Surgeon Makes Tutorial DVD For Conscious Open-Heart Surgery 170
Lanxon writes "Swaroup Anand, 23, from Bangalore, was fully conscious as he underwent open-heart surgery. An epidural to the neck, administered at the city’s Wockhardt Hospital, numbed his body during the procedure. Dr Vivek Jawali pioneered the technique ten years ago and has recently released a tutorial on DVD, which gives a step-by-step guide to the procedure for other surgeons to watch and learn from."
Would you like to be awake for this procedure? (Score:5, Funny)
Doctor: Would you like to be awake for this procedure?
Patient: WTF???
Re:Would you like to be awake for this procedure? (Score:4, Funny)
My thoughts exactly.
I'm sure there's probably some valid medical reason for doing this -- I just have no idea of what it is. I don't want to be awake when the heart-rate monitor goes to a flat tone. Well, I guess you'd no longer be awake at that point, so it's moot. ;-)
Cheers
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My thoughts exactly.
I'm sure there's probably some valid medical reason for doing this
It makes the patient sound like a BAMF.
"Yeah I had open heart surgery. Got to watch the whole thing. In fact, the Doctor and I made jokes throughout the whole procedure.
'That's not a tumour, thats my wife!' "
Re:Would you like to be awake for this procedure? (Score:4, Funny)
Dr.: WTF?
Paitent: Huh?
Nurse: Ohh...that's isn't good.
Patient: WT.......
Re:Would you like to be awake for this procedure? (Score:5, Informative)
It's likely because there are greater risks involved in general anesthetic. Where possible, it's seen as safer for the patient to use only locals.
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Plus, a conscious patient can tell you if something starts going wrong.
And in worst case (Score:2)
And in worst case, a patient who doesn't want to follow and pay attention to the whole procedure, can be given a mild sedative.
The patient will be calmly dozing during the procedure, but it's still not a general anesthetic (= which is controlled coma), only a patient having a nap during a locals (= can be wakened up, or will wake up in case of something hapening).
Commonly done in orthopaedic surgery (= epidural or nervous bloc + mild sedative).
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Yup, my friend had a stent placed in a carotid artery while awake for precisely this reason. They apparently like to assess your mental state while it is going on to detect strokes immediately.
They do tend to dope you up quite a bit though, mainly to avoid anxiety and they don't want you squirming while they put a 2mm piece of tubing in a largely-clogged artery servicing your brain via a catheter that extends from your leg to your neck...
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It just sucks for them a little bit!
Re:Would you like to be awake for this procedure? (Score:4, Informative)
It's likely because there are greater risks involved in general anesthetic. Where possible, it's seen as safer for the patient to use only locals.
And the patient is far from normally conscious under procedures like this. They are sedated, whereby it's generally meant the patient is socked to the gills with drugs like benzodiazepines.
As a gross generalization, I find that the medical profession (and I'm on the fringes of it) tends to overmedicate when it comes to sedation. As one example, my father was going to have a small bone spur removed from a toe. Yes, that can be painful, but a good circumdigit block with lidocaine will fix that. But he was supposed to be sedated for the procedure sufficiently that he would not be able to drive himself home. He called me to arrange for a ride before the fact, more than a little annoyed that a 10 minute procedure would entail such an ordeal, and I replied, "well, just refuse the sedative." He did, and was fine.
Now fixing a toe is very different from open heart surgery. The so-called awake patient during open heart surgery likely will be only slightly topside of conscious. However, there's a big difference between that and the deep general anesthesia that would be required without local anesthetics to block the pain. One of the big reasons for using less anesthesia is basic danger, as other posters have commented. But as we learn more about general anesthesia, and specifically in relation to open heart surgery, there's a significant toll it seems to take on the mind. It's considered a dirty little secret that patients are waking up after major surgery a little dumber than they were before. And, by "dirty little secret," I mean, it's an area ripe for significant research into the improvement of health care. In any case, combining a good epidural block with sedation to achieve the same surgical plane (that's the term used to describe depth of anesthesia) as previously achieved with general anesthesia is going to be a good step forward.
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And the reason that "oversedation" occurs is simple - most people request it. I've had (nominally) adult patients who were upset that they were going to have to be conscious when their IV was placed.
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"I've had (nominally) adult patients who were upset that they were going to have to be conscious when their IV was placed."
