Dear Drug Seeker, I Hate You.

[Arcan57]

In response to JMHO, I'm sorry that the system let you down so badly. Your case is actually a strong example of the ways in which our healthcare system is broken. Because we are always available, people assume that we are just like your family doctor in our ability to work up and fix any problem. Although the pain radiating into the thighs is unusual for pain from a pelvic source, it sounds like your case would have been very difficult to diagnose initially. In the ED, we suck at working up chronic complaints. We have a very limited toolbox we can pull from, and although I doubt I would have labeled you a drug-seeker (although it's possible) I wouldn't have been able to get an MRI (the test of choice for ruling out spinal cord impingement) if your only symptom was pain.

That you started experiencing bladder symptoms and weakness and were not informed that this warranted an immediate re-evaluation is troubling. But honestly, up until that point, even with a CT showing spinal stenosis the only thing I would have to offer would have been steroids and a referral to a neurosurgeon. There are so many problems that are not suited to ED management. It's frustrating on our side as well that I can't fix your chronic pain, only rule-out the emergent complications. And unfortunately, most drug diverters will deny being there solely to obtain narcotics when you present them with verified proof of their activity. They have learned to say "I just want to find out what's wrong."

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[BJJVP]

JMHO, I agree with the sentiments expressed above by arcan57, hothause, & wilcoworld.

I want to say that the limitations in our technology and current medical understanding is also very frustrating. I am just speculating at this point but it sounds like it took a while before imaging of your back was performed. I'm not sure if this necessarily reflects on the competence of your doctors as much as it shows how difficult a case yours was.

I also want to add that the extreme pressure to see pts and move them through the ER also adds to the problem. I would find it much easier to be sympathetic to pts with colds and toothaches if I didn't have the tremendous stress of keeping the department moving.

I did not go into medical school to be like Dr House or some arrogant genious. I really wanted to be the trustworthy, caring and sympathetic physician who will always do what's best for the pt in a kind and humane manner. It's been several yrs since finishing my training and I now see how hard and sometimes impossible that can be.

I dont think most people (physicians included) realize the uniquely stressful environment we work in. Even the best ER docor can crack under the pressure. There have been many days where I leave work completely unhappy with myself because of the way I behaved or felt during the shift. Sometimes it's snapping at the staff, sometimes it's using foul language, sometimes it's because I truly became angry at a patient.

Hearing stories like yours saddens me...not because I think you had bad physicians. I just think the emergency medical system breeds the kind of care and attitude you encountered and I don't see how it can be fixed. It kills me to know that on many days, because I am human, I am part of the problem rather than the solution.

I don't know if this helps you but I just thought that you may feel better knowing that the doctors who saw you would, in all likelihood, be extremely regretful in finding out that you had a bad outcome. On any given day, the most dedicated doctor can be pressured into a bad decision & give an impression of not caring.

 

[JMHO]

...so you went to the ER because you tripped on the sidewalk and everything hurt and you were convinced that every bone in your body was splintered and refused to leave until you had 12 different CT's and were upset when we woudln't give you a percocet Rx simply because you had already filled a Rx for 120 percocets 3 days ago for your previous slip and fall as confirmed by your narcotics database?

because that doesn't sound like what happened to you, so all your righteous fury seems a bit misplaced on this thread that you sought out just so you could yell at a doctor you've never even met before.

Actually I started reading the thread because of the funny ER Stories a lot of the Doctors had posted, and it led me to the main forum. It was not even the Dear Seeker I hate you title that got me so much as the Assumption that Ovarian Pain would classify someone as a seeker.Because that is what I was diagnosed with.

Let me tell you this, By the time I was properly Diagnosed, I WAS A SEEKER! I would have whored myself on the street if I thought even for one second that I would get relief from that horrible constant pain.

And yes another poster was correct, I did not Begin Displaying the CES Symptoms until later. So it made it harder to diagnose me. Add in pieces of disc that were shimmying around causing pain to jump to different parts of the lower Body and I was probably a Doctors nightmare.

I do understand Doctors need a break from the *****'s who they see everyday, and I'm sorry for Jumping on you guys.The thread hit a sore spot with me. Just do me a Favor. The Next time you get someone like me in there, take a extra few seconds to try and figure us out.

