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Perry v. Ethicon: Sales Rep, Doc in the Dark about Pelvic Mesh Dangers

little ricky 300

Ricky Chahal, LinkedIn

Thanks to Courtroom View Network for allowing Mesh News Desk (MND) to observe the proceedings.  No quotations or images may be replicated by MND.

Day four of the Perry v. Ethicon pelvic mesh trial in  Bakersfield, California saw a leading sales representative for Ethicon on the stand to testify how he encouraged doctors to use the Abbrevo sling, a member of the TVT family of pelvic meshes.

Ricky Chahal, was the salesman who encouraged Dr. Hung Luu to switch from his Boston Scientific Obtryx incontinence mesh treatment to the Abbrevo, the newest in the line of TVT (transvaginal tape) products from Ethicon, a division of Johnson & Johnson.   Chahal joined the company in April 2010 and soon rose to the top ranks within the sales division before he left two years later.

Peter de la Cerda

Peter de la Cerda

Under questioning by plaintiffs’ attorney Peter de la Cerda, Chahal told jurors in this product liability trial that he spent about 90 percent of his time in the operating room with the doctors instructing them on the procedure as he had been trained by Ethicon in cadaver labs.

Mr. Chahal is not a doctor and had no medical training outside of his orientation as a salesman for the company.  (See background story on sales reps in operating rooms here.)

In fact, the sales rep was able to take doctors out to dinner to convince them to convert to Abbrevo, as long as there was an ‘educational component’ to the meeting.

Dr. Luu didn’t need much training inside or outside the operating room. That’s because he had been extensively trained as a surgeon with training at Tulane University and a residency in Los Angeles and New York City when Tulane, in New Orleans, was hit by Hurricane Katrina.

J&J Credo

The J&J Credo was introduced to the jurors by the plaintiffs.  It basically says the company’s first responsibility is to doctors and nurses and to patients, mothers and fathers. Chahal was schooled in the credo. He knew it by heart.  It included all of the risks and benefits, he was assured.

But when questioned further about the risks of the Abbrevo, Chahal came up short. The additional risks of erosions and the need for multiple explant surgeries; the rigidity of the laser cut mesh; permanent life-altering vaginal pain; dyspareunia; inflammation and scarring  – none of those warnings appeared in the Instructions for Use (IFU).

Abbrevo IFU

Abbrevo IFU

The salesman was told he could not deviate from the IFU in his training of doctors.

What the IFU did say was that the Abbrevo was contraindicated for women who are smokers, were obese or likely to become pregnant.

As part of his training, in a demonstration by Ethicon, the TVT-O and Abbrevo would be stretched or pulled. With the Abbrevo (laser cut mesh) the sides didn’t fray like the TVT-O (machine cut). Chahal was told that was a real advantage.

He told Dr. Luu the Abbrevo was light weight. The sales rep was never told the Prolene mesh in the Abbrevo was actually a heavy weight. He had learned independently lighter mesh such as Prolift +M was an improvement, but whatever he learned outside of Abbrevo training, he was forbidden from sharing. Chahal also was taught Prolene is inert and nonreactive in the body and does not degrade.

He told Peter de la Cerda he was not aware of those other material facts.

At the end of the day his job was sales. To generate revenue for the company.

Kim Schmid, Ethicon attorney

Kim Schmid, Ethicon attorney

For the defense, attorney Kim Schmid established that Ricky Chahal provided Dr. Luu with information that was “fair and balanced” information on the Abbrevo providing all risks and benefits. [Why the Fox Television/News Corp. slogan is introduced in this trial is unknown].

She also established that Ethicon has a medical affairs team of doctors who are there to answer any questions doctors might have.

Dr. Hung Luu

On Wednesday, implanting physician Dr. Hung Luu, an ob/gyn from Bakersfield testified on the stand for the plaintiffs.  Increasingly, doctors who implant transvaginal mesh are being accused of medical malpractice and Coleen and Patrick Perry have done just that.

Richard Freese, Freese and Goss

Richard Freese, Freese and Goss

But on the stand, Dr. Luu exhibited he had been extensively trained in gynecology but he showed a lack of knowledge about the product.  Under questioning by Richard Freese (Freese and Goss) it was established that he would not have prescribed the Abbrevo for Ms. Perry if he had been told it was heavy weight and small pore Prolene mesh.

