Why This Nurse Cares.

In my time as a psychiatric nurse practitioner I’ve had people react to me in many different ways. I often say people either love me or hate me. There’s not much of an in between. But that’s wrong; I am learning the in between exists.

There’s a gray area where some people live where they just don’t understand me and are scared to hope that I might be real.

It’s taken me some time to recognize this particular response to me as it presents as hate some times. Often times. I’ve had clients scream at me, “BUT WHY ARE YOU BEING SO NICE?! I FUCKED UP!” I’ve had clients say, “BUT WHY DO YOU CARE?! YOU AREN’T MY RELATIVE SO WHY DO YOU FUCKING CARE?”

It surprised me the first couple times. Why would I not care? Why would I be in the profession I’m in if I didn’t give a shit?

I’ve reflected a lot about this particular reaction to me.

Clients that stick with me; who have been with me through divorces, marriages, bearing children, gender changes, sexual orientation changes, sobriety and relapses, and any other major life event you can think of…these clients know that I’ve got their back. They may hate me sometimes. When I’m not doing what they want me to do and I may push them in ways they don’t want to be pushed. But I’m there for them through it all.

I tell clients I don’t get mad at them, I just try and understand where they are struggling and why and work through it with them. And it’s really true. It takes too much energy and would require taking things very personally if I was to get upset with clients and sort of counterproductive to my role.

A client who recently questioned why I cared about them with skepticism said it must be because I have to care because it’s my job because I have to care about everyone who walks through the door. I immediately shook my head no. I do not keep every one who walks through my door. I do not take on everyone who calls. And certainly not everyone keeps me.

It has to be a good fit on both sides. We don’t necessarily have to like each other but we have to have respect for one another and we have to feel safe with one another. I’ve discharged people who threatened me or who were too acute for a private practice. And people have discharged themselves when they don’t get what they want or need from me.

But my peeps, my clients and my patients, yes I care about them. I don’t know any other way to be. I don’t know how to sit with some one and hear their story and try and partner with them to move forward and not feel something toward them. Empathy. Compassion. Because it is from those clients who I learn the most. The clients who take steps forward when the world pushes them back; they are the people who inspire me. They are the stars to see, to feel, to experience, and to be witness to that brings me joy like nothing else.

I saw a client recently and we got in really deep about something and they teared up, and we had this moment, and I’m like you just got therapized. But it’s not just them it’s me who learns from them. Me who learns that it took almost two years to get a tear from them to watch them progress toward feeling the hard mushy feelings.

I care about people because I couldn’t sit in the chair I sit in and not care.

I trained with an APRN who was amazing. She taught me tremendous amounts about everything but mostly she taught me how to see patients as people. She said she did half hour follow-ups instead of the standard fifteen minutes a psychiatrist does because, “Ya know. I like to talk to my people.” I agree with her. I like talking to my people. I like to know them, and although caring about each and every one makes me vulnerable it’s also what makes me good.

It makes people trust me because they know I am prescribing to them in a way that I would prescribe and treat my own family member.

To wonder why some one would care hurts me. Because it means that person has been wounded. Deeply.

Why the fuck do you care?

My answer is because I can. Because I do. Because I see you and you are worthy of being cared about. My question back would be why are you scared of being cared about?

Stop the stigma.

Top Five Most Memorable Nurse Moments From The Emergency Department…Part 1/5

The most memorable moment for me in the emergency department was unfortunately not a happy one and it haunts me to this day. In fact I avoided writing this for awhile as I just didn’t want to. But it’s a story that needs to be told. Over and over. Because I don’t sweep bad stuff under the rug. I broadcast it.

I was in triage. The panic alarm went off, which meant something was happening with the psychiatric patients. I work in mental health now. I love it. However, it was the reason I left the emergency department. In the ED it’s containment, not treatment. It’s dangerous. I had been kicked in the ribs already, and had friends punched and kicked and bitten. But nothing could have prepared me for that night.

I turned the corner and two nurses who I knew very well, one of them who I had helped train, were bleeding, screaming, crying, in the hallway outside a psychiatric patient’s room. They had been horribly physically assaulted.

I worked in pediatric emergency, but a pediatric patient can still be over two hundred pounds and over 6 ft tall. There were too many people watching, patients, families, staff. I grabbed them and put them in a big walk in closet near by with an Attending who was trying to comfort and assess them.

