The One Breasted Warrior

One breasted warriorI’m still fighting. It hurts physically and emotionally. I am not getting any closer to complete healing or a body that has all of it’s parts in place. I remain hopeful though, hopeful that the cancer does not return. My foolish, vain self marched into the plastic surgeon’s office recently and  boldly stated that I would like to discuss my options for making another run at reconstruction. I haven’t  stopped worrying or crying since that bold move.

“We need to find the root cause of the chronic pain in your chest.” stated the surgeon. “It is most likely necrosis of the bone from radiation. I can order an MRI and we can see what is going on in there. If it’s nothing than we can start with a scar revision, then blah, blah, blah…” He continued.

MRI? That picks up cancer too I thought. Is he looking for cancer? Why do these doctors want to continuously look for cancer in my body?

I had two MRI’s done the following week on two separate days, double the stress. One was to check the left breast that still remains with it’s small but perfectly proportioned implant. The other MRI was to look at my right chest and ribs where nothing remains but skin tact down onto my bones and pain that never stops. Wearing a bra and a prosthesis is an act of a warrior. It is like my shield as I go out into the world trying to fit in with the normal breasted women. It is incredibly painful to wear this shield as it hits right where all of the pain is concentrated. I  dig for a warriors courage just to get dressed for work in the morning. By the end of the day that bra must come off immediately and I greet my son and his friends with one breast. Most are too polite to stare, but they all hug me sideways, as if they are afraid to hurt me or confirm what they see through touch.

The MRI’s came back inconclusive. “There is something on your ribs but we are not sure if it is injury or metastatic bone cancer.” Said the surgeon. “I am going to have the Tumor Board review your case and make a recommendation. Don’t worry, it’s probably nothing.”

How many times have I heard that? “Don’t worry, it’s probably nothing.” News flash to my team of doctors, it has always been something when you go poking around looking for cancer in me. I cringe when I hear those words.

The “Board” recommended a PET scan. Where in the fuck is my warrior Xanax?!

The last time I had a PET scan was right before I started chemo therapy a couple of years ago. This time, I merely went to the plastic surgeon and inquired about reconstruction and now I am having a contrast dye put into an IV that is hanging out of my arm. The tears rolled freely down my face as I was positioned into the machine. “Are you okay?” Asked the tall, dark, handsome technician as he handed me a tissue and waited patiently for me to stop crying so he could start the test. I dug deep for my warrior strength and fell still and quiet while the machine hummed around me searching for cells that are ruining my life and trying to kill me.

The results were sent to the Tumor Board and they recommended a biopsy of my ribs.

I called my oncologist and pretty much said what the fuck?! “I don’t think there is anything to be worried about,” he said. I couldn’t breath. I walked outside of the hospital where I was at work to continue the conversation but my legs were starting to go numb from panic.

“Let me have another radiologist take a look at the films.” He offered. “I will be in touch, don’t worry Trina.”

One breasted warrior 1

Responding When Your Relative is Diagnosed with Cancer

Responding When Your Relative is Diagnosed with Cancer_0325_KF_MW (1).docx A special thank you to Kaitlyn Teabo of the Mesothelioma Center for writing this guest blog for my site.

When a family member is diagnosed with cancer, it can be hard to initially handle. It is common and natural for you both to feel overwhelmed, scared, angry, sad and other emotions all at once. This compilation of emotions can make knowing exactly how to react to the diagnosis that much harder.

If you want to help, but you’re not sure how, here are some ways you can make the process easier for your relative and yourself: 

  • Listen. People process issues like a cancer diagnosis by talking about it. Show that you are listening by occasionally paraphrasing what your relative said and asking if that is what they meant. Unless asked, in the early stages of the diagnosis don’t offer advice. Your ears are worth more than anything at this point of the journey. The doctor will help your loved one and yourself through the process, discuss their prognosis, and help find the best treatment centers in your area.
  • Tell Your Relative You Love Them. Even if you think it is implied, hearing that someone loves them can help with feelings of depression and isolation, which are common after a diagnosis. Show affection when you can, this effort can have a huge impact on the coping process.
  • Don’t Compare. Sometimes when someone is going through a similar experience as you or someone you know, it may be easy to bring those experiences into conversation. But not all cancer experiences are the same, which is why you shouldn’t compare your friend’s mom’s cancer to your relative’s cancer.
  • Help Without Being Asked. Some cancer patients don’t like to admit they need help and will neglect to ask when it is necessary. Little gestures can often make the biggest difference. Make your relative’s favorite meal or dessert and stick it in their fridge. Help with the laundry and housework. Drive them to appointments or do daily errands.
  • Provide Comic Relief When Necessary. Yes, this can be a trying time for your relative and other members of the family and close friends, but it is also important to remember to laugh. Be careful not to offend your loved one, and only provide humor when it is appropriate. Remember to stay sensitive when they are grieving and offer a chance to laugh when they could use the reminder. Humor can be a great form of medication and may offer a way of healing.

