Death

I want to discuss death.

I have not died, so I am not an expert. I have seen quite a few people die, though, and each time is both the same and entirely different. The same: breath and heart beat stops, person dies. Different: they may be related to me, they may not, they may be serene, they may not, they may have someone they love at their side, they may not, they may be old, they may not, they may be ready, they may not, they may be human, they may not, and the list goes on.

When my mother died, I was 26 and a new Mom myself, with a 3 month old. I was a new Mom, with a 3 month old, and I was a medical student. Mom was not really "old enough" to die, whatever that means. It took sooooooooo long for her final breath, and that has helped me when I sit with families or friends of people who are dying. I know to tell them it can take awhile, and prepare yourself for that. Sometimes people need you to leave the room when they die. My Mom did. We finally left the room entirely, after holding vigil for days and days, and 15 minutes later when we returned, she was gone.

A lesson I learned too is even when you hold vigil, which is to say you KNOW they are going to die, when the damn thing actually happens it is like you are blindsided. It is just so final, that last time you get to touch your loved one, to smell and kiss them, while they are warm and real.

Though a few months after Mom died, I opened the plastic sealed container that held the last outfit before a hospital gown she wore. Her smell pounced on me when I pealed away the lid and I lost my breath with the impact. They say our memory for smells is profound. I still have that container of clothes, but the smell is gone.

When my father died, I was 29, and almost done with medical school. Two children now, and being the "medical expert" in the family, I got the call from the doctor about the end being near and the recommendation to focus on comfort. Dad died at home. It was also a longer process than expected. He too was "too young." When they came to take his body, I sat on the basement steps of the home in which I grew up, and held my hands over my ears against the zip of that bag. We get put in a bag when we die. Arguably, we are not we, so who really cares. But that was my Pops. Zipped in a bag.

When my dog died, I slept on the floor with him. But then I had to go to work, and the hospice veterinarian came over and ushered him into the hereafter while I tended to the here and now. When I came home for work, I sat on the place where he died and wept. My son held me. It wasn't just the dog I wept for.

And the patients I have seen draw their last breath? Those stories I must hold close to my heart, because they do not belong to me.

Death is not bad, in itself. If every human being stayed alive forever, we would have quite an issue with real estate. It is poetic that we return to the earth, matter not destroyed but repurposed, and that we live on in memory and mail. I am here to tell you I still get mail addressed to my parents, now gone about two decades. Mostly political. Also retail-related. It was a long while before Columbia House gave up on my Mom. Bless their capitalist hearts.

This week held the death of two artists. Well, probably a lot more than two, but two very well known artists that made our world a little bit better than it was before they were born. Incidentally this was one of the last things my Dad said to me: "Make the world better than it was". Also "It is over." *fart* "It is not over (chuckle)". Damn, I loved that guy.

Alan Rickman and David Bowie were both 69. Arguably "too young to die". I wonder how they died, and how their doctors treated them, and how their loved ones are coping. I know for me it is a loss. The morning I heard of Bowie's death, my gut twisted and tears threatened when the cafe I was in played "Changes" over the speakers. I saw Bowie play once, and I know he is/was mortal, but somehow you just don't picture these types of people dying. Alan Rickman was more than Professor Snape, of course.  He was an accomplished actor in the theater, on film, and a good man too, by all reports.

I am well versed in palliative care. I have cared for patients in hospice. I have seen many people die. I have sat at the bedside of some of the people I have loved and known best in the world and watched them die. Still, it never gets easier.

Atul Gawande brought this discussion into the mainstream. Well, at least into the New York Times bestseller list, which may not be mainstream, but still, a feat to be appreciated. We are mortal. HOLY SHIT!

So, I continue to show up each day and I love my family and friends. I run, because it is a blast and perhaps will let me usher in old age with some grace. I respect my elders, and I miss my parents. I feel sad about those who have gone and I never lose sight of the gift of each healthy day offered.

We might be like Lazarus. We might not. Either way, freedom lies in making peace with our mortality. And who knows, maybe what comes next will rock our world.

Snow Day

I remember my clock radio as a kid, which I used as an alarm in the morning, and to go to sleep with, on timer with about an hour of music from WIZM 93.3 FM. In the snowy mornings, I would turn it on and listen to the school closing reports. They would list off which schools were closed, and if yours was on the list…yes! The day could then be spent sledding, cross country skiing, sipping cocoa and generally annoying your parents.