I would be one of those patients. I really hate needles and tend to get nervous to the point of having panic attacks. When I had my wisdom teeth removed (under general anesthesia), the oral surgeon prescribed me an EMLA patch to apply to my arm so that I wouldn't feel the general anesthetic IV go in my arm.
Re:Would you like to be awake for this procedure? (Score:4, Interesting)
Yep, I noticed the "dirty little secret" with my father after a heart bypass. He was a retired mathematician, learned in the old days with slide rules. He could do sums in his head faster than most people with a calculator. After the surgery, not so much. It took weeks and months before he got close to being as sharp as before. He's still very good, but not at the top pitch he was before the surgery.
Re:Would you like to be awake for this procedure? (Score:5, Interesting)
Re:Would you like to be awake for this procedure? (Score:5, Informative)
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The two of you are crowding out the kids posting from their mom's basement. Please, get off the Internet.
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I only hope you don't use your nickname on the job.
I'd be a little worried if I was strapped down to an operating table and heard, "The patient is prepped for surgery... bring in the Demon Rabbit."
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It's ok, you just need to stand up and walk outside. Grab a bite to eat. Take the rest of the day easy.
Advantage? Yes. (Score:2, Informative)
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It's safer unless you are me and imagine all kinds of strange things going on... and manage to pass yourself out.
I have a very low tolerance for blood, stories about it, and other detailed info on accidents, etc. I blacked out in a college speech class a few years back because someone explained his motorcycle accident. I once volunteered for a blood drive and couldn't even carry the blood pouch back to the receiving table without having to sit down in the middle of the room and handing it off to someone e
Re:Advantage? Yes. (Score:5, Funny)
Re:Advantage? Yes. (Score:5, Funny)
Re:Advantage? Yes. (Score:5, Funny)
You'd think a reverse vampire would put blood into people, though.
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Well he did say he volunteered at a blood drive. Doesn't that count?
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I bet you'd be useless in a knife-fight :D
How do you feel about gore in video games (such as F.E.A.R. and Prey)?
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As would likely 95% + of the populace I'm betting.
Cheers
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> As would likely 95% + of the populace I'm betting.
What I meant was, even if OP wins, he still loses. It was not really intended to be interesting, insightful, or informative, nor did I intend for it to become the subject of a discussion (it was merely an observation I considered to be 'funny'). I am however genuinely interested in his (or others who have a similar 'blood-phobia' thing) answer to the gore-question.
Now that we've ventured this far into offtopicness, what's up with the 'Cheers' thing?
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I would want to be awake honestly; the anesthesia disturbs me more than the thought of being sliced open and possibly killed. It really is a personal preference.
Also keep in mind that, while not for open heart surgery, for many operations the anesthesia is the riskiest part of the procedure; the brain isn't built to be turned on and off at will.
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You'd want to be awake while someone slices open your chest and cracks your ribs apart?
You're either really brave, or a liar. ;-)
I think my squealing would be rather distracting to the medical staff. :-P
Cheers
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Well I'm assuming powerful painkillers here, and a screen so I don't have to see it. But honestly yes.
Again, would I like to be cut open? No. But given it must happen, I'd rather be around for it.
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I'm sure there's probably some valid medical reason for doing this
General anesthesia is generally more hazardous than local. I recently had surgery. It wasn't open heart surgery, but nevertheless, they wanted to do exactly what this doctor did. In the end, they decided that in my particular case (because I take blood thinners), the epidural carried more risk than general anesthesia, so they knocked me out. But were it not for that, I would have had this same experience.
When it was described to me, it was not that I would be "awake" for it, but that I'd be rousable - unlik
Re:Would you like to be awake for this procedure? (Score:4, Interesting)
I'd do it in a second, but I'm betting they put up a screen or something below your head so you can't watch, much less put a monitor/camera above my head so I can easily see what they're doing. Which kinda defeats the purpose, from my end at least. :)
I've been given the option to be awake for several procedures, and I always say yes, but then they always change their minds at the last minute and knock me out. Maybe they're put off by how eager I sound. Kinda like when the phlebotomist is about to draw blood and sees me staring at vein on my arm, and she says "Do you want to look away?" and I go "nope!", their look changes from one of sympathy to one of being a little weirded out.
Re:Would you like to be awake for this procedure? (Score:4, Funny)
This text only interface for communication doesn't sufficiently deliver the same weird look I'm giving you right now.