As each diagnosis and each person affected by cancer is different, the ways to help your relative overcome the disease may also differ. These tips serve as a helpful guide, but you are ultimately the best judge on how to respond and act around your loved one. The most important thing is to just be there for them while providing support.

Author bio: Kaitlyn Teabo is a writer for The Mesothelioma Center. She combines her interests in writing, cancer research and emerging scientific technology to educate the mesothelioma community about asbestos and its related diseases.

Prosthetic Breast, Seriously?!

prosthetic breast 1

Part one of my sagas.

The word prosthetic to me sounds old, broken, missing, braced, fake or injured. It gets stuck on my tongue and I don’t like it. I don’t like the way the word sounds, and I don’t like saying it. What is it supposed to mean anyway, a good aesthetic? Does that mean without a prosthesis, I don’t look good, that I am unpleasing to the eye? Crap that is a lot to digest since I have endured 16+ surgeries trying to look “normal.” Still after all of those surgeries, my body rejected the implant, twice.
prosthetic breast

I don’t want a prosthetic breast, although my mom points out that an implant is a prosthesis. Technically she is correct, but for this article I am referring to an external device. I don’t want one because I don’t intend to remain in my current physically unpleasing to the eye state of being. I plan to be fully reconstructed and I have a wonderful and talented plastic surgeon who agrees with that plan. However, in the short-term, until my body can fully heal from the complications of so many surgeries and radiation treatments, I have a missing accessory. One would not be able to stop themselves from staring at my single perfectly augmented breast compared to the empty, hollowness on my right side. I have come up with a temporary solution; gauze (still healing) and cup type inserts that are removable from my bikinis. These breast shaped pads work great, but they sometimes become dislodged from the shelf-bra camisoles that I wear; I’m still too sore for a regular bra. When they become lose they land somewhere in my armpit or in the center of my chest, which is definitely not pro-aesthetic!

After I finished breast-feeding Curtis, my B cup breasts shrank to AA (which really means negative A in the bra sizing world. Why does a DD mean larger than D, but AA mean smaller than A?). I was spending a lot of time on our boat and in bathing suits, and I didn’t want to go out and buy all new smaller cupped bikinis, so I purchased the chicken cutlet looking breast inserts that some women wear to enhance their cup size. They are made of a silicone type gel and they are pretty heavy in weight. They worked fine to fill up my bathing suit tops, until the day I left them in while water skiing. I took a nasty spill that day, and those cutlets flew out of my top and were floating on top of the lake. My friends in the boat had a good hysterical fit of laughter as they were pointing to the fake boobies bobbing up and down in the water while I tried to swim after them to retrieve them. I laughed too, I don’t know why I thought those things would stay in place, and I was slightly embarrassed that my secrets were out and floating on top of the wake for all to see. I hated wearing the cutlets, they were hot and sweaty and obviously prone to fall out because of my active lifestyle. I immediately went out and bought all new bathing suits and sold the cutlets at a garage sale, those suckers were expensive, so I knew someone would buy them. I learned to embrace my small breasts, dress accordingly, and never ever considered augmentation until I was faced with reconstruction post-mastectomy. I quickly warmed up to the idea of insurance paid implants; I think they are the silver lining common denominator for breast cancer survivors or those having a prophylactic mastectomy.

