Wednesday, November 5, 2008
I find dealing with medical aid's extremely frustrating.
Before I could be admitted for confinement I had to obtain a pre-authorization number from my medical aid scheme. The first time I called (which was about a month before my due date) I was told to call back in two weeks because the authorization was only valid for two weeks. I was also told that because it was for confinement, I could call at any time if I went into labour because obviously I could theoretically go into labour at any time and they would then immediately give me authorization. When I called back two weeks later I was told to rather call back on the day I went into labour because that would ensure the number wouldn't expire. Fair enough I thought.
So on the morning that I started having contractions I called the medical aid for my authorization number. The call centre lady asked if my due date was still the same. "Yes" I answered, "but I'm having contractions now so that's why I'm calling for the number now". "Have you seen your doctor yet?" she asked. "No" I replied. There was a short silence, then she gave me the number. At the time I had so many other things on my mind that I didn't really have time to get annoyed.
So I went to the labour ward that evening (21 October) as I've mentioned and gave birth the next morning.
This morning I received an account from the anaesthetist and a note asking me to submit the account to my medical aid scheme. I thought this was strange as accounts are usually submitted by a doctor's secretary so I phoned the medical aid to find out if they had in fact received the account. I was told that the claim had been rejected as their records show I was admitted on the 22nd and how could the doctor operate on me on the 21st if I wasn't even there? I was completely taken aback by the pedantry. Obviously there had been a mix up with the dates somewhere, but they were using this as an excuse not to pay out. I felt my spirits sink because I knew this meant I was in for a fight and I hate fighting.
"I was admitted to the labour ward on the evening of the 21st" I said "and delivered the baby on the morning of the 22nd. And he didn't operate me, he gave me an epidural". "What time were you admitted to labour ward?" she asked. "In the evening around 5" I replied. I didn't see the relevence of the time, but anyway. "Well that's not what our records show" she said, "we'll need a motivation from the doctor". Damn, I thought. I know how much doctor's hate writing motivations. I could tell I wasn't going to get anywhere with this woman so I said goodbye and decided to call the hospital.
Dealing with the hospital was pain free. I stated my problem and was immediately put through to the right person who told me that their records showed I was admitted on the 21st but that the medical aid had probably not received their account yet. She gave me her name and number and said I was welcome to ask the medical aid to phone her directly.
I then decided to phone the anaesthetist's rooms and speak to his accounts lady to cover my bases. This was a mistake. When I told her what was going on she started moaning like a banshee. As I was listening to her tirade, I considered cutting her off and being short with her. After all, it wasn't my fault, why did I have to listen to her whining like I was her boyfriend? You don't shoot the messenger! But I decided to just let her go on because I was too tired to fight - I regretted this afterwards though. When she came up for breath after about 2 minutes of ranting, I told her I'd try to sort it out and get back to her. She then started ranting about the medical aid again before she finally said goodbye.
I phoned the aid scheme again and told them that the hospital's claim did show I was admitted on the 21st. I was told that the authorization was for the 22nd. You have got to be kidding me, I thought. After all the run around I got from them about the authorization? This just pissed off. I was put through to another department.
Once again I stated my case to the next person I spoke to. She put me on hold to check something and when she came back she told me that the project manager wasn't in so she took my number and told me... she'd call me back.
Saturday, November 1, 2008
Due to unforseen circumstances, I ended up having my baby in Cape Town. This meant I had to find a new gynaecologist/obstetrician. My cousin suggested her gynae and I went with him.
I started having contractions last Tuesday morning. As I've mentioned before, my first labour went very quickly, so I was anxious about waiting too long before going to the hospital. When my contractions started getting reasonably strong I decided that maybe it was time to go in. My partner suggested I rather call the gynae first. So I did and he suggested I go to his rooms and he'll check me out. When I got there, I was having fairly strong contractions. However, my cervix was still closed, but because my first labour had progressed so quickly and I was already having strong contractions, the gynae wanted me to go in to hospital. Both my partner and I were uncertain about this but we decided to go through.
We went home first (my parents' home) to pick up our son and my mother to go along to the hospital. When we got to the labour ward, the nurses remarked on how the gynae had been phoning constantly to see where I was. Not a good sign.