Then I called a nurse manager I knew was in the office, I told her to go to the ortho closet now. She did. They thanked me later for doing that. Getting them out of the craziness and into a closet. It felt wrong to shove them in there so I was grateful later to learn that they appreciated it.

With my heart pumping I walked into the room of the patient. There were about six security guards holding the patient down. The patient was still straining and fighting. There was blood on the faces of at least two security guards. One had his glasses broken and hanging off his face. These were all people I had worked with for over five years.

With tears brimming in my eyes I used gauze to dab at the blood so it wouldn’t drip down their faces onto the patient. I tried with all my might to ignore the clumps of hair and scalp on the floor from my friends now in the ortho closet. There was blood spatter on the walls.

The worst part. The ultimate horror of that night was seeing the fear in my all of my co-worker’s eyes. Fear and anger and hurt and knowing there was not a damn thing we could do about it.

The patient was under eighteen. And with documented mental health diagnoses. No one would press charges against them. We had been down this road before. This horrific crime that left two nurses injured for months with neck injuries from being thrown around the room by their hair, punched in the neck, and more…it would go unpunished. Forever.

All the nurses that were there that night; we all quit within six months.

It was too brutal. Too real. Too fucked up for us to forgive and forget and brush under the rug. It also showed how the hospital would never have our backs if assaulted in the line of duty. It showed how the system just lets that go.

I can tell you the patient was in their right mind. Not psychotic. I can tell you that though every single person who worked in our department wanted revenge we swallowed our rage and took excellent care of that patient for the next week they were in our department waiting for an inpatient bed.

I never had to wipe the blood off my co-workers before, and while I have unfortunately, had to do it again during my career in inpatient psychiatry it was never quite so traumatizing as that night in the ED.

I returned to work the next day. There was another nurse standing outside the ambulance bay doors. Just standing there staring. She had been there with me last night. We stood there together for several minutes. Not talking. Building up the courage to swipe our badges to go inside. We never spoke. We didn’t need to. Eventually she swiped her badge. We went inside.

I realized in the days following that it reached a point where I was scared to go to work. Every time I heard the panic button I saw the image of them sitting screaming and bleeding. We were all more cautious, more jittery, more likely to give a PRN (as needed medication) for agitation much faster than we ever had before.

Eventually they came back to work and I was incredibly awed by their strength and bravery. Balls of steel was my actual thought. I don’t think I could have done it. Come back from that.

It shouldn’t be this way. Nurses should not be assaulted/attacked/abused. But we are. On a daily basis.

That day should not be my most memorable. I have fantastic memories of so many funny times and good friends and good talks and pranks on night shift and moments of absolute teamwork that can only be done in an acute care setting. Moments when everyone comes together like a well oiled machine to save the lives of children who were dying. Those moments were breathtaking.

I remember when I was new in inpatient psychiatry. There was a medical emergency. I yelled out what I needed and held my hands out and waited…and nothing. I looked up and there were psychiatric nurses staring back at me like I was nuts. I realized then I missed the ED. I wouldn’t have even had to speak in the ED. We all just would have done our thing. It’s a security blanket I didn’t realize I had until it was gone.

Yet the night I remember most wasn’t saving a life. It was watching lives being shattered. Watching my co-workers and friends broken with their blood on my hands. Literally.

When you ask some one what’s the craziest thing they’ve seen as a nurse. They won’t tell you these traumatic memories. But it’s what we are thinking.

I didn’t leave the emergency department because I didn’t love it. I did. I didn’t leave it because I even wanted to. I would have stayed forever. But not after that night. That night changed something inside of me. Changed my perspective of nursing and how our society treats nurses. That night broke me a little.

To all my fellow emergency department nurses out there. I see you. I know you. I value you. You are epic.

Life With a Nurse

I have the good fortune of having met my wife while working in the emergency department. She was an EMT/tech and I was an RN. She’s been exposed to healthcare. So she gets it on some level when I’ve had a bad day. She’s also been there when kids have died. So she got it when I worked in the ED too.

There are a few core differences to being married to someone in healthcare than to someone who works in an office with no needles or blood.