So now I am planning an annual family trip to Puerto Vallarta, and I am wondering how I am going to navigate resort wear with only one breast. I decided it was time to go for a prosthetic fitting. Fitting, the word should be used to describe Kim Kardashian with a flock of stylists pinning her outfits on her in a way that shows off her spectacular curves. That’s the kind of fitting I want, not one for a fake external boob.

prosthetic breast 6

When I lost my hair from chemo, I would only wear wigs if I were going out in public. I wore them mainly to make other people feel comfortable around me. I didn’t want my cancer to be the center of attention and by wearing a wig I could blend in. People around me were more comfortable without ever even knowing that I was making them feel more comfortable. I on the other hand was not physically comfortable; wigs are hot, sweaty, and itchy, just like the cutlets. So mainly I would wear a baseball cap or a beanie type hat more often than wearing wigs for jaunts to the doctors for treatments or to the store or gym. I was able to continue to work out at the gym during my off weeks of chemo and would just throw on a baseball cap. I drew a lot of stares, but eventually people got used to seeing me at the gym with my bald head under a baseball cap, or I simply got used to the stares. However, I’m not prepared for people staring at my chest and trying to put together the pieces of my life in their minds, especially in a bathing suit.
prosthetic breast 4

I called the local cancer resource center and asked them if there was a place in town that sold breast prosthesis. The center gave me three names: a prosthetic business, a pharmacy, and a lingerie store. I called the prosthetic company versus the lingerie store, I already knew what the lingerie store sold; cutlets. I couldn’t imagine that a pharmacy would be a good place to try on fake boobs for size so I didn’t even write that phone number down. The lady who picked up the phone was kind and told me that my insurance would pay for the visit and for the prosthetic, good news, so I set up an appointment for the following Tuesday.

“It’s no big deal,” said my mom who wears a prosthesis after her own mastectomy decades before. She had widespread early stage breast cancer, had a unilateral mastectomy and reconstruction, and fortunately her breast cancer has not returned like mine did. “See look at mine,” she said as she pulled it out of her bra and waved it at me. I laughed as I dodged it. She uses a prosthetic to create symmetry; reconstructive surgeries are far more sophisticated now than they were 25+ years ago. My mom is obviously comfortable with not only saying the word, but showing me the device. “It’s quite comfortable and look here at this area, it absorbs the sweat,” she was saying and pointing. I looked more out of the corner of my eye than dead onto it, I didn’t want to interact too much with my mom’s prosthetic breast. I didn’t want to face my own need.

prosthetic breast 2

We had a good laugh at the whole thing; sitting outside on the deck drinking Chardonnay with the sun on our chests as we shared our battle scars with each other. Anyone could have driven by and seen us, but we didn’t care because we were not alone in our suffering and we could laugh at our circumstance.

Next week,part two, after the fitting, which by the way seems like a very formal process. NOT looking forward to it. Not at all…

prosthetic breast 3 prosthetic breast 5

New Day, New Doctor, New Hope

Switching doctors
You have heard the saying “It takes a village.” This holds true for cancer patients; it takes a huge team of doctors to treat a person with cancer. It is an often confusing process for the patient; one doctor prescribes a medication and then sends you to a different physician for a drug to counteract the side-effects of the first one. One doctor has an opinion and the next has a different view point. Medicine is not as black and white as one would think, there are too many variables. I consider myself a very informed patient; 20+ years in the pharmaceutical industry taught me how to research, read, and understand studies. I have also had a lot of training on effective communication with physicians. These skills come in handy as a patient.

From the beginning I wasn’t connecting with the oncologist that I was originally referred to following my first diagnosis of breast cancer. She was defensive and condescending during our interactions. Was it because I came to all of our appointments with my black leather notebook filled with my own research and lots of questions for her? Or was it that she had other things on her mind, like her own fiscal health? Either way, I stayed five years and three diagnoses too long.

Have you ever thought to yourself I don’t think this is the right doctor for me? If you have, you were probably right. There is a large continuum of skill and competency in any industry, even those that practice medicine. What? That’s right, I said it, there are some terrible doctors practicing medicine. I saw this first hand over the two decades that I was in “the business”; most doctors were good, some were mediocre, and a few were down right bad.

I should have followed my gut; I should have switched oncologists a long time ago. Why didn’t I? For the same reasons as most; we are indoctrinated to believe that doctors are the all-knowing, ultra-educated, experts on health and medicine. That’s all fine and dandy, after all, they do possess a lot of education and training, but that doesn’t guarantee that they will be good doctors or click with every one of their patients.