Now that I live in California, snow days are nonexistent. Though there is snow to be found, in the hills. Up there, we go to sled and ski and generally frolic. And with our smug California attitudes, we note that on the same day we could surf and ski. We could run in our shirt sleeves and later bundle up for winter sports. We are obnoxious in our weather choices. We have it all.

Just the other day, I ran in snow. This was in Portland, while there to drop my kiddo back at college. The snow, unexpected. Because this was Portland, Oregon, not Portland, Maine. We ran with our good friend and enjoyed the muffled quiet of our foot steps. Daughter stated she prefers snow to heat. I am happy at 72 and sunny. But even I will admit our Portland snow run was magical.

What strikes me most about the snow run is the joy. How often do we encounter joy in life?

Life is hard. Our president is trying to talk some sense into our nation about gun violence. If airline or food safety or "terrorism" statistics were like this, there would be mass rebellion, demanding our safety.
Life is hard. I witnessed two care crashes today, one where the person was out cold, then aroused and as I tried to get them to sit still while awaiting the ambulance, they tried restarting their demolished car, with the air bag in their bloody face and smoke coming out of the crumpled hood. It might have been head injury befuddlement, or it might have been the drug paraphernalia strewn in their lap and the front seat. It took 5 cops to subdue them. I hope they are OK. The idiot. The next car crash was an hour later, when I was driving to the hospital and someone ran a red light and plowed into the car in front of me. Not a great day to be on the road. Life is hard. my team and I show up every day to try to lend a healing presence to the people we care for. Yet we meet so many barriers, as the system and the societal expectations are somewhat askew. I am somewhat mollified by Dumbledore, whom quoted at me while I was driving and listening to a Harry Potter book for the millionth time. Not the part where he marveled at finding the room with all the chamber pots when his bladder was very full, though how cool is that? But rather where he notes that looking for universal popularity is folly, and he himself receives at least 2 owls a week telling him what he could be doing better or demanding he resign immediately.



Joy comes as we invite it in. The double rainbow today greeted us in the morning and again in the afternoon. It arced its way over the very spot the likely methamphetamine-induced car crash appeared. Joy comes as we invite it in. Like the person I cared for today who refuses to be categorized as a patient, and delights in every little nice moment, no exaggeration. Joy comes in as we invite it, in the marvels of a well done 3 pointer, or in the case of SOME people, hundreds of well done 3 pointers.



We can close the door on joy, but that seems rather stupid to me.

Life is hard. Joy is abundant. It is like a Shakespeare tragicomedy. Life's a stage or something to that affect.

Joy comes as we invite it in. Little chocolate donuts, for instance.




And, snow days.

Wellness and Wabi-Sabi

"well, Ness…"

I am expert in disease. This word hails from the French for "trouble, discomfort, inconvenience, lack of ease". That's a hell of a thing to be well schooled in, and even though I am well-schooled (to the tune of 1/4 million bucks in student loans which I will possibly pay off before trouble and discomfort claim me), I still struggle with just how well a living being is supposed to be.

Should we never have pain? Should we always be at our athletic peak, able to leap down stairs without a thought and climb hills without gasping? What does it mean if you are born with disease? Why is good health "normal", when in my experience, every day threatens us with trouble and inconvenience? Some people, whom the modern slang might describe as "haters", even consider disease and trouble as a sign that God is angry with a person, or more often a group of people who do not share the hater's views. Most of us, when we get sick, can find some blame somewhere, and I suppose most often in ourselves. Because we are supposed to be healthy.

I have a kid who likes to get 100% on tests and assignments. And though we are not biologically related, I can tell you that apple did not drop far from the adoptive tree. I find myself telling her to let there be imperfection, to rest more, to cut herself some slack. Deja vu and bullshit, because I have heard those words myself and do I listen? Yes, I do! And I meditate five times a day! And I lived happily ever after.

Being bald, with an autoimmune system that eats my skin alive and stroke-worthy hypertension is the trifecta of beauty and perfection. Just the other day, Sports Illustrated called up to see if I would be the centerfold for the next swim suit edition. I, of course, had to tell them no because I am too busy doing my  MKSAP 17. Also, napping and taking warm baths. "My doctor made me take some time off, and posing for your magazine is way too strenuous for my delicate self. Good luck finding someone as cute as I am!"


