City Paper-Philadelphia, PA, By Mike Newall
May 12-18, 2005
"…..a City Paper survey of six-dozen paramedics, 911 dispatchers, firefighters and city officials reveals a system in severe distress. Those surveyed said they’re dangerously overworked and under-resourced. On a routine basis, sometimes even daily, the city runs out of ambulances. All too frequently, they conclude, people wait too long for the help they need……"
On April 4, 12-year-old Taylor Lee and her little sister Jackie were walking home from school along Ridge Avenue when a silver Lincoln driven by a man allegedly high on drugs smashed into them. Eyewitnesses quickly dialed 911, but at the time, the city only had a few ambulances available to respond to the call. The Lee sisters lay bleeding in the street, awaiting a ride to the hospital for 18 minutes. The next day, Taylor Lee died.
A month later, Taylor’s death remains the subject of an independent Fire Department investigation, and though there’s been no resolution, this case and others like it have come to serve as an emblem of widespread and ongoing failures in the city’s Emergency Medical Services system.
A City Paper survey of six-dozen paramedics, 911 dispatchers, firefighters and city officials reveals a system in severe distress. Those surveyed said they’re dangerously overworked and under-resourced. On a routine basis, sometimes even daily, the city runs out of ambulances. All too frequently, they conclude, people wait too long for the help they need.
According to Fire Department officials, Philadelphia’s ambulances respond to emergencies within the national eight-minute standard 95 percent of the time. Paramedics tell a different story. Those interviewed estimate, on average, that 30 percent of their runs have response times of 10 to 15 minutes or more.
"We’ll run out of squads and then we’ll be sent everywhere, no matter how far away," explained paramedic Jonni Kuonen, during a recent ride-along. "A 25-minute response time is not unusual."
"Do you know how many times a week people say to me, "Hey, what the hell, I called you 20 minutes ago’?" asked paramedic Lou Rosmini. "But they don’t know I just had to drive 50 blocks to get to them."
Every paramedic surveyed told a recent horror story of their own:
The baby in cardiac arrest waiting 20 minutes.
The child in seizure waiting 22 minutes.
The women with asthmatic convulsions waiting 20 minutes.
Fed up with a system they say has been mismanaged for years, they’re quitting at alarming rates. Recruitment is at an all-time low; there are currently about 287 paramedics with about 35 vacancies that need to be filled. In mid-April, the city hired a class of nine paramedics. Since then, six other paramedics have quit and three were fired. The net gain for the city: zero paramedics.
"Bad news travels fast," said one under the condition of anonymity. "People see how shot to shit our system is and go work somewhere else."
The workers who remain uniformly agree about the failing system.
Says one veteran paramedic, "You’re better off calling a cab."
Mirroring national trends, EMS calls are skyrocketing in Philadelphia, having increased 73 percent from 1994 to 2004. But Philly’s 40 ambulances seem meager when compared to the EMS resources of other cities, which have taken steps to deal with rising demand. Houston, a city with a relatively similar population and EMS call volume to Philadelphia, deploys 91 emergency medical vehicles. Phoenix has an annual EMS call volume less than half that of Philadelphia’s but still deploys 31 squads.
Some Philly paramedic squads average 15 to 20 runs during busy overnight shifts, among the highest workloads in the country. They’ll walk in the back door of the firehouse at the start of a shift, hop in the ambulance, drive out the front door and never come back. On a weekend night in the summer, they may knock out a shooting, stabbing, car accident and a rape in one shift. They also have to deal with the stress of doing a job with resources stretched thin.
Philadelphia also lays claim to the nation’s busiest ambulance squad: Medic 22, the North Philadelphia Cowboys.
The Cowboys almost never stop riding. There are 8,760 hours in a year. Most EMS ambulance runs last at least 30 minutes. In 2004, the eight members of Medic 22 did 9,456 runs, 451 more than any ambulance squad in the nation, according to a survey by Firehouse magazine, a national fire-industry publication.
"I love my job, but we’re getting hammered out here. Day-in, day-out hammered," said Medic 22’s Kevin "Action" Jackson, a tall, sinewy, seven-year-vet with a bone-weary expression. "We’re trying to keep up, but it takes its toll."
As Jackson talked, two men were arguing in a school yard on the 1500 block of Allegheny Avenue. One of the men pulled a gun. A bystander fell to the pavement, screaming, shot through the ankle. The call came over Jackson’s radio.
