Rural Doctoring

Bigger & Crazier Than I Am

I mean the Pacific Ocean, and I mean in a good way:

This is why I need to make a greater effort to crawl out of the hospital more often, and remember why I moved all the way to Rural.

When a Lump is Just a Lump

A commenter kindly asked for a Noo update, so here it is:

After her critical illness this summer, the oncologist did not recommend resuming interferon therapy for melanoma. He had an antibody titer panel done which showed a weak immunologic response to the four months of interferon she'd already completed, and even though this isn't proof positive that the treatment "took," it is better than nothing and we were all quite relieved to shelve the idea of resuming thrice-weekly therapy, with its attendant exhaustion, diarrhea, and general unwell-ness. Since recovering from her hospitalization, Noo has been having regular skin exams, all uneventful until the last appointment when the dermatologist noticed an enlargement of one of her anterior cervical lymph nodes and sent her back to the general surgeon to have it looked at.

Now, the problem with these two events is that they were separated by a couple weeks of anxiety while the referral went through the usual channels and Noo had to wait for the next available appointment with the surgeon. Being in the medical field, I know better than to expect immediate reassurance, but I have to admit--it would have been nice if she had been sent from the derm office directly to a waiting surgeon who could excise the damn node the same day. And it would have been terrific if the pathologist agreed to cancel her dinner plans that day in order to get the sections prepped and stained, and then spent a leisurely hour looking at them under the microscope before dictating her findings. But this is not how things work, and I know this well, and now I also know a bit more about the gnawing worry the patient and her family experience while they are waiting for results, whether good or bad.

In this case, the news is good:  the excised node is a simple reactive node, no recurrent melanoma, no cause for alarm. So Noo has been restored to the category of Practically Normal People and we are carrying on with our post-melanoma lives, more dazed and confused--but also more grateful--than we were before the diagnosis became a personal journey.

Me, Abandoned by Martians

It's been several months since the space-time continuum was indelibly altered by Noo's critical illness and my decision to leave Gimbels. Whereas previously I was a bit of a chatterbox on this blog, I have to acknowledge a certain surly silence which has take the damn thing over ever since. I've never been good at change, and there's been nothing BUT change since July, and all I could do was surrender myself to it and see where it would take me. Most of the time I feel like one of those ordinary citizens in the movies who, through no fault of their own, wake up at the center of a David Lynch movie, apparently plunked there by Martians. A video montage of this movie might include scenes such as:

My State of Mind, In a Nutshell

The holidays are around the corner, and yesterday I read the word "Hope" on a holiday display as "Hep C."

Hoo boy.

Silence. Listen.

Noo and I had to put our cat to sleep ten days ago, a very bad day indeed. I was starting a week at Nordstrom and had to drive back and forth from work to home three times that day, and it's hard to drive on rural highways when you're crying.

I've been quiet on the blog because I've been listening to myself. I realized that I've been putting solutions together for years which look good on paper but truly suck in practice. Flashing my middle finger at Gimbels and working at Nordstrom (a good job, btw, but...) seemed so reasonable at the time, but I hate being away from my home for a week at a time, and I hated missing my cat's final moments because I was on my way from 60 miles north. Not that working at Gimbels that day would have been a walk in the park, but I would have been there and I would have been able to hold her one last time. Thank goodness Noo was there. We raised this cat from a 4-week old kitten and she was like the warm pulse of our household. I don't expect everyone to understand this sentiment, but cat people will, and I honestly don't give a shit about any opposing opinions.

"Being there" is an emerging theme in my current reflections about doctoring, early middle age, the creative life, and What Comes Next. I'm going to try to get some of these reflections onto the blog but only episodically. I need to be quiet. I need to listen.

Everyone Has Her Limit

No, I haven't disappeared off the face of the earth. Since my last post, I've been holding down the jobs at Macy's and Nordstrom and one of my cats got sick. She was diagnosed with diabetes and kidney failure, and now--in addition to being an effective nocturnalist and itinerant rural hospitalist--I am also learning how to give her subcutaneous fluids (twice a day), insulin (twice a day), and vitamin B12 supplements. She's got diabetic polyneuropathy so she can't really walk around, which means I'm changing a lot of linen and investing in waterproof crib liners to keep the house habitable.

