood fast motorcycles, world finance, aircraft, IPv6, programming, and meditation.

Because I am always trying new things, and never stick to one thing, I am a master, of nothing.
If I had kept to one path, I could have gone far. Most of my friends are masters of some skill or trade. I greatly envy, and admire them for sticking to what they know best.

Now my life is about learning cancer and prosthetic knees. None of my friends need that knowledge. It is not a topic that we naturally share. But because they are good friends, they do learn and share these things with me. They learn about these things only because these things affect me. It shows how good friends, they actually are.

The things I used to have in common with friends and loved ones, are disappearing, or no longer there. It is a real strain on a friendship when there is no common ground such as hobbies or passions.
Some people have been my very good friends for a long time, but now it seems the binding I have with them, is mostly out of habit. I no longer have anything to share or contribute to the friendship, and... I am losing them.
Some friends have decided that the lack of anything we have in common, is reason for them to move on in life, and search for other friends.
 I fear more of my friends, will follow that same path.

--
There is not much worse than a sad, and boring blog.
So, on a lighter note:

I am well into fantasy football.
American football season got going yesterday.  There were 13 games. YEEHAA!! I am playing two teams this year.
Some Fantasy Football money sites now take Bitcoins.

Here are some Fantasy Football news quotes...

"Spending & Saving Tracker said 74.7 million Americans plan to participate in fantasy football this year, spending $4.6 billion."

"In 2006, the Unlawful Internet Gambling Enforcement Act (UIEGA) banned online poker, but left out fantasy sports. Wagering money on fantasy sports, was deemed a game of skill – requiring knowledge of players’ likely performances – and not a game of chance."

There is a new real, actual, player, a rookie, that I ended up with in the draft. I wasn't happy with him, but he was all that was left. Then another team in my league tried to trade for him. I thought they were crazy, but before I could do the trade, "another" team also tried to trade for him. I decided that maybe he was more valuable than I had originally thought, and so I kept him.
My teams just barely won both of their games this weekend. :-) The player I almost traded away gave me the few extra points needed to win. He is now my hero. :-) I don't even know what he looks like.
Fantasy football is the ultimate non racial sport. Nothing matters except performance and statistics.

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Here is an interesting article:
https://www.rio2016.com/en/paralympics/news/marieke-vervoort-euthanasia-paralympics-belgian-athlete-paralympian-wheelchair-racer-rio-2016

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Sep 05-09 2016 - Pipe legs and Driving

Sept 05 2016
I have been trying to find a way of standing to do dishes, that does not entail balancing on one leg. I came up with a piece of PVC piping that my stump fits into, and I flared the top. You can laugh, :-) but I can stand for hours now.

I also have been working on designing a socket that allows for stump volume variations. By being able to vary the volume, I can keep it tight all the time. I built this.

Again, you can laugh, BUT,... it does not hurt. No Pain. Next is to get both together, and then make a way for the pipe not to fall off when I take a step.

Online I found a socket that looks like it would work, but they want house prices for these things.

--
Sep 06 2016
I went to the prosthetic place today. I told Bradley (my prosthesist) That I want a pain free walking leg by the end of the month. We discussed many, many options.
He made another cast to make another socket. It should be ready by Friday.
We plan on making this socket like a normal solid socket, but without an end on it, so the bottom is open, and also put a slit down the side, and use clamps to tighten it on tight.
I think the best clamps/straps will be similar to ski boot bindings.

My stump pain seems to be increasing, not decreasing. I think the stump is shrinking in length, which put all the muscles, scars, and skin at the end more forceful against the bone end.
--
Sep 08 2016
I spent a few hours with the surgeon today. He thinks we might somehow "pull" the stump end to stretch the muscles and skin to relieve some of the force on the end of the bone.
We need to think on that.

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Sep 09 2016
I'm just back from a few hours with Bradley, the prosthesist. We tried on the new socket. It is similar to the old , hard sockets, but is split down the side to allow adjusting it's volume.
He left the bottom end closed, but wide enough that the stump never touches the bottom part. That way we can still apply a vacuum to the bottom of the stump if needed.
The socket was very tight at the top, and floppy at the bottom. Just like it should be. It caused no pain. He had made this one out of very transparent plastic, to allow seeing where it is tight and where loose by noting skin color.
Hopefully I'll walk away on the new socket next Wednesday.