Let’s start with bad days. When my wife has a bad day…I mean now she works in management in retail. Stressful for sure. But no one walks in bloody and dying. My bad days have evolved from trauma in the emergency department, to insanity on an inpatient psychiatric unit, to a different sort of bad in outpatient psychiatry. I hear horrible stories of abuse, rape, murder, and often it’s not random. The abuse is by a parent. The sexual abuse or predator is a relative. They are horrific, soul-deep stories.

Over time I’ve grown a thick skin. And doing medication management for some people means I won’t hear the actual detailed story. But for my clients I do therapy with. Yeah I’ll hear it.

I also, even in the prescriber role, end up being the first person some one has told something. Often a kid. Often sexual abuse or physical abuse. They could have been in therapy for awhile, and for some reason, it’s just happened a lot, they tell me in our intake. I don’t know why. But it happens. Then I have to tell the parents. Then I often have to tell DCF. Then it totally backlogs my packed day.

So yeah. Bad days in my eleven year career have evolved from death and dying and abuse to abuse but in a different presentation. I’m not collecting the rape kit now I’m helping with the emotional healing after the rape.

It’s heavy stuff. Some times it gets to me. My wife knows. She doesn’t ask anymore because I don’t tell her. Obviously. I can’t. But she knows. She knows because I scoop up my sons and hold them and she sees the tears prick at the corners of my eyes. She sees me on my laptop until late into the night catching up on notes and billing. She knows I’ll put on something hilarious on the tv, or something that will make me cry so I have an excuse to let it out. I’ll pick up more hot yoga classes. I’ll make an effort to connect with a friend for a drink.

The bad days are bad when you are married to some one in healthcare and the recovery can be emotionally taxing on every one if you do not practice self care.

A couple other things: I have a high tolerance for bringing my kids to the doctor and I do a lot of self treatments at home. Which my wife thinks I’m totally nuts to do. e.g. An ingrown toenail. I’m opening that baby up, getting the pus out, and treating that at home. Rashes- unless it’s something I know is bad, we stay home and slap on some aquaphor. Head and mouth injuries- the boys have had a few- with lots of blood. Unless something is dislodged (like a tooth) or a bone is broken, we aren’t going. And the one time I went to an urgent care clinic for asthma that I tried treating at home- well I was taken by ambulance to the ED and evaluated by the ICU doc’s in the emergency department because they thought they were going to have to intubate me. I don’t mess around.

She can’t watch medical shows with me. I can’t tolerate them and she can’t tolerate me. Doctors never do blood draws, and nurses are sorely underrepresented, the whole situation generally just pisses me off. And I can usually guess the mystery diagnosis, which irritates my wife. So we don’t watch them.

I am a human lie detector. I don’t know if that’s a nurse thing, or specifically an emergency department/psychiatric nurse thing. Because all the ED nurses I know are scary and also are human lie detectors. So it’s definitely a thing. It means my clients can’t get away with a damn thing. Neither can my kids or my wife;)

I have interactions with law enforcement and attorneys regularly regarding clients. I’ve had high profile clients and cases and through it all at the end of my day I have to shut it off and go home and make dinner and pretend I’m normal, and that the case on the 5:00 news is complete news to me, not a case I’ve spent all day dealing with. After a day full of what feels indescribable and insurmountable acting “normal” just seems impossible.

Life with a nurse is interspersed with bad days, but it makes the good days that much sweeter. Because I walk with the worst regularly I relish the best. I give so much of myself to my clients that sometimes it’s hard to have anything left for my family.

But the days I have with them means I am present. I am there and I bask in the fun because I know all too well how quickly life can change. There is a darkness hanging over nurses, an edge, because we truly know that life is precious and we’ve seen people waste it, abuse it, lose it, and we don’t take our own for granted. I’ve seen people’s brains and insides. I’ve taken care of people who are murderers, rapists, and I’ve taken care of the victims. Those are things that can’t be unseen or unheard or forgotten.¬†We’ve seen the worst of humanity in every possible way.

In Adrian Monk’s words, “It’s a gift, and a curse.” And it truly is. Nursing makes me smarter, tougher, kinder, more open and more educated. But it also makes me more cynical and more suspicious. Nursing brings out the best and the worst in me, and always pushes me to be better. I can’t speak for my wife, but I can hazard a guess. Life with a nurse is never boring, always a little unpredictable, and lots of fun- because for real, we are pretty fun.

