Today's visit was before noon. Marie was initially asleep, but the nurses came in to move her up higher in the bed (the bed which was set to about 30 degrees - I have given up on pointing out the sign on the wall. At this stage I must assume that either the doctor has changed his mind or most of the staff are incompetent.).
When she woke up, she was in fine fettle. Someone - she wasn't sure if it was a psychologist or psychiatrist - had come to do an assessment. Apparently Marie had only managed to correctly answer 11 out of 16 questions.
Marie told me that she had wanted to know which ones she missed. One of them was a test where the shrink asked Marie to repeat after her:
"Tinkle, tinkle, little star..."
And Marie said "Twinkle, twinkle, little star..."
The shrink pointed out that she had said "tinkle"not "twinkle".
Marie's hearing aid was in the box on the bedside table.
"Did you tell her you have some hearing impairment?" I asked.
"Yes, but they don't listen."
"What else did you get wrong?"
Marie held up one hand and pointed at it with the other.
"What's this?" she asked.
"Your hand," I said.
She shook her head. "No. I am pointing at my wrist."
"Could you see that?"
"No. She was standing right there, right in the centre."
Again, the macular degeneration. With her peripheral vision, Marie had made out that the doctor was pointing to her other extremity, but she couldn't see it clearly. So she failed the question, which is supposed to be testing her mental acuity. I think it was more a test of the acuity of the doctor, and she failed.
"Did you tell her you are blind and can't see anything clearly in the middle of the field of vision?"
"Yes, but they don't listen."
I then heard about how it was the second night in a row she had needed extra painkiller because of the pain in her gut. The staff had gone through the dance of saying they would have to call the doctor and get an order because there is no standing order. Now, Marie is under the impression that there IS an order because when she was at the height of her distress some weeks ago, there WAS. It is hard to know if this has been changed and not communicated to Marie, or if it was changed and Marie was told but she has forgotten, or if it was not changed but the standing order is so far back in the file - like the order for the bed angle - that no-one thinks it exists.
They got the order and, for the second night in a row, brought hydromorphine. Marie, for the second night in a row, refused to take it.
Now, when Marie came in to the hospital, she told them she had previously experienced negative side effects to morphine. They gave her dilaudid (hydromorphine) as an analgesic and she had a couple of rough days which included hallucination. The doctors later decided that this was likely more owing to her electrolytes being unbalanced than any reaction to the dilaudid. This has been explained to her many times by the staff and by us, but she does not believe it. She has even had dilaudid since then - with no negative side effects. But Marie doesn't want to risk it - and given her helplessness in the hospital, I have some sympathy with her position.
To her mind, she has told the doctors she can't have morphine, and the hallucinations proved it. So she does NOT expect nurses to try to give her morphine, and she complains when they do. The nurses are caught in the middle - a patient who needs pain relief but refuses what the doctor orders.
"So what happened last night?" I asked.
"They went out of the room to call the doctor again, and then they came back in and gave me an injection. For all I know it was the hydromorphine and they just waited outside the room."
"And did it work?"
"I was out like a light and have had trouble waking up all morning."
"That's what you want it to do - knock you out so you can sleep. No hallucinations or side effects?"
"No."
"Then it's all good."
But it isn't all good, of course. We should not be having this conversation at all. She is of the opinion that no-one is listening, and that the staff are doing things that put her health at risk. Since we have already witnessed many incidents where this is true, it is hard to combat the impression.
The nurses change so often that Marie seldom knows who to expect - and whether or not the person she gets will know about her impairments or issues. My experience is that the nurses are generally quite competent at their tasks, but ill-informed about the needs of the patient. That is one of the problems with such a fast rotation - nurses don't get to know how to meet the need in a competent and efficient manner, and the patient has to keep going over the same territory - or fear the same risks. It is exhausting for the patient and frustrating for the nurse, who perhaps unjustly appears incompetent or stupid.
Last night we had a "floater". She knew very little about Marie or her condition, but she was a nurse who paid attention and who listened so everything went well. So is it some kind of compassion fatigue when the other staff - the ones who have been dealing with Marie for almost two months - either can't get it right or don't communicate the changes in the care plan?