The midwife set me up in the labour ward and gave me an enema as per the doctor's instructions. Unpleasant. Anyway, she then told me she would call the anaesthetist to get me an epidural. I said I felt it could wait (I wanted to know how far I had progressed first because I didn't want to have the epidural too early) but she told me the gynae had said that the anaesthetist was very busy and that if I didn't get it then I might end up not getting it at all. My contractions were starting to get quite painful and I didn't want to end up not getting an epidural. Also, I knew they could top it up if started to wear off, so I agreed to go ahead with it. The anaesthetist who was first on call was indeed too busy so the second on call came in. He also apparently had alot lined up that night so in the end I was happy I'd gone for it then.
The epidural was much more painful than my first one had been and I reacted quite badly to it. At a stage the anaesthetist even dropped my bed and drew up some adrenaline. I recovered with only fluid resus though. I felt terrible though and at a stage I even wondered what was worse: the pain or the effects of the epidural? (The epidural started to wear off later though and I came to the conclusion that the pain is definately worse!)
Then my gynae came to see me. He remarked to the anaesthetist that he was exhausted. I knew this didn't bode well. He did a PV. I was only 1cm dilated. He seemed unhappy. It was already about 8 in the evening by now. He decided to rupture membranes to speed things along. He came back to check on me about an hour later. 1 and a half centimetres. I knew he would soon try to sell me a caesar. He started talking about how I should have progressed much further by now and started throwing around phrases like "big baby" and "malposition of the head". Then it came: he said that we could either wait and see or we could just call it quits and go for the caesar then. We told him we'd wait.
He decided to go home and asked the midwife to check my progress in about another hour. My partner and I discussed the situation. I felt he should only check on me in another 4 hrs seeing how I was still in passive labour. We both knew there wouldn't be much change in an hour. We knew he would try to coerce us into taking the caesar.
After about an hour, the midwife came to check on me. No change. She called the gynae. She came back with the message. He had given it a chance but I was not progressing so he would book theatre for a caesar. I said no. I told the midwife that as far as I was concerned there was no rush. I was still in passive labour and doing fine and the baby was being monitored and she was fine. If anything went wrong, we would know immediately and then we'd agree to a caesar, no question, but right now, there was no need for it and we were happy to wait.
She seemed to agree with me but said she'd give us time to discuss it.
We agreed that there was no reason to have a caesar. My partner decided to call my original gynae (a colleague of his) to cover our bases. He confirmed what we suspected. We turned down the caesar. The midwife relayed this to the gynae and he asked us for a time frame for how long we were willing to wait. It was nearly 11 at night by then. We said we'd wait until 6 in the morning. She came back and said that he'd told her that if nothing had happened by 06h00 he would book theatre. I was still not happy with that and told her that if nothing had happened by then we could discuss it again. She said that would be easy enough to do.
We decided to try and get some sleep. I was unable to rest easy though. At about 02h30 the midwife came to check on me again. She said she thought something was happening. She was right: I was 5cm dilated. Relief washed over me (and my partner when he woke up an hour later. He slept slightly better than I did ;) ).
By about 05h30 I was fully dilated and the midwife called the gynae. At 05h47 I delivered a perfectly healthy little girl. (He made some remark about how the head must have turned at some stage. Yeah right.)
I ended up having an episiotomy and a vacuum extraction as the baby's head remained high, so it wasn't actually an NVD, but at least I escaped having unnecessary major abdominal surgery.
Thursday, October 23, 2008
Monday, October 13, 2008
Maybe it's because the transition from 'lay person' to doctor happens in front of them so they don't view you as a real doctor, but invariably, when they ask you for advice, they don't take you seriously and they don't bother to take it. It's quite frustrating because you think "why did they bother to ask?" but after a while you just get used to it, shrug your shoulders, shake your head and brush it off.
And they tend to be non-compliant. My dad has essential hypertension. He's had it for years. Still, he tends not to take his meds on time and sometimes even skips a few days. Two of my uncles have type II diabetes mellitus yet still continue to eat poor diets, but not only that, all their kids are obese! If I were faced with such a terrible affliction, I'd make damn sure my kids don't get it, but it's like they're making sure their kids do! All advice falls on deaf ears.
Then there are the phone calls saying they have x, y and z signs and symptoms. You ask a few questions to guage the severity, but whenever you think it might be something serious and suggest they go see a doctor in person to be examined, they say they don't think it's necessary. So why did they ask you wonder once again? But it's pointless trying to get them to listen to you.
