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Could This be True?

Just read something I find hard to believe. Found it in a short article by Liz Szabo writing for USA Today. She says that, according to a report released online in  The New England Journal of Medicine, “Eight hospitals reduced the number of deaths from surgery by more than 40% by using a checklist that helps doctors and nurses avoid errors.”

The article goes on to suggest that, “If all hospitals used the same checklist, they could save tens of thousands of lives and $20 billion in medical costs each year.”

Szabo says the Journal article quotes a surgeon and associate professor at the Harvard School of Public Health who explains, “An operation involves hundreds of steps with lots of team members…We’re good at making sure we do most of these things most of the time, but we’re not good at doing all of them all of the time.”

The last thing I want to do is to be self-righteously moralistic or unrealistically critical of anyone. I’m even thinking that what I’m about to say sounds like one of those, “In a perfect world” kind of scenarios. But the New England Journal of Medicine study seems to be dealing in such realistic possibilities for change that I’m wondering, what if we could realize just a fraction of those results in our own individual lives by taking the time to be more careful in how we relate to those around us.

For instance, instead of a checklist of 19, what if we had a checklist of 7 that we used to second guess ourselves whenever we are approaching a threshold of conflict? What if we gave even the briefest, “please Lord help me” to do this” calls for help before doing something that had the potential for real-life consequences?

My thoughts go to the Apostle James who is practical in applying the ways of Jesus to problems like class prejudice, careless criticism, and the mindless things we say about those who either aren’t like us– or don’t like us.

First James encourages followers of Christ to ask for wisdom when we don’t know what God wants us to do in times of trouble (James 1:5). Then he goes on in the 3rd chapter of that letter to tell us how to recognize such wisdom when God gives it to us (James 3:13-18)

According to James who had already seen a lot of conflict in his time, it’s really about being more careful to recognize why we’re doing something and how those motives are affecting the manner in which we respond to those around us (James 3:16). So he goes on to suggest that the wisdom that comes from God is:

(1) Pure (motive)… then (2) peaceable… (3) gentle… (4) willing to yield (i.e. to truth and grace)… (5) full of mercy and good fruits…(6) without partiality… and (7) without hypocrisy. (James 3:17)

Yeh, I know, in a perfect world… But still, if the New England Journal of Medicine is willing to publish speculation about a surgical room checklist that could save 10,000s of lives and 20 billion dollars, maybe it really is worth thinking about the what could happen if we ramped up our desire to seek the help of Christ in… I know this is nothing new… and it’s theoretical… am still thinking about the real possibilities– both ways…


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40 Responses to “Could This be True?”

  1. scottn says:

    Hey Mart, way to go on keeping the pot of thought stirring, I hope it never boils over.

    Any way I was thinking about the suggestion you made of

    “For instance, instead of a checklist of 19, what if we had a checklist of 7.”

    That sounds pretty good in making things simpler. But As I get older I have a desire to increase not decrease the way I think. Even though I often think of Akums Razor.

    Your buddy
    Scott N

  2. BruceC says:

    Good mornign Mart! Got up early to keep the woodstove going. It’s below zero here and calling to get colder!

    I for one have blown it more than I care to admit by responding to situations and people from the flesh. Reacting instantly to something or someone we don’t like can many times leave us looking foolish and feeling bad. Been there, done that!
    What I have learned to do is to literally(but gently) bite my lip and ask the Lord to help me and give me the grace to get through it. I have found that by doing so I have averted making the situation much worse than it could have been. As an example; my wife and I have a difficult time with her sister at times. She often says and does things that are hurtful to my wife and of course I get hot under the collar about that. She recently said something to me about an occurence and I did what I said above. I kept quiet and didn’t erupt. I wanted to tell her not to come over anymore until she learned to grow up. About a week later she called on the phone and asked my wife and I to forgive her; which we did. Had I blown up it may have worsened the relationship between her and my wife; and it may have gotten back to her Mom who is elderly, sick, and doesn’t need any more problems. My sister-in-law has a problem unloading her troubles on Mom and that is part of the issue we have with her.
    So by using my “check list” as you call it; further problems were avoided. My wife used her checklist too and refrained from confronting her and replaced it with forgiveness and prayer. Good post Mart. Reminds me of what my Mom used to say. Stop and think before you speak and act. Sometimes I fail miserably.

