July 24, 2014 Health Edition

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JULY 24 | 2014 | DEFENDER

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Defender Special Edition

Heart disease Blacks’ No. 1 killer

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By TIFFANY L. WILLIAMS Defender

eart disease is the No. 1 killer of men and women in America. According to the Centers for Disease Control, Americans suffer more than 1.5 million heart attacks and strokes each year.

“Everyone has a heart. It’s the most vital organ in your body,” said Myra Robinson, executive director of the American Heart Association Houston (AHA). “So, it affects people at much higher rates than other diseases.”

The massive killer, also known as cardiovascular disease and coronary heart disease, results from plaque buildup in the walls of the arteries. After the arteries narrow, it becomes difficult for blood to flow and the risk for heart attack or stroke becomes greater.

In Houston, most recent data from AHA Houston reveals 6,004 residents died from cardiovascular disease and more than 1,440 died from stroke.

Other types of heart disease include heart failure, an irregular heartbeat (or arrhythmia) and heart valve problems.

High blood pressure, obesity and diabetes are the most common conditions that increase the risk of heart disease. Some people affected by heart disease also suffer from congenital heart defects, meaning they are born with it.

Additionally, the risk of heart disease is strongly linked to family history.

For African-Americans, the risk of suffering from some form of cardiovascular disease is greater than other groups.

Nearly 44 percent of African-American men and 48 percent of African-American women are affected in some way.

Statistics from the Centers for Disease Control show

Nearly 44 percent of AfricanAmerican men and 48 percent of African-American women are affected in some way. that in general: • About 600,000 people die of heart disease in the United States every year – that’s 1 in every 4 deaths.

• Coronary heart disease is the most common type of heart disease, killing nearly 380,000 each year.

• Coronary heart disease costs the United States $108.9 billion each year in terms of health care services costs, medications and lost productivity.

In addition, each year, approximately 720,000 Americans have a heart attack. Of these, 515,000 are a first heart attack and 205,000 happen in people who have already had a heart attack.

Warning signs and symptoms of a heart attack include: • Chest pain or discomfort.

• Upper body pain or discomfort in the arms, back, neck, jaw, or upper stomach.

• Shortness of breath.

• Nausea, lightheadedness, or cold sweats.

Robinson said many times, people do not pay attention to their bodies when something is not right.

“Someone may feel dizzy and think ‘I’m just dizzy, I need to lie down,’ instead of thinking, ‘I’m dizzy, this may be from high blood pressure and I need to seek medical attention,’” she said.

Failure to listen to one’s body or to change one’s diet and exercise routines can be deadly.

“We live in a drive-thru era,” Robinson said. “A lot of times it’s easier to stop at the drive thru between volleyball practice and homework than to cook a healthy meal with fresh vegetables.

“Preventing several types of cardiovascular conditions is tied to the way we live our lives.”

For more information, visit the American Heart Association’s website at heart.org/ or call 713-610-5000.

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DEFENDER | JULY 24 | 2014

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health

Detecting heart disease

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Inside Preventing heart disease 3B Texas Children’s Hospital

Follow family safety tips 4B What women should know 6B Kids and heart disease 7B Reducing risk in men 7b MD Anderson Cancer Center

Eat food with less salt 8B Memorial Hermann Health System

New health line answers questions 10B

By CIERRA DUNCAN Defender

arly detection of heart disease can play a critical role in preserving and maintaining heart health.

“There are multiple screening tests for heart disease,” said Dr. Felicia Jordan, an internal medicine specialist with Memorial Hermann Medical Center. “In general, most would be detected through tests available in a general practitioner’s clinic.”

The most common test is an electrocardiogram or EKG. It is a non-invasive test that involves 12 electrodes placed on the patient’s chest, arms and legs.

Dr. Felicia Jordan “EKGs look at the electric activity of the heart and determine if there are arrhythmias or different problems with blood flow to certain parts of the heart,” Jordan said.

A doctor may also perform an echocardiogram, which is an ultrasound of the heart that allows doctors to see it beating and its structures. Other screening tests include wearing a Holter monitor, which is a small device worn for at least 24 hours and records the heart’s activity during a patient’s normal day.

Jordan said once a person is diagnosed with heart disease they should take special precautions to keep all risk factors in control. This would include implementing a

balanced diet, controlling blood sugar and blood pressure levels.