Showing posts with label nursing. Show all posts
Showing posts with label nursing. Show all posts
Thursday, June 25, 2009
Wednesday, June 24, 2009
Oxygen part 11
The nurse today was young, and she reminded me of one particular student at Aristotle University: a Greek sculpture come to life. This one had her name badge on backwards, so I didn't know what to call her.
When I arrived, the bed was at a 20 degree angle. It was left there by the previous shift. I cluck about this and point out that the bed is supposed to be higher, looking pointedly at the sign on the wall. The nurse asks Marie if she wants the bed raised, and soon it is at 35 degrees. Marie is coughing a bit, and she has abdominal pain. She is due for her next painkiller at 9:30 and it is only 7:15.
The nurse takes her vital signs, and they are excellent - 106/63. There is some discussion about whether or not this pain is related to constipation. Marie says it IS bowel pain, but she has had a couple of movements today so it is NOT constipation. She rates the pain at 8 out of 10. The nurse goes away to see what can be done about an analgesic.
While the nurse is out of the room, Marie says she wonders if something has irritated her bowels. "Like what?" I ask. "Oh," she says, waving toward the feeding tube "all this stuff they keep pushing through." She is bored, she is uncomfortable, and she is wondering where she'll go next.
I want to say to Marie, "You HAVE to tell them when the head of the bed is too low," but there are several other things I want Marie to hear, and I am choosing my battles. After weeks of the staff not paying attention to the instructions in the book or the sign on the wall or the repeated instructions from family, I can hardly expect Marie to feel like they will listen to her.
It seems like such a simple thing to me: the patient cannot control reflux because of the procedure done on her esophagus. She is supposed to stay at an angle of 35-40% minimum for 4 hours after feeding. She is on continuous tube feeding, so she is supposed to be at that angle all the time. It has been almost two months, and the message doesn't seem to stick with the staff. I have spoken with the nurses, with the nurse practitioners, with the doctors.
They are all caring, in their way. I don't want to suggest they aren't. But many of them seem to lack the laser focus that Marie herself brought to nursing - the attention to detail that made her a gold medallist. The reasons why they are lacking in focus - well, I could speculate. Some have been undergraduate nurses who are learning how to pay attention. Others have been around longer, but they are overworked and Marie is supposed to be a fairly straightforward case now - heading to rehab.
The nurse returns. She has been authorized to administer Tylenol 3 through the feeding tube. So she puts some water through the line, then the Tylenol mixed with water, and then she flushes with more water. She accomplishes this with no fuss, no mess.
When I arrived, the bed was at a 20 degree angle. It was left there by the previous shift. I cluck about this and point out that the bed is supposed to be higher, looking pointedly at the sign on the wall. The nurse asks Marie if she wants the bed raised, and soon it is at 35 degrees. Marie is coughing a bit, and she has abdominal pain. She is due for her next painkiller at 9:30 and it is only 7:15.
The nurse takes her vital signs, and they are excellent - 106/63. There is some discussion about whether or not this pain is related to constipation. Marie says it IS bowel pain, but she has had a couple of movements today so it is NOT constipation. She rates the pain at 8 out of 10. The nurse goes away to see what can be done about an analgesic.
While the nurse is out of the room, Marie says she wonders if something has irritated her bowels. "Like what?" I ask. "Oh," she says, waving toward the feeding tube "all this stuff they keep pushing through." She is bored, she is uncomfortable, and she is wondering where she'll go next.
I want to say to Marie, "You HAVE to tell them when the head of the bed is too low," but there are several other things I want Marie to hear, and I am choosing my battles. After weeks of the staff not paying attention to the instructions in the book or the sign on the wall or the repeated instructions from family, I can hardly expect Marie to feel like they will listen to her.
It seems like such a simple thing to me: the patient cannot control reflux because of the procedure done on her esophagus. She is supposed to stay at an angle of 35-40% minimum for 4 hours after feeding. She is on continuous tube feeding, so she is supposed to be at that angle all the time. It has been almost two months, and the message doesn't seem to stick with the staff. I have spoken with the nurses, with the nurse practitioners, with the doctors.
They are all caring, in their way. I don't want to suggest they aren't. But many of them seem to lack the laser focus that Marie herself brought to nursing - the attention to detail that made her a gold medallist. The reasons why they are lacking in focus - well, I could speculate. Some have been undergraduate nurses who are learning how to pay attention. Others have been around longer, but they are overworked and Marie is supposed to be a fairly straightforward case now - heading to rehab.