The last time I went to the ER, I already had Incomplete CES , I was treated as if I was A Drug seeker, and the first words out of the Doctors mouth were that they were not going to write me any Scripts for Narcotics. Funny thing is, my FDA Print out showed 1 script in 2 years, and then 10 for the third year when I had 4 surgeries. They had gone in every year and added the print out for my file and used that as the justification not to help me.

The worst Part of this? I used to be a EMT , And had enrolled in College for Nursing. That dream is gone now.

 

[JMHO]

JMHO, I agree with the sentiments expressed above by arcan57, hothause, & wilcoworld.

I want to say that the limitations in our technology and current medical understanding is also very frustrating. I am just speculating at this point but it sounds like it took a while before imaging of your back was performed. I'm not sure if this necessarily reflects on the competence of your doctors as much as it shows how difficult a case yours was.

I also want to add that the extreme pressure to see pts and move them through the ER also adds to the problem. I would find it much easier to be sympathetic to pts with colds and toothaches if I didn't have the tremendous stress of keeping the department moving.

I did not go into medical school to be like Dr House or some arrogant genious. I really wanted to be the trustworthy, caring and sympathetic physician who will always do what's best for the pt in a kind and humane manner. It's been several yrs since finishing my training and I now see how hard and sometimes impossible that can be.

I dont think most people (physicians included) realize the uniquely stressful environment we work in. Even the best ER docor can crack under the pressure. There have been many days where I leave work completely unhappy with myself because of the way I behaved or felt during the shift. Sometimes it's snapping at the staff, sometimes it's using foul language, sometimes it's because I truly became angry at a patient.

Hearing stories like yours saddens me...not because I think you had bad physicians. I just think the emergency medical system breeds the kind of care and attitude you encountered and I don't see how it can be fixed. It kills me to know that on many days, because I am human, I am part of the problem rather than the solution.

I don't know if this helps you but I just thought that you may feel better knowing that the doctors who saw you would, in all likelihood, be extremely regretful in finding out that you had a bad outcome. On any given day, the most dedicated doctor can be pressured into a bad decision & give an impression of not caring.

Dont feel bad, I had a better outcome than many.
Going into surgery, I was told
" You have a 90% chance of never walking again, because of how long you were compressed. But hopefully we can get in there , relieve the pressure and prevent you from getting worse, and possibly save some sensation in your legs."

I can walk. It hurts, and my legs are weak but I can walk. Because a dedicated and caring Physician took a gamble on me and won. Had I been diagnosed sooner, its very likely nothing would have been done because of the placement of the herniation. It was to dangerous to operate on. One of the bloodlines was partially compressed. It did in fact tear during surgery. Which is why the 90 minute surgery took 10 hours, and 4 units of blood. But hey, I went home to my Husband and Kids, Ill take the cane over the wheelchair any day of the week, except Friday.

 

[morbo]

One of the weirdest aspects of medicine is developing a pattern of interactions with the typical drug seeker. None of my friends who aren't doctors don't have to talk to heroin addicts on a daily basis.

Whoa... I have friends who aren't doctors?

 

[Rendar5]

Actually I started reading the thread because of the funny ER Stories a lot of the Doctors had posted, and it led me to the main forum. It was not even the Dear Seeker I hate you title that got me so much as the Assumption that Ovarian Pain would classify someone as a seeker.Because that is what I was diagnosed with.

Let me tell you this, By the time I was properly Diagnosed, I WAS A SEEKER! I would have whored myself on the street if I thought even for one second that I would get relief from that horrible constant pain.

And yes another poster was correct, I did not Begin Displaying the CES Symptoms until later. So it made it harder to diagnose me. Add in pieces of disc that were shimmying around causing pain to jump to different parts of the lower Body and I was probably a Doctors nightmare.

I do understand Doctors need a break from the *****'s who they see everyday, and I'm sorry for Jumping on you guys.The thread hit a sore spot with me. Just do me a Favor. The Next time you get someone like me in there, take a extra few seconds to try and figure us out.

The last time I went to the ER, I already had Incomplete CES , I was treated as if I was A Drug seeker, and the first words out of the Doctors mouth were that they were not going to write me any Scripts for Narcotics. Funny thing is, my FDA Print out showed 1 script in 2 years, and then 10 for the third year when I had 4 surgeries. They had gone in every year and added the print out for my file and used that as the justification not to help me.

