sad patient stories

BlondeDocteur

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    At the risk of being labeled a freak who revels in the misery of others, I'd like to know-- what's the saddest story you've heard in your career thus far? The most gutwrenching patient?

    I'll start. The most difficult thing I had to be a part of was my very first day of third year, on Ob/gyn call. I was intimately involved in this patient's care because I spoke the language in question.

    The patient was a 42 year old woman 20 4/7 wks along with her second pregnancy. She desperately wanted children. Her first pregnancy, at age 40-- after a decade of trying-- ended suddenly, at 20 weeks gestation, with an unexpected miscarriage. The patient presented in florid pre-eclampsia. Pressures rising by the hour, no seizures (yet), proteinuria off the charts... and 3.5 wks away from viability for the fetus. It was explained to her that unless she terminated the pregnancy she would surely die. Weeping quietly, she and her husband agreed... they were numb and in shock.

    We put the fetal heart monitors on and injected KCl into the fetal heart. For a few agonizing minutes, we heard the beats get weaker, softer, farther apart, until it stopped altogether. Labor was induced, and a perfectly formed stillborn boy was delivered. We placed him in mom's arms and left her and her husband to grieve.

    They were still in shock... couldn't believe it. After all they had come in only 12+ hours earlier for headaches.
     

    H_Caulfield

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      :sleep:

      I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to. Could one argue that I ought to be sad about everything that pushes its way out of me? Maybe I'm just naturally cold.

      I do think physicians should carry their tragic memories silently. You know, just to maintain professionalism and their patients' confidence.
       

      zver81

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        :sleep:

        I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to. Could one argue that I ought to be sad about everything that pushes its way out of me? Maybe I'm just naturally cold.

        I do think physicians should carry their tragic memories silently. You know, just to maintain professionalism and their patients' confidence.

        I am sorry to say this, but you ARE naturally cold. It is one of the biggest tragedies for a woman to lose her child, even if she didn't "know the kid" as you say.

        I think that physicians should share their sad memories. After all, we are human and we need to vent and to express our sadness. We can't always do it at work or at home, and this is not a bad place to do it. By the way, EM forum has something similar http://forums.studentdoctor.net/showthread.php?t=154841&highlight=medicine+sucks
         
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        docB

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          :sleep:

          I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to. Could one argue that I ought to be sad about everything that pushes its way out of me? Maybe I'm just naturally cold.

          I do think physicians should carry their tragic memories silently. You know, just to maintain professionalism and their patients' confidence.
          That is just a messed up attitude and statement. If you can't understand why a pregnant woman who has miscarried is sad and equate a miscarriage or stillbirth with "everything that pushes it's way out of" you then you really need a reality check.
           

          yaah

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            We had a case in path where one day in the path lab we received both legs of some guy, amputated above the knee, because they were ischemic and gangrenous after he developed Strep pneumo sepsis. A few days later we got an arm. A few days later we got 5 fingers. Then we got a chunk of his nose that was debrided after it was finally determined it wasn't viable anymore. Guy was previously healthy, was skiing and just got sick. Had his spleen removed a few years prior for a traumatic injury.

            I actually saw the guy in the hospital a couple of weeks later. No legs, one arm without fingers on it, no nose.

            I daresay that was the saddest thing I have ever seen in a hospital.

            I dunno, different things hit you at different levels. I will always remember a guy I took care of in med school who came in fatigued and had some belly pain, turned out he had metastatic gastric cancer. He was 35. We had to tell him what he had and the look he got in his eyes when he comprehended what it meant was devastating.
             

            mlw03

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              :sleep:

              I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to. Could one argue that I ought to be sad about everything that pushes its way out of me? Maybe I'm just naturally cold.

              I do think physicians should carry their tragic memories silently. You know, just to maintain professionalism and their patients' confidence.

              damn... that is rather harsh. and i'm a baby-killing, pro-choice liberal according to some of my conservative classmates. miscarrying that far along is sad, especially to a woman in her 40s who knows her supply of good eggs is rapidly drying up.
               

              smq123

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                :sleep:

                I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to.