Once a doctor prescribes a medication, which can include aspirin or blood thinners, it is important for the patient to follow dosage instructions. Not taking the medication or not following dosage instructions can lead to worsening heart disease, which in extreme cases can lead to surgical procedures, like a heart bypass, being required.

“If you are on medication it’s for a reason,” Jordan said. “Take your medication.”

Jordan said that because African-Americans suffer from risk factors such as high blood pressure, diabetes and obesity in larger numbers, it causes them to suffer from heart disease at a greater rate.

She added that all Americans should lead a healthier lifestyle.

“Two thirds of Americans are overweight and one-third is obese,” Jordan said. “Diet plays a huge role in preventing heart disease.”

Jordan recommends that a person gets at least 150 minutes of exercise a week and limit alcohol consumption. Women can have a maximum of one drink a day and men can have a maximum of two. “Anything over that increases your risk for heart disease,” she said.

Message from the Publisher

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Sonceria Messiah-Jiles

e’ve all heard the phrase “serious as a heart attack” but heart disease is no joke. It is America’s No. 1 killer, and takes approximately 600,000 lives each year.

African-Americans are disproportionately affected, with almost 1 out of 2 having heart disease.

According to the U.S. Department of Health & Human Services, in 2010, African- Americans were 30 percent more likely to die from

heart disease compared to whites.

One way to combat heart disease is to know the facts. Did you know that the key risk factors for heart disease are high blood pressure, high cholesterol and smoking? About half of Americans (49 percent) have at least one of these three risk factors.

Other medical conditions and lifestyle choices can put you at risk for heart disease. They include diabetes, obesity, poor diet, physical inactivity and ex-

cessive alcohol use.

The Defender is proud to present you with more facts about heart disease in this special edition. We would also like to acknowledge our partners – MD Anderson Cancer Center, Memorial Hermann and Texas Children’s Hospital – who assist us in bringing vital health information to you.

Heart disease is a serious issue, and we owe it to ourselves and our loved ones to fight this No. 1 killer.

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health

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Have your cholesterol checked.

Your health care provider should test your cholesterol levels at least once every five years. Talk with your doctor about this simple blood test.

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Eat a healthy diet. Choosing healthful meal and snack options can help you avoid heart disease and its complications. Be sure to eat plenty of fresh fruits and vegetables. Eating foods low in saturated fat and cholesterol and high in fiber can help prevent high blood cholesterol. Limiting salt or sodium in your diet can also lower your blood pressure.

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Monitor your blood pressure.

High blood pressure has no symptoms, so be sure to have it checked on a regular basis.

Manage your diabetes. If you have diabetes, closely monitor your blood sugar levels. Talk with your health care provider about treatment options.

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Maintain a healthy weight. Being overweight or obese can increase your risk for heart disease. To determine whether your weight is in a healthy range, doctors often calculate a number called the body mass index (BMI). Doctors sometimes also use waist and hip measurements to measure a person’s excess body fat.

Exercise regularly. Physical activity can help you maintain a healthy weight and lower cholesterol and blood pressure.

Don’t smoke. Cigarette smoking greatly increases your risk for heart disease. So, if you don’t smoke, don’t start. If you do smoke, quitting will lower your risk for heart disease.

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tips for preventing heart disease

According to the Centers for Disease Control (CDC), you can help prevent heart disease by making healthy choices and managing any medical conditions you may have.

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JULY 24 | 2014 | DEFENDER

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Take your medicine. If you’re taking medication to treat high cholesterol, high blood pressure, or diabetes, follow your doctor’s instructions carefully. Always ask questions if you don’t understand something.

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Limit alcohol use. Avoid drinking too much alcohol, which causes high blood pressure.

If you have high cholesterol, high blood pressure, or diabetes, there are steps you can take to lower your risk for heart disease.

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Talk with your health care provider. You and your doctor can work together to prevent or treat the medical conditions that lead to heart disease. Discuss your treatment plan regularly and bring a list of questions to your appointments.

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health

Is your home safe for your young family?

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By THE CENTER FOR VACCINE AWARENESS and RESEARCH AT TEXAS CHILDREN’S HOSPITAL

any childhood injuries occur at home, a place where children should really be the safest.

Preventable injuries are the number one killer of children in the U.S., and around the world a child dies every 30 seconds from a preventable injury.