The worst Part of this? I used to be a EMT , And had enrolled in College for Nursing. That dream is gone now.

sorry to have jumped down your throat too. hope everything keeps improving for you since it sounds like you had a disastrous time of things.

 

[JMHO]

I know someone who was severely addicted to Narcotics of any kind. She was popping 40-50 pills a day for several years. She claimed that her Gastric Bypass was causing absorption issues, which is why she needed to take 30mg of vicodin at a time for her Fibromyalgia and Stomach Pain. I would have to lock up pills when ever she came over because she would steal them!

Anyways I remember 2 different times she got Letters from the local Hospital Banning her. It basically said that because she had a Significant History of coming in and Seeking Narcotics, that she would never again be written a Narcotics Prescription barring Broken Bones or a Severe Injury. They attached a DEA print out to the letter.

Can't you guys do Something Similar? Red Flag seekers patient files and have a Nurse go out and hand them a standard letter, that says they will not be given any narcotics at this Hospital , Unless they can show a Severe Injury. I bet 90% of them would walk out the door. It won't stop people who Use False Names but I bet it would help enough to make a difference.

You wouldn't be Refusing Treatment, they would be going AMA!

Whats fuuny, is that Friend Eventually Collapsed with Severe stomach pain a year ago. Turn out she had Necrosis of the Bowel. Seems her Gastric bypass wasn't done properly and her Stomach acid and contents were leaking in to her abdomen. She had emergency surgery, had a horrible recovery but none of the pain meds were strong enough because of her intolerance. She developed a post op infection and pneumonia , was readmitted and had Another Emergency Surgery , was Kept in a Medically Induced Coma for 2 weeks and nearly Died.

It took her 4 months just to close the Surgical Wounds and 6 Months to walk normally, all spent in HORRIBLE Pain , because she had such a high intolerance.

So thats one thing to look forwards too. The Seekers who are addicted will eventually learn what REAL PAIN IS!

 

[Old_Mil]

Out of 12 Doctors who examined me, only one did a Ct scan and it was of the Pelvic area , not where the Injury was from. Can any of you guess what was wrong with me?

My symptoms got worse at the end of 2010 and I switched Doctors at the new year. The first person I saw was a Nurse Practitioner. She ordered a Ct scan of the spine. T12 , L1 Right Sided Herniation and severe Central Spinal Stenosis. It took a month just to find a Neuro who would touch me. By the time I found a Decent Neuro , I had lost control of my bladder and could barely walk.

The Neuro gets into my Spine and Ends up spending 7 hours of a 10 hour surgery chasing Down Disk Fragments. 9 of them total.

So much fragmentation without any hint of the back pain that would have triggered at least a spinal CT early in your illness? A CT scan that revealed severe central spinal stenosis and an intervening month without neurological dysfunction before finding a neurosurgeon? Sure.

 

[JMHO]

So much fragmentation without any hint of the back pain that would have triggered at least a spinal CT early in your illness? A CT scan that revealed severe central spinal stenosis and an intervening month without neurological dysfunction before finding a neurosurgeon? Sure.

You assume I had Back pain. I didnt. I strained the muscles once a few years before, but that was it. I had no Back or Spine pain and no symptoms of a back problem at all.

My Only symptoms for 2 1/2 years was Lower Ab Pain and Upper and Inner thigh pain. Confirm where you are in your medical training/career and I will forward you the Mri/Ct Scan and Radiologist reports.

 

[JMHO]

You assume I had Back pain. I didnt. I strained the muscles once a few years before, but that was it. I had no Back or Spine pain and no symptoms of a back problem at all.

My Only symptoms for 2 1/2 years was Lower Ab Pain and Upper and Inner thigh pain. Confirm where you are in your medical training/career and I will forward you the Mri/Ct Scan and Radiologist reports.

http://i54.tinypic.com/20ro1oy.png

DATE OF SREVICE 02/08/2011
Preoperative Diagnosis : T12-L1 Herniated intervetbral disk with cauda equina syndrome.
PostOperative Diagnosis: T12-L1 Herniated intervetbral disk with cauda equina syndrome.


Procedure: Right sided t12-l1 hemilaminectomy, partial medial facetomy and disecomtomy.


Surgeon, and meds are all listed.