"Sorry," he said. "Gotta run."
International Association of Fire Fighters (IAFF) experts contend a yearly workload of 4,000 runs for a single ambulance squad will lead to paramedic "burnout," a dangerous cocktail of physical and mental fatigue that affects the individual health of the paramedic and the treatment they provide to patients. Only 10 of Philadelphia’s 40 paramedic squads did fewer than 4,000 runs last year, according to department statistics. Half did between 6,000 and 9,000.
"Of course, it’s dangerous for the public," said one paramedic. "We’re all burned out and that affects our attitude and that affects our level of care."
Realizing the need for help, the Philadelphia Fire Department is in the final stages of an arbitration process with the firefighters’ union, which would result in eight new ambulances hitting the street sometime this summer. To offset the cost of the new ambulances and meet a $6.9 million funding cut imposed by Mayor Street, department brass also plan to put eight fire engines and ladder trucks out of service. The firefighters’ union welcomes the new ambulances but has bitterly fought against the closures, contending they severely compromise public safety. Street and Fire Commissioner Lloyd Ayers defend the realignment of resources as the "right-sizing" of the department given that structure fires are down and medical emergencies are through the roof. Fire protection will not suffer, they say, and the new ambulances will greatly improve EMS service.
"It’s a plan that meets national requirements," said Ayers, "and protects the safety of the people of Philadelphia."
Ayers, who took helm of the Fire Department last August, said the department is in a period of "great change" and is re-examining the entire EMS service.
"We’ll continue to do the best we can with the resources we have," he said.
If there is an EMS crisis, said Ayers, it will end when the new squads hit the streets. Many disagree with the commissioner, however.
"With Philadelphia’s call volume," said Lori Moore, a national EMS consultant and an assistant to the president of the Washington, D.C.-based IAFF, "I can guarantee these eight ambulances will be absorbed with little or no impact. Nobody’s going to see any substantive relief. Not the medics. Not the citizens."
To the average man and woman, paramedics and firemen interviewed for this story say this plan is akin to putting a Band-Aid on a hemorrhaging wound. Unless wide-ranging improvements are implemented, they said, EMS service will continue to deteriorate even further. (Street’s press office did not respond to a request for comment on the paramedics’ concerns.)
Most paramedics who offer
ed their criticisms spoke anonymously fearing their jobs would be jeopardized otherwise. Others, like Rosmini, a stocky, tattooed, nine-year vet, spoke bluntly.
"I got a daughter going to college, three other kids and a house payment," he said. "I should just keep my mouth shut, but people ought to know the truth about how bad a shape the system is in. I know I don’t want my family calling 911 in this city."
The problems with Philadelphia EMS begin as soon as you pick up the phone. When you dial 911, your call is answered by one of the 30 police dispatchers who work on the second floor of police headquarters at Eighth and Race streets. If your call is a medical or fire emergency, it is transferred to the fire department’s communications center. The men and women whose job it is to deliver a fire engine or ambulance to your door sit in the basement of the fire administration building at Third and Spring Garden streets. Their office is a cramped and windowless room with bad climate control. In the winter it is sweltering hot; in the summer, freezing cold. It is infested with mice, and last summer there was a flea outbreak. The dispatchers eat at their consoles, raise their hands to request relief for a bathroom break and, if there is time, slip outside for a breath of fresh air or a smoke.
"The people upstairs refer to us as the animals in the basement," said one dispatcher.
Although EMS calls in Philadelphia rose from 136,887 in 1994 to 237,586 in 2004, the number of people manning the fire dispatch controls stayed the same. There are only four call-takers working the phones at any given time. During a busy eight-hour shift, each person answers roughly 100 calls. Plus, they monitor eight nonemergency phone lines, which also ring incessantly.
"We need more people per shift," said one dispatcher. "It’s way too much work for the number of people we got handling it."
The call-takers process the emergency calls to dispatchers who assign them to fire companies or ambulances. They coordinate all radio traffic and keep track of ambulance availability and status by asking paramedics their locations.
On a given shift, only two dispatchers handle the entirety of the city’s medical emergency calls. One dispatcher handles the north side of the city; another handles the south. The dividing line is Lehigh Avenue.