                The TOS prevent me from telling you EXACTLY what I think of you. Although, honestly, it might be well worth the infraction. :mad::mad::mad:
                 

                Rogue_Leader

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                  We had a case in path where one day in the path lab we received both legs of some guy, amputated above the knee, because they were ischemic and gangrenous after he developed Strep pneumo sepsis. A few days later we got an arm. A few days later we got 5 fingers. Then we got a chunk of his nose that was debrided after it was finally determined it wasn't viable anymore. Guy was previously healthy, was skiing and just got sick. Had his spleen removed a few years prior for a traumatic injury.

                  Had he not gotten pneumovax after the splenectomy?
                   

                  gutonc

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                    The TOS prevent me from telling you EXACTLY what I think of you. Although, honestly, it might be well worth the infraction. :mad::mad::mad:

                    Agreed. Wait until you are or are married to that woman then you'll understand. It sucks...hard. The second time is even worse. Fortunately (for us at least), the 3rd time was a charm and we now have a gorgeous 1 yr old daughter. This mitigates but in no way completely relieves the pain of the 2 miscarriages.

                    All in favor of suspending the TOS just this once, say aye.
                     

                    Doc Oc

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                      That poster couldn't possibly understand, as obviously he/she is not a mother. Sometimes, complete cluelessness needs more credit, and I think is a better descriptor of someone who would say that, rather than pure evil.


                      Saddest story of mine - a couple who had three miscarriages, then carried one to full term, delivered, turned blue within an hour, and died while being transferred to a hospital with a NICU. She had a diaphragmatic hernia. Just heart wrenching, even more so now when I think about it, since I am a mother.
                       

                      dpmPOD

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                        :sleep:

                        I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to. Could one argue that I ought to be sad about everything that pushes its way out of me? Maybe I'm just naturally cold.

                        I do think physicians should carry their tragic memories silently. You know, just to maintain professionalism and their patients' confidence.

                        Seek help.
                         
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                        smq123

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                          Agreed. Wait until you are or are married to that woman then you'll understand. It sucks...hard. The second time is even worse. Fortunately (for us at least), the 3rd time was a charm and we now have a gorgeous 1 yr old daughter. This mitigates but in no way completely relieves the pain of the 2 miscarriages.

                          All in favor of suspending the TOS just this once, say aye.

                          *Raises hand*

                          gutonc - I'm so happy to hear that you and your wife were lucky enough to have a healthy daughter. I'm sure that the previous two miscarriages were incredibly hard to deal with, but I'm glad that the third pregnancy turned out well.

                          That poster couldn't possibly understand, as obviously he/she is not a mother. Sometimes, complete cluelessness needs more credit, and I think is a better descriptor of someone who would say that, rather than pure evil.

                          Or a parent, period.

                          The worst moments on L&D are watching the father of the baby try to keep it together. The mother was often in too much pain, or too sedated, to understand what was going on. But the father was fully conscious and could see everything - and you could just see how helpless and worried these guys felt.

                          I know that OB/gyn is supposed to focus on "woman's" health - but sometimes I felt like, on L&D, the guys needed just as much care and attention as the women did. Seeing some of those guys cry when something went wrong was heartbreaking.
                           
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                          Doc Oc

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                            Consider "parent" substituted for "mother", absolutely.

                            *Raises hand*

                            gutonc - I'm so happy to hear that you and your wife were lucky enough to have a healthy daughter. I'm sure that the previous two miscarriages were incredibly hard to deal with, but I'm glad that the third pregnancy turned out well.



                            Or a parent, period.

                            The worst moments on L&D are watching the father of the baby try to keep it together. The mother was often in too much pain, or too sedated, to understand what was going on. But the father was fully conscious and could see everything - and you could just see how helpless and worried these guys felt.

                            I know that OB/gyn is supposed to focus on "woman's" health - but sometimes I felt like, on L&D, the guys needed just as much care and attention as the women did. Seeing some of those guys cry when something went wrong was heartbreaking.
                             

                            docB

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                              Hi, I'm docB and you're here because you're 9 weeks pregnant and you have belly pain? Oh, you say that your husband was just deployed to Iraq for a year and you're all by yourself here in Vegas now that he's gone but that the thing that kept you going was knowing you're having a baby. Well I have to tell you that your tests show that your baby is actually an ectopic and now not only are you not having a baby but you're going to lose one of your tubes which will make it harder to get pregnant if your husband gets back in one piece. And as a bonus flip off to you from the universe you get to go through the whole operation alone. Once you're done with that you get to figure out how to tell you husband all this by phone if you're lucky. You'll probably have to write a letter.