This whole cancer/amputation thing has resulted in me staying away from Texas for so long that my Texas drivers licence is expiring. It will be cheaper for me to get a South African license, than to travel to the states to get a new Texas one.
I now get to experience the South African bureaucracy first hand. 100% bureaucratic bullshit. It should take a month or two. depending on how many times I flunk the driving test. Without bribing, it usually take a few flunks. Flunks pump up the stats for the inspectors to prove how hard they work, and how many tests they have to do each month.
I just chatted with a lady that flunked her driving test 7 times. Seven is a lot even for South Africa. Three seems to be about average.
I have to first get a learners permit, then I can apply to take the driving test.
--
I just had coffee with a friend at a local restaurant. It was nice to get out and interact a bit.

I have been looking at the paralympics. I look at all the people competing, and find someone worse off than me. Then I look more, and find someone worse off than that person.  Then look some more, and find someone even worse off than that person. It seems there is always someone worse off than someone else. Which I guess really means that I am MUCH better off than so many others.

I read some good observations regarding the Paralympics:

 We could see blind runners taking a course unaided thanks to headsets which can watch for hurdles as well as providing left and right instructions.
(The step from driverless cars, to blind people walking, is not a large step.)

Actually our wheel chairs are like Formula One cars; they're the absolute cutting edge of technology. Thanks to carbon-fibre chairs and precise engineering, the wheel chair weight is down to just 2kg. 
(Mine weighs 18kg.)

The Paralympics is wedded to science and technology. In the paralympics charter, science is a huge part of it. It’s all about enhancement, it’s all about making people better. 
(Able bodied people will soon need body enhancements, or get left behind by disabled people.)

The ‘Brain Sled’ was designed by engineering students at Imperial college, and uses electrical signals in the brain to ‘steer’ a sled in a bobsleigh event. Now we can have totally paralyzed people competing in sports. 
(Is this still an "athletic" competition?)

The current exoskeleton can only walk slowly, and the expensive, computer-controlled hydraulic machines is used to deliver the health benefits of walking to paralysed patients. 
(Isn't an exoskeleton just a step up from a fancy prosthetic knee?)

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Sep 4 2016 - Nightmares and Immortality.

A few mornings ago, I awoke from a nightmare at 03:30. I didn't sleep again till after 05:30.
In the nightmare, my body was covered by hundreds of Angiosarcoma tumors.

There is nothing I can do to prevent my death, and anything I do to delay death, seems to make my current existence less enjoyable.

Sallekhana is the spiritual detachment, and declaration that a person is finished with this world and has chosen to leave it. Usually because of old age, famine, or disease.
It is not suicide. No violence to the body. Just a choice to return the soul to the universe, from where it came.

Energy cannot be created nor destroyed. As I sit here and breath, my body heat is warming this room a bit. Therefore, it is also warming Africa (a tiny bit), and also warming the whole Earth (a very, tiny bit).
The growth of a cactus, on a ranch in Texas, is being affected, by my sitting at a computer in South Africa. (a very, super tiny bit).

 If I die right now, by having rearranged the distribution of energy, I have changed the world.
All my friends are changed. The energy my friends get from the earth, and from the air they breath, is different, because of me.

All the energy, and morality I put into this universe, will change everyone, and everything, till the end of time.
I am immortal. :-)

My immortality didn't keep Maddie from moving on with her life, and finding another man. She has paid her dues by taking care of a husband that died from cancer, then taking care of me, with cancer, and the losing of my leg.
If I was her, I would be looking for someone to take care of ME for a change. I wish her the best of luck with life.

Today I had to go get more prescription drugs at the pharmacy. It seemed like all the stupid and rude people in the world were also at the pharmacy. I came home, and there was no-one to tell about the stupid people. It takes a very intimate friend to care about what I did this day. Today's events were trivial, but I still wanted to share them.

I miss Maddie. :-(

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Aug 24 2016 - Exercises and crutching

21:45
I am in a very lackadaisical mood. I don't know why, and I can't blame drugs.

 I am doing a good series of exercises for all stump muscles and range of movement of the stump. Trying to get the stump muscles and skin stretched so not to cause pressure on the sore spot.
My brother mentioned shoulder exercises to strengthen my shoulder so I could use the crutches better. I used some old weights laying around and did five sets of right shoulder exercises. Then I tried the left side. I couldn't even do one set. My left arm and shoulder are so weak. I was shocked.
At first I thought I must have had a small stroke, and didn't know it. Then I started noticing how many actions around the house use my right arm. The toilet grab bars use the right arm. The bed brace for getting in and out of bed is also right arm. I don't ever seem to use the left arm. Now I have added shoulder exercises to my daily routines.