Just in case you have never received permission to challenge your doctors or seek a new one if the one you are seeing isn’t working for you, let me be the first to offer you that permission. If it doesn’t sound right, feel right, or the person makes you feel uncomfortable in anyway, request your records and get the hell out. Find a doctor that works for you, not just for their own bottom line. Medicine is commerce and one should have their eyes wide open on this knowledge, and never forget the patient is the customer. I have seen the same scenario play out over and over again in doctor’s offices; the doctor is kind, calm, and happy, so is their staff. Then they move into a new building, take on a huge mortgage and they become anxious, rushed, and snarky, and so does their staff. Doctor’s in private practice work hard to cover their overhead and Medicare and the insurance companies pay less and less each year for services rendered. Couple that with a patient who has a disease and wants compassion, time with their doctor, answers to their questions, a plan to get healthy or stave off disease, and it can be like water and oil.

So what do you do? You get personal references from friends, family, acquaintances, or on-line (healthgrades.com is an on-line service where you can gain valuable information and reviews on doctors). Listen to your gut, and make a move if necessary. People stay longer than they want to with their hair dressers and their doctors because they don’t want to make anyone feel uneasy. When I lost my hair from chemotherapy; I thought to myself that was the perfect time for me to switch hair stylists. I loved the stylist that I had been going to forever, but I thought he was charging me way too much and sometimes he seemed distracted and I left his chair with a bad pixie cut, however, it took me being bald to make a change.

So on my last uncomfortable visit to my oncologist, I said enough is enough. I requested my records and got the hell out. I asked my breast friends who they saw and a particular doctor’s name kept coming up. With a little help from a dear friend who happens to be a physician, I was able to get an immediate appointment with this oncologist that I was courting. Right off the bat I liked him. He said the one thing I had been longing to hear, “It’s hard to believe this right now Trina, because you have been in the thick of this disease for so long, but soon you will have all of this behind you, you will be cured, reconstructed and you will go on to live a long and healthy life just like the rest of us.” Hope. He gave me hope. Hope that I would be whole and healthy. Hope that I didn’t have to feel uncomfortable with any part of my health care village.Hope that I had found the right doctor for me. This hope was worth any uneasy feelings that came with a break-up.
New HopeNew Doctor

No Fear

This is what I know for sure. After three diagnosis of breast cancer, I don’t fear much anymore.

It has been said that there are two psychological houses that humans approach each and every situation from; the house of love or the house of fear. If you approach life with love then you are compassionate, forgiving, loving, giving to others, altruistic, kind, empathetic, ready to serve, possess inner peace, forgiving, and you don’t lead with your ego. If you live in the house of fear, then you lead with your ego, constantly beating on your chest to prove that you are right, you are angry, hurt, snarky, rude, demanding, and unforgiving. The truth is not many humans achieve living in the house of love at all times, that is what makes us human, we possess a myriad of emotions and learning to control and direct them for the good of yourself and others is a very hard thing to do. It takes practice, discipline, willingness, and hard work.

So what is it that we are afraid of in this house of fear? I say we fear not being loved. Which let’s face it is a fascinating concept; we act in fear because we are afraid we won’t be loved, instead of acting through love where love has no fear. I know, I know… I am starting to lose myself here. It is a complex, yet simple theory.

So back to my lack of fear, when I say I don’t fear much, that doesn’t mean that I don’t visit the house of fear, it just means that I have stopped living life in fear of all things big and small. I am not afraid to take a risk, to say what I mean to say, to stand up for what is right, to show up and be counted, to take a leap, to try a new hair color, to learn a new trick, to mend a fence, or to tear one down if it no longer serves me well. No fear. I don’t have time to be afraid. Do you?

A week ago I attended a memorial service for a 17-year-old boy who died tragically in a car accident. He went to the same high school as my son, they played little league together when they were young and I have known his mother professionally for 21 years. The entire high school and their parents were at this memorial, we are a small, tight knit community and to lose one of our children had a ripple effect that enveloped us all. There is no greater a test on this earth than the one that was set before his parents.

Alex Maier

Alex Maier, a fearless hero to me.

We stood in silence in the stands of the football stadium, where Alex was a star soccer player. You could have heard a pin drop as Alex’s parents walked through the two rows of soccer players to the white chairs that were set out for them in front of a stage where large pictures of their son smiling for his senior photo sat on easels. They sat down at first, but then his mother, father, and sister, stood back up and turned around and faced all of us standing there for them and for their son. With their arms wrapped around each other for support, they stood looking at us looking at them, acknowledging all of us with love and appreciation. They were thanking us for showing up, for showing support, for sharing love with them. They did not exhibit fear at that moment, only strength, grace and gratitude.