"You’ll listen to the dispatchers over the radio," said one paramedic, "and you’ll hear the calls popping up on their screens one after the other. Bong. Bong. Bong. You just shake your head because you know they’re getting their butts kicked."
Until a few years ago, ambulances mostly stayed within the immediate neighborhoods of their firehouses. But now, with the increase of calls and the stress they have wrought on the system, it is normal for an ambulance stationed in Center City or North Philly to respond to calls in the far Northeast or the outlands of Southwest Philly.
Surprisingly, EMS dispatchers receive little training on the geographical layout of the city, other than having to memorize the location of fire stations and hospitals. The fire department spent an undisclosed sum last year to install a global information system (GIS) to help dispatchers better track and more easily deploy ambulances. Four 52-inch plasma screens were placed in the center of the room and smaller additional screens were mounted above each individual dispatch console. That system, however, is rarely used. Dispatchers say they haven’t been trained in it and are often too busy too fool with the GIS screens placed above their main monitors. Yet to be fully integrated into the current computer system, the plasma screens often remain dark.
The dispatchers are a drained, bleary-eyed, disgruntled bunch. More than a decade ago, a city-sponsored study found their work schedule to be unhealthy. The union offered them a vote to change it, but dispatchers kept the schedule, which they still work today: six days on, two days off, with eight-hour rotating shifts. But, as call volume increased, the dispatchers filed a grievance with their union, District Council 33, two years ago asking for a schedule change. The fire dispatchers would be happy to have the schedule of police dispatchers, who have a five-day workweek and set people assigned to the overnight shifts. But the fire dispatchers, who are civilian employees, say they have yet to hear back from the union. Ann Cohen, president of AFSCME Local 1637, said the union is currently scheduling meetings with the fire department to change the schedule.
"We are losing experienced people who know how to do their job because of this freakin’ schedule," said one dispatcher. "It wreaks havoc on you mentally and physically. It’s killing us."
"With all the stress we’re under," said another, "you’d think they’d want us at our most alert."
It is not uncommon, said one dispatcher, to see people sleeping at their positions during the overnight shifts.
"They don’t want us using our cell phones," said the dispatcher. "They’re probably afraid of someone taking a [camera phone] picture of a person sleeping and sending it to the news."
The unsanitary work environment and fatiguing schedule may account for the high rate of sick time. This year alone, the 46 dispatchers have used nearly 250 sick days, which averages to slightly more than five days per employee. Other workers cover the shifts and the cash-strapped city doles out more overtime pay.
The sheer amount of calls, the understaffing, the working conditions, the scheduling, and the poor training can lead to mistakes. Sometimes, they are fatal.
Last November, candles ignited a fire in the home of a 46-year-old Kensington man. The 911 operator typed in the wrong address and firefighters broke down the door of an elderly woman while the man’s house blazed nine blocks away. A second operator answered several subsequent calls for help but never confirmed the initial address. The man, Edward Neild, died in the fire.
On another occasion, a dispatcher failed to ensure that a first responder fire engine was sent to the scene of a cardiac arrest and the patient died.
"Both incidents have been investigated. The dispatchers received appropriate suspensions and are now back to work," said Ayers, a 31-year department veteran. "It is a human system and, sadly, mistakes happen. We do everything we can to ensure they don’t happen again."
A third dispatch console will be installed to handle medical emergenices in the upcoming months, said Ayers, and the city will then be divided into three areas — North, South and Center City — to decrease dispatcher workload. A fire EMS officer has recently been stationed in the dispatch center during peak hours to assist with deployment. Ayers would not comment on the dispatcher’s schedule, stating that it was a labor issue, but he said the GIS screens should be fully operable next year and other technological updates, including an advanced phone system, is in the works as well.
"We are looking at all sorts of ways to ensure dispatch service is as efficient as can be," said Ayers.
For their part, the dispatchers are weary.
"That all sounds nice and good," said one. "Now let’s see it."