He would not have used Abbrevo if he had been aware it degraded.

Dr. Rosenzweig, from his promotional materials

Dr. Rosenzweig, from his promotional materials

Dr. Bruce Rosenzweig

Following the testimony of Mr Chahal, the plaintiffs called their next witness. Dr. Bruce Rosenzweig has been an expert medical witness in other pelvic mesh trials (Huskey, Tyree). Questioned by attorney Thomas Cartmell, it was established the urogynecologist from Rush University in Chicago, did a fellowship at UCLA and has had advanced training in pelvic surgery. Currently in his own practice in chicago he operates up to two days a week and sees patients the other two.

Thomas Cartmell, Wagstaff, Cartmell

Thomas Cartmell, Wagstaff, Cartmell

For stress urinary incontinence (SUI)and pelvic organ prolapse treatments, he chooses nonsurgical options including the burch procedure.  He also performs mesh excisions (removals), a small portion at first if it is merited.

Dr. Rosenzweig says he has so far done about 300 revision surgeries and has treated about 2,000 patients for SUI.

In 2003 he started using synthetic slings as an operation for women who have very bad stress urinary incontinence, something he indicated was a last resort. Dr. Rosenzweig  had come to the attention of Ethicon and was flown to Belgium to train with the inventor of the TVT-O (transvaginal tape obturator), Dr. Jean de Leval.

While he used synthetic polypropylene mesh for a few years, the doctor said he stopped their use in 2006 or 2007, the same year he began treating women with pelvic mesh complications.

His treatment of choice for women include nonsurgical and surgical options, nerve blocks and physical therapy.  The majority of patients he treats, about three-quarters, are for mid-urethral polypropylene sling complications, slings like the Abbrevo.   #

The afternoon session continued, this story is in production.  

LEARN MORE:

JNJ CREDO HERE

http://www.jnj.com/about-jnj/jnj-credo 

WHEN SALES REPS ARE IN THE OPERATING ROOM, Washington Post, April 2013

http://meshmedicaldevicenewsdesk.com/when-the-sales-rep-is-in-the-operating-room

 

16 Comments

  1. PLC says:

    If people knew sales representatives with no medical background were going into the operating rooms to be teaching the surgeons how to use a product during the actual surgery, I think there would be a lot of people not going through with surgeries period.

  2. justme says:

    And the Government of the United States, the Sate medical Boards, all of the medical universities and teaching hospitals including Columbia, Harvard, MD Anderson, the Mayo Clinic, the FDA and the Hospital Chief of Staff’s are all on board with this type of protocol within the the medical community and hospitals? Under HIPAA, how is this allowed? Under US laws how is this legal or ethical? These are/were live women, real breathing human beings, not cadavers, all believing they were in good hands and the right to the truth and privacy. The FDA went after the fake diet pills and extend for men more aggressive than the mesh makers? Oh wait, because men were involved..My bad.

    Medical care is just like food you eat everyday. Chalked full of dangers that you don’t know about until it is too late. My daughter was diagnosed with NHL at 19 years old. We went over and over how this could happen, and it is possible that the long packs of sugarless gum she was chewing while working on her computer, chewing pack after pack on a daily basis for months, did in fact contain high amounts of Aspartame. It was new to the market, the next big thing and was advertised as being safe until it wasn’t. She chewed sugarless gum so she would not get cavities and to keep fit. We learned real quick to avoid anything with the word “artificial.” And never to eat anything but real cane sugar. Cancer sux, chemo sux, but the FDA sux the most. Who do they really look out for or protect?

    And personally, I was never told a sales rep would/could be in the OR, nor was I given any fluff pamphlet describing anything to me about mesh or the dangers, or side effects. I never even saw my doctor but ONE time before he did the surgery. He did not meet with me the morning of..odd right? BTW, I never saw that man again, and I am thankful. he almost killed me. I have never experienced such pain in my life as I did for months and to this day from the mesh surgery

    It took an outside OBGYN to accept me as his new patient, Post OP (which is totally unheard of and a no no in the medical world of oddities), to save me, and get me as well as he could, and I would not be alive had it not been for him. He looked and said, “What a mess” on my first visit. regarding the mesh.

    There is more than enough probable cause to hold a congressional hearing on pharmaceutical mesh.