I wish I had a webcam and photobucket available right now.
Re:Would you like to be awake for this procedure? (Score:4, Funny)
I wish I had a webcam and photobucket available right now.
How interesting, the rest of us are thankful you do not.
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This text only interface for communication doesn't sufficiently deliver the same weird look I'm giving you right now.
I wish I had a webcam and photobucket available right now.
I also wish I had some kind of bucket available.
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Yes, they most likely put up a screen. But more importantly, unless they put up a mirror, you aren't going to be able to watch the whole procedure anyway unless they prop your head up so that it would be in the surgeon's way. When someone has your heart in your hand, you don't want them to have to worry about bumping your nose.
If they wouldn't put up a mirror so I could watch my vasectomy, they sure aren't going to for a heart operation. And yes, I was awake and chatting with everyone in the room during
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I've been given the option to be awake for several procedures, and I always say yes, but then they always change their minds at the last minute and knock me out.
Are you sure they actually put you under? For many procedures, instead of full general anaesthesia, the patient will be administered a sedative (hypnotic?) that keeps them awake, but without any memory of the procedure. I've had that done a couple of times, and from my perspective it was just like general anaesthetic (a discontinuity of consciousnes
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Are you sure they actually put you under?
Well that's what the anesthetist told me they were doing in each of these cases, so I'm guessing yeah.
Absolutely (Score:2, Informative)
Doctor: Would you like to be awake for this procedure?
Patient: WTF???
Doctor: We'll put up a screen so you can watch Spongebob and give you a bunch of morphine and a spinal epidural so you can't feel shiat, but if we put you completely under, your blood pressure may drop due to different autonomous reactions, and since we're doing heart surgery, that could be bad... So this improves the chances that you're awake after the operation, rather than on a slab in the morgue. Got it?
Re:Absolutely (Score:5, Funny)
I bet Spongebob is awesome on morphine.
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A sponge is pretty small.
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Morphine might work, I guess; nothing less. Otherwise I suspect the trauma of fully knowing what is happening, feeling with the part of the body that can feel anything the mere mechanical stresses, movements from opening your ribcage/etc., might be not helpful too.
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I didn't want to be awake for getting my wisdom teeth taken out. Why would you? So you can learn about recent movements in your doctor's mutual fund account?
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Could be worse:
http://www.youtube.com/watch?v=SVFstSSUm1w [youtube.com]
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Because it barely hurts, it's an interesting experience, and it only takes a few minutes (YMMV, but I'm sure they can give you a good estimate before they begin)? Because it's cheaper?
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I had a wisdom tooth pulled. The anesthetic shots(all 6 of them) were terribly painful, extracting just a couple of precious tears from my eyes.
About 15 minutes later, I couldn't feel the right lower half of my face and talking to the incredibly attractive assistant was becoming amusing. Oral surgeon walks in, sticks a prybar looking thing between a couple teeth, yanks it a couple times, puts funny looking pliars in my mouth and picks up my tooth. Good fucking god it's amazing how long the roots are for wis
No. And I liked it that way. (Score:4, Informative)
I had open-heart surgery. General & deep anesthesia is a wonderful thing. "Lie here ... ok ... we're going to give you a little something now to make you comfortable ..." And then I woke up a few hours later. No sense of time passing, just one moment in the OR and then the next moment I'm in the recovery room.
Now, given what happened in the recovery room, wouldn't want to extrapolate back to the idea of being awake for the procedure. ... well, it gets kinda fuzzy and unpleasant from there.
"Waking up" consisted of returning consciousness, but with no vision or hearing, and the totality of my existence being devoted to getting the breathing tube out, engaging enough self-control to know it's supposed to be there and to not panic (!!!!!), and discover that my hands were restrained to prevent acting on exactly that reaction. Then I was aware that something horrible had been done to my chest. And then
Now, if awake thru the whole procedure, that would mean not only being aware of the chit-chat ("scalpel ... clamp ... ") and other mundane activity, but the process of ramming that d@mn pipe down my throat, the sensation (however muted) of having my rib cage sawed up and pried open with a car jack, buckets of ice cubes being dumped into the gaping chest cavity, heart being stopped and partially disconnected, and generally knowing that a whole lotta things are being done to ME that are not naturally part of human existence - apart from, well, being dead (which, arguably, I was).