From the communications center, an emergency medical call is dispatched into a meshwork of ambulances, almost always on the move and dispersed throughout the 135 square miles of Philadelphia. During the first three months of this year, the city experienced periods every day where no ambulances were available to respond to calls. Sometimes, the periods lasted for a few minutes; other times, as long as an hour or two. The department has experienced periods of "no squads available," as they call it, in the past, said Ayers, but never on such a
There have been fewer periods of "no squads available" in the last month, said Ayers, thanks to the EMS officer stationed in the dispatch room with the authority to pull paramedics who are working on post-run reports out of hospitals and force them to "go available." For their part, paramedics attribute the lull in ambulance shortage to the erratic weather. Runs pick up when it is consistently cold or consistently hot, they said. Right now is just a natural slow period. The department’s numbers support the theory. Last year, April was the third slowest month for ambulance runs. The suffocating days and wild nights of summer are the busiest time of year.
"We were out of ambulances so much this winter," said Rosmini. "All anybody’s talking about is how nuts the summer’s going to be. We get sick even thinking about it."
When all ambulances are unavailable, a fire engine or ladder truck is dispatched to attend to a patient. Firemen can only provide the most basic medical treatment and are not capable, or officially permitted by the department, to transport patients to the hospital.
On a bitter cold March afternoon, Sharnelle Anderson slipped outside her Mt. Airy home, shattering her ankle, dislocating her foot and breaking her shin. 911 was called and neighbors covered her with blankets as she lay crying on the icy ground. Firemen arrived within minutes but could do little more than wait with Anderson until an ambulance showed up 45 minutes later.
"Thankfully," said Anderson, "my situation wasn’t life threatening."
Tom O’Drain, president of the Fire Fighters Union Local 22, said he routinely gets calls from firefighters who waited 20 to 30 minutes for ambulances to arrive on the scenes of medical emergencies. Two firemen interviewed for this story told of waiting more than 20 minutes for ambulances to arrive at cardiac-arrest calls. (A new study by the Mayo Clinic in Minnesota finds that cardiac arrest victims are either saved or lost in six minutes.) Some firefighters have coined a phrase for situations where they stand over a dying person awaiting an ambulance. They call it "The Circle of Death."
Last week, Danny Rumph, a standout guard at Western Kentucky University and a Mt. Airy native, collapsed after a pickup basketball game at the Mallery Recreation Center at Morton and Johnson streets. His heart had stopped. His friends immediately called 911. A first responder fire engine arrived in four to five minutes, but there were few ambulances available, the closest at Broad and Oregon streets in South Philadelphia, more than 13 miles away. Rumph lay on the court for 30 minutes before an ambulance arrived. Rumph died where he fell.
Paramedic Jeff Neary testified about these situations during a 2002 salary arbitration hearing: When his unit gets a call for chest pains, "you know you have a 15-minute to 20-minute race up the Roosevelt Boulevard at 5 p.m. or anywhere, Chestnut Hill or down the airport. … You get there and then the person is in cardiac arrest. It started out as chest pain; now they’re in cardiac arrest because you didn’t get there quick enough and then you’re working as hard as you can; you just can’t get a pulse back and you just say to yourself, "Maybe if there were a few more squads, somebody a little closer, this guy would be alive today.’"
In cases of infant cardiac arrest, firefighters will ignore protocol and transport patients because they can fit a child in a fire truck. But this is not ideal. In March, a call came into dispatch for an infant cardiac arrest in the Northeast. There were no available ambulances nearby. A first-responder fire engine rushed to scene, initiated CPR and "scooped and ran" with the infant to the closet hospital. The baby died. Paramedics could have intubated the infant to more effectively restart breathing and provided drugs to chemically kick-start the heart.
"You can’t say for sure that the baby would have lived," said a paramedic. "But we could have given it a fighting chance."
From a cursory review of Philadelphia’s resources and call volume, IAFF’s Moore estimated that if "Philadelphia tries to solve its EMS crisis by adding more ambulances," adequate protection would take between 70 to 80 ambulances. "But," she added, "we know Philly doesn’t have the economic resources for 70 ambulances. So, they have to find better ways to utilize the fire department resources they do have."
Other cities rotate paramedics onto fire engines, a system that ensures that advanced life support personnel arrive on scene in less than five minutes. It also gives paramedics a break from the constant grind of the emergency runs. But since Philadelphia does not train paramedics in fire suppression, it cannot rotate them into fire companies.
Houston floods high call areas with paramedics driving Chevy Suburban trucks. If a patient needs to be transported, an ambulance is called to give the patient a ride to the hospital. The Suburban then goes back on the road to take another call.
