:: to the teeth ::   thoughts on social justice, medicine, race, hope and beats
"Another world is not only possible, she is on her way.
On a quiet day, I can hear her breathing." :: Arundhati Roy ::
"The most common way people give up their power is by thinking they don't have any." :: Alice Walker ::
Sunday, July 30, 2006
Sustainable Economic Development
about a year ago we fundraised $35,000 from private donations and two small grants to purchase an ultrasound machine for the clinic. we bought a small, portable, sonosite Titan machine, brand new, and started using it during urgent care hours, mostly for early pregnancy dating and miscarriage.
we also started a new business, called Access Ultrasound, run by two wonderful women who coordinate with licensed ultrasound techs and a radiologist to offer high quality abdomenal and pelvic ultrasounds for an affordable price. they charge $100 per study, noone is turned away. the Radiologist is semi-retired and gave us a great deal, $25 per read. the techs earn about as much as they do elsewhere but their gift to the process is extreme flexibility in the face of a slow building process.
currently the ultrasound business takes referrals from about 4-5 clinic, a few midwives and some nurse practitioners, in albuquerque and some very distant towns. word is spreading.
and just this past week the ultrasound business gave out it's first dividend checks to my clinic and to the Kalpulli Izkalli, our partners who run the Traditional Medicine clinic. $350. it was a proud moment for all of us. A first visible step towards sustainable economic independence in a way that supports and promotes people's health instead of preying on their wallets at their moments of vulnerability.
with a health system so out of control, so profit driven, and with some really good, relatively affordable technology available, it's hard work but doable for small groups to set up competitive businesses and make human scale profits that price fairly for the average working-poor person.
posted by andru | 7/30/2006 09:04:00 AM | (0) comments |
Monday, July 24, 2006
FIBROMYALGIA - what the heck is this thing?
last night i worked a shift in the hospital, admitting patients from the ER to the floor. a 55 yo woman came in with concerning symptoms of stroke. right sided facial, arm and leg numbness. her motor exam was normal and a CT of her head was normal, it didn't show any stroke, but CT's can be normal with a stroke so the standard of care is to admit these patients, watch them overnight, get an MRI, an ultrasound of the heart and an ultrasound of the legs to make sure everything is working okay. that's about a $10,000 work up.
i've dealt alot with chronic pain. upon taking a history of the patient, she revealed that she had fibromyaligia, chronic fatigue syndrome, anxiety/panic disorder, depression, hypothyroidism and had a hysterectomy for fibroids, and most recently, her gall bladder removed for gall stones and pancreatities. she had tried a vast number of alternative medicines including acupuncture, herbs and remarkably, was not yet on chronic pain medications. she felt hopeless.
she had had a panic attack, one of her worst, the night her symptoms started and got scared because the numbness on her right side didn't go away.
what the heck is going on? what kind of illness is this? i don't believe she had a stroke. it was more like a peripheral nerve palsy. we got to talking, spent a good hour together. she had great family support, with about five really caring people in the room during the whole time. no easily identifiable stressors but then we got to NUTRITION. BINGO!. the woman is a coke fiend, not cocaine, soda. she eats mostly fried foods, still cooks in lard (manteca) an eats tons of sweets.
you don't learn nutrition in medical school. we are basically taught that food is calories, fairly interchangeable (carbs, fats, protein) and vitamins. we learn that study after study shows minimal benefit or harm with all kinds of combinations and permutations of these different entities. it's a mess from a physicians perspective. hard to advise on anything. even with diabetes, once the person has it we can safely say to avoid carbs but noone really counsels their patients at high risk that sugar might CAUSE diabetes.
i take a stronger stance. from my experience and lots of reading, this woman's chronic pain and fatigue make sense. and the failure of alternative therapies makes sense as well. teh most basic element in life, to sustain it and to promote health, is FOOD and WATER, followed closely by exercise. if someone is malnourished, you can give them all the drugs you want, it won't make them healthy, even if it makes their numbers look better.
this woman is profoundly malnourished. she has fed her cells on a diet of sugar and heavy, saturated fats for 45 years. it's simply the wrong fuel. i owe my education on nutrition not to medical school or residency training but to the many naturopaths, midwives and acupuncturinsts who have taught me how to see past the puree of processed research that compared plastic oranges to vinyl apples and sees no difference in outcomes.
by the end of our time together this woman was prepared to try changing her diet with the energetic and sustained support of her family. break the sugar addiction, remove the heavy fats, add in fiber and vegetables, clean out the liver and intestines (detox) and slowly begin to heal. perhaps i'm wrong, but for sure, that woman had hope, she had a pathway that she could follow, and one that didn't prey on her wallet or force her into a dependency role taking medications for the rest of her painful life.