I've coped effectively with the upheaval in my professional life, Noo's melanoma diagnosis and subsequent critical illness--but my cat getting sick sent me over the edge. So I've been crying a lot and succumbing to retail therapy and generally being fairly insane, but things are getting better because my cat is getting better, so I'm hoping to resume thoughtful blogging about the life of a rural doctor soon.

Comparison Shopping for Rural Hospitalists

Recently a reader asked me why I left rural practice, and I took this as a sign that my recent job-hopping has made me seem like one of them fancy-pants, highfalutin' cityfolk doctors who make such a stir on TV. At one time, I too believed a country doc stayed in one town for thirty years, delivering babies and burying octogenarians, until you finally drop dead in the office one day after seeing a clinic full of patients. Modern doctors seem to move from job to job, role to role, throughout their careers, as mobile as information technology supervisors, customer service representatives and hedge-fund managers, regardless of the demographic they serve.

Crawling Into The Hole

OK, I'm starting my second run of night shifts at Macy's, this time SEVEN in a row so I'm hoping my day-to-night transition method is going to hold up:

Rural Career Tip #1

Do NOT, under any circumstances, start working at two different hospitals in the same month. You'll mis-remember all the door codes, wear the wrong ID badge, and won't be able to tell all the Amandas, Daves and Chris-es apart.

Trust me on this one.

Wanted: Nocturnalist Ruralist Hospitalist

Couldn't resist the title--have you noticed how sub-sub specialized medicine is becoming? Tonight I begin the first run of night shifts at Macy's (four nights in a row, a mere warm-up to doing as many as eight). I haven't had regularly scheduled in-hospital night shifts since residency Night Float rotation. I'm a bit rusty at the night routine and have to re-create the correct timing of coffee, protein-rich meals versus carb-rich meals. Meanwhile, the white noise machine and blackout curtains haven't arrived, so this weekend might be less slick than I'd hoped. Cross your fingers for me.

There's a New Kid On the Playground

So I've started working as a hospitalist at Macy's, having worked four day shifts to get a feel for the place and a lay of the land. I've located all the bathrooms and all the working fax machines. I have a yeoman's grasp upon the EMR, which is pretty good and makes life as a resentful Gimbels refugee at least 15% easier than that of a harried Gimbels hospitalist. Everyone is very nice and does a very professional job and I really have nothing to complain about. Not that I'm going to let this stop me, no sir-ree.

The Brave New Hospitalist

If you've been following the details of my little saga closely, you might remember that immediately prior to Noo's illness I was bracing myself to leave Gimbels. Actually, Noo was hospitalized during my last week there, and the emotional upheaval of leaving Gimbels was overshadowed by the emotional turmoil of worrying about her. This was a mixed blessing at best, because now have the relief of knowing Noo is getting better, I still feel unresolved about leaving Gimbels. I suppose this is how the people who believe they were abducted by aliens feel.

Everything is (Sort Of) Back to Normal

Noo is back home, after several days in Macy's rehab unit, during which she received intensive PT and OT to get her well on her way to recovering lost strength. Our dog is ecstatic--Noo is her Person, if you know what I mean--and I notice the cats carry their tails a bit higher now that our little family is reunited.

Noo herself is incredibly upbeat, euphoric from the nectar of survival. I've noticed this in a lot of patients who have survived a critical illness: they awake from ventilator sedation with a sense of amazement at what has happened to them, especially the fact that they are alive to ask the question at all. Life takes on a profound new significance; every taste, every sound, even the aches and pains of ongoing recovery are gifts from this New Life. It is quite a wonderful experience to witness.

So much suspense and turmoil, followed by so much wonder and gratitude, all played against a backdrop of everyday life. I feel like I've been cast in a Shakespearean romance, shipwrecked, stranded, then rescued by benevolent spirits and indelibly transformed. My mind hasn't settled yet.

If Lost, Please Find

Good news: Noo was extubated today and appears to be doing OK from the respiratory standpoint. She might be a tad bit delirious after seven days on the vent, but I give everyone a pass on the day of extubation. It is unrealistic to expect My Dinner With Andre, if you know what I mean.

Because If It Weren't Chaotic, It Wouldn't Be Life

More reasons than usual for the dense silence on this blog lately. Noo was hospitalized last week with severe bilateral pneumonia, intubated, and transferred to Macy's, where she is slightly better and getting tapered off the vent. 