I have been trying to "invent" a way of getting the silicone liner on without pain.
My latest invention is a string of round beads on a piece of wire. The two ends of the wire are held together with a rubber band. I put the liner against the stump end, then insert the beads against the inside of the liner. When I pull the liner, it rolls over the beads. It causes much less pain, but still not near zero pain.
Next I want to make a tube, of PVC that the liner is stretched over, and when the liner/tube is put over the stump, the tube takes all the strain, and the liner is then slid off the tube onto the stump.
So today I went shopping for a 185mm PVC pipe. All PVC pipes are 160mm or 200mm. One plumbing place gave me  great deal in 1 meter of 160mm PVC pipe. I bought it, even though it is a bit to tight. The only 200mm pipe was sold in 4 meter lengths. R600. Shriek!

I got very tired crutching around. I was being very gentile on my shoulder, and that was hard work.
I went to a hamburger place for lunch, and just sat in the car. The hassle of crutching into the restaurant was not worth the getting to eat. I finally just drove away.
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Aug 17 2016 - MRI results, and getting up from a fall

09:00
After my success in getting up from my wheelchair without using my hands, I decided it was time to learn to get up from the floor without using any aids.
I have been healing from an internal stump pain for the last 8 weeks. During this time I have been doing exercises to strengthen and stretch parts of my body that will assist my one leg lifestyle.

I have been able to get up after falling by using my cane reduced to it's shortest length, (about 18 inches) or by climbing up something or someone. A strong kitchen chair seems to be the best and most sturdy getting up aid. Lately with my sore shoulder, getting up with the cane is not possible.

I am hoping that much of my stump pain can be relieved if the muscles in the stump are stretched more, so to be not as tight. Being not as tight, means they should be less likely to strain or tear. So I have been on the floor doing lots stretches and flexibility exercises.
I do a set of basic stretches every morning, but I am now doing much more, and doing it twice a day. While I don't see or feel any immediate benefit from this extra stretching, I also don't think it can, in any way, be a bad thing.
Having a more stretched hamstring in my good leg, allows me to have the leg straighter when I am bent over at the waist.

 I do my teeth brushing in a semi squat position. When I am done, the good leg thigh muscle is screaming and burning. While washing dishes I do the same. This now allows a one leg, deeper squat position than I have ever had.

The combination of these two exercises, means if I am on the floor, I can get up by my self. The secret is to get in the position like I am on starting blocks. The good foot behind with toes bent.  Sort of like being on all fours, except there are only three, so I am on all threes.
Then I push my bum up in the air so my third point is now my foot, not the knee. Then I slowly walk my hands back toward the foot. Soon I can stand up. My balance is not so good, so it helps if there is something to grab, or fall onto.

--
11:30
I just talked to the surgeon. He looked at the MRI and the blood test results.
The blood test show no signs of gout.
The MRI is pretty conclusive.
Myositis Ossificans.
That is normally caused by a broken or damaged bone, and muscle injury. I think amputation qualifies as both.
There is excessive calcium present where the bone is healing. Some of this calcium can sneak into a damaged muscle, and start growing. It is slow to grow, sometimes 4 to 6 months. This bone growing inside the muscle causes pain in the muscle.
The "cure" is exercise, and drugs. I currently spend about an hour a day doing stretches and exercising the stump and core muscles. I can't see any increase in exercises helping much. I am close to overdoing it as it is.

There are drugs that help to break up the small bone growing in the muscle. Also stronger anti-inflammatory drugs. The doctor sent the prescription to my phone. He says the pharmacy will accept that, and issue the drugs. There "should" be noticeable results within 4 weeks. I'll go see him again in a month.

I still can't use the crutches because of my shoulder. I don't know how I will get these drugs.
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12:30
I tried calling the pharmacy to get the email address, so I can email the prescription.
I could not even tell what language the person on the phone at the pharmacy was speaking. It sounded like Zulu, so she was probably spelling the email address in phonetic Zulu. I would have had better luck if she had been using Arabic, or Mandarin.
Three phone calls, stress, bullshit, hassle, and I am still no closer to getting my pills.
My life is now complex, for what used to be simple things. This sucks.
My buddy says he will come by and fetch the drugs from the pharmacy. But it would be a huge inconvenience for him. The pharmacy will deliver in 5 days, but only if I can send the prescription.
I called the pharmacy help line. After 5 minutes of listening to computer music, the computer told me to call back later. Grrr.
I called the pharmacy AGAIN, and asked to speak to an English speaker. This time I got someone that speaks English better than I do.  She was very helpful and said they would deliver everything for free right after lunch.
Solved.......Maybe
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16:44
A scooter just drove up with my medicine.
When the system works, it is fantastic.
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