  3. Mart De Haan says:

    scottn, hey, gotta look up Akum’s razor :-)…

    And BruceC, when you mentioned temp, I went to check our thermometer. Have one of those that is supposed to give the inside and outside readings. The indoor says 65, but the outdoor reading gave nothing. That hasn’t happened before. Wonder if it’s frozen up :-). Am about to hit the road for work. Guess I’ll find out the real way then…

  4. M Rose says:

    Mart,

    “In a perfect world”….”nothing new”…”theoretical”…”self-righteously moralistic”.
    Because of these concerns of yours…I felt compelled(I never Blog)to comment on how inspiring the message was to me! What down-to-earth, and appropriate way to remind us how to deal with conflict. Thank you so much for that….

    Maria Rose

  5. bretnb says:

    Mart

    It is only 39 here in Jacksonville Fl

    I think if we all had a list of rules/truths that we went over. Before some of the actions we took in our lives we would probably cut out most things we do.

    All the truths are in the Bible I just chose to ignore them to often.

    Bret

  6. gr8grannyjacobs says:

    Cute the Akums Razor. May be a lot of truth in that analogy. Speaking for myself I am noticing if I pray before I post and seek God’s help I seem to be much gentler in my approach. Sometime I am responding in my own self and that is probably not a good thing. I like the idea of a checklist though I doubt I would be perfect in following one.The hospitals probably wouldn’t want me on staff :>). Truly it is my hearts desire to always respond to others in a way to help and not harm. It is about helping others to know the love of Christ in all things not to push them further away. Will be praying for God’s wisdom.

  7. carlj says:

    Reading James 3, my mind went back to the Sermon on the Mount. I suppose one theme of the Sermon on the Mount could be “don’t do what is natural to you, do what seems unnatural”. Learning to shelve my first emotion and relying on God to direct my responses takes more discipline than I thought.

  8. pegramsdell says:

    I was reading James 4 and thought maybe this would be a good checklist:

    7Submit yourselves, then, to God. Resist the devil, and he will flee from you. 8Come near to God and he will come near to you. Wash your hands, you sinners, and purify your hearts, you double-minded. 9Grieve, mourn and wail. Change your laughter to mourning and your joy to gloom. 10Humble yourselves before the Lord, and he will lift you up.

    Also, I agree with you that we need to ask “Lord help me to do this” before doing or saying something important, or anytime really. And good application from BruceC’s “checklist”.
    A kind word turns away wrath. Knowing when to argue a point and when to stay quiet is difficult sometimes.

  9. pegramsdell says:

    Oh, btw, it is 30° here in ocala, fl this morning.

  10. Mart De Haan says:

    pegramsdell, so I’ll bet 30 feels colder to you than 0 does to some of the rest of us :-). Lived in St Pete, Fla for awhile and remember watching the snow birds go swimming in Gulf water we wouldn’t touch :-)…

  11. soloyo says:

    LAST YEAR WE’VE STUDYING PSALM 119 AT CHURCH, OUR DAILY BREAD FOR TODAY MAKES REFERENCE FOR V. 32, SO I RELATED IT WITH THIS ARTICLE, (I READ BIBLE IN SPANISH SO PLEASE DON’T EXPECT ME TO WRITE VERSES LIKE KJV, I JUST TRANSLATE)TO EXPAND OUR HEART, THE BARRIERS OF OUR HEART MAKE LIMITS FOR GOD’S WORK IN OUR LIFE, I HEARD A WOMAN TALKING ABOUT THE MANNERS OF OTHER CHRISTIANS, BUT SAYING THEY’RE NOT FROM A “GOOD FAMILY” SO “THEY DO THIS OR THAT…” YOU KNOW, LIKE PUT THE ELBOWS ON THE TABLE, I SAID “BUT I DON’T WANT TO HEAR ABOUT THIS, THOSE KIND OF GOOD MANNERS IN NOT WEALTHY PERSONS DON’T AFFECT THEIR RELATION WITH GOD, PSALM 34 TELLS US ABOUT NOT SAYING BAD ABOUT NOTHING (V. 13-14) BY THE WAY” SHE SAID TO MY DAUGHTER “IT’S EASIER FOR HER TO CHANGE THAN ME ‘CAUSE I’M OLDER, SO OBVIOUSLY SHE HAD TO, I’M NOT AND I WONT”. THIS IS A VERY BIG BARRIER, AND SO ALL OF US HAVE IT, ALWAYS WE SAY I CAN’T CHANGE OR I DON’T WANT TO, WE ARE ADDING A BRICK EACH TIME WE SAY AND THINK THIS WAY, SO, WE WONT RUN IN HIS WORD, WE WONT SEE ANY FRUIT MENTIONED IN JAMES 3 “FULL OF MERCY AND GOOD FRUITS”, HOW WE THINK ABOUT OTHERS, HOW WE THINK ABOUT US, WHAT WE CARE, IN FACT WHAT IS THE MUST IMPORTANT FOR US IN OUR HEART.
    IN A TOWN, THERE WAS A MAN WHO NEVER NEVER TALK BAD OF ANYTHING, PEOPLE EXPECTED TO FIND SOMETHING THAT DISAGREE TO HIM. SO, THERE WAS ALSO A MAN, THAT KIND WHOM YOU CAN’T SAY ANY GOOD ABOUT, DIRTY, DISHONEST, ETC. ONE DAY THIS LAST MAN WAS WALKIN BY WHISTLING, SO ANOTHER MAN SAID “THIS IS IT, THE OPORTUNITY TO SAY SOMETHING BAD!” AND ASKED THE GOOD TALKING MAN WHAT HE THOUGHT ABOUT THAT MAN, HE STARE AT HIM AND SAY “OH, HE WHISTLE VERY WELL.”
    OOOAAAAAGHHH! WHY CAN I DO THAT WAY??? IT’S BECAUSE WHAT I’M THINKING ABOUT, WHAT I KEEP IN MY HEART, IS GOD’S WORD OR MINE WORDS, GOD’S THOUGHTS OR MINE… 8Finally, brethren, whatsoever things are true, whatsoever things are honest, whatsoever things are just, whatsoever things are pure, whatsoever things are lovely, whatsoever things are of good report; if there be any virtue, and if there be any praise, think on these things.

    9Those things, which ye have both learned, and received, and heard, and seen in me, do: and the God of peace shall be with you.
    HE HE! BRING IT FROM GATEWAY, YEAH IN KJV!
    BLESS YOU ALL, THANK YOU MART, FOR ALMUST 20 YEARS YOU HAVE BEEN LIKE AN UNCLE, ROCKING MY HEART WITH GOD’S WORD.

  12. soloyo says:

    OH, BY THE WAY, COULD THIS VERSES OF PHILIPIANS 4, BE THAT CHECK LIST, ISN’T IT? OR GALATIANS 5:22-23 … YEAH, WE WILL FIND PLENTY VERSES TO CHECK THE HEART, AND TO ASK FOR WISDOM.

  13. soloyo says:

    DON’T KNOW HOW MANY DEGREES IN MEXICO CITY, BUT IIIII’M COOOOOOLD, 3 DAYS MISSING SUNNY DAY, WAIT ME IN FLA! I’M ON MY WAY HE HE. (I JUST LEARN TO WRITE “BTW”, THANK YOU PEGRAMSDELL

  14. kaliko88 says:

    It may be nothing new, but that’s why it’s good to have someone bring it up again. We tend to ignore the familiar. I think we trick ourselves into thinking something newer and better will come along instead of simply using what has already been proven to work. Personally, I try to keep those things in mind, and with practice I’m getting better, but somehow I never pictured it as a checklist. Instead I always imagined a guardian angel following my every move, wearing combat fatigues and barking at me like a drill seargeant.

    It’s 1 degree right now here in Kansas, but the wind chill makes it feel about 20 degrees colder. And it’s time for me to drive to work. Brrrrr!

  15. SFDBWV says:

    soloyo, just wanted to say hello and tell you how much I enjoyed your comments. Thanks.

    To all, it’s 07 degrees here and we have 7 inches of fresh snow. You ever notice they seldom talk about Al Gore this time of year….

    Checklists are still only as good as the people who are to follow them.

    The aircraft industry is awash with checklists but human error is always going to be a factor.

    I read one of thoes medical stories a couple years ago about how they thought there would be less hospital “caused” deaths that year. Something in the area of cutting it down to less that 20,000 (twenty thousand).

    I was flabbergasted, first of all that they admitted that they killed people acidentaly and then as to the numbers of people that they hoped to kill less that year.