Alex was a giver, unbeknownst to his parents he had signed up to be an organ donor when he applied for his driver’s license. He saved 6 lives with his generous gift and gave many more the chance to heal with tissue donations. I am a recipient of donor tissue. I have received this gift from a stranger during a reconstructive surgery. I quietly vowed to Alex that I would live in service of others, working hard to live in the house of love and to be forever fearless.

What do you fear? And are you a registered organ/tissue donor?

organ tissue donor

A Botched Boob-Job

 

If you Google botched boob jobs, the pictures you see here will come up; grotesquely undesirable breasts complete with commentary. I had a botched boob job, but mine was far different than those of these women.

During a unilateral mastectomy (one boob) a couple of years ago, I had immediate reconstructive surgery. The breast health surgeon was there as well as the plastic surgeon. One giveth, one taketh away. It has been complicated because I had already had one course of radiation on that breast and radiation degrades the tissues and its ability to maintain a foreign object. It all went well and after multiple surgeries, I had two perfectly natural looking augmented breasts. I was impressed.

Then the cancer came back for a third time. The doctors told me I would have to have the implant taken out and a tissue expander put back in for the better part of a year while I underwent chemo and another course of radiation. I was devastated at this news. The tissue expander is by far one of the most painful aspects of this whole journey. I know I have complained about it before, but I just can’t complain enough about this torturous device. There has got to be a better way to “hold the space” for an implant without putting a hard squeaky toy in a woman’s chest wall. I spoke endlessly with my surgeons about this, even negotiated a way to live with the tissue expander for a shorter amount of time than what they originally wanted. However, I may need to become an advocate for a new type of technology, or hire a team of engineers to come up with something different on my own, because what is available is ridiculously painful.

I got through the nine months or so with the tissue expander and now it was time to remove it and replace it with a nice soft pliable silicone implant. I was never happier to undergo a surgery. But after surgery, things started to go downhill. My body was not healing. The radiation oncologist warned me that all of the radiation that I have had could cause the body to reject an implant all together. The tissue is no longer healthy, which is what they wanted in order to keep the cancer from returning. But without healthy tissue, there is no healing.

4 weeks post-surgery the incision opened up and a flood of fluid pooled around me. I was completely freaked out as I could tell that my body was “rejecting” the implant. The radiation oncologist suggested that I just remove the implant altogether and have only one breast…I looked him square in the eyes and asked him how many body parts he was living without because of cancer. He looked away. I called the plastic surgeon. 

“We need to get you in tomorrow for emergency surgery” said the surgeon. “I want to swap out the implant which has probably become infected, move the incision in order to find healthy skin that will heal and put a drain in so there is no pressure on the incision as this will take a long time to heal.”

“Fine,” I said. “We need to save her; I’m not ready for a uniboob.”

So back to surgery I went, I think this was the 15th on this same little breast, but I wasn’t giving up.

Since I was their last case of the day, I couldn’t eat or drink anything and I had to wait around all day while they squeezed me in for this emergency procedure. It was starting to get dark outside and the staff was starting to leave the surgery center for the day. Finally it was my turn. They wheeled me into the OR and I looked at the clock, it was 4:30 pm. The anesthesiologist came in and mixed up a nice cocktail for me that he put into the IV. He asked me a question, but I don’t remember answering it, man I love that stuff!

A couple of hours later I was in recovery and Joe was back by my side. We drove home and I settled in to begin the long road to healing. It has been 10 days since the surgery, I still have the drain, but the surgeon is seeing good signs of healing. I told the universe that I am coming out of this thing with two breasts and no cancer. I will settle for nothing less and I won’t give up on being healthy and whole.

But the question that still lingers on my lips is why oh why do woman have grotesquely weird augmentations done to themselves? 

Slightly Carbonated Coconut Cottage Cheese

 

I have to admit that I am stumbling towards enlightenment when it comes to super foods and supplements to support my immune system. I know they are vital to the well-being of my fragile immune system and to my long recovery ahead. I have had too many surgeries and too many treatments for breast cancer not to know that I am utterly screwed if I don’t take concrete measures to improve the way my body handles carcinogens.  I have been discovering and trying all kinds of juicing, powders and supplements, and I have learned some interesting things, some the hard way.