My wife didn't take it well in the waiting room when told "your husband is doing fine ... they just stopped his heart." Somehow I don't think I'd like being awake for observing it first-hand. And I don't think the doctors would be keen on having to watch their language/behavior knowing that the patient is watching & listening; I want them focused on the job, not on how I'll respond to their commentary.
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There are not enough mod points to elevate the parent post to where I'd like to see it. I'm like, "Crack my chest? I'm dead to the world, bub. I don't want to know a thing about it."
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As a recipient of an open-heart surgery, the only thing I have to say about being awake during such a procedure is:
Aaaaaaaaaaaaaaaaaaaaagggggggggghhhhhhhhhhhhhhhhhh!!!!!!
Why would that ever even cross somebody's mind?!
What's the odds... (Score:2)
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The odds are 100%, as this has always been the ACTUAL method used by woo-woo, acupuncture, "complementary alternative" medicine peddlers who to this day are still selling the laughable fraud of "acupuncture-only [csicop.org] anesthesia" surgery.
They do this for other things too (Score:2)
Conscious card cath? Now THAT was interesting! (Score:2)
Being awake for a cardiac catheterization is a different story. Since there are no apparent after-effects, and no slicing-and-dicing of organs, it really was fascinating to watch a live x-ray of my heart in action while feeling only a faint strange tickling in my chest. Nothing showed up wrong save the expected valve regurgitation.
Never dawned on me to ask for a copy of the video ... I'll have to ask about it.
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My friend had a Cardiac Cath examination and got to watch the whole thing on the same monitors that the cardiologists were working from.
Oh hell yeah. That's what I'm talking about.
Bad Idea! (Score:2)
Have you never heard of Job Security through Obscurity?
If me and my roomates can learn to preform open heart surgery on each other - why on Earth will we need to go to a surgeon!!!
(This is a pre-emptive woosh for those of you who are about to point out the obvious)
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Oh, I can foresee a whole new category of Darwin awards being handed out for that one. :-P
Cheers
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I'd be all for it as long as all amateur surgeries were required to be filmed and posted on youtube.
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Well, yeah, dude!
Why wouldn't you??
Re:Bad Idea! (Score:5, Funny)
If me and my roomates can learn to preform open heart surgery on each other - why on Earth will we need to go to a surgeon!!!
Unions? ~
Beep, Beep, Beeeeeeee (Score:2, Insightful)
Link (Score:2)
Doesn anyone have the torrent link to this tutorial? :-)
about this tutorial ... (Score:2)
is it DIY?
You aren't exactly wide awake... (Score:5, Informative)
There are many different surgeries done now where the patient is not rendered unconscious. Advances in technique and in local anesthetics have made the precision nerve blocks required possible. However, make no mistake, you aren't wide awake and cracking jokes while the surgeon does his thing; you are doped to the gills with tranquilizers. It would be very bad if you panicked or tried to move around during the surgery. Keeping you awake is done because it is easier to keep you from not dying when they aren't trying to put you to sleep, shut down sensation of pain, and cut your memory. They don't do it because it's really cool, or to educate the patient.
SirWired
Re:You aren't exactly wide awake... (Score:4, Interesting)
From what a nurse told me, it’s just that the narcotics have a very small area between “doesn’t do anything” and “kills you instantly”. So it’s very hard to get it right.
Which is why still so many people die in the process!
Especially older people often simply go crazy from it. And die more often too.
She told me, from her experience, that whenever you can, avoid full narcosis at any cost! It’s very far from the convenient trick to get around experiencing it. The one deciding on the dose sweats blood and tears because every time, he makes a decision that can kill you.
Re:You aren't exactly wide awake... (Score:5, Informative)
Now, there is a problem with postoperative cognitive dysfunction in the elderly, one that is currently a very hot topic of research, but the elderly don't have a lot of plastic surgery - if they're in for surgery, they usually need it to continue living.
Finally, very few people die - the risk is somewhere less than 1 in 150k for elective surgery, with risks rising for those who are having risky surgeries or who are very ill to start with. Anesthesiologists made a conscious decision in the early 1980s to reduce the risks of anesthesia, and created the Anesthesia Patient Safety Foundation [apsf.org] to review all closed claims - that's lawsuits, settled in or out of court - and to look for common factors. We have been enormously successful at this task. Drugs have been pulled off the market because the APSF identified them in series of deaths. Safety equipment has been mandated - for example, the size of the connectors for breathing masks, breathing tubes, and ventilators is specified so that all of it interoperates, regardless of manufacturer.