The nurse returns. She has been authorized to administer Tylenol 3 through the feeding tube. So she puts some water through the line, then the Tylenol mixed with water, and then she flushes with more water. She accomplishes this with no fuss, no mess.
Tuesday, June 9, 2009
Oxygen part 5
Yesterday was a good day. Marie was feeling better, and despite the low oxygen setting her levels were in the normal range. She had physio and Big Mike, as she calls him, managed to get her standing - twice! Someone had taken away 12 cans of Pulmocare and 5 bottles of Ensure as well as some of the other paraphernalia that was cluttering up the place. And she'd been told the IV would soon come out - she'd be getting all her nutrition and liquid needs from the stomach tube and orally. This is terrific!
Her first warm food in 5 weeks was soup - but she tells me there was some confusion and instead of letting her eat it the usual way, they put it through her feeding tube! They had also given her prune juice - and she thought they might have given her a laxative as well.
Today I had to work all day, so Candas and I went this evening. The head of the bed was down too low AGAIN. We put it up. Later, when the ice cream came, Candas tried to put the head even higher, but the controls on that side of the bed wouldn't work at that point (again!), so Candas went around to the other side and those controls worked.
The water bottle was off the oxygen - probably a good thing, since she doesn't have moist air at home. Supper had been brought and taken away again before she even knew it was there - she couldn't see it and no-one said anything to her - or if they did, she couldn't hear. A nurse kindly brought her some ice cream while we were there. The nurse suggested we might want to bring food for the patient, because the food services are "hit and miss". The patient in the next bed is new - she transferred from another unit. Her food had to come from that other unit - and took several hours, according to the nurse.
The only stats on Marie's chart were from 16h00. Her blood pressure was the best it had been in quite some days. Her blood oxygen was 94. Looking good!
When we asked her about her day, and the physio, she said it had been difficult because she got so dizzy (any wonder, after being bedridden for almost 6 weeks!). And apparently, according to Marie, her blood oxygen went down to 80 when she exerted herself. But, according to the nurse, this is not entered on the chart - the physio gives his report directly to the doctor.
Marie was still suffering the effects of the laxative, but she was waiting for the shift change and the bedtime clean-up. She was upset about how dirty her hair is - I don't think it's been washed since she went into the hospitral - almost 6 weeks. She's been having trouble hearing, and today she put the hearing aid in. It kept squealing. I checked the manual and it said the reason for this would be excessive cerumen (ear wax). Candas says she has already spoken to the staff about whether or not the increasing deafness in the one ear, quite noticeable in the past couple of weeks, could be because she's not getting her ears cleaned. Apparently that is someone else's department. Of course, perhaps the patient could clean them out herself if they gave her the tools to do it - but since she can't get up... We'll have to bring something along and do it.
We are seeing more and more the reasons why Liepert's plan won't work. By having fewer nurses and assigning care tasks to a raft of less-specialized/less-trained aides, there is no-one who sees the patient on an ongoing basis. They come in, do their one assigned task, and go out - often not even talking. The patient gets no stimulation, and no-one gets a clear picture of what is happening to the patient over the course of the day. When a nurse has a small enough patient load to actually help with the care, the nurse can spot emergent problems. The nurse can notice if food has not been eaten - and she might know what the effect will be. The nurse can spot if the patient isn't really tracking, and check the oxygen levels. The idea of hiring cheaper untrained staff so the nurses seldom have to come to the room unless they are administering medication - well, it removes the element of attention and caring from the role of the nurse - and it is that attentive role which has made the nurse so valuable in the medical system. It is the nurse who can see if there has been a change in the patient's condition - but only if the nurse is actually able to be at the bedside often enough and long enough to know what that condition is.
The nurses who keep lowering the head of the bed clearly do not know what procedures have been done to this patient, or they would understand why the bed MUST NOT be lowered. But none of them really have time - and Marie is so grateful to the few who have spent a few minutes talking to her...
Her first warm food in 5 weeks was soup - but she tells me there was some confusion and instead of letting her eat it the usual way, they put it through her feeding tube! They had also given her prune juice - and she thought they might have given her a laxative as well.
Today I had to work all day, so Candas and I went this evening. The head of the bed was down too low AGAIN. We put it up. Later, when the ice cream came, Candas tried to put the head even higher, but the controls on that side of the bed wouldn't work at that point (again!), so Candas went around to the other side and those controls worked.