I am not so delicate as to stop running though. Yes, I recently found myself on a casino floor and yes, I sprained an ankle on my Thanksgiving day run. But me and Klay? Nothing can keep us down. Not even hypertensive encephalopathy, the Milwaukee Bucks and other such inconveniences.

Why should people be unwell? And if being unwell is part of being human, why do we fight it so very hard? Many of my colleagues bristle at the battle analogy for dealing with disease. I tend to see more grey area here, because I understand, as an athlete, how approaching something hard as a challenge that you must face is valuable. We find out who we are and tap into our own strength when we compete. The thing is, disease is not a foe with any scruples. As a matter of fact, disease is a concept that we have created to describe the physical and mental imperfections of being human. Therefore, fighting disease is a little like fighting ISIS. It hurts, it stinks and it makes no sense. Finding the perfect battle plan is folly.

Which is not to say we should give up on being well. Here are ten pointers on how to guarantee wellness in the New Year:

1) Psych! Never believe this shit!

Seriously though, I do have a few thoughts on wellness.

1) Listen to your doctor/NP/PA. No, I am not saying this to promote my already inflated sense of ego, but rather to say, these folks care about you. I actually listened to my doctor and I am starting to feel better already. It was not easy, because it is widely known that doctors are second only in being the worst patients to nurses. Nurses: love ya!

2) Exercise.

3) Beethoven. Or whatever music floats your boat.

4) Allow yourself to grieve. For whatever life throws at you that gives you grief.

5) Hugs.

6) It is normal to have some disease. Don't ignore it. Seek help. And don't judge others OR YOURSELF for their/your suffering or infirmity. That's just mean.

7-10) For me, personally, I have to run. Even when I've been benched from the rest of life for impending cerebrovascular disaster.

Lucky for me, I get to run here (watch this video). And while watching this, remember, even the young and fit have imperfections. They just hide it better. Imperfection is beautiful. Reduce dis-ease by accepting the transient nature of suffering. Go full on wabi-sabi!

It Was a Dark and Stormy Night

I was lying on the floor of my hotel's casino after my recent half marathon, wondering what the point of   anything was and whether anyone would ever notice that I was there. Perhaps it is a frequent occurrence, the person laying flat on their back on the (rather digusting) carpet while the lights continue to flash and the booze continues to flow. Thankfully, a friend texted:
where r u?
To which I answered:
on the floor of the casino

She heroically came down to fetch me, and the hotel pseudo-medics did their best to talk me into an ER visit. No offense to my friends in the ER business, but no thanks. So instead I got a first class limousine wheelchair ride to the 22nd floor of Mandalay Bay, baby, with a gallant assist-transfer into the fetal position in bed.

The end.

All of this is to say, if you are going to run a half marathon, consider adequately training first. Then consider that 40-50 mph gusts of cold wind with sand flying into your eyeballs while rain is falling in the dark on the strip of Las Vegas at night may not actually be ideal running conditions.

Still, I am glad I did it. No really, I am. Mainly for the time with the good people that I spent time with in Sin City. Also, because it reminded me that even when running reminds me of some kind of Dante circle of hell I still like it and the medals in Vegas had these slot machine things on them that were pretty snazzy. Also, I met Meb at the expo. He is very kind.

Big race expos are bizarre. Or maybe like a bazaar. How much running related merchandise can one fit into a convention center? Is that much spandex in an enclosed building hazardous to your health? And how much stranger can the Gu energy gel flavors be? These are the questions I have.

Today I was walking down the street, basically minding my own business, when a bird nailed me. That is to say, it shat upon me, on the front of my pants. I was 15 minutes away from my next house call and this was one impressive stain. The last time I was targeted by a bird was in 6th grade, on one of my first dates with my boyfriend Fritz. That time we were holding hands under a tree when a bird nailed me on the shoulder. He laughed at me. That relationship was short-lived.

Last night, I was awakened by a windy, rainy storm. I groggily raised my head, and my trusty dog was sitting up on his haunches, staring intently at the skylight. I finally coaxed him back to a restful position, but he was disturbed.

Storms, bird assaults, casino floors. What is the meaning of all of this?