And whenever you suggest a certain treatment or specialist, you're invariably faced with "but can't I just do this or use that?". "No" you say. They never listen.
A close family friend told me she had a personal problem. "Yes?" I asked and listened. "I have a painful swelling on my vagina", she told me. Knowing her personally, I wasn't keen to examine her, but she gave me enough information for me to make the tentative diagnosis of a Bartholin's abscess. I told her what I suspected the problem was, advised her to see a doctor asap and told her it would have to be cut open. "But can't I just put antiseptic ointment on it?" she asked. "No" I replied. She didn't listen. About 4 days later, in the middle of the night of course, the pain apparently became completely unbearable and her husband had to rush her to casualties. I laughed when I heard this. She was probably seen by some poor casualties officer who wondered why she had waited so long and until the middle of the night. I'd often wondered that myself whilst draining an abscess in the wee hours of the morning, now I seemingly had the answer.
But what can you do? They're family, so when they ask, you have to listen and advise, even if you're smiling to yourself knowing they won't listen anyway and wondering once again why they even ask and why you even bother.
Friday, October 3, 2008
With my first pregnancy I decided that I didn't want to be one of those annoying women (like many a patient I've seen) who comes in claiming to be in labour, turns out to have a cervix that's 1cm dilated, gets told the true signs of labour and to come back when she's got those but shows up again the next day and is then only 2cm dilated.
Maybe it's because I did all my obstetrics in the state, where days are long and beds are few, that I always got annoyed by those women. In private, you probably get admitted if you want to, but in the state, your admission ticket is active labour and nothing less.
So I decided, armed with my knowledge, I was going to do everything right. And I did. But things actually went too well. When I showed up at the labour ward, my cervix was 4cm dilated. I got my epidural and then, even though I was a primigravida, within 1 hour I was fully dilated and ready to deliver.
So this time around, knowing that the second time everything goes much faster, I'm nervous because I know I have to get to hospital asap!
I have great respect for midwives. Most babies can actually be delivered at home by a midwife. A trained midwife though, because although most pregnancies are actually uneventful, when things go wrong, they go very wrong and you want someone who knows what to do and when to get you to a doctor. Having said that, there is no way I'd deliver at home. I know too much and I'm way too paranoid. I want to be in a fully equipped hospital with lots of drugs readily available and a fully trained obstetrician. But I have to get there on time to have that.
I always find it amusing in movies and TV when the expectant couple rushes to hospital at the first sign of labour, tearing up the streets, only just making it there in time before the baby pops out, because real labour is nothing like that, but I've really been worried this pregnancy that that might really happen to me.
Today I had a few mild contractions. I was pretty sure they were Braxton-Hicks, but when they started coming approximately every hour, I started thinking it might be early labour. Then I started wondering if I should go to the hospital. Like I said, I've already decided to make haste this time, but then I started thinking: how early is too early, even with a history of a previous short labour? Also, I wasn't convinced they were real contractions. So I decided to wait and see. I thought I might be taking a gamble, but it turned out ok because after a few hours they stopped.
So in the end it was good I didn't rush off to the hospital because I would have looked like a fool.
But now I'm really left with the predicament of how soon I should act.
Sunday, September 28, 2008
Just as common as corruption around these parts is the desire for a DG or disability grant. It is highly sought after. Scoring a disability grant is almost like scoring a jackpot to alot of patients around here. It's a strange phenomenon. Even better than getting a DG for a serious illness though, is getting one for no good reason at all.
What I am about to say is absolutely true.
A group of staff members at a community clinic were caught trying to abuse the social welfare system. In South Africa, the government grants DG's to HIV patients with CD4 counts less than 200. So what these people did was intercept the blood specimens of HIV positive patients who looked very ill and send the blood away for a CD4 count under their own names. In this way, they had a legitimate record of a very low CD4 count which qualified them for a DG.
Fortunately though, the actual application for a DG has to be filled in by a doctor (usually one who does nothing else but that) and when one of these people approached one, he was suspicious of a very healthy looking person supposedly having such a low CD4 count. In this way, this person and eventually all of them were caught out. They even received disciplinary action. Now that's something that's rare in Africa.
Friday, September 12, 2008
One case that affected me quite badly was that of a young pregnant woman with TB .