    • Still Suffering says:

      As far as not being told there will be a sales rep in the OR; they may have it in fine print on the form you sign right before you go info surgery.

    • Terri white says:

      You are so so right. I long for the day that our government decides it is time to be involved. They are well aware of this Mesh Fiasco . Yet they remain silent in all that is happening. I have done my part and more in raising a red flag. I would hope that all victims and their families have done the same. This could very well be the biggest medical disaster ever to effect this country and others. Ten years and counting I have dealt with the fall out from mesh. Right down the unethical emotionally damaging actions of unscrupulous attorneys.

  3. msm says:

    Be aware that with the electronic health records, there is no privacy and you have no way of knowing who is accessing your records and for what purpose. Most systems allow access to all physicians and other “healthcare professionals” as well as billing and insurance staff within that system. That system may be limited to a small practice or it may serve huge corporations, medical education systems,etc. The scariest part is that you may never know what systems you are in and what errors are contained in your data. You can get a copy of your credit report and see who has been accessing or requesting your credit info. But you will never know who is accessing your medical records.

    Vendors and sales reps are in most ORs. Whether it’s a heart valve or a total knee or TVT the companies are offering “product support” and “customer service”. Remember the J&J credo lists doctors as their first priority. NOT patients. Sorry about the rant but the whole system is just wrong!

  4. Emmie says:

    Did anyone go to Atlanta to have mesh removal by Dr. Miklos and Moore? I would fly to Georgia alone. Meet with doctors on Monday, surgery on Tuesday, discharged on Wednesday, stay in area until Saturday. Need someone to be with me for discharge Wednesday and Saturday. They advised I could hire a nurse if I had no one else to help me.

  5. Emmie says:

    I fear the surgery and fear not doing surgery. I exhausted all doctors in my area for removal surgery. My last doctor recommended Miklos and Moore. I lost my job and on SSD. They do not accept medicare. Any one have a cost ballpark $.

    Prolift 2006…TVT 2007 and lots of medical problems since…diabetes..12″ loss of colon..fistula…sepsis…kidney and small bowelobstruction..Chronic pain.

    • Deborah says:

      Emmie…please take the time to read my story before agreeing to a surgery to remove the mesh. This can be a VERY serious surgery with ongoing consequences.

      Deborah Smith

  6. Janet B says:

    Emmie, please join our facebook support group for mesh-injured women, there may be women in Georgia who can help you. https://www.facebook.com/groups/317477065098820/?ref=br_tf

    • Emmie says:

      Thanks Janet. I used your link and I don’t know how to join. I need to get someone to help me. I have a computer science degree from 1998. Started with thyroid cancer the next year and dropped interest in keeping up with technology.

      My last 12 years have been one health issue after another. Prolift in 2006 and TVT in 2007. My spirit is broken. I want my life back.

      I am starting to have problems walking and especially doing steps. I am only 56…miss working…miss so much. Thanks to greedy doctors and Ethicon.

  7. karen says:

    Hi jane. Thank you and all the wonderful reporters for up dates. All of my life I was healthy. But I watch closely how our family members became ill. This vaginal mesh is pushinge too a limit of not wanting I live, but I know its a fight. I have learned with the help of my son he going to school to be a scientist that we truly have to change what we do every year or soon. . The foods and drinks the clothes, the soaps, the laundry detergent, all these Contamination will slowly give us a poison , our bodies can not fight against. So since I have the mesh particles still in my body I watch what I touch, eat, and go . This is like my husband years ago he lost his kidneys and couldn’t do normal (so to speak) activity we had to watch closely.II believe in God and when things seems like it only for the person your helping its God way of telling us everyone change your life also . Every medicine have side effects and about 6 months to a years our immune system starts to give up and then some weird things starts happening. Then we are told we have a medical condition that we knew it shouldn’t be their . I wish I could finish getting all the polypropylene out of my body from this vaginal mesh product. I wish my legs and pelvic bone was the way it was 5 years ago

    I wish I could stand on my feet without my left leg giving out and start feeling like im on the operating table. I WISH THE BEST TO ALL WOMEN !!!!! God bless us all