As Snoopy noted, it was a dark and stormy night. And this, though terrible writing, is an accurate depiction of so much of life. Why do people hurt each other? Why do children die? Why must people respond to fear with hateful actions and thoughts?

A wise person I know mentioned that the woods at night represents the dark parts of our being. However running in the woods is like the light that diminishes what is scary and dark. And having someone with you running in the woods at night is even better.

Running the Las Vegas strip at night? Perhaps not so profound. Still, as I ran toward the finish line at The Mirage in Las Vegas (the irony here was not lost on me), I could see the light. Mainly from the fake volcano and the neon signs. Still, light is nice, especially on a dark and stormy night.

My dog peering at the fathomless night sky may not know the mystery but he knows that what matters is we are safe. Or maybe we are not. If you cannot be safe, be near those you love. Thus he snuggled next to me, spine to spine. And the wind howled on.

The Woods at Dusk

There are eleven things worth living for today, I reckon.

1) Dogs. Dogs who like to run. Dogs who cuddle up to me during house calls. Border collies are always my favorite (sorry Miles). Dogs with names like Miles, which apparently is from the Germanic "Milo", meaning gracious. There is a local kid named Milo who is an amazing dancer, by the way. It could also be from the Latin "miles" for soldier. Or the Greek Miles for "destroyer". Or Irish meaning servant or Hebrew meaning gift from God. All of this is from the internet, so I don't believe a word of it. Tonight, running at dusk in the woods, he acted the soldier-destroyer once when a fellow (who seemed perfectly nice, btw) surprised us on the trail. Miles does not mess around. Phyllis is a good dog name too. Apparently derived from foliage (Greek), and might be linked to a woman who killed herself out of love for some guy named Demophon and then turned into an almond tree. The Phyllis I know takes no shit from boy dogs, so I am suspecting she is safe from becoming almond milk at Trader Joe's some day.

Miles and Phyllis, October 2015

2) Husbands. Specifically mine. I do not know how your's behaved today or on average in recent days, months and years. Mine is a saint. There is no internet derivation of his name, which is unusual and often misspelled. 

3) Friends. They are the people who show up every day, any hour of the day, without whining or complaint. They say funny things. They often are a lot wiser than I am, and they do not mind when my hair falls out, including half the hair of one eyebrow. Friends like their half bald, half-eyebrowed companions. You know who you are. 

Any bets on how bald I will be tomorrow?

4) Running. OK, I have not been talking enough about running on this blog purportedly about running! I am not as fast as I used to be, and in this town I was never that fast to begin with compared to the elites who seem to breath speed through redwood mist or something. But, I can run. I mean literally, I can put on shoes, go outside and run. There are many people that cannot do this physically. Or are so busy trying to just survive that the idea of spending time running in the woods is ridiculous. Tonight's run, in the woods at dusk, was nice. And every time I run somewhere beautiful, I feel better. Every single time. 

This is my back yard. Yes, I am boasting. 

5) Patients. Erma Bombeck once said "Never go to a doctor whose office plants have died". Which is why I never keep plants in my office. Seriously though, if your doctor has the time to tend their plants, they are not working hard enough! Your doctor should be oliguric, and preferably divorced because they have spent so much time with you that their spouse left 16 years ago and your doctor hasn't even noticed yet. Their children are all nuclear physicists and your doctor's last day off was at age 10 when they skipped piano lessons to ride their bike to Kwik trip to get an orange push-up. Seriously though, my patients are why I do medicine. And when I am with them, time melts away. Like an orange push-up on a summer day.

6) Children. Full disclosure here: parenting is harder than anything I have ever done in my entire life. This includes: 

a) childbirth, which is hard but temporary

b) standardized tests

c) learning Ravel Jeux d'eau

d) The Tour of the Unknown Coast

e) all of the marathons I have run, including the one NYC marathon where I cried all the way through Central Park

Children, whom I would lay my very life down for in an instant. They make me soar, they stomp on my heart, they can destroy me in an instant. Love them. 

7) Music. I am currently rereading, for about the 18th time, Song of the Lark by Willa Cather. It captures something about music and musicians in a very organic way. And I do not mean organic like Whole Foods, California, healthy, snobby, righteous organic. (I only buy organic). I mean salt of the earth organic. Music is at the very core of who I am. For some reason I shied away from it and decided to be a doctor. This could be why I get so sad sometimes. KIDS IF YOU ARE READING THIS: FOLLOW YOUR TALENTS AND PASSIONS. Unless they are illegal, in which case I suggest you get your shit together immediately. 