When a child dies, or is seriously injured, the lives of families and entire communities are changed forever. But these tragedies don’t have to happen.

The important thing to remember about preventable injuries is that they are preventable. They often occur in predictable ways and can be completely avoided with the right education, awareness and planning.

Kristen Beckworth, manager for the Center for Childhood Injury Prevention at Texas Children’s Hospital, offers these tips to help families protect their loved ones.

• For poison help call 1-800-2221222. Call if you need help or want information about poisons. Call 911 if someone needs to go to the hospital right away.

Prevent falls

Prevent fires and burns

Prevent poisonings

Prevent choking and suffocation

• Use stair gates at the top and bottom of stairs.

• Install window guards on upper windows.

• Never leave young children unattended on furniture (i.e. beds, couches, changing tables).

• Keep cleaners, medications and beauty products in a place where children can’t reach them. Use child safety locks.

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• Have working smoke alarms and hold fire drills. If you build a new home, install fire sprinklers.

• Use back burners and turn pot handles toward the back of your stove.

• Set your hot water at 120 degrees Fahrenheit to prevent burns.

• Keep coins, latex balloons and hard round foods, such as peanuts and

hard candy where children cannot see or touch them.

• Things that can fit through a toilet paper tube can cause a young child to choke.

• Place babies to sleep on their backs, alone in their crib. Don’t put pillows, blankets, bumpers, comforters or toys in cribs. These things can sometimes keep a baby from breathing.

The Kohl’s Cares® philanthropic program supports the Center for Childhood Injury Prevention in helping parents identify hazards in their homes and ways to keep their children safe.

For more information, visit www. kohlssafeathome.texaschildrens.org.

healthnotes How to prevent child heatstroke in vehicles Heatstroke is the leading cause of vehicle related death for children, aside from car crashes. On average, every 10 days a child dies from heatstroke in a vehicle. In 2014 alone, there were 43 child heatstroke deaths in vehicles, with five of them occurring in Texas.

“Babies and young kids can sometimes sleep so peacefully that we forget they are even there,” says Kristen Beckworth, manager for the Center for Childhood Injury Prevention at Texas Children’s Hospital. “It also can be tempting to leave a baby alone in a car while we quickly run into the store. The problem is that leaving a child alone in a car can lead to serious injury or death from heatstroke.”

Young children are particularly at risk, as their bodies heat up three to five times faster than an adult’s. These tragedies are completely preventable. In fact, Texas has made it a crime to leave a child alone in a car.

Below are some tips to help everyone work together to keep kids safe from heatstroke.

Reduce the number of deaths from heatstroke by remembering to ACT. A: Avoid heatstroke-related injury and death by never leaving your child alone in a car, not even for a minute. And make sure to keep your car locked when you’re not in it so kids don’t get in on their own.

C: Create reminders by putting something in the back of your car next to your child such as a briefcase, a purse or a cell phone that is needed at your final destination. This is especially important if you’re not following your normal routine.

T: Take action. If you see a child alone in a car, call 911. Emergency personnel want you to call. They are trained to respond to these situations. One call could save a life.

Drowning prevention In 2014 there were 82 drowning deaths in Texas; 23 of those were in the Greater Houston area. Drowning happens quickly and quietly in a matter of minutes.

Every drowning is preventable and can be avoided by following these simple safety tips: • Parents should always actively supervise children whenever they are around any body of water, including pools, spas, bathtubs or open water.

• Always assign a designated water watcher who actively supervises the children and is not distracted by texting, reading, drinking alcohol, socializing, etc.

• Enroll your children in swim lessons.

• Use Coast Guard-approved life jackets, not air filled toys, for all non-swimmers.

• Learn CPR. • Keep a phone near the water at all times so that 911 can be called in an emergency.

As families visit local lakes and beaches, there are some additional tips to consider when out on the open water: • Parents should always actively supervise children whenever they are around open water and always remember to assign an adult water watcher.

• Make sure kids swim only in areas designated for swimming.

• Do not let kids use personal water crafts such as jet skis. These are intended for adults and require special training..

• Children should always wear a Coast Guard-approved life jacket when on a boat or around open water.

• Never drink alcoholic beverages while boating.

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JULY 24 | 2014 | DEFENDER

Big coverage for the little ones.