The water bottle was off the oxygen - probably a good thing, since she doesn't have moist air at home. Supper had been brought and taken away again before she even knew it was there - she couldn't see it and no-one said anything to her - or if they did, she couldn't hear. A nurse kindly brought her some ice cream while we were there. The nurse suggested we might want to bring food for the patient, because the food services are "hit and miss". The patient in the next bed is new - she transferred from another unit. Her food had to come from that other unit - and took several hours, according to the nurse.
The only stats on Marie's chart were from 16h00. Her blood pressure was the best it had been in quite some days. Her blood oxygen was 94. Looking good!
When we asked her about her day, and the physio, she said it had been difficult because she got so dizzy (any wonder, after being bedridden for almost 6 weeks!). And apparently, according to Marie, her blood oxygen went down to 80 when she exerted herself. But, according to the nurse, this is not entered on the chart - the physio gives his report directly to the doctor.
Marie was still suffering the effects of the laxative, but she was waiting for the shift change and the bedtime clean-up. She was upset about how dirty her hair is - I don't think it's been washed since she went into the hospitral - almost 6 weeks. She's been having trouble hearing, and today she put the hearing aid in. It kept squealing. I checked the manual and it said the reason for this would be excessive cerumen (ear wax). Candas says she has already spoken to the staff about whether or not the increasing deafness in the one ear, quite noticeable in the past couple of weeks, could be because she's not getting her ears cleaned. Apparently that is someone else's department. Of course, perhaps the patient could clean them out herself if they gave her the tools to do it - but since she can't get up... We'll have to bring something along and do it.
We are seeing more and more the reasons why Liepert's plan won't work. By having fewer nurses and assigning care tasks to a raft of less-specialized/less-trained aides, there is no-one who sees the patient on an ongoing basis. They come in, do their one assigned task, and go out - often not even talking. The patient gets no stimulation, and no-one gets a clear picture of what is happening to the patient over the course of the day. When a nurse has a small enough patient load to actually help with the care, the nurse can spot emergent problems. The nurse can notice if food has not been eaten - and she might know what the effect will be. The nurse can spot if the patient isn't really tracking, and check the oxygen levels. The idea of hiring cheaper untrained staff so the nurses seldom have to come to the room unless they are administering medication - well, it removes the element of attention and caring from the role of the nurse - and it is that attentive role which has made the nurse so valuable in the medical system. It is the nurse who can see if there has been a change in the patient's condition - but only if the nurse is actually able to be at the bedside often enough and long enough to know what that condition is.
The nurses who keep lowering the head of the bed clearly do not know what procedures have been done to this patient, or they would understand why the bed MUST NOT be lowered. But none of them really have time - and Marie is so grateful to the few who have spent a few minutes talking to her...
Thursday, June 4, 2009
Who needs oxygen?
Yesterday morning I looked out the kitchen window into the empty lot. There's a 4x4 canopy out there right now, serving as shelter. There were three people out there, moving about, trying to get night out of their legs. Their clothes were dirty and the dust of the previous days stuck to their oily unwashed hair. They talked to each other, planning their day, talking about who they might meet, who they would avoid, where they might get food or money. All they had was the clothes on their bodies, the canopy (which I think our regular homeless guy, Len, might have put there) and each other. And, as the song would have it, the sun in the morning and the moon at night... and they can breathe. It might not be much of a life from the point of view of outsiders, but it is a life.
Yesterday afternoon I went to the hospital to visit my mother-in-law, Marie. She's 93 and has had a turn of bad luck in the past 6 weeks. She took a tumble in her apartment and came to the hospital, where things went odd. No broken bones from the tumble, but she did wind up with an extreme achalasia, aspirate pneumonia, and a bout of hallucinations (either from painkillers or a mineral imbalance). Yesterday was the procedure for the peg feeding tube.
My mother-in-law has been on home oxygen for about a year following a bout of congestive heart failure and the discovery that her lung function was compromised, perhaps owing in part to the shrinkage of her skeletal structure. She was on oxygen when she went into the hospital, and she has been on oxygen for the 5 weeks of her stay.