                              Holy crap. She was still weeping as they rolled her out to the OR. That sound had been hanging with me for a few days. The image I can't shake is how I imagine her leaving the hospital the next day. I'm sure she got discharged and had to walk out of the hospital all alone, lost the baby and a tube, gonna get bills up the wazoo, husband's in Iraq and she's gotta tell him what happened.
                              I still remember this one to this day.

                              I've gotta say that I'm just about the most bitter, hardened, cynical bastard any of you are likely to ever run across. But if you lose touch totally with people's pain and grief you just can't be in medicine. You just can't.
                               

                              Faebinder

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                                I didnt want to tell this story...mm.. here goes.

                                32 year old man, married with a 3 year old. Diagnosed with rectal cancer, got neoadjuvant chemoradiation and even had an excision done to take out the cancer. Came back after a year with pain still... In the OR, peek and shriek carcinomatosis. 80% wont make it past a year. So elected to give him a diverting ostomy so he can tolerate food and live the rest of his life somewhat functional. He refuses.. leaves. Still wants to fight and get chemo.... comes back in a week after first dose of chemo again, white count of 1.1.. hasnt pooped in two weeks or eaten that much. Ends up getting emergency lap and diverting ostomy....Insists on eating liquids to try and recover to go back to chemo ASAP. He is so full of $hit and he gives multiple signs of possible leak from handling his fragile bowels. Gets taken to the OR , vomits his own $hit into his lungs even with an NGT and OR taking out 2 liters of nothing but filmy loose stools from his bowels.

                                Ends up in the ICU for 2 months. Needs rehab for a long time, lost so much muscle..... How do you encourage a guy to do rehab when he has a terminal disease? Wife+parents+kid visited EVERY day. That's when your curse the fact that you are not in rotations.
                                 

                                ekydrd

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                                  This happened in the VA so maybe not so mainstream, but here goes...

                                  Man in his 50's admitted to my medicine team because his wife is concerned about all the weight he'd lost over the past 4 months (roughly 65lbs). Had a history of prostate cancer treated with chemo and radiation, then a second round of chemo, then a third round in a drug study. Last dose of chemo about 1 yr prior. Had told his wife he was finished with chemo, and that the doctors said he could go back to his normal life. What he didn't tell her was that he was terminal. We had to tell her that because by the time he was admitted he had brain, bone and lung mets, and quickly became unresponsive (within 12 hours of admission). We consulted Hospice and in the process of transferring to their service he passed away (just over 24 hours after admission). The wife was absolutely devestated because there was still so much she had wanted to do with him, and thought they had time to do them.
                                   
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                                  nonesuchgirl

                                    12yo girl with ALL, dx'd at 8, I think. Harry Potter fangirl. Died before she could finish her fanfic. We have the same first name.

                                    15yo girl had a root canal. 6 wks later, still feeling miserable. Parents take her to the ED. Dx'd with leukemia. Died 23 hours later.

                                    8 month old boy, leukemia. His obit had a picture of him with his teddy bear.
                                     

                                    radonc

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                                      12yo girl with ALL, dx'd at 8, I think. Harry Potter fangirl. Died before she could finish her fanfic. We have the same first name.

                                      15yo girl had a root canal. 6 wks later, still feeling miserable. Parents take her to the ED. Dx'd with leukemia. Died 23 hours later.

                                      8 month old boy, leukemia. His obit had a picture of him with his teddy bear.

                                      91 year old passes away from natural causes. is that any less sad than what everyone else wrote?
                                       

                                      dpmPOD

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                                        91 year old passes away from natural causes. is that any less sad than what everyone else wrote?

                                        There is a difference between someone living to 91 and having the chance to live a long, meaningful, and fulfilling life and someone who is struck down in the prime of life by a terrible illness. Yes, it is less sad.
                                         

                                        elperro

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                                          50's male admitted for non-healing ulcer, gets vascular procedure and strokes out on POD 5. CT of head shows diffuse pneumocephalus. PICC line found to be in brachial artery, with tip in aortic arch. Original CXR read as "tip in SVC." Still makes me sick to think about it.
                                           
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                                          Winged Scapula

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                                            Several come to mind but two are of interest (to me at least) because of the very different way they presented...