If you prefer to be unconscious for surgery, it can usually be done safely. Of course, if you want to be awake, that can usually be done safely as well. Ask your anesthesiologist [lifelineto...dicine.com].
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What if I don't want to be kept from not dying?
Re:You aren't exactly wide awake... (Score:4, Funny)
You have a duty to your fellow man to continue paying taxes.
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Ya I also don't want to hear the doctors talking about the game last night while cutting on me...
Re:You aren't exactly wide awake... (Score:4, Interesting)
The procedure started a small camera being shoved up my rear end. In front of me, I could see a color television screen showing the constantly the changing view of the inside of my colon. I was surprised at how spotlessly clean it was (except for occasional puddles of dirty water). I jokingly asked if I could get a VHS tape to show to other people. They said that the best that they could do was give me a printout with color photos.
After a while the doctor and the anesthesiologist (or someone) started asking each other why they were not there yet. As time went on they sounded increasingly puzzled and concerned that they had not yet reached where they were going. They would say things like, we should have been there long ago. They briefly considered the possibility of it having somehow having turned around and started going back the other way.
They were having increasing difficulty getting the cable with the camera to go much further and were discussing the possibility of having to give up. But then, the entrance to my appendix came into view in the distance as well as two polyps also visible up ahead. But, for a while they were not able to get the cable to move any further.
I asked what they would do if they could not reach the polyp. I was told that they would fire a harpoon and reel it in. But, then a moment later, I realized that he was kidding.
I then mentioned, that I could feel two places in my abdomen were it felt like the cable was binding up with the most pressure. The anesthesiologist (or the doctor) than pushed firmly on certain portions of my abdomen which finally brought the camera up to the two polyps. I remember them then taking a sample from the first polyp, and then I fell asleep after that.
Afterwards, they gave me a printout with several high resolution color photos, showing the inside of my colon (sorry about not having a link). Later on, I was eventually told that both polyps had been removed and that one of them would have probably eventually turned into cancer.
When I had a follow-up colonoscopy from another doctor a couple of years later, I was out the entire time. But, before the procedure, I warned the doctor that she should use the longest cable that she had.
Not for the weak of heart (Score:3, Funny)
Does DVD include different Camera Angles? (Score:2)
Subject says it all, DVD has had this feature for a long time, yet there aren't really a lot of people using it.
So what if I had these extra angles? I think the whole thing is probably one giant director's commentary so that is a given.
Deleted scenes? probably not
Alternate Endings? stay with me here, I don't necessarily mean the patient dies. But since they have 10 years of experience with this procedure, what are some of the complications they've seen, what are some things to avoid.
And yes, when can I add
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Yup. Multiple angles are real. But they share the 9.8Mbps data stream. So in order to add a second angle, it lowers the quality of the primary angle. And with MPEG-2, you need all the bandwidth you can get. That's why Hollywood isn't doing it.
Open Heart Surgery for Dummies (Score:2)
When does the book come out?
Interesting. (Score:4, Insightful)
There's also the small matter of maintaining the integrity of the pleural space - if you expose lungs, the patient can no longer breathe. It's impressive that they've made it work.
Old people (Score:3, Interesting)
The reason why this is big news is that some people (mostly old people) who get knocked out, never wake up again, and it has little to do with the surgery itself but with the drug induced unconsciousness. Having a method or ability to do this without knocking someone completely out would reduce risk for those in the high risk to die while under. This is why you always have to sign a consent form when getting a general. I had some oral surgery a couple of years ago in my late 20's and I still had to sign a bunch of stuff that says I am aware of the risks and that I might die from being knocked out, and please do not have your relations sue us if that is the case. Now if your in your 80's and have the same procedure, it might be better to keep you awake during the procedure.
(I was awake for the "tooth extraction" which translates to the most horrific medieval hammer and fscking chisel, and horrible horrible sounds and pressures you do not want to remember. So when it came time for the "tooth implant" I decided to get knocked the heck out. It cost me an extra 300$ bucks I think, but I was not going through that nightmare again. Not sure if it was as bad, but I wasn't taking any chances. If I had to do it again, I would have had them knocked me out for the "extraction" and would recommend anyone who has to get a tooth implant in this fashion do the same.)