Findings: Extremely Large free fragment of herniated intervetebral disc at T12-L1 with considerable tension on the thecal sac. Neurophysiology monitoring improve during the course of decompression.


PROCEDURE:
Im skipping the we use this and such padding blah blah blah. The got me in position and padded every joint.



After they did the facetomy using punches and high speed pneumatic drill, they went on to the Disectomy. The Report States , that Significant Epidural and Venous Bleeding was apparent secondary to the severity of the of the compression of the thecal sac and venous hypertension appeared to ensue. This venous bleeding was relatively well controlled using bipolar electrocautery and floseal. Having achieved adequate homostasis., the thecal sac was gently medially deviated proper to the initiation of the surgery. Electrophysiologic monitoring was initiated for the management of free running EMG and SSEP, and motor evoked potential. During the course of the decompression of the thecal sac, the neurophysiologic parameters appeared to improve. Once the thecal sac was partially deviated, a large protrusion underlying annulus was identified. A bayoneted microdisectomy knife was used to initiate a disectomy using meticulous microscopic techniques using the Microscope to provide illumination and magnification for microdisecton. Several large free floating fragments were removed from this space. At the completion of the dissection the thecal sac appeared to be free of any undue resistance. Next meticulous homeostasis maintained with bipolar electrocautery and floseal. The wound was copiously with bacitracin irrigation. The muscle and fascial later was closed with interrupted vinyl stitches and skin staples. Dressing of telfa and tegaderm were applied. The patient was gently rotated from the prone back supine position on the recovery room bed. Foley catheter remained in place. She was awoken from anesthesia and take to PAR to await extubation in hemodynamically stable and satisfactory condition. All needles, sponge and instruments counts were noted to be correct x2 Per nursing at the end of the case.


This is the draft , I was given when I was referred to a Spinal Injury Doctor.


Incision, minus 3 popped staples that were removed at the 4 day mark when I was readmitted for Spinal Cord Irritation.
http://i55.tinypic.com/k9c5mw.jpg

They were left in for 2 weeks.

 

[substanceP]

Had a narc-seeker arrested this week using a fake ID. He had been seen under his previous name almost weekly in the ED for nearly a year. His complaints were typical of Sociopathic Malingering Syndrome (SMS) and ranged from chest pain, abdominal pain, back pain to unwitnessed seizures. Finallly in June of this year enough of us cut him off of pain meds that he had to buy/steal an ID of a person who looks nothing like him. He had five visits under the fake name until I saw him and looked at his ID. I called PD and they took him to jail.

Today PD was back in the department asking about "damages" to the hospital since he was comitting fraud. His bill for one visit in June was $12,000 so with 5 visitis I gave the estimate of $65,000.

beyond awesome. this is the reason i walk around the ED mumbling and cursing to myself after examining one of these guys.

 

[chable]

http://www.craigslist.org/about/best/sfo/301345524.html

here's a funny message from an ER doc to drug seekers

 

[Groove]

I used somebody's trick that I think I read on here awhile back....

Wrote a paracetamol (tylenol) Rx. Told him he was getting "the good stuff", so try not to take too much of it. Our ED pharmacist was telling me she had to tell the outside pharmacist that it was tylenol because they didn't stock it and had no idea what it was. I laughed, but was secretly crying on the inside. Trick the druggies is our motto.

Next shift, I'm going to make it my goal to write a Rx for Dilobid.

 

[FoughtFyr]

You Disgust me both as a Doctor and as a Person. It is Doctors like you who treated me like I was a Pill Seeker, a Idiot and a Liar for 2 years! I was told my pain was Ovarian in nature too. I even had a Hysterectomy to try and beat the pain.

I went to the Emergency Room, I went to my OBGYN, I went to my PCP, I went to a new OBGYN, Then I went to a new Emergency Room. I explained my weird pain in the lower belly and inner thighs over and over again. But you know what I was always told?
" Narcotic's are not the answer!" " You do realize this is a Emergency Room , right?"

I said fine then don't give me Narcotics just find out what is wrong with me!

Out of 12 Doctors who examined me, only one did a Ct scan and it was of the Pelvic area , not where the Injury was from. Can any of you guess what was wrong with me?

My symptoms got worse at the end of 2010 and I switched Doctors at the new year. The first person I saw was a Nurse Practitioner. She ordered a Ct scan of the spine. T12 , L1 Right Sided Herniation and severe Central Spinal Stenosis. It took a month just to find a Neuro who would touch me. By the time I found a Decent Neuro , I had lost control of my bladder and could barely walk.