                                            1) before medical school I spent several years running some research protocols on patients with neurodegenerative diseases. 50s male, brilliant nuclear engineer. Diagnosed with ALS. I saw him for a few days, running tests every 6 months for several years and watched him progress from a vital, albeit depressed man to someone who couldn't speak but still able to communicate with his eyes and hands to being totally incapacitated. The worst part was watching his wife being almost too upbeat in her struggle to make some sense of this.

                                            2) Traumas. Death of young children. Always hard. I had one where a teen male was driving his siblings around, had a little bit to drink (but was not legally drunk), was driving too fast in the snow, lost control, rolled the Jeep and none of them had seatbelts on. He survived, his siblings did not. I was meet in the trauma quiet room by his parents, and a pregnant fiancee of one of the deceased. She proceeded to collapse onto the linoleum floor screaming as the parents stoically tried to start a discussion about organ donation and calm her down. I've often wondered how that family (especially the surviving son) did afterwards.
                                             

                                            Doowai

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                                              The patient was a 42 year old woman 20 4/7 wks along with her second pregnancy. She desperately wanted children. Her first pregnancy, at age 40-- after a decade of trying-- ended suddenly, at 20 weeks gestation, with an unexpected miscarriage. .


                                              Whew not sure why you want to dwell on the worst moments of a work life but I can think of 2:

                                              1) older woman desperately wanting a baby. So happy about it. Week 40, due any day and IUFD.

                                              2) the one that upset me the longest : 9 year old girl, tried to committ suicide by pouring boiling water on herself. Had a couple of previous suicide attempts - one in which she tried to hang herself. Her dad found her blue in the face, string around her neck, the dad had to cut the string off her neck it was on so tight. The dad had just gotten custody of her. She had been living with her real mom and stepdad up until just a couple of months previously, where she suffered alot of abuse. The step-dad had sexually molested her so severely that she had a complete uterine and vaginal prolapse on her first admission to the emergency room the day the dad brought her home. Her real dad got custody of her and in those few weeks she tried to kill herself several times - the burning earned her a new admission. What had sparked her suicide attempts was her grade school had a legal demand that if the real mother or step-dad showed up they were not to get to see the girl. The mother showed up at the grade school and asked to see her, and the school went and got the little girl - the mother scared the little girl - she went home and tried her first suicide attempt. So we have us a future borderline personality candidate here too. Okay - I think this was the saddest story.
                                               
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                                              nonesuchgirl

                                                Whew not sure why you want to dwell on the worst moments of a work life but I can think of 2:
                                                .

                                                The story about that little girl is sick. People suck.

                                                It's not dwelling. If you keep things bottled up, it'll eventually explode and hurt you and the people you care about in your personal life. This is a safe space to dump it, if you will- rather like the "Medicine Sucks" thread in EM.
                                                 

                                                Geri_Gal

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                                                  I took care of a 35 year-old woman who had vague abdominal pain x 3 mos, had seen physicians multiple times who had given her a couple trials of a PPI. An abdominal ultrasound a month prior to admission was read as clean. She was comforted by this and went on holiday to Spain with her 10mos old son and 8 year old daughter...then noted that her pants were a bit tight around the waistband...and a week later noted she looked 5 mos pregnant. Flew back to the U.S., where the abdominal CT scan revealed her large gastric mass with extensive peritoneal carcinomatosus.
                                                  It is hard to forget the look of anguish on her husband's face.
                                                   

                                                  Baditude

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                                                    Personal friends of our family so maybe it makes this worse for us........ 38 yo F pregnant with 1st child miscarries at 22 weeks sad on it's own but then goes on to get pregnant again 6 months later. She says "she doesn't feel right" about this pregnancy so she goes for some additional testing and finds this baby has trisomy 13 (Patau's). Well she now has to go out of state if she wants to abort the baby because she is 16 weeks along and where she lives doesn't allow 2nd trimester abortions. So she drives for 150 miles to get the abortion. The doctor punctured her uterus during the procedure and she almost dies from blood loss and ends up with a hysterectomy. :(
                                                     

                                                    GoofyDoc

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                                                      :sleep:

                                                      I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to. Could one argue that I ought to be sad about everything that pushes its way out of me? Maybe I'm just naturally cold.
                                                      I don't think "cold" is sufficient to describe you. As someone who has experienced the devastation of miscarriage, I feel violated by your abhorrent comment. Please never repeat that statement again. Keep your feelings to yourself.