    “Put a watch over my mouth” There are just plenty of good advice all throughout scripture in suggesting we think before we speak….But oh my, that is sometimes harder than it sounds.
    “A kind word, turneth away wrath.” Used that one plenty.I have also found that there are times that don’t work either.
    Sometime it is best to just get things off your chest rather that keep them in. Sometimes kept in unsaid things have a way of growing into larger matters and then come out at the wrong time.
    Have come to a point in life where honesty is the best policy, and it’s best to say nothing sometimes.

    Counted 12 deer in my yard this morning and a dozen grey squirrels. Love feeding the critters.

  16. Mart De Haan says:

    Steve, I never get tired of watching the deer. We’ve gotten so much snow this winter, they’ve really been out of pattern in our area looking for food. If you ever get a good picture of them in your back yard wish you’d e-mail it and I’ll try to post. Am sure others would like to see what you and Matt are feeding :-).

  17. NatusNemo says:

    Mart:
    I think what you are after can be summed up by Ephesians 4:15 “But speaking the truth in love…”. These two balance the believer in his action & attitude. Truth & Love are also attributes in which we are to grow, or increase. Really we all just need to grow up! We need to grow up into Jesus Christ… What we require is transformation.

  18. carlj says:

    I am a list maker. Anytime I get ready to do a project I make a list of what needs to be done. The hospitals using a checklist and the computer tech using a checklist seems logical to me. What has never crossed my mind until today is a checklist for living with a “wisdom-orientation”. I am asking myself today what if I put together a checklist based upon James 3, Galations 5, Phillipians 4, and others and keep that with me in laminated form in my pocket. When a situation presents itself of any kind, pulling out the checklist and reviewing, with prayer for guidance, to see how best to proceed or not to proceed. The checklist is relevant but I think the pause mode is what makes the checklist effective at least until the checklist becomes as natural as breathing.

  19. GeraldG says:

    This is a great word picture for myself, to enable me to overcome the challenge of being only a ‘hearer’ of the Word of God and translating it into being a ‘do-er’. I can see that asking God for His grace each time these tools are needed will help me develop God habits which will become a part of my life and others will see the difference and some will want to know more. Being a do-er consistently is my growth challenge this year, how about you? Sincerely in Christ…:-)

  20. pegramsdell says:

    Steve, who’s Al Gore? lol…
    and yeah, Mart, it is so much more colder here in ocala, than anywhere else…at least I think so. I’m from Miami, and if it ever had the nerve to get down to 40°, we just didn’t go to school….lol
    (btw)…your welcome soloyo.

  21. wretch-like-me says:

    Welcome, Soloyo, como esta’? Are you originally from Mexico and now living in Florida?

    I am blessed by your comments, one and all. I can relate to making lists. I have been using them for years to compensate for failing memory and increasingly complex world we live in that requires ‘multi-tasking’.

    However, my major problem is “Remembering where I put the list”! (;P) Seriously, lists are good reminders for short term needs; but for long term behavior changes the ‘list’ needs to become a habit. Isn’t that what we are all trying to do; make Christian Living a habit… as in a Way of Life?

    I, too, struggle with ‘repressing my angry feelings’ especially when they result from interaction with friends or loved ones. My counselor described me as having a ‘garbage can’ on my back.

    I kept putting my anger in the can until it got so full I could no longer keep the lid on. The next little bit, regardless of how tiny, caused me to lose the lid and ‘spill the garbage’ on everyone in my presence at that time. People who had nothing to do with my problem got the ‘whole load’ I had been packing around.

    I am learning that Jesus wants to take the ‘can’ off my back, IF I WILL LET HIM. It’s part of that ‘surrender’ thing; tied to my self-image, macho, masculinity crap. (Can I get a ‘HOO-Jah!’?)

    Amazing how good it feels to have the load lifted!!

    BTW… finally made it back home to Northeastern Washington State where its 29 degrees and overcast. I take great joy in seeing wildlife…please post the pics.

  22. poohpity says:

    All I have to say is I resemble that topic. The tongue is a hard thing to master because it is a reflection of what is in the heart. I feel a little nervous about telling the temp. here. 67 degrees in the shade. :)

  23. Laurielee says:

    It moved from cold to dangerous here today 25 below …schools cancelled, except of course the college where I have to go soon.