My New Neuro had me in Surgery 24 hours after I called his office. Primary Diagnosis? Have you figured it out yet?

Cauda Equina Syndrome, Secondary to Conus Medularis Syndrome. Thats right T12 L1 Is the tail end of The CM Branch of the nerves and the top of the Cauda Equina. So I had two Conditions requiring emergency surgery that 6 ER Doctors missed.

The Neuro gets into my Spine and Ends up spending 7 hours of a 10 hour surgery chasing Down Disk Fragments. 9 of them total. Then a Disectomy, Laminectomy, and some other crazy sound procedure. So from what I understand each of those pieces of disk would have been a Emergency in itself!

Now Im lucky most days if I dont need to self cath , and I cant leave my house with out a cane. Up until a month ago I was still in Chronic Pain. Nucynta changed that for me and most days I can walk and move around my house at least.

All this crap, and Im not even 30 years old yet. I will use a cane and cath for the rest of my life. All because a Doctor like you guys failed to slow down and connect the dots of my symptoms. Not all of us are Seekers. I sure as in the hell wasn't.

Umm, yeah. You had ill defined pelvic pain for 2 years. Not an emergency. It progressed to CES, an emergency. However, by that point you had so many negative work-ups that not only did your physician have to overcome your challenging diagnosis, but also their preconceptions regarding your frequent visits...

 

[deleted109597]

Umm, yeah. You had ill defined pelvic pain for 2 years. Not an emergency. It progressed to CES, an emergency. However, by that point you had so many negative work-ups that not only did your physician have to overcome your challenging diagnosis, but also their preconceptions regarding your frequent visits...

I'm trying to figure out where she got a "pelvis" CT that didn't include abdomen.

 

[telenurse]

Interestingly enough...my clinic sent me to the ED for an acute pain issue. Personally I think it was to shut me up, (if I can tell when a pt is sick, why don't you trust me when I say I am sick?).

I declined their kind offer to call 911 for me as I was at home , went by private car to a different hospital. Was given a handout. The gist is below

"Abuse and Diversion Control of Narcotics in the Emergency Department."

The ED will not prescribe additional narcotic pain meds after the first visit for an acute or chronic complaint when you are already recieving or have received meds elsewhere....

Frequent flyers with chronic conditions receive non-narcs.

NO lost or stolen scripts will be refilled, no methadone doses will be given,
NO benzos will be given.

Etc, etc, etc.

I liked the flyer...it even says healthcare laws allow the hospital to share and request the pt's medical info.

I really liked this hospital, it's a bit further away, but great staff. Gave me some fluids, pain management, told me the results of everything. I have kidney stones in addition to my GYN troubles. Was great about giving me a referral to a different GYN in case I needed a second opinion as my husband had ranted a bit about my GYN problems.

 

[michaelrack]

I'm trying to figure out where she got a "pelvis" CT that didn't include abdomen.

I'm not sure why her doc would order a CT of just the pelvis, intead of the more common abdomen and pelvis CT.

 

[IpMan1970]

Soon, meowdoc, you too shall turn to the dark side.

My goodness, was it the day, the year or the career....or was it the massive amounts of corruption which we see on a daily basis and it's not all admin, look around at your peers, those above in years (coughs suspiciously), and those with years to go before they have a true grasp....
Maybe that wasn't really the best formed question, but I must say I am glad you are letting it out HERE in this forum and not upon the PTs.

It always reminds me of being a judge, do we really want to send an innocent person to the gas chamber for fear of the process to ensure our endeavors?

If it wasn't for all the bureaucracy to begin with, we could easily tag such people internally, hit them with the bare minimum, a clon patch and referral to the even more overloaded mental health system.

Whoopie Goldberg always cracked me up when she said, "It's easier to get Heroin, Cocaine, etc., than it is a Cuban Cigar...what does this really say?"...as best quoted as I can. I don't know the answer but I surely do not want people, humans, of any kind burnt to a cinder. My family had enough of this when another great thinker moved a people to ideals much larger than themselves and became sometime much more insidious and destructive.