                                                      As far as sad patient story is concerned, as a student I took care of a 57-year-old male admitted for recurrent fevers. Apparently this had been going on for more than a year and no one had been able to diagnose him with anything. His mental status had also been declining over the prior 2 years, and he was clearly demented at the time of his presentation to us. His wife of 26 years was selflessly by his side throughout his admission. We worked him up for everything but could not make a diagnosis. We finally decided to ask the wife for consent for an HIV test. She was shocked by the request but we explained to her that we had to rule it out and she agreed. By this time, the diagnosis should have been obvious, but I was still horrified when the test was confirmed positive and the CD4 count was found to be extremely low. He was already full-blown AIDS, and I had to bear the news to his loving wife, who had to be asked to undergo an HIV test herself. That was my last day on the rotation, so I didn't find out what happened after that. But a couple of months later I was heading to clinic and spotted her with her husband. I don't think I'll ever be able to forget the look on her face when our eyes met. For some reason, this case just disturbed me much more than any of the 30-somethings presenting with metastatic cancer.
                                                       

                                                      ocean11

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                                                        I just finished a rotation at a forensic psych unit and saw so many sad cases.

                                                        We had a guy who was 29 y/o dx with schizoaffective d/o with bipolar features. He had a very emotionally abusive childhood. his parents forced him to get an arranged marrige and him, his wife, and parents were all living in the same house. His wife and father put him down repeatedly and he stopped taking his psych meds to 'fit in'. Anyhow, one night in a psychotic state, he woke up, and (won't get into details) killed his father. He subsequently passed out and woke up in the police station with NO IDEA or clue what had transpired. IT was there that they broke the news to him... he was and still is devastated, he loved his father.... he was found Not Guitly by Reason of Insanity and sentenced for life to the mental hospital which I was working at... his wife left him and his whole family is shunning him.

                                                        He is actually a really really nice person, with learning disabilities and a serious psychiatric condition... now that he's on meds he's stable, but very depressed.... I tried to play cards and interact with him as much as I could.... I wish him the best...

                                                        sigh........
                                                         

                                                        Museless

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                                                          91 year old passes away from natural causes. is that any less sad than what everyone else wrote?

                                                          It's not that it's not sad - but it's not quite the same, either. There's a normal endpoint to life, who really wants to be a 140-year-old lying around in bed somewhere? When life ends after it's complete, yeah, that's different than life ending before it's had a chance to begin.

                                                          My story:

                                                          A little boy at his sister's 8th birthday party sneaks up behind his sister and pops a balloon right in front of her face. The girl, surprised, ends up sucking in a piece of balloon as it pops and she gasps. It lodges in her trachea and she dies in the ambulance. 40 minute ED resuscitation attempt unsuccessful.
                                                           

                                                          RTrain

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                                                            I'm most affected by patients, particularly elderly debilitated patients who can never recover, forced to stay alive in the ICU in unknowable states of pain and suffering by misguided, loving families who can't or won't let them go gently into that good night.

                                                            Recently I had a 90 year old man who was admitted to the ICU with status epilepticus after a shower of embolic CVA's. After resolution of his status, he remained a difficult wean and ended up with a trach. Meanwhile, the ischemic leg he developed early after admission was amputated above the knee. As his mental status improved, he developed a haunted, hollow-eyed look, nodding silently every time someone asked if he was in pain; soon, "depression" found its way onto his problem list and we started throwing an SSRI down his PEG tube. All the while, his children insisted again and again that "Daddy is a fighter, he would want us to do everything to keep him alive." Decub's, aspiration pneumonias, every indignity we can inflict, finally transfer to SNF, and the horrible knowledge we all had - everyone but his family - of why he was depressed: because he had, indeed, been kept alive. :(
                                                             

                                                            gutonc

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                                                              Just had a guy die today after 5 days in the ICU.