  8. Maria Garcia says:

    If the MDL is too much for Judge Goodwin to handle in his court maybe I can offer up a solution that works for everyone. Let all the cases be brought back to their respective cities still sharing the same information from all of the discoveries as if they were being handled in West Virginia. Judge Goodwin has already compromised all the remaining cases by saying the rest will not be million dollar cases and he does not have time for them all. Most attorney groups were counting on the four bellwether trials and a few appeal fights and then the money train settlements without going to trial. I say make the attorneys work for it and spread the cases all over the country which will make it easier for the plaintiffs and their attorneys and harder for the companies like Ethicon which will have to hire more lawyers. The whole concept of an MDL is to group cases of like devices and let the common discoveries move the cases along. When a company vows to fight and settles more than letting cases play out to a jury the MDL process is circumvented as far as I am concerned. If you live in Dallas then your MDL should convert back to a defective product case. It should be a local court and be heard keeping all of the discovery information in tacked. On one hand Judge Goodwin is acting like a patient advocate and on the other he is saying that the cases that have received millions should not have. I say the system has failed and Judge Goodwin needs to disperse the case load to the city where the plaintiff lives. It’s not right for a judge and some attorneys to decide that the rest of us should get even less than the lowest awarded plaintiff. What really rattles my cage is the defendants lawyers asking Judge Goodwin to disallow punitive damages in any case and the Judge grants their request! The only reason the cases are MDL is the way the attorneys word the actual filing of the case. Linda Batiste had her day in a Dallas Texas court and everyone of us should have the same chance without Judge Goodwin limiting anything for the rest of us. Don’t listen to all of the fear mongering and ask your attorneys ahead of time about your day in court if the settlement is not OK.

    • abandoned says:

      First I am changing my profile name to abandoned no more. Through this site and many prayers…God has connected me with two friends from high school . When they unexpectedly called and heard of my struggles, they both arranged to take off work and fly to meet me at Mayo (splitting the time) at their own expense and leaving their hubby’s at home. Jayne has reached out to me and so have others.

      The comment is yes, we all need our day in court and everyone needs fair representation. Our gov’t should protect and represent us, then, the Medical Device Companies should reimburse each State or County for their legal expenses. And, after that…the persons involved in the cover up should be charged with second degree manslaughter, and racketeering. Perhaps have mesh implanted in their brains and colons before they are sent to the nastiest prison in existence…not federal prison either.

  9. Deborah says:

    Smith vs. Johnson & Johnson Case #11-60624

    The Woman Behind the Case Tells Her Story

    ABDOMINAL SACRAL COLPOPEXY AND MESH REMOVAL SURGERY

    Better, Safer Than Trans-vaginal Mesh?

    By Deborah Lane Smith

    She woke up from a nightmare in which she saw herself in a coffin. She was crying uncontrollably and screaming. My father consoled her as best he could. “It’s just a dream, Baby. And it’s just a simple hysterectomy. Women do it all the time. What could possibly go wrong?” Well, the answer to that is short and sweet…a heck of a lot.

    My mother, 32 at the time, never came home from the hospital. She bled to death on a warm spring night in June of 1972. They called it DIC. She began hemorrhaging during the hysterectomy and even though blood donors poured in by the dozens nothing could be done to save her.

    Daddy never did recover. He did his best to raise his 5 girls…and keep the farm. He remarried twice but each spring he stomped through the creeks and swamps to gather the pink honeysuckles she loved…He brought them to her just like he always had but there was no joy in it…..our lives were forever changed and not for the better.

    My name is Deborah Smith. I’m the oldest of the 5 girls mentioned above and I just lost my lawsuit: Smith vs. Johnson & Johnson; case #11-60624. My husband and I filed suit for severe injuries from Mersilene mesh which was implanted during an abdominal sacral colpopexy to correct a failed hysterectomy. I’ve become aware that the FDA did not include abdominal placement of mesh in its warning in July 2011 but I’m living proof that it should have. Some attorneys along with some doctors propose abdominal sacral colpopexy is a better, safer alternative than transvaginal mesh. I plan to put an end to that myth.

    In December of 2001, at 42 years old, I had a hysterectomy for break-through bleeding. I didn’t realize at the time that it was unnecessary, as so many are. See, I grew up thinking that a hysterectomy was part of the natural course of events in a woman’s life…you know, first the menstrual cycle, then children and eventually, a hysterectomy and menopause. Needless to say, I was terrified because of Mama’s horrific hysterectomy experience but when I woke up following surgery…all I could think of was that I’d made it. I was going to be ok.