"We experienced a 2.7-minute reduction of response times in the high-call areas" since adding the Suburban squads, said Houston EMS’s medical director David Persse, "and our citywide response time dropped by a minute."
Of the 40 ambulances that protect Philadelphia, one serves the airport exclusively. Twelve others are peak-hour "system status" squads, which, because they are only available 12 hours a day, are all out of duty by midnight, leaving the city with only 27 ambulances. "People see an ambulance parked in their firehouse and feel safe and protected," said one medic, "but what they don’t realize is that after 9, 10 o’clock, that ambulance is out of service and not going anywhere."
A independent review of Philadelphia’s EMS system conducted by the IAFF during the 2002 paramedic salary arbitration process recommended the city abolish the practice of system status squads.
"While an improvement during those 12 hours of the day," read the report, system status squad coverage "does not solve the deployment issues faced by the department. The 12-hour medic units must be transitioned to 24-hour medic units and redistributed based on call volume."
Paramedics interviewed for this story all said the system status squads are a main reason for paramedic burnout. "Peak hours are a thing of the past," said one medic. "We run constant now. It may slow down a bit, but it never stops."
However, Ayers said fire-department statistics consistently show there is no need for 40 ambulances during the late-night and early-morning hours.
"The system status squad ambulances have been bang for the buck," said Ayers. "You have people on duty handling the demand when the demand is there. When the demand goes away, it’s a waste of funds and resources to have ambulances sitting there doing nothing."
The eight additional ambulances, said Ayers, will also be part-time squads. The news falls hard on the ears of paramedics.
"On weekends and in the summer, we run crazy till 3 or 4 in the morning," said Rosmini. "Paramedics are still going to be burnt out and people are still going to continue to wait longer than they should, it’s as simple as that."
Three quarters of the calls that flood Philly EMS are for non-life threatening situations. Calls come in for stubbed toes, stomach aches and even toothaches. Like it has all across the nation, 911 in Philadelphia is a social net for the poor and indigent who lack proper health care access, people whose primary physician is the emergency-room attendant.
Many people incorrectly believe they are guaranteed prompt service in the ER if they arrive in an ambulance. It is common, paramedics say, to pi
ck up a patient with non-life threatening ailments who lives just blocks from the hospital.
"A lot of times, I’ll pull up to a scene," said one paramedic, "see that it’s not an a emergency and be told, "*uck you, mother*ucker, I want a ride.’"
People are always going to use EMS for non-emergencies, said Gary Ludwig, Memphis’ deputy fire chief and a nationally respected EMS consultant. "But," he added, "a lot of cities have taken great strides in rerouting those low-end calls, which put such a crush on their system, to other modes of transportation." Philadelphia is not one of those cities.
Some cities have instituted call-prioritizing dispatch systems that determine the seriousness of calls and assist them in deploying more appropriate means of transportation besides lights and sirens ambulances. Other cities use the private ambulance industry, ParaTransit vans, and even taxis to assist with non-emergency calls. Philadelphia prioritizes the nature of calls but still sends an Advanced Life Support ambulance on each run.
While Philadelphia paramedics have the right to refuse someone a ride to the hospital, they must first call the ER and get a doctor to sign off on the decision. But many doctors and paramedics balk at refusing service after the 2002 lawsuit involving a West Philadelphia infant named Marquis Dunson, who died after paramedics did not transport him to the hospital. The two paramedics were summarily fired before a federal judge could clear them of any wrongdoing. (Both were eventually offered their jobs back.) Paramedics say they now transport on everything, no matter how inane.
"We’re just the Big Red Taxi service," said one medic.
Many cities have established substantive public-awareness efforts to help fight the deluge of non-emergency calls. They send EMS officers into communities and schools to educate people on the proper uses of 911.
The Philadelphia Fire Department attempted an awareness campaign during the final months of Commissioner Harold Hairston’s administration last year. The department aired an educational TV commercial and put up two billboards advising people to only call 911 "for real emergencies." But the department, ever liability cautious, did not spell out what a "real emergency" actually was, so the billboards could easily be misconstrued as an advertisement to call 911. They’ve since abandoned that campaign.