When my other half arrived to visit her yesterday, the hospital bed was at too low an angle for the third day in a row. Because last week my mother-in-law had a procedure to inject botox into the sphincter at the base of the esophagus in an effort to solve the achalasia, she has no control over reflux. The head of her bed is supposed to be at 40 degrees or more to prevent her from aspirating stomach acids. I came after work, and I sat with her mother while she went to talk to the nursing staff about the bed issue. Again.
Marie was not in the best shape after this procedure, and no-one expected her to be. She was dozy and not really tracking. The oxygen tubes were in her nose, disappearing out of sight over the head of her bed, and the oxygen supply was burbling in the plastic container attached to the wall. The plastic container had a spare long, coiled plastic tube around it, and I noticed the green-tinted ends of it. Then I noticed another loose green-tinted end and realized with horror that the oxygen was on but my mother-in-law wasn't actually hooked up to it. The end of her tube was dangling behind the bed, not connected to the supply.
A week ago Tuesday I came to the hospital to wish my mother-in-law luck for the botox procedure. I found her lying on a gurney in the hallway, almost flat and feeling like the mess in her throat was coming up to choke her. She had a portable oxygen supply on, but she had no bell, and she had been trying to get someone to stop because she was afraid she was going to choke to death. No-one would stop. I got her attended to, and then they announced that the procedure was postponed because of an emergency.
I went away while they transferred her back to her room. When I returned, she was lying in her bed with her oxygen tubes in. The other lines were not reconnected yet (the feeding tube, the intravenous). She was anxious and disappointed. I spent some time with her, trying to calm her down and reassuring her that the procedure would go ahead in the next couple of days and she just needed to hang in there. She was still anxious, and she wasn't really tracking. It took a while before I noticed the oxygen hadn't actually been turned on.
I told the nearest member of the nursing staff (they seem to rotate every day, so you never know which one is responsible for which room on any given day). 10 minutes later two nurses came in. I asked them to turn the oxygen on. "Maybe she doesn't need oxygen," one of them said. I explained that she had been on home oxygen for a year, that she had been on oxygen for the 4 weeks of her hospital stay to that point, and that nothing had changed that would affect her need for oxygen. One of the nurses went to get the blood oxygen meter while the other stayed to argue with me. I held out my arms in as open a gesture as I could make and I said "I am not prepared to have an argument over this. Oxygen is essential for life and you will turn it on." [link to cerebral hypoxia]
They took the reading but refused to show me or tell me the result. They turned the oxygen on and left. They have been giving me the stony-faced treatment for the past week.
So yesterday the charge nurse came in, hooked up the oxygen, then brought in the machine. The saturation level was 60%. (When her levels were as low as 78% during her congestive heart failure episode we were told it was an emergncy.) It quickly climbed into the 80s as my mother-in-law breathed the oxygen in. Her mind sharpened over the next 15 minutes.
In that ward, there are 4 nurses for 19 patients. The provincial government has announced another set of cutbacks, and the management levels have been told they will have to re-apply and compete for their jobs. In the current climate, I can understand that staff are stressed and that the stress might lead them to make mistakes. I am trying to respect the difficult position they are in. I am not a nurse. But I am also thinking that 6 life-threatening mistakes in 8 days is not acceptable. It is inappropriate to brand me as a difficult family member for having caught those mistakes and having spoken up.
The nurse practitioner on staff yesterday danced around the issue, refusing to speculate about what a period of that level of oxygen deprivation might do to the brain. Do medical professionals not realize that people now have fairly easy access to that kind of information? Not only through general information sites, but through online respected medical journals (I have access because of my job)
We family members are also in a difficult position; we have a loved one lying in a bed in the hospital and being put at risk not by her illness (which is a situation that is resolving) but by the staff. We feel like we should be camping in my mother-in-law's room to prevent the staff from making mistakes.
The vagrants in the empty lot survived their day on the streets and last night they slept under the canopy. They got up relatively early this morning, helped themselves to water from our tap, and they have ventured out into the world again. Breathing.
Yesterday afternoon I went to the hospital to visit my mother-in-law, Marie. She's 93 and has had a turn of bad luck in the past 6 weeks. She took a tumble in her apartment and came to the hospital, where things went odd. No broken bones from the tumble, but she did wind up with an extreme achalasia, aspirate pneumonia, and a bout of hallucinations (either from painkillers or a mineral imbalance). Yesterday was the procedure for the peg feeding tube.