    Well, the hysterectomy failed six weeks later while my husband and I were at a social gathering. I stood up and felt something fall inside me. I called Dr Mills, the ob-gyn who had performed the surgery and his first response was ‘that’s impossible!!’ Well, that’s what I thought too! We decided to meet at the ER. He examined me and declared that everything was normal! I was baffled until I realized that I was lying down. So, I stood up and told the doctor “now examine me” and he did. His words were “oh! OH!!” I said, “Now Dr Mills I don’t know about everyone else but THAT is NOT normal for me.”

    Until that point I was a vibrant, healthy, independent and sexually active mother of two. I was capable of anything I set my mind to and proud of it. Even Dr Mills couldn’t believe what had happened because I was so healthy, young and had great muscle tone. His actual words! He apologized profusely and told me there were other things he could have done to prevent this if he’d suspected this outcome. He explained that my vaginal apex had dehisced and prolapsed along with a portion of my small intestine which fell into the vagina. I don’t mind telling you I was scared to death.

    He suggested a urogynecologist he knew and made an appointment. This urogyno/surgeon treated me like a bug under a glass. He called in nurses and staff to come take a look. I was humiliated and left with no intention of ever walking back in his office.

    In April of 2002, Dr Barksdale performed an abdominal sacral-colpopexy. By then, I was a mess. The plan was to go in abdominally and attach my vagina back in place with a mesh. This would be a permanent fix. If there were other options, no one told me but at the time I was just so relieved. I’d never even heard of such a thing and I was very grateful that IF this could happen to a woman, then at least, they could fix it. But that was before the Mersilene mesh became infected and had to be removed.

    Approximately a year and ½ following the sacral-colpopexy surgery, I began to have major complications: pain and infections which became progressively worse and then, bleeding. After seeing two other doctors and taking several rounds of antibiotics, a thorough exam was done and it was discovered that I had “mesh erosion”. “Mesh erosion”? What?

    I went back to Dr Barksdale, who did a brief exam. The look on his face said it all; it was kind of a green, pasty look. He told me the mesh was infected and had to come out. I asked what he meant. I thought the Mersilene mesh was permanent. I asked what would keep my vagina in place if they removed it. There were no answers. He said that he would have a team of surgeons in the OR, including a cholorectal surgeon. When asked why, he said that it was likely I would end up with a colostomy….for life, due to all the scar tissue. I was shell-shocked. I cried all the way home. I call Dr Mills. He thought Dr Barksdale was just giving me a worst case scenario…but he didn’t see the look on the man’s face. I tried to speak with Barksdale again but my calls weren’t welcome.

    During this time, we invested in a computer. I began to learn how to use it and started researching the mesh removal surgery and seeking experienced surgeons. What I read terrified me to the point that I made out my will.

    I came across a Dr. Miklos. I e-mailed him and he called me very early the next morning and talked to me for a long time. So I made an appt and my husband and I drove from Mississippi to Atlanta, Georgia to see him. I came prepared with questions, my medical records and a recent CT, which he never even looked at. He assured us that he’d done 1000s of these mesh related cases and removals. His opinion was, since a sinus tract formation had developed, the mesh would just pop out and because he was doing it laparoscopically, I would be back on my feet and home in a week. (I would later read a study by Miklos where he had done five (5) mesh removals at that point in time.)

    Well, nothing went as planned. I was in extended recovery for 3 days. My husband called in the family. When I came to I was in a room. I wasn’t allowed to eat or drink. I was bleeding and afraid. Dr Miklos assured me that I was going to be fine and I believed him… until I ate. See, during surgery, Miklos had perforated my rectum and all I consumed came out through my vagina. Later, he explained to my family that there were pus pockets and so much scar tissue; they had to literally chip it away. He said they removed as much of the mesh as they could, piece by tiny piece, but were unable to remove all of it.

    My abdomen began swelling. I had peritonitis. I had to undergo a colostomy placement. This did not go well due to the swelling and another perforation. I remained in ICU for weeks hooked to an NG tube and every kind of machine imaginable. My abdomen actually burst open where the colostomy surgery incision was and I had to be wheeled back in for another procedure. There was talk of yet, another surgery, but new doctors arrived with a new approach to tackle the Illeus? issues. The following week I was sent home. So, nearly 6 weeks hospital stay, most of it in ICU, for a ‘simple’ mesh removal surgery.