Dr. Wordsmith

The other day I heard one of our nurse's aides use the word "parsimonious" correctly in a sentence and I was stopped in my tracks.

What does it say about American culture that months go by in Rural County with nary a three-dollar word in use? Not that three-dollar words are better than the discount variety, but I miss the wonderful surprise of hearing an ordinary statement expressed in extraordinary words.

Maybe this is why I enjoy the works of Shakespeare. When Falstaff says "I am the veriest varlet that ever chewed with a tooth," oh, how I know how he feels.

The Plan, For Now

I admit, I have been hoping for a last-minute rescue--in that way you learn to do in early childhood, from watching too many cartoons--which would keep me at Gimbels. Well, none is forthcoming, and I have been busy devising the following back-up plan:

Another Reason Why Family Medicine ROCKS!

Here's an article about doctors from my residency alma-mater who provide free care to the homeless in Salinas, CA. I did a rotation at the free clinic when I was a second-year resident, and reading this article makes me homesick for those days.

It's always good to remember where you came from.

A Sick, Unruly Kind of Love

Last Wednesday I was rounding on the hospitalist service and I got into one of those time-wasting gripe-fests with one of the general surgeons. He was beefing about an incentive spirometer he'd ordered for a patient the day before, which never materialized, and I told him I'd had to transfer a patient to Macy's in order to get an echocardiogram over the weekend, and then we both shook our heads and talked about how Gimbels was falling apart. This is the kind of conversation you have when you've decided to leave a job.

Sometimes, the Inmates Run the Asylum

I haven't been in a blogging frame of mind lately, and I blame it on professional chaos. In a recent post I mentioned that my hospitalist colleague came very close to resigning from Xpress Hospitalists, the name I choose to use for the staffing agency who took over our hospitalist program when we could no longer staff it ourselves. Well, things have evolved since then. Here's a precis:

R.I.P

Dr. George Tiller.

Dr. Santell's Rounds: The Long Goodbye

I've been through a bumpy ride professionally the past several months, and last week my colleague and I were on the verge of giving notice and looking for greener pastures, but a certain amount of ingenuity and iron nerve (mine) and a large amount of diplomacy (his) managed to save the situation, at least temporarily. I would say "phew" except I don't really feel relieved. Practicing medicine is difficult, but making a living, holding down a job, keeping one's foot firmly planted in the realm of acceptable working conditions is even more so.

The Bread and Circuses Memo

Dear Hospital CEO,

Thank you for an eventful and fun-packed National Hospital Week. The entire staff looks forward to the annual celebration of hospital services and wishes to extend their gratitude--and feedback--for the activities presented this year.

Who Knows?

A certain quiet has fallen over this blog in the past couple of weeks. There are a number of professional upheavals going on in Rural, none of which I care to broadcast here but all of which distract from the more pleasurable pursuits of life, such as writing. Have no fear, Noo is doing extremely well, the sun is shining, the cats are fat and sassy, and I think I'll end up on my feet after the smoke clears. Fingers crossed.

One Little Question

I've been following the news about the medical student accused of being the Craigslist murderer, Philip Markoff. The one thing that bothers me most about this case is this: How the HELL does a second-year medical student have time to solicit sex workers on an online classified service or gamble at casinos? 

When I was a second-year, I was too busy struggling to pass pharmacology to solicit anything online, and the only gamble I was willing to take was betting my tuition against the chance of making a living in medicine.

All I can say is that Boston University needs to start working their second-years a little harder. The devil makes works for idle hands.

With Apologies to Mom and Dad

Yesterday was my birthday, and I hope you will forgive me for not having installed neon fonts or flashing banners on the blog for the occasion. After all, I merely turned forty-one, what's the big deal? My fortieth birthday had some gravitas behind it, but forty-one? It's a non-event, a prime number, not a big deal.

At least I wasn't working.

Dr. Santell's Rounds: The Ticket

Every doctor sees patients with diseases related to substance abuse, both legal and illegal. The other day I looked at my hospitalist census and realized 65% of the patients I was seeing had illnesses either caused by or worsened by alcohol and tobacco abuse.