When she came in she was already 7 months pregnant and had been on TB treatment for a few months. She was in a bad way. She was wasted and malnourished, had oral candidiasis and was short of breath. She tested HIV negative on rapid test. I didn't believe the results so I sent stat blood to the lab for an Elisa. It also came back negative.
In the meanwhile, she'd had a chest x-ray which should extensive infiltrates and lung damage - she barely had any normal lung left.
I made a tentative diagnosis of multi-drug resistant TB.
The baby was also not doing so well. There was very little amniotic fluid and although there was a heartbeat on ultrasound, there were no foetal movements.
The patient also complained of abdominal cramps and on abdominal exam she did seem to be having some mild contractions. On vaginal exam her cervix was very posterior and very difficult to assess.
I sent her to the state hospital with a diagnosis of probable multi-drug resistant TB, oligohydramnious and possible early labour.
She was reluctant to be admitted but her mother seemed to understand the gravity of the situation and talked her into it.
Next day, on enquiring after her at the state hospital, it seemed there was no record of her being in either the gynae or obstetric wards (the baby was viable, but the state hospital did not have adequate staff or resources so whether the baby was considered viable by them probably depended on whether they had a neonatal ICU bed. Nevertheless, she was apparently in neither ward.)
I remember thinking that she might have absconded, considering how reluctant she had been to be admitted. More likely though was that she was in fact in the ward but the hospital staff were just too lazy to look and claimed they had no patient by that name (very, very common in South Africa. In fact, if you enquire after a patient, it's the exception rather than the rule that anybody bothers to make any effort to help you).
About two months later, I saw her mother again on an unrelated issue. She told me that her daughter had been admitted to the hospital. She said that the baby had died in utero and that her daughter had then died a few days later.
I was devastated.
She had essentially died from a curable disease.
What had happened up to the point that she'd presented to me was uncertain. Whether the system had failed her, or she had been non-compliant, I don't know, but from the time that I saw her, it was already too late it seems.
Friday, September 5, 2008
(Unfortunately, even with the latter type, patients who have been away from their families often only return to their families when it is too late and sometimes even refuse treatment even when the family members -usually their mothers - do everything they can - even forcing them to go to hospital etc.)
One day I saw a very elderly woman who tested HIV positive. She was about 75 years old and demented. She also had a previous stroke (found on examination, not history), was blind from cataracts, and was in
adult nappies (diapers) with a severe nappy (diaper) rash.
I couldn't help wondering why, with all these co-morbidities, she had been brought in to test for HIV. I was even more surprised that she had tested positive.
The only thing that could really be attributed to the HIV was that she also had a severe peripheral neuropathy. The dementia may also have been attributed to the HIV but AIDS Dementia is really a diagnosis of exclusion and I thought it was probably due to something else in her case considering her condition. According to her family member though, she had been quite functional before and had rapidly deteriorated in the last month or so. I felt that she was in a dismal condition, but in view of this, decided to do a work up.
The family member who accompanied this woman was her 20-something year old grandson. He had been taking care of her for a while. This was an exceptional case so I didn't expect him to fall into either family category frankly. In fact, I felt quite sorry for him: I thought his sick grandmother was probably quite a burden for this young man but that he had been caring for her out of duty and now needed some reprive.
I got the social worker involved. My plan was to admit her to hospice, treat her other problems symptomatically and do a work up for the dementia. Thereafter I planned to place her in a long term palliative care facility. I decided that if the dementia was due to AIDS Dementia Complex, I would start her on ARV's, otherwise I didn't think it would be practical or beneficial.
I asked the social worker to explain the situation to the grandson and then arrange placement. The grandson however was not happy with this plan. He did not want his grandmother to be placed in a palliative care home, he wanted to take care of her himself!
I was amazed. Here was a young, single male telling me he wanted to care for his sick elderly moribund grandmother.
As it turns out, this woman had only one child - a daughter. Her daughter in turn had 3 children. The youngest of these was the young man now accompanying his grandmother. His mother (the patient's daughter) and 2 siblings (the patient's other 2 grandchildren) had all passed away (I didn't ask what of but in our setting it's likely it was also due to HIV). This sick elderly woman was therefore the only family he had left.
I was so touched I nearly cried.
I had such sympathy for this young man, but more than that I was deeply impressed by his devotion to his grandmother.