Fibromyaligia, to me, is a combination of dietary disaster, sedentary life and complex stressors (emotional, financial, familial, work) that are unique to the United States of America at this point in history with our wealth, processed, non-nutritive foods, and car/TV/computer culture. speaking of which, i'm outa here. i need to go stretch and walk. before my chronic back pain gets any worse.
posted by andru | 7/24/2006 11:35:00 AM | (5) comments |
Saturday, July 22, 2006
Clinic Vignettes July 2006
yesterday we saw 23 patients, today (saturday) 15... we are too busy. patients are now waiting up to 2 hours to be seen, some are leaving before being seen. part of me feels bad, i hate for someone to have to wait so long, but at least here the prices are fair and we stay as long as we need to in each visit, ensuring the person is heard and cared for as best we can, once they get to their visit. i would love to see five more clinics like this in Albuquerque, at least. we need a resurgence of independent, local, fair-trade, neighborhood health clinics.
chronic pain - i have about 14 patients on chronic pain medications from narcotics to benzodiazepines for anxiety/panic. Many doctors won't do this because they feel like they are promoting addictive beavior. I have similar concerns and I pay attention to the issue but i'm finding that my patients on chronic meds, with loving encouragement and some alternative medicine tools, are finding their way off of the meds within 3-9 months. i have had to send away two patients over the last year who were manipulating to the point where it felt unhealthy to me to even try to help them, but otherwise, i am really comfortable with the progress my chronic pain patients are making. It is a process of empowerment, phsychology, learning self-care and new behaviors in an environment of non-judgement that seems to be stimulating these transformations. people seem genuinely happy to have someone take their pain seriously at first and then work to help them find simpler, natural ways of dealing with it.
Obesity - overweight and obesity are some of the fasting growing problems in the U.S. population. Why are people overweight? why isn't there a simple cure? one case this week highlighted the reality for me quite clearly. a 35yo woman, obese, with multiple physical complaints. she has been fully studied and all results are normal yet she continues to feel like something is wrong. upon further exam and questioning we determine she has alot of anxiety about her physical health. she has fairly good information about foods. she works in a bakery and loves her job, but only has one day off every two weeks and two small kids at home. she states that when she tries to quit eating sugars and fats, two things happen. 1. she is okay for 1-2 weeks and then she hits a major craving and satisfies it by binging. she is definitely dependent/addicted to sugar. 2. she works in an environment where everyone drinks coffee and eats sweets for breakfast and when she changes her diet she is castigated and punished by her peers who pick on her because of their discomfort.
it's a mess. we did some education work around healthy foods, flax seeds and aloe to help with her constipation and a full exam of her diet to remove all of her milk products. she knows she gets bloating and constipation with milk but thinks that if she isn't "drinking" milk directly it doesn't count, like in ranch dressing, milk in cereal, chocolate milkd and oatmeal, etc...
what i think is really going to help her is addressing her sugar addiction and the peer pressure, along with gentle encouragement to "follow her gut" around dairy use. we spent alot of time together and helped her find some behavior tools and flower therapy to strengthen her resolve against these two forces. sometimes just being conscious of the forces working against you is enough to empower you to overcome them. we'll see. obesity is not a simple problem, there is no simple cure.
had a patient come in towards the end of thursday night. she had continuous vaginal bleeding for 3 months. she did a good job at home waiting to see if the symptoms would resolve but the bleeding was actually getting worse. she is 45yo and of course concerned that it might mean she has cancer. we were able to do a uterine biopsy during the same visit and arrange for a pelvic ultrasound within 1 week to evaluation for fibroids or cancer. I am proud of that. no hassle, fast, affordable service even for fairly complex medical problems. It's happening. We don't need big systems, or misManaged Care to attain quality and efficiency in healthcare. We need networking, collaboration, fair distribution of resources, affordable tools and medications, accessible hours for patients, safe places for people to come with their worries and fears, a focus on reducing pain with medical procedures... patient-centered care. not system-centered care. not lawyer-centered care. not research-centered care.
35 yo man came in six weeks ago and was diagnosed with diabetes. this was new information for him. at the time, he seemed interested, so we did a complete dietary counseling session, started him on one medicine (metformin), and got some labs to see how bad his diabetes was. his hemoglobin A1C came back at 18. for those who don't know, below 6 is normal. 18 is the highest i've ever seen in my life. the patient came back to the clinic two days ago. he had truly changed his diet, cut out all sodas, started on flax seeds, nopal (cactus) and regular oatmeal (without milk). he was doing a great job recording his sugars and his average was already down to 130 which is just about the most remarkable improvement i've ever seen in six weeks. we ordered another A1C test for a week and i'm very excited to see what it comes back as. this is as close to a cure of diabetes as i've ever seen so far. and you could feel the man's pride during the visit, he was so happy with his success. it certainly helped that i was seriously so floored that i kept saying "WOW." he's hispanic, very into futbol, so at one point i looked right at him and said, "GOOOOOOAAAAAAAL." he loved that. :>
posted by andru | 7/22/2006 01:36:00 PM | (0) comments |
Friday, July 21, 2006
Medication Prescribing Errors
Institute of Medicine Issues Report on Medication Errors
The other day in the clinic a patient came in and told me he was recently in the ER with severe hypotension. He had a rough time, they poked him relentlessly to try to find a vein, wound up putting in a central line first in the artery by accident and then finally in the vein and after all that they wound up not needing to use the venous access since his blood pressure was resolving nicely with IV fluids from the initial IV started by the ambulance crew.