8) Books. I am surrounded by writers. My husband, my eldest child. Sometimes I think my poodle is writing a book in his head because, just like my husband, he will suddenly sit down and stare into space intently like there is something there he is trying to figure out. I can converse with husband or dog at these times, until I finally realize I am essentially talking to myself. Writers live on some different plane of existence. I am grateful for them because when I read, I too get to escape to a different plane of existence. As long as it is not a real plane, because I dislike those intensely.

9) Rocks. Literal and figurative. I can spend hours collecting rocks. I can also appreciate the solidity of them. Today I bought a couch for my office. It represented to me the solidity of the decision I have made around work. A couch is kind of a sign of commitment. Nothing is really set in stone, and stones actually change with weather and water and time. But they are so nice to hold in ones hand. And a good, solid couch? Let me explain, my couch is not made of stone. It is actually comfortable and soft. I just think couches represent solidity. 

Stones. October. Woods at Dusk.

10) Hats and the people who make them. 

Do you like my hat?

11) The Woods at Dusk. This is when the mountain lions are said to prefer eating people. I never worry though, as I have lightning speed and a fierce poodle and West Highland Terrier to protect me. The woods are good anytime, but early mornings and late evenings are the best. The light is ever changing. The redwoods split the light, which is one of their superpowers. It is quiet and usually few others are around. It is like a cathedral, but with big hills which suck the living air out of your lungs and make your heart almost explode. It is a labyrinth with cut backs and fern canyons and redwood droppings as soft as pillows underfoot. It is not for the meek of spirit. It renews your soul and kicks your ass all at the same time. It can save lives.

I have a cathedral in my back yard. Nyah, nyah.

Lippity-Lippity-Not Very Fast

"I am sorry to say that Peter was not very well during the evening. His mother put him to bed, and made some camomile tea-and she gave a dose of it to Peter!

One tablespoonful to be taken at bedtime.

But Flopsy, Mopsy and Cottontail had bread and milk and blackberries for supper."

-Peter Rabbit by Beatrix Potter

Fictional mothers are rock stars. Peter Rabbit's Mom, for instance, can solve everything with camomile tea. Granted, Peter lost yet another jacket and with Mr Rabbit already baked into a pie by Mrs. McGregor it is all she can do to keep the family clothed, fed and housed. 

Then there is Little Bear's Mother. She cooks, sews, tells stories, never gets angry and generally kicks ass. Little Bear is well-adjusted, kind and high achieving. And they are all drawn by Maurice Sendak. Sometimes I wish I was drawn by Maurice Sendak.

Perfection in parenting is all around us. In the doctor's lounge, it is manifested by tales of science fair victories by future nobel prize winners. At sporting events, it is a gaggle of future olympians, bringing honor and glory to us all, with parental button-popping serving as a serious threat for eyes being put out all over the place. Which is why I ALWAYS wear protective glasses to children's sporting events. On Facebook, which I personally am quite fond of, it is happy, shiny people with happy, shiny children and happy, shiny dogs. Guilty as charged. 

I spend my days with people. Which seems like a stupidly obvious statement because unless you live on an island that is yet undiscovered or unless you are one of those Humboldt hermits, you too probably spend your day with people. But I am an introvert and I am telling you I spend my day WITH PEOPLE. Like up close and personal, getting right to the intense stuff because generally there is no time to waste in end of life care and/or geriatrics. And here is what I can tell you about the state of people: they suffer.

I think Maurice Sendak might've been trying to get at that concept with Where the Wild Things Are.

I am, in general, not in favor of suffering. 

But without suffering, there is no sense of relief. Like the pleasure of gulping water when thirsty, of an ache that subsides, of a heart break that slowly becomes nostalgia, then a portal to something bright and precious that has been crystallized by time and the searing heat of tears and intolerable grief.