    There were months of recovery for this ‘simple’ surgery with more corrective surgeries to follow and of course, additional recovery time; new wounds to pack and wound vacs and home health. It’s been a vicious cycle. My husband and I learned to do things we never dreamed of.

    The first corrective surgery was a recto-vaginal fistula repair to fix the rectal perforation. Then, finally they took down the colostomy bag but the recoveries were neither short, simple or painless. The only thing left to do was to repair the huge hernia. My abdomen was so large I looked 12 months pregnant but with none of the usual expectations. Once again, I started seeing surgeons and they all wanted to use more synthetic mesh!!! Well, that wasn’t going to happen and I wondered if they were crazy or they thought I was….just sayin’.

    Eventually, I learned about Alloderm, a human cadaver product used instead of mesh. I found a surgeon who had experience using it and made an appointment. Did you know that Alloderm doesn’t hold up real well? It’s also prone to infections. This recovery and the many follow-up procedures was another nightmare. As a result, I have multiple hernias and infections that are causing sinus tracts. I’m afraid to let another surgeon touch me and yet, I know, the day will come when I’ll have to. The last surgeon said that until or unless we get the infections cleared up, there will be no surgery. I can’t say I blame him. That’s my biggest fear; the embedded infections. I am currently seeing an Infectious disease doctor to address this on-going complication.

    So, we have an abdominal mesh placement post hysterectomy surgical failure, followed by mesh erosion and removal of infected mesh, which resulted in perforation of the rectum, colostomy placement, illeus issues…and a 6 week hospital stay w/Home Health for months. Corrective surgeries include recto-vaginal fistula repair and eventual colostomy take-down, a hernia repair w/complications requiring many more months of HH, other surgeries, infections, recurrent hernias and on-going infection issues. I’m disabled and suffer varying degrees of chronic pain on a daily basis with no end in sight. So, “Dear Attorney”, PLEASE tell me how an abdominal placement of mesh is any safer than the transvaginal placement. I’d really like to know.

    Here’s what I do know. Synthetic mesh is designed to create scar tissue to hold it in place; which is horrific, in and of itself! Synthetic mesh can become infected and cannot be treated or SAFELY removed. Polymers used to manufacture mesh should NEVER be used in the human body; not temporarily, not permanently, not for any reason!!

    So I ask you: how could the method or placement of said product make one damn bit of difference when it’s the chemical make-up of the product that is the problem? Just think about it!

    It’s too late for me and so many others. My life is essentially ruined; No more baseball, no more long walks, no more fishing or canoeing, no more work and no more sex….it’s over. But, the next generation is coming. I have grandchildren and I do not want this product used on any of them…not EVER.

    One other thing worth mentioning is that my case never went to trial. The manufacturers never had to look me in the eye. They never had to see what their product did to me or even give me a sincere apology. I feel the legal system let me down…but I’m not dead and that’s something to be grateful for… Right? Well… it’s something.

    The point is as long as I draw a breath…it ain’t over. I only hope I live long enough to see this product banned forever. I strongly believe that the use of this product will become a case in study for the manufacturing industry, for doctors, the FDA…and the legal field for many years to come. Each of you has a mother, a sister, a wife or daughter that could someday have this mesh implanted; or a father, brother or son who may need a hernia repair someday. Do NOT let it happen. Do Not allow one more person to fall victim to the agony so many others have to live with every day because of synthetic mesh. I want the people who work at those mesh manufacturing companies held accountable for the incredible pain and suffering I live with every day of my life!! I want them exposed and I want them stopped!! To them, it’s just money in the bank. To the victims like myself and so many others…it’s total madness.

    So, that’s my story in a nutshell. Life as I knew it is over and there’s no happy ending in sight, just my unending mesh mess. And as for those attorneys and those doctors who propose abdominal sacral colpopexy is a better, safer alternative than trans-vaginal mesh, what are you thinking?

    Deborah Lane Smith

    December 2, 2012

    (copyright protected)

    • Jane Akre says:

      Thank you for sharing Deborah… I”m so sorry. I hope people read this and learn. If you would care to expand, in hindsight, what do you think should have been performed instead, perhaps leave your uterus in place/ I just want people to walk away with as much information as they can from your experience. thank you. ~ jane a.

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