    This is a wonderful article…I try to read them as they work in my life, and try to apply the areas I find I’m lacking in my own life. I, too, am a list maker. soloyo, great post! I also try to follow the verse from Phillipians. gr8grannyjacobs, your posts make me smile, what a gentle, caring soul!

    When I pray, I ask the Father to remake me into what He would have me be, not what, in my own eyes, I think I should be. I have to ask for His help because I am incapable of doing it on my own.

  24. sitsathisfeet says:

    Checklists are a great idea. I went to look up the last checklist our Pastor gave out for our “God – devotion inventory”, so to speak , based on some scripture we were going over. And the Bible study has weekly checklists with scripture that I find very helpful. When I am confronted with things that at first I have no idea what to do, I pray, read scripture and eventually things make it through the fog of my mind, and guess what, I get a list of possible actions to take. After prayer and mulling it over I usually get a sense of what God wants me to do. Sometimes it is very hard, and I don’t want to do it, but eventually the still small voice wins out and I am able to do it. It is interesting that my daughter is in the Navy, combat division, and when I went to see her I was surprised at all their checklists. A great part of their jobs is to routinely, methodically, timely check everything – equipment, weapons, defense, communication, personnel, uniforms etc. etc. And then they check that the checks have been performed in the proper time, proper order etc., which they stake their careers and lives on. They get medals and accomadations for this work. ( not only for saving lives directly etc.) This might be common knowledge to anyone in the military, but was interesting to me. My daughter said her best preparation for going into the military was her attendance at Christian school. Having spiritually, and physically followed God’s “rules”, she was better prepared to conform to the military environment than someone who did not have that discipline. Now I am not promotting the military or anything like that, but our God being the God of order and not chaos, can enable us to order our lives so not one detail of his desire in our lives is omitted. Praise God that he is a God of order , details and yes, sometimes checklists!

  25. poohpity says:

    In 2001 I almost lost my mother to infection after a reconstruction surgery at Mayo Clinic. She did not even have cancer in the mastectomy but got three different infections from the surgery. She was in ICU for 7 weeks and the doctors called us in twice to tell us she was not going to make it because they could do no more. I told them we have the Great Physician and He can heal her and He did. She lost not only the reconstructed breast but also all the soft tissue from her stomach and has several hernia’s. Never did they admit their wrong.

    I speak many times without considering the consequences. I do however admit when I have done wrong which is a lot. Maybe one day I will learn the lesson of thinking before I speak so I do not have to ask for forgiveness so much.

  26. pegramsdell says:

    WLM – “Hoo-Jah!” Very funny, thanks I needed that laugh.

  27. poohpity says:

    Is that the USMC call for agreement or unity.

  28. Jwigg says:

    carlj is “right on the money” to link the Sermon on the Mount to the understanding of the Letter of James. James the Elder was the half-brother of our Lord. James’s letter is so full of ideas and phrases which echo the teaching of Jesus as it is reported in Matthew, Mark and Luke that the epistle should never be read without reference to the first three gospels.

    James presents heaven’s wisdom as diametrically opposed to the demonic pseudo-wisdom of this world.The whole letter is about getting our minds into gear with Heaven’s “gearbox” before we open our mouths, and about actually doing what Christ’s law of liberty says instead of just “looking into it” or being a “hearer only”.

    A fitting prologue/executive summary of James chapter 3 is verses 19 & 20 of chapter 1:

    “So then, my beloved brethren, let every man be swift to hear, slow to speak and slow to wrath for the wrath of man does not produce the righteousness of God.”

  29. poohpity says:

    This info on the doctors is so timely for my hip replacement surgery on tuesday. I am so excited now. :(

  30. Laurielee says:

    The Apostle Paul was quite a list maker throughout his letters.

    poohpity, please do not fear! I’ve heard those who have had hip replacements done have so much less pain when they are recovered. I’ll add you to my prayers asking that your surgery go well…I don’t know your name, but God does…and even more importantly, YOU know HIM! God bless you and bring you safely through surgery, and may your convelescence be swift!

  31. poohpity says:

    Thank you Laurielee my name is Deborah. This well be my eighth hip surgery. Your prayers are greatly appreciated.