Milestone 5: A Preview of Great Things to Come

Now that Noo is solidly on the path to melanoma wellness, I find myself with more time for my annual midlife crisis. The past several years, around the time of my birthday, I find myself succumbing to a certain disillusionment and generalized ennui. I do a lot of ass-dragging and complaining, find fault with my colleagues, bemoan the decline and fall of human civilization, read too many books and articles about crime/financial collapse/political instability/ovarian failure, and generally take stock of the daily tedium of Real Life:

Labor Files: What it Takes to VBAC in Rural County

One of our pregnant citizens had a successful vaginal birth after Cesarean (VBAC) this weekend. Not to take a single credit away from her, but this is the kind of event which takes a village to achieve. Here's why:

Why Doctors Should Read Newspapers

One of our intermittent hospitalists previously worked in suburban and urban hospitals, and has found our two-ring rural circus a bit challenging. I knew he was settling in nicely when he told me the following story:

Phew!

I passed ACLS for another two years, so feel free to code at Gimbels, because I know what to do.

Hey, April *is* the Cruelest Month!

OK, I know I've been a wee bit of a downer lately--even though I have every reason to be grateful and optimistic--and I want to reassure everyone I'm going to get over it soon, because the days are longer, the black-tailed deer have returned to my field, and the farmer's market begins any week now, so what's not to cheer up about?

One barrier remains: April. Can I tell you how sucky this April is going to be? Here's why:

The Ugh of March

I spent most of the last 48 hours lying around my house in a goopy puddle of depression. Not clinical depression, just everyday "what's the point?" anhedonia. Here's a few reasons why:

Case: My Life on the D-list

Today I worked up a 50-ish man who was admitted with altered mental status, cystitis and acute renal failure. He'd been in the hospital for just over twenty-four hours without much improvement. He wasn't hallucinating anymore, but restless, agitated, strange.

Interferon Diary, Day #20

Today Noo receives the last of twenty doses of IV interferon! This signals the end of daily weekday schleps to the infusion center, and the beginning of the real endurance trial: eleven months of thrice-weekly subcutaneous doses. She's done so well with the IV doses, I think she'll weather through the rest of the year's treatment in similar fashion. Our emotional landscape--at first so overwhelmingly dark, when we got the diagnosis--has almost returned to normal: mostly sunny, some overcast days, scattered showers.

Dr. Santell's Rounds: Still My Conscience After All These Years

This isn't a story about Dr. Santell, but it illustrates why the memory of Dr. Santell is so important to me, and why sometimes I pretend he's still alive and only a phone call away. I know this is nothing more than childlike fantasy, but it gets me through some long days and--as this story shows--keeps me honest on the job.

Twenty

I'm nearing the end of a gnarly run of hospitalist days. Our census has been averaging 21 patient encounters every day, all of whom need to be seen by moi. For those of you who have never made rounds, that's a lot of patients to see, data to track, decisions to make. Personally, I'd rather limit my rounds to no more than 15 patients, because I notice that's the number at which my performance peaks. The problem is we're a small hospital, with a correspondingly small hospitalist program, and right now we only have one person staffing during the day. Ow.

Warning: I Blither Aimlessly in This Post

Last week was odd, to say the least. Noo started interferon therapy, and this went smoothly--she's taking it like a champ, side effects and all. We're lucky to have some help, in the form of our Girl Friday, who can take Noo to the infusion center when I can't. However, I was able to go with her three out of the five treatment days last week, which is pretty good considering I was covering night shifts for the hospitalist service.

Interferon Diary, Day #1-2

So Noo has two IV interferon treatments under her belt and here's our impressions so far:

• Pre-treatment anxiety is worse than the treatment itself.
• Sitting in an infusion center for two hours is about as interesting as it sounds.
• A small dose of lorazepam (day #2)  makes the infusion time go by faster.
• So does reading vampire thrillers (Noo) and slightly vulgar essays by John Waters (me).
• Shaking chills develop within 15 minutes after concluding the infusion, usually on the way home in the car.
• Noo says the chills are so awful that it feels WONDERFUL to feel them go away, about two hours later.
• A gnarly, throbbing headache sets in 3-6 hours after returning from infusion.
• Ditto clammy, all-over achiness.
• You will sleep like a rock after infusion. Noo, who tends toward insomnia, thinks this year promises some of the best sleep ever.
• Maybe infusion centers should provide recliners for friends and family members as well as for patients. Napping in a regular chair makes is like sleeping on an airplane.
• Note to self: Signing up for night hospitalist shifts during the first week of infusion therapy was probably not the cleverest idea I've ever had.
• It is OK to lower expectations during infusion week. (Hint: I don't have all my tax stuff pulled together yet.)