It seems there really are selfless people out there willing to do whatever they can for the people they love.
Tuesday, July 29, 2008
Usually African news is deeply depressing but I read a few things over the past week that really made me laugh.
Firstly, our mayor's house got burgled, but that's not the funny part, what's funny is that when he went to the police station to report it, he had to wait an hour and a half before he was seen to. He hadn't declared that he was the mayor (but shouldn't the police know who their mayor is anyway???) and I respect him for not wanting special treatment, but in true African style, no-one could be bothered to help him. Eventually he could take it no more, so he told them who was and he was seen to immediately. We're always complaining about how pathetic our police service is but at least now we know they treat everyone equally badly.
The next thing I found amusing was a report on an abandoned house somewhere in Nelspruit. The residents were complaining that it was attracting criminal elements etc. and wanted the municipality to do something about it (which they rightfully should but most probably won't). One resident in particular was complaining that the house still had running water so homeless people were coming there to cook and even bathe! (those damn dirty homeless people taking baths!)
But the most hilarious news by far is that the Zimbabwean reserve bank has now issued a $100 billion note! Ohmigosh, I can't breathe! ONE HUNDRED BILLION DOLLARS! Can you imagine having a one hundred billion dollar note? Manohman, I have got to get my hands on one of those! And I think $100 billion (Zim) is equal to about R5. How can mad Bob seriously still say there's no crisis in Zim when their reserve bank has got to issue $100 billion notes because of their ridiculously high inflation rate?
Wednesday, June 25, 2008
Before I tell this story, let me just express my intense hatred of all Microsoft programmes. I hate my Microsoft. It is unpredictable and unreliable. I hate it hate it hate it hate it hate it. That off my chest, lets begin...
I recently saw a patient with a serious medical condition and another, even more serious, underlying medical condition.
The patient was started on treatment for the one condition but treatment of the other condition was delayed.
The patient then returned. He had applied for temporary disability leave form his employers and had brought
I asked him if he understood what this form meant and he seemed to have no idea, so I told him that it meant that I could tell his employers about all his medical problems, including the very serious medical condition that he had, and give them copies of all his blood results, etc. He said that he only wanted me to tell his employers about the less serious illness. Again I explained to him that he had signed this form and that it was a legal document giving me permission to disclose all his medical information. He said that he did not want his employers to know about the underlying condition.
This obviously left me in a bit of a predicament. I now had to decide whether I should fill in the forms in their entirety as the employers requested on their forms, in view of the signed consent, or whether to only disclose information about the one condition.
I wasn't sure what the legal implications were - whether I was legally obligated to disclose, all things (including a signed consent form) considered. I reasoned though that consent is fluid and that a patient is allowed to withdraw their consent at any time. I also felt that my ethical obligation to the patient outweighed any other present obligations.
So I filled in the forms, only disclosing information about the one condition and indicated that the patient had asked me not to disclose any other information. There was also a "declaration" section which I had to sign which stated that all information I supplied was true and correct. I had no problem with that, but it also stated that I had not withheld any information. I drew a line through that section and signed it.
Afterwards I felt uneasy about the whole situation and sought legal advice from the medico-legal society of which I am a member. I was advised that I had done the right thing and that I was legally in the clear. I was relieved but felt that I had always been morally in the clear.
Tuesday, June 17, 2008
Anyway, so I’ve been impregnated again by the said caboodle-hole.
Pregnancy really changes your perspective on things. For one, paranoia.
Now I’m paranoid on a good day - I’ve always had mild OCD which I manage to keep reasonably under control in my every day life and doesn’t affect my work too much - but being pregnant elevates my paranoia to a whole new level.
Working with HIV patients on a daily basis, there’s always that fear in the back of your mind that you’ve picked it up somehow. It didn’t help that at a recent conference I attended we were given statistics of doctors
who have seroconverted after exposure to HIV infected blood – some supposedly through blood splashes on the skin. Freakin blood splashes on the skin! Now, I’ve had blood splashes on my skin – who amongst us hasn’t – so that made me worry to no end. Then I thought to myself that I should have myself tested again (my last HIV test having been as an intern after a blood splash. The patient turned out to be negative though, thank God! And so did I) but like most doctors I am terrified of having HIV and even of having an HIV test. It’s ridiculous I know. I’ve discussed it with other doctors before and even though we keep telling patients to “know your status”, the truth is, we're terrified of being tested ourselves in case it’s positive. Anyway, so I reasoned to myself that if I was positive, I’d better find out now since I’m pregnant and it would be irresponsible if I did have it and passed it on to my baby. So I got tested ... and it was negative! WHAT - A - RELIEF!!! Even caboodle-hole was relieved because it basically meant he didn't have it either (and his risk is even bigger than mine. He even went and pricked himself recently.)