Over the summer, Joe planted a wonderfully abundant organic garden and we juiced daily from its bounty and drank our nutrients. Juicing fruits and vegetables accomplishes two extremely important functions; the first is that you are able to consume a lot more nutrients by taking pounds of fresh fruits and vegetables and reducing them to an eight-ounce glass of juice that is packed full of super-nutrients that our bodies need to be optimally healthy. Secondly, by juicing you free up the nutrients from the fiber that it is attached to. For example, if you eat a carrot, the body may absorb 10-30% of the beta-carotene, the rest of the beta-carotene is attached to the fiber of the vegetable and eliminated unabsorbed by the body. If you juice that same carrot and separate the nutrient from the fiber, your body can absorb 100% of the beta-carotene from that same carrot. 

It is November now and the summer garden is long gone, so I searched for an alternative. A dear friend of mine who works in holistic healing brought over a green powder that consists of freeze-dried nutrients, even more potent than what we could juice from the garden. The directions said to mix 1-3 tablespoons into water and drink. I took out a small glass placed the recommended amount in, added about a half cup of water and stirred like crazy. The powder and the water were not mixing too well together and I was afraid I would end up with a big patch of unmixed powder in my mouth. I stirred and stirred, I was ready to take the plunge. Holy cow it was nasty tasting, and I was right to fear the pockets of powder. I looked at Joe and shook my head, “I don’t know how compliant I am going to be with this,” I said.

The next day I decided to mix the green powder with some organic pear nectar. I figured the nectar was thick enough to handle the powder and the sweetness should be able to help with the taste a little bit. That did work and I mixed a palatable shot that I could swallow really quickly in just a couple of gulps. “I believe in the power of these super-nutrients” became my mantra as I got through the week supply that my friend had dropped off. I called her for the source; I needed more of this stuff. My appetite is a mess from the pain medications and trauma from two surgeries back to back, and I need to continue to offer my body nutrient-dense foods. She gave me the name and number of the guy who delivers this stuff right to your door. She also kept telling me that I need to drink his coconut probiotic concoction to promote healing and keep my digestive system in tip-top condition; which is also a mess from the pain medications and prolonged use of antibiotics because of the infection.

So I called Rob the green powder guy and he was at my door within an hour with a pound of the powder and a mason jar full of coconut probiotic sludge. $95 for the two, not cheap, but that’s a lot of nutrients right?

After he left I went into the kitchen to pour myself the recommended starting dose of ½ cup of the sludge. It smelled like coconut but had chunks like cottage cheese in it. I got out a spoon and tried to stir the chunks into the liquid, but that didn’t make them smaller, nor did pressing the chunks into the side of the glass with the back of a spoon. So I decided I would just take a swig and be done with it. What hit my taste buds was a slightly carbonated coconut cottage cheese drink and I thought I was going to projectile vomit the whole mouthful right onto the kitchen counter. Rob had sold me on the benefits of the probiotic and I was financially invested in this, so the sludge was going down. I stirred and drank, stirred and drank, then followed it with a shot of pear nectar with green powder. The whole thing was exhausting so I went back to bed. 

About a half hour later my stomach started to gurgle really loudly, and churned. I had a war going on inside my digestive tract and I was crossing my fingers that I was going to come out of this without a rapid elimination of all of these expensive, hard to get down nutrients. I sipped water and my stomach finally calmed. Phew.

The next day, Joe, being the smoothie king that he is, offered to blend the sludge into a tasty mid-day snack for me. The smoothie he made tasted just like anything you could buy at Jamba Juice and I was thrilled, I could live with this. He offered to incorporate the green powder, but I didn’t want to take the chance of ruining a perfectly good smoothie so I took the pear nectar shot separately.

After about a couple of weeks of taking these supplements I can feel real energy returning to my body, and my breast is healing from surgery. Joe also said that my skin looks really good which is a plus, but that could also be because another good friend turned me onto her anti-aging creams, but I will write about that another time.

For a great documentary on the benefits of juicing check out “Fat, Sick and Nearly Dead.” By Joe Cross.

http://www.fatsickandnearlydead.com/trailer.html