  32. pegramsdell says:

    Deborah, my prayers are also with you on Tuesday. My son-in-law (Tod) just had his hip operated on and a plate put in because of an accident he was in on news years eve.
    He is doing well, actually walking a little. Praise God! “The prayers of a righteous man avails much.”

  33. poohpity says:

    I am so very very glad to hear that. Thank you for keeping us informed.:)

  34. sitsathisfeet says:

    Dear Deborah I pray right now for your hip surgery on Tues. I ask that the Lord God guide and direct the doctors hands and minds as they perform the surgery and that you are with all the hospital staff as she is operated on. I ask also that you be with her family her children, and her mother that you comfort them all, and give them your Peace that passes all understanding as you guard their hearts and minds in Christ Jesus. May the operation be such a success that all the glory can only be given to you Lord. Be with Deborah, let her feel your presence every step of the way and relieve her physical pain, and give her emotional, spiritual, and physical healing through it all. We ask this in Jesus Name Amen. Janice

  35. BruceC says:

    poohpity,

    May the Lord be with you and comfort you during and after surgery and may He speed your recovery.

    9:00 PM here and already -12. Not “that” bad. Bout’ 31 yrs. ago after we were first married it hit 45 below here and never got above zero during the day for a week. Now that’s cold!

    Thinking about the usefulness of “checklists”. Seeing the news about the miraculous survival of those people crashing into the Hudson River and the checklists pilots, attendants, and emergency personnel go over and over again in training until they have it right. And then to see it all come together flawlessly. Of course, with most of the help coming from Lord. Angels must have been busy!

  36. Laurielee says:

    Deborah…what a beautiful name…I have a soft spot in my heart for names that end in ‘ah’. My granddaughter is Corah. She was specifically named with an ‘ah’, as her mother is Jewish and named Rebekah. I’m sure it has been very difficult on you with all the surgeries. I pray that it’s your last one.

    I hope we’re all on the List that counts!

  37. soloyo says:

    ESTOY BIEN WLM GRACIAS. “BTW” I’M FROM, AND ACTUALLY LIVE IN MEXICO, ABOUT FLA, JUST KIDDING ‘CAUSE I’M SOOOO COLD (LOOKS THE THE DATE TO TALK ABOUT HE HE)

    DEB, YOU KNOW, YOU’LL SEE, THAT’S WHY WE’RE BROTHERS AND SISTERS, TO SUPPORT EACH OTHER EVEN IN DISTANCE, AND TO LOVE EACH OTHER ENOUGH TO GIVE UP OUR SIN TO BE IN GRACE WITH GOD FOR PRAYER, MAY GOD BE WITH YOU, FOR CONFORT AND STRONG TRUST, MAY HIS PLAN BE DONE IN YOUR LIFE AND YOUR LOVED ONES, YOU KNOW, IN HIS HANDS YOU’RE SECURE. FILIPIANS (IT’S CORRECTLY WRITTEN? HOPE SO! UF) 4:6-7; PSALM 103:1-5.
    THANKS FOR ALL I’VE RECEIVED FROM YOU, I’LL REMEMBER YOU IN PRAYER, WE ARE A PRAYER TEAM, ISN’T IT? EVERYBODY? ISN’T IT MART? ;-)

  38. david and christine wade says:

    “carlj Says:
    January 15th, 2009 at 7:48 am Reading James 3, my mind went back to the Sermon on the Mount. I suppose one theme of the Sermon on the Mount could be “don’t do what is natural to you, do what seems unnatural”. Learning to shelve my first emotion and relying on God to direct my responses takes more discipline than I thought.”

    If I may add to your post, Carl.

    The issue of our behavior and the influence of any list on it comes down to our “mode of transport” IMHO. The Apostle Paul devotes many words to walking in the flesh (natural) and walking in the Spirit (unnatural – I prefer supernatural). Any list requires we stop, consider our initial reaction, change it or continue – all seemingly untimely.

    Walking in the Spirit – where we are not condemned (Rom 8:1)- is an un-natural state
    that requires a firm devotion and intent – both to please our God. Many Christians, when asked, reply they rarely spend more than 50% of their waking day “in the Spirit.” It’s simply not natural in these fallen bodies.

    A devoted, determined prayerful life has little need of any list of reaction alternatives. The list may be a good place to start, but instinctive Spirit walking is the true answer. Practice it. At 70 years of age, I’m still trying. Dave

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