My mother-in-law has been on home oxygen for about a year following a bout of congestive heart failure and the discovery that her lung function was compromised, perhaps owing in part to the shrinkage of her skeletal structure. She was on oxygen when she went into the hospital, and she has been on oxygen for the 5 weeks of her stay.
When my other half arrived to visit her yesterday, the hospital bed was at too low an angle for the third day in a row. Because last week my mother-in-law had a procedure to inject botox into the sphincter at the base of the esophagus in an effort to solve the achalasia, she has no control over reflux. The head of her bed is supposed to be at 40 degrees or more to prevent her from aspirating stomach acids. I came after work, and I sat with her mother while she went to talk to the nursing staff about the bed issue. Again.
Marie was not in the best shape after this procedure, and no-one expected her to be. She was dozy and not really tracking. The oxygen tubes were in her nose, disappearing out of sight over the head of her bed, and the oxygen supply was burbling in the plastic container attached to the wall. The plastic container had a spare long, coiled plastic tube around it, and I noticed the green-tinted ends of it. Then I noticed another loose green-tinted end and realized with horror that the oxygen was on but my mother-in-law wasn't actually hooked up to it. The end of her tube was dangling behind the bed, not connected to the supply.
A week ago Tuesday I came to the hospital to wish my mother-in-law luck for the botox procedure. I found her lying on a gurney in the hallway, almost flat and feeling like the mess in her throat was coming up to choke her. She had a portable oxygen supply on, but she had no bell, and she had been trying to get someone to stop because she was afraid she was going to choke to death. No-one would stop. I got her attended to, and then they announced that the procedure was postponed because of an emergency.
I went away while they transferred her back to her room. When I returned, she was lying in her bed with her oxygen tubes in. The other lines were not reconnected yet (the feeding tube, the intravenous). She was anxious and disappointed. I spent some time with her, trying to calm her down and reassuring her that the procedure would go ahead in the next couple of days and she just needed to hang in there. She was still anxious, and she wasn't really tracking. It took a while before I noticed the oxygen hadn't actually been turned on.
I told the nearest member of the nursing staff (they seem to rotate every day, so you never know which one is responsible for which room on any given day). 10 minutes later two nurses came in. I asked them to turn the oxygen on. "Maybe she doesn't need oxygen," one of them said. I explained that she had been on home oxygen for a year, that she had been on oxygen for the 4 weeks of her hospital stay to that point, and that nothing had changed that would affect her need for oxygen. One of the nurses went to get the blood oxygen meter while the other stayed to argue with me. I held out my arms in as open a gesture as I could make and I said "I am not prepared to have an argument over this. Oxygen is essential for life and you will turn it on." [link to cerebral hypoxia]
They took the reading but refused to show me or tell me the result. They turned the oxygen on and left. They have been giving me the stony-faced treatment for the past week.
So yesterday the charge nurse came in, hooked up the oxygen, then brought in the machine. The saturation level was 60%. (When her levels were as low as 78% during her congestive heart failure episode we were told it was an emergncy.) It quickly climbed into the 80s as my mother-in-law breathed the oxygen in. Her mind sharpened over the next 15 minutes.
In that ward, there are 4 nurses for 19 patients. The provincial government has announced another set of cutbacks, and the management levels have been told they will have to re-apply and compete for their jobs. In the current climate, I can understand that staff are stressed and that the stress might lead them to make mistakes. I am trying to respect the difficult position they are in. I am not a nurse. But I am also thinking that 6 life-threatening mistakes in 8 days is not acceptable. It is inappropriate to brand me as a difficult family member for having caught those mistakes and having spoken up.
The nurse practitioner on staff yesterday danced around the issue, refusing to speculate about what a period of that level of oxygen deprivation might do to the brain. Do medical professionals not realize that people now have fairly easy access to that kind of information? Not only through general information sites, but through online respected medical journals (I have access because of my job)
We family members are also in a difficult position; we have a loved one lying in a bed in the hospital and being put at risk not by her illness (which is a situation that is resolving) but by the staff. We feel like we should be camping in my mother-in-law's room to prevent the staff from making mistakes.
The vagrants in the empty lot survived their day on the streets and last night they slept under the canopy. They got up relatively early this morning, helped themselves to water from our tap, and they have ventured out into the world again. Breathing.
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