                                                              35, h/o well-controlled seizure d/o. Standing on his mom's porch having a smoke, apparently seizes, falls down flight of 8 concrete steps to sidewalk below onto his face. Down ~30 min before EMS gets a pulse (he was V. fib on arrival). Laforte II fracture.

                                                              Comes to ICU, gets cooled for 24h, warmed up, goes into non-convulsive status, broken w/ benzos and dilantin. Serial CTs show worsening of loss of grey-white border until CT on HD #4 shows complete loss of grey-white border and his entire cerebrum is a uniform color. Care withdrawn, off vent but tube left in overnight so all family can come, today, tube pulled, airway closes off w/in minutes b/c of communited facial fractures.
                                                               

                                                              BSN2DOC

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                                                                It's not that it's not sad - but it's not quite the same, either. There's a normal endpoint to life, who really wants to be a 140-year-old lying around in bed somewhere? When life ends after it's complete, yeah, that's different than life ending before it's had a chance to begin.

                                                                My story:

                                                                A little boy at his sister's 8th birthday party sneaks up behind his sister and pops a balloon right in front of her face. The girl, surprised, ends up sucking in a piece of balloon as it pops and she gasps. It lodges in her trachea and she dies in the ambulance. 40 minute ED resuscitation attempt unsuccessful.

                                                                Wow. No more balloons in my house!
                                                                 

                                                                theboo

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                                                                  :sleep:

                                                                  I've never fully understood the devastated potential-mother phenomenon. She really didn't know the kid she gave birth to. Could one argue that I ought to be sad about everything that pushes its way out of me? Maybe

                                                                  I do think physicians should carry their tragic memories silently. You know, just to maintain professionalism and their patients' confidence.

                                                                  Cold? I have a better name... A heartless bastard who should NOT be in the medical field in any sort of way. I could go on but instead of hurling insults at you i want to educate you. Losing a baby whether stillbirth or otherwise is horrific. Something i wouldnt understand a man to get but i would expect a human too.
                                                                   

                                                                  Mad Jack

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                                                                    Worst for me I won't share too many details about, but the gist is it was a young mother that died of the flu in less than 24 hours. I watched her husband beg her not to leave him alone as she slipped away for two hours. Said he was sorry for all the terrible things he'd said over the past week. That he couldn't raise his kids alone. This was a tough guy, and I watched him break down because he realized he was losing the one thing he cared about most in the world, and he was losing it fast and without reason. Man, I don't know exactly what it was that got to me about it, but it just hit me right in the feels in a way I've never shook.

                                                                    There's also been some really tragic neuro cases over the years. People that are just changed, whose families are struggling to cope with the new person that's sitting in the skin of the person they loved. Those were always hard to see.
                                                                     
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                                                                    Winged Scapula

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                                                                    1. Attending Physician
                                                                      Worst for me I won't share too many details about, but the gist is it was a young mother that died of the flu in less than 24 hours. I watched her husband beg her not to leave him alone as she slipped away for two hours. Said he was sorry for all the terrible things he'd said over the past week. That he couldn't raise his kids alone. This was a tough guy, and I watched him break down because he realized he was losing the one thing he cared about most in the world, and he was losing it fast and without reason. Man, I don't know exactly what it was that got to me about it, but it just hit me right in the feels in a way I've never shook.

                                                                      There's also been some really tragic neuro cases over the years. People that are just changed, whose families are struggling to cope with the new person that's sitting in the skin of the person they loved. Those were always hard to see.

                                                                      Even reading your account of the event made me sad.


                                                                      Sent from my iPhone using SDN mobile
                                                                       
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                                                                      Cold? I have a better name... A heartless bastard who should NOT be in the medical field in any sort of way. I could go on but instead of hurling insults at you i want to educate you. Losing a baby whether stillbirth or otherwise is horrific. Something i wouldnt understand a man to get but i would expect a human too.

                                                                      You bumped an eight year old thread for this?
                                                                       

                                                                      alpinism

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                                                                        In contrast to many posters on here the worst i've delt with by far are the times when there aren't any loved ones left to morn someone's death.

                                                                        Young children left to die alone after their whole family was killed in a car accident or house fire...
                                                                         
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