 

 

 

Violence Against Nurses

So I’ve been MIA for a little bit. I’ve been dealing with a lot personally and professionally. Professionally it’s brought up a lot of memories from when I worked in the emergency department as a staff nurse. Warning- this blog post has nothing to do with me being a lesbian mom- it’s a memory and commentary on violence toward women and the state of our health care system. Seeing our current administration downplay and ignore the #Metoo movement pisses me off. Feeling scared and vulnerable also pisses me off. So I’m going to tell a story as to why we need to have discussions around violence.

I had been working at the ED for over six years, almost seven. It was a crazy night, I was in triage. We had a lot of psychiatric patients in the ED, which is NOT the place for them, but there is no place for them, so there you go.

We had a lot of medical emergencies, and then they panic alarm went off. We use that to alert security and staff that we need bodies with the psychiatric patients because some one is escalating. There always has to be a nurse in triage. So my partner went to the back to check it out, security guards ran by, the rest of the nurses were in a medical emergency. I was in the middle of a triage assessment when I heard screaming. Not patient’s, but staff. Lots of screaming.

I followed the screams and rounded the corner and saw a pretty gruesome scene. Two nurses had been physically and violently assaulted by a patient. There was blood, clumps of hair, and what would turn out to be permanent injuries. There were about six security guards holding the patient who was still fighting. There was blood running down the faces of at least three of guards. The nurses who were attacked were screaming and crying, and in shock and I dragged them into a closet because all the patients in the ED could see them. It’s all very open. There was a doctor with them who also went into the closet. It was a big closet. I remember I grabbed gauze and held it over the blood on the guard’s faces because it was pouring into their eyes.

This was as bad as it sounds. No charges were pressed against the patient even though both nurses tried, because of a variety of reasons the police would not do it. It was quite possibly the worst part about the whole experience. They had permanent injuries and they would never obtain justice. It’s also sad because who wants to press charges against a psychiatric patient? No one. But in that moment, when I had known all of those staff members for over six years, and we were friends and we had each other’s back, to see them hurt was fucking awful. It was painful, and made us all feel pissed and vulnerable and scared.

I had to go back to work the next day. I don’t know how I did it, but I did. And when I got to the doors two nurses were standing there. They had been there the night before too. They couldn’t go in. None of us wanted to. We all wanted to walk away, erase that memory. Erase the fear. We all didn’t even say anything, at some point though one of us badged open the doors and we all silently filed in for our shift. We didn’t need to speak.

The part about going back after seeing something horrific is that today it could be us.

The week of my wedding, a couple years earlier, I got kicked in the ribs by a patient. I was bending over to pick up something on the floor and they just kicked me. I had a bruise on my ribs about 4 inches in diameter while my family tied me into my corseted dress.

I was no stranger to the violence of working in the ED, and it’s something that when you are there you have to kind of put out of your head otherwise it would just break you.

I don’t know what the solution to this problem is. But I know it’s a problem. I also know hospitals don’t like to talk about it, and they don’t like to take responsibility for it, and management likes to minimize it and it falls to the RNs on the front lines walking in every day not knowing if they are going to leave with a black eye or worse.

If you know a nurse thank them. Because you cannot possibly imagine the shit they see and face on a daily basis.

If you are a nurse. Keep fighting. We need rights, we need protection, and we will get none of it if we let these things keep happening with no recourse.

Thank-you to the state of CT who passed legislation making it a felony to assault a healthcare worker in the line of duty. Don’t be scared to utilize it.

What I consider a hard day as a nurse.

This day occurred two or three years ago.

I walked in at 7:30 AM to the inpatient psychiatric unit. I found out quickly I was the only provider for twenty-six patients. We were already short one, then one call out and one psychiatrist working in the interventional suite. I had a team of three residents and two medical students, and myself, so we all just buckled down and started seeing patients.

It was kind of wild in general on the unit that day. We had a run of manic/psychotic patients who were loud, up generally all day and night, refusing medication, and one out of all of them who was particularly rude and verbally aggressive in their unmedicated state.

The other part of the culture on that unit was there was a very anti-nurse practitioner view by patients. They always wanted to see the doctor. But that day they didn’t have a choice because there were no Attending physicians to be had. It was nice always having a resident with me because I could at least say there was a doctor with me, but I ultimately was the one making decisions. So, there were a lot of irrational unmedicated patients. Some were angry about being involuntarily hospitalized and they really had no time for me because they wanted to see the Doctor.