I was running today (this is a blog about running, after all). It was in the woods, and it was with dogs. They and I meandered. They gained on me on the uphills (dogs seem completely oblivious to the hell of incline), and fell behind when I went down. I have been in a deep state of grief in recent days, but today I laughed twice. Not just a giggle but an unexpected eruption of hilarity. First time was at the car wash. I was out doing housecalls and my car was so dirty I could barely see out my window, so I went into the automated carwash. I was listening to Beethoven's Choral Fantasy during this and it was so in sync with the massive red brushes and dramatic shower of water on my car that it was actually kind of idiotically spectacular. I could totally see it as a scene in an avant garde film. I hereby claim this so don't try to use it in your next avant garde film. Second time was while running. I was running down hill after what seemed like endless climbing and I kind of lost control. I mean, I just started bicycling my legs faster and faster and essentially let go and I was flying. I was suddenly 7 years old again. The dogs were in my dust, It was a blast, and I just burst into laughter.

Grief. It is a funny thing. It engulfs you and you feel trapped inside of it, unable to breathe. Then it releases you and you fly up into the light and gulp the post-rain pine scented air only to fall back down, wracked with the ruinous violence of sadness. Like breathing, there is not a choice.

Parenting is to know that suffering is worthwhile. You cannot have the smell of your child's sweet head without the hurt of loss. You cannot control how the world, the genetics, the impulsive decisions of young people and the immaturity that believes suffering is only something other people should do informs the path your beloved child takes. 

When grief lets you go for a bit, you fly up into the light. You revel in Beethoven and run with abandon down a path in a redwood forest. You release some of your lightness and send it with a kiss to where the wild things are.

Unarmed

This morning I was going through my usual routine of a cup of coffee with quick email, Twitter and Facebook check before work. This is after showering, dressing and smooching my family and dogs. There might be cereal or, better yet, waffles with peanut butter involved (a breakfast I learned from a surgery intern when I was a medical student: damn good fuel for a day that might not allow you to pee, much less to stop and eat something).

Anyway, I was looking at social media and came across a headline: "Shooting on Oregon Campus". Irrationally, or maybe actually rationally, I stabbed at my iPhone screen to open the article because I immediately needed to know WHICH Oregon college campus and please God let it not be the one where my child is right now.

It was not. But does that make it OK? Several people had children, family, friends who were murdered on a college campus today. Why is that OK?

The evening before I was at the hospital admitting someone who would have rather not been admitted but such is the way of healthcare in our advanced society. The first thing this person said to me when I walked through the door and introduced myself was "They sent me here unarmed!" In my head I was saying "Yeah, that was intentional"because I know the history of expertise in concealed weapons in this particular individual. To my credit I did not check every square inch of the bed and bedclothes.

Maybe I would be safer if I armed myself? Then every threat I receive in my line of work would be countered with my calm bedside manner accompanied by a steady finger on the trigger. Does that sound crazy? Hell yes, it does, because IT IS.

Thoughts and prayers are nice, but inadequate.  There is a thing going around on social media now about letting people who love guns have them, because America is about freedom. But I have to ask myself how free I feel when I can seriously contemplate, over my morning coffee, that a mass shooting on a campus might involve a child of mine. Other countries do not have this problem, because they control gun access. Period.

I run in beautiful places whenever I get the chance. It allows me to clear my mind, to feel blessed by beauty, to let go of anger, stress and fear, to feel the strength of my own body and to tap into endorphins which are almost as powerful as waffles with peanut butter. I have, occasionally, been threatened by unsavory men. Once I was almost intentionally run over by a guy in a pickup truck. But ultimately, I feel safe because I do not feel hate toward others. I actually like people and I will and have and will again not attend some family function because some stranger needs me due to their health crisis.

I believe in compassion. I am in favor of freedom. I fight for health in individuals and my community for a living.

Today, we were robbed. Someone walked into our home and stole from us. I actually suspect it was some kid who has been here before, and although I feel invaded and frankly pissed off, I also recognize that humans are flawed and there is no way to avoid unpleasantness in life. Suffering is part of the human condition, and those who perpetrate hate and burglary and murder are certainly suffering the most. Otherwise, why would they do this?

I have also been recently robbed of a ring my father gave my mother not long before she and he died, and my one pair of real pearl earrings, received as a gift from a dear friend over 25 years ago. That hurt. But mainly because I want to believe in the goodness of people, of children, of my neighborhood, of my community.

But no amount of hurt, anger or vulnerability could prompt me to arm myself against another human being.

Can guns be OK? Yes. Should they be very, very, very difficult to buy, carry around your community and point at another human being? Fuck yes.

Enough is enough.