Our Girl Friday is taking Noo to infusion today, so I can take a wee nap and get some essential paperwork (damn those reapplication for hospital privilege deadlines!) done. If it were up to me, cancer patients and their families could flip a switch and go into Bureaucratic Bypass mode for the duration of their treatments.

Zippidee Doo Dah!

We're starting interferon today!  Well, Noo is, to be specific; I'm just along for the ride. However, I am beginning to understand the parallel experience a patient's family goes through whenever they confront a major illness.  I may not be receiving interferon, but I am in charge of making sure we come home to a comfortable, well-stocked house after each treatment. So I made a couple of gallons of black bean chili yesterday, and made sure we had plenty of toilet paper. That was the limit of my coping skills for the day. Let's see what this day brings.

It's Delightful, It's De-Lovely, It's Delirium!

Recently I helped take care of a 90-ish year old man who fell down and broke his hip.  He's moderately demented at baseline, and while waiting for and ORIF--our Anesthesia department was balking at his cardiac co-morbidities--he got more than a bit delirious.  Delirium is a common hospital-based problem, especially in older patients with cognitive losses at baseline who develop an acute illness or who have a condition which requires interventions such as bladder catheterization, NPO status, ICU observation, TPN, beeping IVs, and almost everything else I was compelled to order for this poor gentleman.

If Esme Were Extremely Interested in Depravity

This post is a bit all-over-the-place.  I know it already, only after writing the first few words.  Noo and I are in Ashland, OR, to see a few plays at the beginning of the season, before Interferon robs us of any opportunities for pleasure.  I drove us up here yesterday, after completing a truly awful week of hospitalist rounds, the kind of week that raises disparate literary allusions in my mind.  At one time, I wanted to be a writer and a scholar, so I'm afflicted with disparate literary allusions from time to time.  I think these allusions are the primary occupational hazard of literary scholars.  Believe me, I prefer to examine infected wounds and gangrenous feet than wrestle with renegade literary allusions.

The Quick Update

Oh dear, there is everything EXCEPT blogging going on these days in Rural:

• The master bedroom is now SPINACH GREEN. 
• Now I need to get on curtain-making duty.
• This means I have to figure out how my sewing machine works. This scares me.
• The bathroom renovation has been shelved, because my contractor fell off the face of the earth.
• Instead, I'm going to do a light renovation of my garage to turn it into a gym/craft space.
• You may be asking why a feng-shui problem in the bathroom will be fixed by a garage reno, but the idea is to shift the center axis of the house, and using the garage regularly will accomplish this AND expand my living space at the same time.
• Interferon is scheduled to begin on 2/23/09. I doubt the curtains will be sewn by then, but come hell or high water.
• Oh yes, I'm still working, but primarily on hospitalist shifts--relatively little OB call or clinics. 
• One of these days, I've got to post about the economics of providing OB care, and why it is not a breadwinner for me, but I'm not in the mood.
• My general sense of inward insanity has settled down but is still present in the form of a constant hum of activity. I'm resigned to this.

Off to the hospital. I think the moon was full last night, so in addition to discharging patients I might have to conduct an exorcism as well.

On Grim Rural Self-Sufficiency

Recently I met an internist who may be relocating to a rural community to work as a hospitalist.  When I told her our hospital has no dialysis services, she asked, in horror, "What happens if someone comes in with hyperkalemia?"  Uhhhh....I rattled off a few intern's pearls on the subject before I realized I probably sounded condescending and hastily changed the subject.

What to Expect During Your Cancer Year

Yesterday, Noo and I went to our friendly local oncologist's office.  He was great, and we weathered the tour of the infusion center (read: chemo chairs) pretty well, all things considered.

Before we left, we were provided with several pamphlets and booklets about support groups through the American Cancer Society--sort of a "Welcome to Cancer!" information packet, if you will.