Other cities have improved their EMS systems expediently by inexpensively partnering with the community. Boston and Seattle have managed to dramatically increase the amount of sudden cardiac arrest victims they save a year by offering CPR and defibrillator training to corporate businesses, restaurants and schools. Those cities save 40 and 45 percent, respectively, of sudden cardiac arrest victims. Philadelphia does not run such a program. According to statistics from 2001 — the last year data was compiled — Philadelphia saved only 4 percent of its sudden cardiac arrest victims, said EMS Medical Director Crawford Mechem.
The department is currently working on a new awareness campaign, said Ayers, and exploring ways to better partner with community organizations. "Right now, we are in an analysis stage," he said. "We are reviewing our data and examining every possible way to make sure our EMS is effective, efficient and offers the best possible service.
"It’s not just inside the department that things have to be changed," he continued. "Things have to be done in the neighborhoods where the demand is coming from. We are working on creating programs that work with citizens to reduce violence and increase public safety. You take away shootings, stabbings, scaldings, beatings, that’s four of my top 10 right there."
He urged patience.
"Changing a system," he said, "doesn’t happen overnight."
It’s near midnight as EMS Lt. Ray George drives down Frankford Avenue making the rounds. His job is a formidable one. Many EMS systems ensure one supervisor for every 12 paramedics. On any given shift, George is the only EMS supervisor for the entire city north of Lehigh Avenue. He supervises 40 paramedics and 20 ambulances spread across half the city.
"I’d like to get dispatched to any major incident — shootings, stabbings, heart attacks — but we can’t with only two of us," he said. "I always thought they should break the city up quarterly, but we can’t increase the role of supervision without the resources. We make due with what the city’s willing to give us."
The lieutenant is a bull dog of a man with a square jaw. He wanted to be a paramedic since he was a kid and watched the televison series Rescue 911. He is well-liked and respected by his medics. "Yeah, a lot of the guys are upset," he said. "They love their job. They just hate the system."
George has seen it all in his 16 years on the streets. Too much carnage to keep track of. A few months ago, he helped save a mentally disabled man who tried to kill himself by swallowing a bedside Bible. The man was choking to death on the word of God when George and other paramedics arrived on scene. They held the man down in the back of an ambulance and pulled the Bible from his throat.
"That will stick with me," he said. "I couldn’t forget that it if I tried."
Tonight has been unusually calm for a Friday. "The Northeast seems quiet now," says George. "But it’s early."
There are only five full-time ambulances to protect the entire Northeast. The hospitals there are spread out, which makes the average times of runs longer and eats up ambulances. Plus, on a daily basis, ambulances from the Northeast get pulled down into sections of the lower Northeast and North Philly. Paramedics said many of their long response times occur here.
"It’s funny," said one paramedic. "The people who pay the bills for the city get the worst coverage."
"Yeah, I worry about my family," said George, who lives in the far Northeast with his wife and two children. "God forbid something happens when I’m not around and they call 911 and there’s no ambulances up here."
One after another, the calls begin to pop on the George’s radio. By 12:17 a.m., all but one of the five ambulances covering the Northeast are unavailable.
"Let’s hope nothing big happens right now," George says.
Shortly after 1 a.m., a group of men allegedly leave a bar and start drag racing. According to police, one man’s truck careens out of control near Frankford Avenue and Levick Street and smashes head-on into a small Honda. The call comes over the radio. George flips on the sirens.
The Honda is crunched like an accordion. In it are a woman and her young daughter. Paramedics have already extricated the daughter and are rushing her to the hospital. The mother is trapped behind the wheel. A gash on her head exposes her brain. Her femur is broken and her femoral artery might have been severed.
"Oh my God," the woman screams. "Oh my God."
Luckily, a few of the Northeast ambulances have come available and are at the crash site. If the crash happened 30 minutes earlier, ambulances would be racing up from the lower Northeast. George advises the firefighters that the woman’s injures are too grave for them to try and forcibly pull her out. The Jaws of Life will be needed. The firefighters take his advice and cut the car door off to free the woman.
George then attends to one of the passengers in the truck who has a head wound. Soon, another ambulance arrives to take the man to the hospital.
The lieutenant wipes the sweat from his brow and gets back into his vehicle.
"That was a good job," he says, in a rush of relief and adrenaliane. "E
verything went according to how it should. Paramedics just want to make sure they can do that every time out."
Sometimes, like tonight, the system works say paramedics. A lot of times, it doesn’t.
"Calling 911, right now," said one paramedic, "is Russian roulette. We may be able to get to you. We may not."