Texas Children’s Health Plan covers children from newborns to teenagers. We even cover adults and pregnant moms through STAR Medicaid. Families with children who qualify for CHIP pay $50 or less a year. Those who qualify for Medicaid pay nothing.

CHIP and STAR Medicaid offer a wide range of benefits including checkups and shots, dental services, medications, and more.

With Texas Children’s Health Plan you also get: ■

Over 2,100 doctors.

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A 24-hour nurse hotline.

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Free transportation to doctor visits.

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Pregnancy support program and classes.

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Help losing weight through the Keep Fit Program.

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Learn how to play soccer from the Houston Dynamo coaches.

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Fun, free member events!

For more information, to receive an application, or to find an event in your area, visit us online or call today.

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What women should know

Heart disease myths vs. facts

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here are a number of misconceptions about heart disease in women, and they could be putting you at risk. Here are myths and facts from the American Heart Association.

Myth 1: Heart disease is for men, and cancer is the real threat for women Fact: Heart disease is a killer that strikes more women than men, and is more deadly than all forms of cancer combined. While one in 31 American women dies from breast cancer each year, heart disease claims the lives of one in three. That’s roughly one death each minute.

Myth 2: Heart disease is for old people.

Fact: Heart disease affects women of all ages.

For younger women, the combination of birth control pills and smoking boosts heart disease risks by 20 percent. And while the risks do increase with age, things like overeating and a sedentary lifestyle can cause plaque to accumulate and lead to clogged arteries later in life. But even if you lead a completely healthy lifestyle, being born with an underlying heart condition can be a risk factor.

Myth 3: Heart disease doesn’t affect women who are fit.

Sixty-four percent of women who die suddenly of coronary heart disease had no previous symptoms.

Because these symptoms vary greatly between men and women, they’re often misunderstood.

Fact: Even if you’re a yoga-loving, marathonrunning workout fiend, your risk for heart disease isn’t completely eliminated. Factors like cholesterol, eating habits and smoking can counterbalance your other healthy habits. You can be thin and have high cholesterol. The American Heart Association recommends you start getting your cholesterol checked at age 20, or earlier, if your family has a history of

heart disease. And while you’re at it, be sure to keep an eye on your blood pressure at your next check-up.

Myth 4: “I don’t have any symptoms.”

Fact: Sixty-four percent of women who die suddenly of coronary heart disease had no previous symptoms. Because these symptoms vary greatly between men and women, they’re often misunderstood. Media has conditioned us to believe that the telltale sign of a heart attack is extreme chest pain.

But in reality, women are somewhat more likely to experience shortness of breath, nausea/vomiting and back or jaw pain. Other symptoms women should look out for are dizziness, lightheadedness or fainting, pain in the lower chest or upper abdomen and extreme fatigue.

Myth 5: “Heart disease runs in my family, so there’s nothing I can do about it.”

Fact: Although women with a family history of heart disease are at higher risk, there’s plenty you can do to dramatically reduce it. Simply create an action plan to keep your heart healthy. Because of healthy choices and knowing the signs, more than 627,000 of women have been saved from heart disease, and 330 fewer are dying per day.

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Exercise, sitting less reduce risk in men

Kids cope with heart disease too

By CIERRA DUNCAN Defender

eart disease can occur at any age. There are various types of problems that can affect children, ranging from congenital heart disease to heart disease acquired later in life due to illnesses such as viral infections.

“For most children who are born with a heart defect, the heart did not develop properly in the womb during the very early months of pregnancy,” said Dr. Daniel Penny, chief of cardiology at Texas Children’s hospital.

“Some children who are born with heart disease can deteriorate quite rapidly after their born and may need emergency treatment, either some surgical intervention that’s carried out in a heart center. Other children that are born with minor heart defects can be treated in an outpatient center intermittently.”

Congenital heart disease (CHD) is the most common heart condition found in children, occurring in an estimated eight out of 1,000 live births.

CHD is present at the time of birth and usually begins to form during the first months of a woman’s pregnancy.

CHD involves a malfunction with the heart muscle or the heart valves.

Examples include heart valve conditions where there is narrowing of the aortic valve and defects in the wall that separated the left and right side

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of the heart called the septum.

Children can also be born with holes in their heart that are usually in the walls between the major blood vessels and the chambers.

According to Penny, the underlying causes of CHD cannot be determined. However, there are precautions pregnant women and those who plan to become pregnant in the near future can take.