Do not give in to the Dark Side my Padawan. Heh. My kids will love the Star Wars....speaking of, my eldest, a child of the original trilogy received his second doctorate. We cannot be more proud of our Astrophysical Sociologist. I assume he will be among those who speak to the 'cloud people' when they arrive.

IpMan

P.S. - Blessings Old_Mil, as you and I both know you've helped many. Let that feed you and fill you. Doctors, good ones, are a precious commodity and us older gents need stay unabashed and yet ever ready to bend to the winds of change. I'm half retired and in about 5 more years will make my final rounds exception a few shut-ins with me for years. And again, Blessings.

 

[RustedFox]

Limited idea what that (above) means, at all.

 

[Arcan57]

Limited idea what that (above) means, at all.

Crazy cakes?

 

[RustedFox]

Crazy cakes?

Post Count: 6.

 

[gutonc]

Crazy cakes?

Drunk.

 

[Birdstrike]

My goodness, was it the day, the year or the career....or was it the massive amounts of corruption which we see on a daily basis and it's not all admin, look around at your peers, those above in years (coughs suspiciously), and those with years to go before they have a true grasp....
Maybe that wasn't really the best formed question, but I must say I am glad you are letting it out HERE in this forum and not upon the PTs.

It always reminds me of being a judge, do we really want to send an innocent person to the gas chamber for fear of the process to ensure our endeavors?

If it wasn't for all the bureaucracy to begin with, we could easily tag such people internally, hit them with the bare minimum, a clon patch and referral to the even more overloaded mental health system.

Whoopie Goldberg always cracked me up when she said, "It's easier to get Heroin, Cocaine, etc., than it is a Cuban Cigar...what does this really say?"...as best quoted as I can. I don't know the answer but I surely do not want people, humans, of any kind burnt to a cinder. My family had enough of this when another great thinker moved a people to ideals much larger than themselves and became sometime much more insidious and destructive.

Do not give in to the Dark Side my Padawan. Heh. My kids will love the Star Wars....speaking of, my eldest, a child of the original trilogy received his second doctorate. We cannot be more proud of our Astrophysical Sociologist. I assume he will be among those who speak to the 'cloud people' when they arrive.

IpMan

P.S. - Blessings Old_Mil, as you and I both know you've helped many. Let that feed you and fill you. Doctors, good ones, are a precious commodity and us older gents need stay unabashed and yet ever ready to bend to the winds of change. I'm half retired and in about 5 more years will make my final rounds exception a few shut-ins with me for years. And again, Blessings.

This post has rhymes in it. It's mysterious. It has references to gas chambers, Star Wars, the "cloud people", the overloaded mental health system and even has a shout-out to a fellow SDNer. What's not to like? On the other hand, I don't have a damn clue as to what he's talking about, but that's besides the point. I kinda like it.

At least it's not boring.

 

[KLPM]

 

[gutonc]

At least it's not boring.

After a shift/day/week/career spent listening to people who can't string 6 coherent words together, do you really want to come home and read the same thing?

But I'll grant you that it's not boring...at least in the conventional sense of the word.

 

[SserPrun95]

I document that the drunk with a BAL of 300 cant get ativan cause I worry about them, same for the drunk with TBD (total body dolor).

Does it make me a better or worse person that on my initial skim I read this as total body "odor" and got a quick chuckle out of it?

 

[Arcan57]

Does it make me a better or worse person that on my initial skim I read this as total body "odor" and got a quick chuckle out of it?

I did a pelvic on a morbidly obese lady tonight and she smelled like dirty armpit in the groin region. It was really weird because I'm not used to encountering that particular odor south of the nipple line.

Carry on....

 

[SserPrun95]

Wait, there's a database that tells you when the pt. last got a scrip for narcotics in this state? (I'm in KY)

In KY there is.

 

[ajh1983]

I did a pelvic on a morbidly obese lady tonight and she smelled like dirty armpit in the groin region. It was really weird because I'm not used to encountering that particular odor south of the nipple line.

Carry on....

Thank you so much. My morning tea now tastes somehow.... less amazing.

 

[emd123]

I did a pelvic on a morbidly obese lady tonight and she smelled like dirty armpit in the groin region. It was really weird because I'm not used to encountering that particular odor south of the nipple line.

Carry on....

Nice.

 

[24IdaFire]

Nothing to see here.

I've read this sob story in EVERY comment section of any KevinMD.com article.