However when I read the title I envisioned the surgeon performing open heart surgery on himself while awake... now that would take some balls!
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"I was awake for the "tooth extraction" which translates to the most horrific medieval hammer and fscking chisel, and horrible horrible sounds and pressures you do not want to remember."
Try tooth extraction without anesthesia someday. Now that's an experience (yes, I know it firsthand).
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Well there is extraction and extraction.
Technically I could "extract" some teeth by punching someone in the mouth or a similar traumatic impact or accident.
The best as I can describe it (and this one all of one tooth), was that the had me lie down, and froze the bajesus out of my face.
They then put a cloth over my eyes (so as to not get tooth chunks in them? I suspect simply so I could not see and panic), but I could still see out at a hard angle looking straight down.
The dentist kept saying "your going to
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I had a molar extraction without anesthesia when I was a kid. The doctor injected several doses of novocaine but without any effect.
So the doctor had to extract tooth with me fully conscious and two nurses holding my hands :) It was not that bad, just about 10 seconds of blinding pain.
Re:Old people (Score:5, Insightful)
I would say if the Novocaine isn't working, to screw off.
At least give me whatever drugs are in your desk, and the bottle of whiskey in your filing cabinet!
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I had both my lower wisdom teeth taken out with just a local anesthetic (since it was cheaper and I didn't need a ride afterwards). It really wasn't bad (except for when I had the second one done, they didn't give me enough anesthetic at first which hurt like a motherfucker). They took what sounded like a small rotary saw and used it to cut the tooth in half, and then pulled it out. It feels pretty damn weird to have someone tugging on your jaw that hard, simply because your brain is going "this should hurt
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Mod parent up! I'll second his story. When I was a teenager, I went to the dentist thinking I was just getting a cleaning, when he started extracting a wisdom tooth! Not only did I not know he was going to do it, but by the time he started and I figured out what was up, there was no turning back. I had them knock me out to get the other three. Never again!
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Putting in implants is unpleasant (makes a lot of noise when they are splitting your jaw bone to make it wider) but not really painful (needed about 20 injections against pain). Rode back home on my bike after which the injections wore out. After that I wanted to die for about 2 days before the pain become a lot less.
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OK I didn't need to hear about the splitting of my jaw bone. I was blissfully unaware and asleep during that part.
I do remember that I only had significant pain for a couple of days after, as opposed to the extraction where it hurt for like a whole week.
Oh and to top it all off, the antibiotics that they gave me for the implants, caused me to get C Diff, which was like the worst 3-4 days of my life.
C Diff is like a really bad flu, except you have live angry stinging scorpions in your gut, and they really ha
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Sedation is a pretty decent middle ground, on price, risk and not noticing what they're doing.
It's about $100, or a bit less, and generally something along the lines of taking one pill (nothing I was familiar with) the night before and then an Ambien an hour or so before the procedure. I like to combine it with music on headphones, and very little sleep; I had two root canals that way, and have almost no memory of them.
I would HOPE the doctors would be conscious... (Score:2)
I would HOPE the doctors would be conscious during this kind of surgery.
Oh, wait, what?
Nevermind.
So, now (Score:2)
Here's the real tutorial. (Score:4, Funny)
1: Ignore the screaming patient on the table.
2: Use leather restraints on the patient. The web ones are too easily snapped by someone in a full fight-or-flight frenzy.
3: Avoid the use of the word "oops"
4: Avoid the use of the phrase "uh oh"
5: NEVER use "oh shit", "oh crap" or any other variants thereof.
6: Have a mallet ready for "topical anesthesia" if necessary. If the need exists, apply to patient's forehead both vigorously and repeatedly.
7: Use surgical drapes, most patients freak (hard!) if they can see their own inside pieces and parts.
8: Avoid calling your surgical assistant "Igor", even if that is his name.
9: Refrain from cackling maniacally.
My wife had an epidural during childbirth... (Score:3, Interesting)
And it wasn't 100%. I think that either way, effective or not, you'd want to say "Ow! That hurts!"
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Ha, hahaha, ha, if you only knew what their practices were...
They used to take the poisonous tips of stingrays and jam it into their own reproductive organs.
I'd rather die by half-open-heart-surgery.
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