“Any women who is contemplating pregnancy should make sure she is immune to rubella disease,” Penny said.

“There is some evidence that multivitamins can reduce the chances of or prevent heart disease,” he added.

He also advised that women who are on long-lasting medications, such as those prescribed for psychiatric disorders, visit their physician to see if their medication can be altered because they have shown to be harmful to children while still in the womb.

Congenital heart defects may have long-term effects on a child’s health.

They are usually treated with surgery, catheter procedures and or medication. In the most severe cases, a child will need a heart transplant.

Some children will require lifelong monitoring and treatment for CHD. However, with advances in medical technology, many can go on to live full lives.

ng the Houston area for over 80 years

Sitting for long periods increases heart failure risk in men, even for those who exercise regularly, according to research published in the American Heart Association journal Circulation: Heart Failure.

Preventing heart failure, researchers found, requires a two-part behavioral approach: high levels of physical activity plus low levels of sedentary time. The study is the first to examine the link between heart failure risk and sedentary time, said Deborah Rohm Young, Ph.D., lead researcher and a senior scientist at Kaiser Permanente in Pasadena, Calif.

“Be more active and sit less.

That’s the message here,” Young said.

Researchers followed a racially diverse group of 84,170 men ages 45 to 69 without heart failure. Exercise levels were calculated in METs, or metabolic equivalent of task, a measure of the body’s energy use. Sedentary levels were measured in hours. After an average of

nearly eight years of follow-up, researchers found: • Men with low levels of physical activity were 52 percent more likely to develop heart failure than men with high physical activity levels, even after adjusting for differences in sedentary time.

• Outside of work, men who spent five or more hours a day sitting were 34 percent more likely to develop heart failure than men who spent no more than two hours a day sitting, regardless of how much they exercised.

• Heart failure risk more than doubled in men who sat for at least five hours a day and got little exercise compared to men who were very physically active and sat for two hours or less a day.

The study supports the American Heart Association recommendation that people get at least 150 minutes a week of moderate-intensity aerobic activity to reduce their risk for heart failure and other cardiovascular diseases, Young said.

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DEFENDER | JULY 24 | 2014

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health Eat food with less salt

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By MD ANDERSON CANCER CENTER

our body needs sodium to function properly.

But eating too much salt every day can increase your risks for stomach cancer. It can also cause high blood pressure, increasing your risk for hypertensive heart disease.

“I didn’t realize how much salt is in almost everything we eat,” says Lyle Rhymes.

“Diabetes runs in my family so my health is top priority,” Lyle says. “I thought I was doing a pretty good job at cutting back on salt. Then, I learned eating less sodium means more than just putting down the salt shaker.”

“Even if you don’t add salt to your food, there’s still a good chance you’re eating more sodium than you should,” says Mary Ellen Phipps, a wellness dietitian at the University of Texas MD Anderson Cancer Center.

“That’s because half a teaspoon of salt alone has almost 1,200 milli-

Recipe Creamy Green Dressing This dressing is a great low-salt alternative to traditional salad dressing. It’s also a perfect dip for fresh vegetables. Just cut the oil by at least half if you’re using this recipe for a dip. And, keep your portion sizes small.

grams of sodium.”

A healthy dose of sodium for most people is no more than 2,400 milligrams per day. “If you’re age 51 or older, African-American or have hypertension, diabetes or chronic kidney disease, you shouldn’t eat more than 1,500 milligrams per day,” Mary Ellen says.

Many foods have hidden salts

“I found out that many of my favorite foods, like canned soup, are loaded with salt,” Lyle says.

Even if your food doesn’t taste salty, it still can be high in sodium.

Watch out for hidden sodium in these foods: • Cereals • Breads • Chips and crackers • Soups • Sports drinks “Some foods, like cheeses, seafood and olives, are naturally higher in sodium,” Mary Ellen says.

“So, eat these foods in moderation as well.”

Add flavor, not salt

Follow these smart food tips to gradually reduce the amount of sodium you eat. It may take some time for your taste buds to adjust to eating less salty foods.

Lyle Rhymes Photo by Carter Smith

Eat fresh, unprocessed food.

Fresh food has less sodium. Canned and pre-packaged foods tend to be high in sodium. Processed meats, like ham, sausage, hot dogs and luncheon or deli meats, are also high-sodium offenders and increase colorectal cancer risks. Try to avoid them.