Which raises the question:  How does one prepare to receive interferon therapy for a year?  The first month is IV, five days a week, two hours per session, best scheduled in the afternoon so the patient can go home, have a light meal, and sleep through most of the aches and chills which follow.  But what about the nuts and bolts of daily life with a PICC line, interferon, aches, chills, indifferent appetite, fatigue?  I don't claim to have the answer to these questions, but here's what Noo and I are going to do before she starts interferon at the end of the month:

• Make gallons of vegetarian soup to freeze and serve up on those "by golly, I've just had interferon and I don't have ANYTHING to serve for dinner" moments.
• Draft a general "movies to rent" list so she can watch one on a portable DVD player while she's stuck in the chemo chair for two hours.
• Paint the master bedroom a deep green, so at least the four walls in which she sleeps off the interferon won't be Landlord White.
• Invest in a really good mattress.  Ours are twelve years old and as bowed as backyard hammocks.
• Put our game faces on.  Most of what we're facing is the unknown, and you can't really plan for the unknown, can you?

Can you?

Grandma, What Big Teeth You Have

While I've been slogging away in Rural County, making my living by delivering babies and rounding on sick hospital patients, Wellsphere, one of the many direct-to-consumer health information websites, has been quietly building up their business by inviting health care bloggers to post their feeds on their site.  In exchange, bloggers received a nifty logo for their sidebar and precious little else.

Bang a Gong, It's the Year of the Ox!

Right after slugging our way back up to Rural after Noo's Melanoma Center appointment, my first order of business was readying us for the Chinese New year.  Today everyone enters the Year of the Ox (or the Cow, if you're more vanilla in your zodiac descriptions), so all the babies born from now until next February are going to be little oxen.  This is the usual reason I get excited about the New Year:  the babies I deliver are suddenly transformed from dogs into rats, or whatever.  This appeals to my sense of the absurd.

Two Jittery Women, Loose in the Big City

Noo and I had an appointment with the UCSF Melanoma Center yesterday, briefly summarized below:

• Jittery nervous energy all morning.
• Grim-faced drive across the Golden Gate Bridge ($6 toll! I remember when it was $3).
• Urban driving moment as I pulled up into a no-stopping zone in front of Mount Zion to let Noo (walking with a cane) off first while I went to park the car.
• Urban parking moment as I squeezed into a too-small parking garage on the next block, narrowly missing people driving Suburbans down the exit ramp at top speed.
• Classic medical office snafu, in which an administrative assistant said, "Oh, your appointment has been cancelled" and we replied "!!!!!!!!"
• Snafu elegantly resolved by squeezing us into the schedule of another of the medical oncologists.
• Jittery nervous energy while we waited an extra hour for the squeeze appointment. Passed time by reading bad design magazines.
• Ushered into a very small exam room.
• Noo changes into the obligatory exam robe.  I pillage the handout display and score an order sheet for IV interferon in melanoma.
• Jittery nervous energy while waiting in exam room. 
• Oncologist enters, almost on time, and is very nice and humorous, which sets us both at ease.
• Noo's chart missing most of the pathology reports from her recent procedures, despite the 25 phone calls made to various providers offices to release this information.
• However, I am an excellent historian and fill in the blanks.
• Oncologist spends almost 30 minutes discussing different approaches to Stage IIC/IIIA Melanoma (Noo's stage).
• He recommends interferon, and verifies almost to the word my understanding of the research and ACS recommendations for this adjuvant therapy.
• Quick exam of Noo's skin, then handshake and farewell.
• Another urban parking moment when I return to the garage and pay $14 for two and a half hours parking. Muttered curses.
• Another urban driving moment when I have to execute a nifty U-turn to pull up into the same no-stopping zone in front of the hospital to retrieve Noo.
• Pensive drive back to our hotel.

I'm in a jittery nervous head space about all of this, so that's all I'm up to writing right now. More about interferon and urgent progress in interior decorating later.

Hither and Yon

A couple weeks ago a commenter asked me to give my partner a nickname so I wouldn't have to refer to her by that rather bald, generic term "partner" which can too easily be interpreted as a medical associate rather than a significant other. So I hereby designate her as "Noo" and will refer to her by this moniker from here on out.

Hospitalist Rounds: The Great Mystery

I knew her from several other hospitalizations, all for drug abuse-related medical problems:  MRSA abscesses, hepatic encephalopathy, opioid withdrawal. This time she was hospitalized with massive ascites. Her belly was twice the size of the rest of her body and her eyes had the sunken, pinched look liver disease patients have at the end of their lives. She was only a few years older than me.