Then my assistant got diagnosed with TB (by me FYI) and I started worrying that I had that. I worry about TB everyday anyway but now I felt like it was really possible that I had it. Nevermind the small fact that I was asymptomatic.
I’ve since seen to two people with suspected MDR TB and every day at least one undiagnosed TB patient comes into my room coughing their freakin lungs out. Great. So I’m spending the majority of each day breathing in TB bacilli infested air.
Then, to add to my paranoia, I’ve been having sacro-iliac pain. Now, I know that it’s because of the pregnancy, but at a recent talk, this HIV medicine guru presented a case study about a guy who had chronic sacro-iliac pain which turned out to be caused by a retro-peritoneal TB abscess. I know that I don’t have a retro-peritoneal TB abscess, but I just can’t stop thinking about it.
on a long holiday, but mostly because when I got back, someone very
close to me went on a blog radio talk show and failed to mention my
blog when asked a question that was directly relevant to it. This made
me question my writing ability and I lost confidence and motivation.
What his actual reasons were I will never know, but I've since decided
that he was just being a caboodle-hole. So now I'm back...
Wednesday, March 19, 2008
Sunday, March 9, 2008
Monday, February 25, 2008
It was fairly hot and since their pool has recently taken on the appearance of a small swamp (frogs and all), the kids asked grandpa to hose them down with the 'tuinslang'. Grandpa was only too happy to oblige! My 20 month old son saw this and thought it looked like great fun! He snatched the hose pipe from grandpa and proceeded to chase and spray anyone within range. My boyfriend happened to be in the firing line (watering line?) and got squirted. He later told me that as our son was squirting him, he was shouting " 'skies papa!" (sorry daddy!).
Thursday, February 21, 2008
I ended up having to ask my patient's family to take her to the hospital in the back of their bakkie (pick up truck).
Monday, February 18, 2008
Thursday, January 31, 2008
SAMA speaks out on
None, Immediate Release
The South African Medical Association expresses its grave concern about the closure of emergency services at hospitals in the
Reports have been received that Bethal, Standerton, Secunda and
Of great concern is that patient care is compromised when interns who have to work under the supervision of a medical officer in a hospital, are now expected to work without such supervision. This problem has emerged as a result of the two-year internship programme which was introduced in 2006, as opposed to the previous one-year internship programme. It has therefore created a gap in the provision of Community Service doctors who normally fill posts of medical officers in peripheral hospitals when they complete their internship.
The Provincial Department states that they do not currently have the budget to finance additional overtime for doctors, and that funds will be made available when the new financial year starts on
In 2007 the South African Medical Association made suggestions to the Department on the envisaged shortage of medical officers for 2008. They were very receptive to the suggestions and advised different provinces to implement them to avert a crisis. However, some provinces such as
SAMA urges the Mpumalanga Department of Health to engage urgently with medical officers in the affected hospitals to ensure continuity of patient care, as well as considering the utilisation of additional capacity from doctors in the private sector who are prepared to assist in containing this crisis. We would like to urgently meet with the Mpumalanga Department of Health regarding these issues.
Issued by the SAMA Corporate Communications Department to the South African media on
Corporate Communications Manager - SAMA
Wednesday, January 16, 2008
"The patient fell and the finger knows it's painful". Does he?!
"Virginal itching" (spelt eaching). If it's itching down there it's probably not virginal.
"Sport in the body". Isn't that a good thing?
"Sport under the feet". Dito
"Sore leg and week". I've also had a sore week dude.
"Lazy body". Yep, I have that too.
"Little beat eating". What?
"Headache side by side". With what?
"Anus liking pus". Bwahahahahahahaha!
"Buttocks rash". Okay, there isn't really anything wrong with that, it just sounds funny.
And here are some strange names I've seen (maybe South Africans will appreciate these more):
Pleaseman (yes, it's a real name)