Get smart about dining out. Restaurant meals and fast food are usually loaded with added salt. When dining out, ask your waiter to have your meal prepared without salt.

Then, use the salt shaker sparingly when your meal’s at the table.

Read labels. Check the sodium content on nutrition labels. Look for words, like low-sodium or sodium-free, to spot healthier options. Compare foods and choose the ones with lower sodium levels.

Try to choose foods with less than 600mg of sodium per serving.

Add herbs for flavor. Focus on adding fresh herbs and spices for flavor instead of salt. When cooking, taste your food before adding salt. You may have sufficient flavor without the added salt. And be sure to read the seasoning labels – not all herb and spice mixtures are saltfree.

“My advice is to not procrastinate. Start immediately with the next thing you put in your mouth,” Lyle says. “You’ll be so much better off. And the more you do it the more likely it’ll become a habit.”

Ingredients 1 cup olive oil 2 tbsp. apple cider vinegar or fresh lemon juice 2 tbsp. 100% apple juice 2 tbsp. parsley, chopped 1 tsp. basil, chopped 1/2 tsp. salt 1 clove garlic, minced 1 cup low-fat yogurt 6 spinach leaves (big, not baby leaves) Instructions Put all ingredients in the blender, except for the oil.

1 2 3 4 5

Blend for one minute.

While the blender is running, slowly add the oil.

As soon as the dressing thickens, turn off the blender.

Chill for 30 minutes.

Nutrition Content Makes 20 servings Calories: 105 Total fat: 10.91g Saturated fat: 0.88g Carbohydrates: 1.32g Protein: 0.68g Cholesterol: 0mg Sodium: 77mg Dietary fiber: 0.27g For creative ways to cook healthy, visit www.mdanderson.org/recipes

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Talk to a nurse for free, around-the-clock

Health line answers medical questions when you need them

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By MEMORIAL HERMANN

itizens living in Houston, Harris County and the eight surrounding counties are now able to talk directly with a registered nurse 24 hours a day, seven days a week by calling the new Nurse Health Line at 713-338-7979.

Call night or day, weekday or weekend, and reach an experienced registered nurse who will carefully evaluate your health needs and advise you on the best course of treatment for your illness or injury.

After an assessment is made, callers will be advised to seek care with their physician of choice or referred to local emergent care centers. Additionally, community health workers will be available to provide information on free or low cost community resources or clinics.

“When you don’t feel well, the last thing you want to do is wait in a crowded emergency room,” said Dan Wolterman, president and CEO of Memorial Hermann Health System.

“This new, free community-wide resource lets you talk directly with a registered nurse who will ask questions, determine what level of care you need, then refer you to an appropriate resource.

“It’s important to note that this service is not just for

713.338.7979 Memorial Hermann patients; it is available to all residents living in Harris County and the greater Houston region.”

From diaper rash to migraine headache, this free service is available regardless if you have insurance or a primary care provider. When your child has a fever of 102 degrees or you have a nagging cough at 2 a.m., the Nurse Health Line helps you to: • Decide when and where to go for treatment.

• Get help after your doctor’s office has closed.

• Find a better way to get medical care than sitting for hours in an emergency room.

• Figure out options to treat a sick child.

• Talk over your health concerns with a registered nurse.

• Locate a nearby clinic or low-cost health care provider

with extended hours of operation.

• Get help with both kid and adult medical complaints.

• Find some much-needed peace of mind.

The Nurse Health Line features bilingual staff and language interpreters who are a valuable source of reliable and caring health information, education, and support.

All calls to the Nurse Health Line are confidential and answered by a staff of professionals who are experienced in assessment of clinical situations. To help patients who call, nurses use their training, experience, evidence-based decision-support tools, and peer-reviewed materials to conduct their assessments.

The Nurse Health Line is one of several Memorial Hermann-sponsored Delivery System Reform Incentive Payment, or DSRIP programs. Memorial Hermann is part of Region 3’s Southeast Texas Regional Healthcare Partnership anchored by Harris Health System, and includes the counties of: Austin, Calhoun, Chambers, Colorado, Fort Bend, Matagorda, Waller, and Wharton.

The Nurse Health Line is not designed to assist with life-threatening conditions or emergencies. People with lifethreatening conditions and emergencies should immediately call 911.

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