I was in the middle of a particularly trying interview with a patient who was becoming verbally threatening around not being discharged when I saw a nurse run out of a patient room. He looked frazzled. On impulse I got up and went out of the interview room mid-sentence and stopped the nurse who told me a patient was seizing.

I was now in charge of a medical emergency. We called for transport to the emergency department. I started an IV and we gave Lorazepam (an anti-seizure medication). The patient was large, and it was hard, and we were doing this all in a psychiatric room which is not at all equipped or set up for medical emergencies. I was literally holding the oxygen mask on the patient after just pushing in the IV Lorazepam when some one tapped on my shoulder. “What?” I asked with somewhat of an attitude, as I was clearly busy.

“Um, you need to come out to the front.” I heard the voice of a tech.

“Kinda busy here,” I replied irritated.

“Um, the Secret Service is here.”

I sort of stopped and turned my head.

“You’ve got to be fucking kidding me?” I said. But I knew they weren’t. Because at that point I worked there for a few years, and we had been visited by federal marshals, sheriff’s, and the FBI, so really all that was left was the Secret Service. Psychiatry is nuts.

The ambulance stretcher rolled in. Thank God for paramedics. I gladly gave over my patient and walked out the door to go talk to the goddamn Secret Service.

My day didn’t get better from there.

After all of that we still had to write twenty-six notes. We discharged four patients, and admitted four patients. We reviewed labwork, EKG’s, medication doses, changes, etc. etc. etc.

We had to do all the normal shit healthcare providers do on top of rescue a seizing patient and deal with the Secret Service while working with one provider on a unit where there was supposed to be four. We did all this while one of the patients yelled racial and religious slurs at all of us. All day.

It was a Friday.

I vividly remember this day. I remember thinking I don’t get paid enough to keep my brain sharp enough to deal with this shit. I remember thinking NFL players get paid way too much to get their brains turned to shit. I remember feeling thankful I had my colleagues: the nursing staff, the residents, the social workers, everyone was a team. That’s the benefit to working in a hospital setting. I remember feeling burnt out; physically and emotionally exhausted, and also gross because the seizing patient puked and I felt like I had flecks of vomit on me all day. I hope to God I didn’t. But it was a possibility.

I remember mostly though that whole day no one cared or thought to ask about my sexuality. It didn’t matter that I am a lesbian when I threw the IV into that patient’s arm and pushed the anti-seizure medication. The families I met with to review discharge plans for their family members, the patients who screamed and swore at me for not discharging them, and all the staff. No one could have given two shits that I was married to a woman. Because I was competent and I got the job done. I’d like to think I got it done well.

The religious right says the homosexual agenda is to “normalize” homosexuality. Well duh. Because my identity as a lesbian has nothing to do with the ability to perform my job as a nurse practitioner. It has nothing to do with my ability to be a wife or mother or daughter. Being homosexual is normal. For me. I am a normal person who happens to be gay. If that was your relative seizing, and I was the one running the response, would it really matter to you if I am a lesbian or not?

Would you want me to step back and let a straight person who might have less skills as a nurse step in because they are straight? Gotta be honest even if that’s what you want I wouldn’t let it happen. Because my duty as a nurse and a human being would not allow me to let someone potentially die because of some one else’s ignorance. I’d tell you to shut the hell up and get out of my way most likely.

My ability to function and to be a contributing member of society has nothing to do with my sexuality. And this debate over whether people have the right to refuse services to others based on sexual orientation or gender identity infuriates me.

Illness eventually touches everyone. Illness does not discriminate. Remember that every single person will at some point be in a hospital. Think long and hard about whether you want to give your nurse, doctor, tech, surgeon, anesthesiologist, the right to discriminate.

 

 

 

Only when you’re a nurse.

Tonight I had these two tender moments one with each of my sons. One of my sons crawled onto my lap with an afghan in his hands to pull over us, and then he laid chest to chest and put his hands around my face. He smiled and babbled because he still doesn’t talk coherently. I’m sure he was telling me a wonderful story. We had a fire going and it was just lovely. Then later my other son came and stood next to me on the couch, and wrapped his little arm around my neck and just leaned into me to cuddle. These small moments in life are just precious and if we had not been able to conceive I would be missing out. Big time. It made me start to reflect on how we conceived.

IVF sucks. I’ve talked about it here. The egg retrieval requires sedation by an anesthesiologist. My anesthesiologist was an anxious man with broken English. He sort of flitted around me when he was starting the IV (blood spurted out on the floor while he fumbled with the tubing- luckily I’ve started probably hundreds of IVs so I just put my finger over my vein and pushed hard to stop it while he figured out the tubing) and then when I was going off to sleep he told me to count backward from 99. I was extremely nervous and not really paying attention so I started counting forward from 99, he became more agitated and said no backward and literally didn’t give me the drugs until I started counting backward.

As I was coming into consciousness afterward I saw my wife. Eventually I was mostly coherent and the nurse told me what happened when I was waking up. She told me I cried and said over and over “I lost a patient, I lost a patient.” She knew I worked on an inpatient unit and asked if perhaps we had literally just physically misplaced a patient.

I had no recollection of my hysterical emergence from anesthesia. I had indeed lost a patient that week. They died. Not at the hospital and not related to psychiatric issues, but a long time patient we all knew well, and a rather traumatic death.

I remember feeling so floored by the questions from the recovery nurse. I hadn’t thought I was affected by that loss. But apparently that was the first thing on my mind waking up.

About six years ago I was still working in the emergency department and I was there for a code. The child died. I didn’t cry. I thought there was actually something wrong with me. It was the first death I was present for that didn’t cause at least some tears. I remember worrying that I was losing my empathy and compassion. I left for a vacation the next day. We went to New York City for a few nights. I was up around 1 AM reading a book, If I Stay, I got to a scene in the hospital. I remember I started to well up in my eyes. Then I started sobbing. I thought, “Aha, here it is,”. My wife woke up and was like what the hell? I just shook my head as I sobbed trying to tell her it was okay, this was good, this meant I wasn’t a cold hearted asshole who doesn’t cry when a kid dies.

This is the shit. It still happens. Nursing is hard work. Caring and empathy and then we have to come home and care for our own kids and families. It takes so much out of me.

Many people have funny stories about coming out of anesthesia. They hit on the nurse or they think they are on vacation. It loosens our inhibitions and opens us up to emotions. For me it allowed me to be in touch with grief. We take our patient’s losses and gains home with us.

When I went into psychiatry I thought it would be less emotionally draining than the emergency department. It is but in different ways. There are funny times too. People think because I’m a nurse I’m an expert in rashes. I don’t know why. I’m not. But people lift their shirts, drop their pants, and text me pictures asking my opinion about various rashes. I generally tell them to put their clothes on and stop showing me because I treat psychiatric illness not skin.

People tell me about their mom who’s a nurse or their cousin, as if all nurses just naturally know one another. One of our neighbors when we met said, “Always good to have a nurse around”. I thought that was weird. Why? Why is it good to have me around? Just in case some one needs CPR? An emergency rash that I can’t identify? I don’t know. People just feel safer when there’s a nurse around, more secure.

I know I am privy to more information about people than they may share with non-nurses. I don’t take that for granted but it is also exhausting. I refuse to go to the grocery store. Because whenever I go someone stops me and tells me their life story. Some times I just want to run in and grab bananas and run out but inevitably I hear about some one whose spouse just died or who just called DCF on their family member. I don’t solicit these conversations at all. I make no eye contact and I generally try to look completely unapproachable. But it still happens.

What’s fascinating to me is that none of these experiences have anything to do with my sexual orientation. When people are in crisis they don’t care if I’m married to a woman or not. It doesn’t enter their mind to even wonder. I saw clients for a few years before some knew I was married to a woman. It just doesn’t come up because it’s not about me. But I also know I’ve cared for homophobic clients and families over the years. Nothing about my care taking changes when I have homophobic patients. I treat every one the same. But apparently if a homophobic patient of mine has a business they want the right to be able to refuse my own business. This makes no sense to me. It’s okay to allow me to care for you often in the most vulnerable aspects of care taking but you can’t bake me a cake?

I don’t get it. As a human being and as a nurse with a brain and a heart I would never refuse care to some one even if they are the most homophobic person on the planet. Because it just goes against my value system and my duty as a healthcare professional.

But we can’t have it both ways.

I’m not sure what the solution is. However I’m very aware there is a problem.