He is a patient i was seeing for chronic pain and chronic high level opiate use (pills). I was trying to help him detox off the narcotic medications and I had used a routine medication, Clonidine, (a blood pressure medicine). It is usually started at a fairly high level for people detoxing off opiates and then weaned down as their symptoms of withdrawal ease. He had started it two days prior to his emergency.
Turns out that he had high blood pressure, was already on three blood pressure medications, but i didn't review his medications before starting the new drug. It was in the chart right in front of me. A dumb and potentially dangerous oversight on my part.
I recognized my mistake while he was telling me the story of his ER visit and started to apologize. It is part of my practice philosophy to own my mistakes and apologize, and even to refund money if the person feels harmed by an error. While i was attempting to apologize, he was very kind, and refused to accept my apology. He acknowledged that the error was mine but didn't feel angry. Somehow in the matrix of life, he actually felt even more strongly about getting off the narcotics and was prepared for another round (without the Clonidine) after resting for a month.
While he refused to accept my apology, out of kindness to me, I know he heard it, I could see him relaxing a bit as I acknowledge my error. he felt validated for his fairly rough experience in the ER and the bill he will now have to deal with. Contrary to the fear promoted by insurance companies and professional physician organizations, honest apology works as a powerful form of malpractice protection. most people are reasonable until they feel betrayed or abandoned by their physicians and then they get upset and use whatever tools are available to them to "get even."
This seemed a fairly timely incident to discuss given the most recent report by the Institute of Medicine citing medication errors as a huge cause of morbidity and mortality. You can bet that I read it carefully and will now be more vigilent with my prescriptions. I find their recommendations to be fair and accurate and even useful. see below.
Institute of Medicine Issues Report on Medication Errors
More than 1.5 million patients are estimated to be injured each year
by medication errors, a committee of the Institute of Medicine
The committee's report, "Preventing Medication Errors," was written
at the behest of the Centers for Medicare and Medicaid Services,
which intended to estimate the incidence of drug errors and identify
the best preventive strategies against them.
Among the report's recommendations that directly affect physicians:
-- All prescriptions should be written electronically by 2010.
-- Providers should improve communication with patients about how to
take drugs safely and about potential risks.
-- All medication mistakes should be disclosed to patients.
-- Doctors should use electronic decision-support tools to write
-- Physicians should regularly review all medications with patients
and other providers involved in a patient's care, particularly when a
posted by andru | 7/21/2006 12:43:00 PM | (0) comments |
Yes, I'd like a 7-layer burrito, oh wait hold up lemme check my PDA
Yesterday evening i spent some time trying to update the programs on my Sony Clie NX80 PDA to better assist me in the hospital. I was checking out some freeware and came across the taco bell calorie counter!
Now I can switch up my order at the drive thru window after reflecting on how many calories my 7 layer burrito contains. Or, I can show a patient how his 2600 calorie taco bell diet is hindering him from losing weight. Oh, the uses of this application!
posted by Anjali Taneja | 7/21/2006 07:05:00 AM | (0) comments |
Saturday, July 15, 2006
Delivering another message around OB...
We've been caring for pregnant women at the office who fall thru the chasms in the system and have no affordable place to go. Most recently I cared for a woman who got caught in a crossfire between Medicaid and the Public Hospital. She was uninsured, working, earning too much to qualify for Medicaid, too little to pay for private insurance. By the time she registered at the public hospital she was no longer working so they told her to apply for Medicaid again before they would put her on their payment plan. No resolution yet and she's already had her baby...
finances aside, i had the opportunity to follow this patients progress while in the hospital. I have a few thoughts to share. i had worked for 6 months helping this woman face her fears around pain, her underlying depression and fear around becoming a mom, the tensions of her relationship with her husband, her stress and anxiety around the hospital bills. Towards the end of the pregnancy she was particularly ancy about having the baby as soon as possible, ready to get the whole experience over with. we did some counseling and some therapies to help her relax, accept the pace her baby and her body were setting and find some joy and peace in her pregnant condition. and she was shifting, relaxing, enjoying.
when her contractions started, 5 minutes apart, she went in. she was 4cm so they admitted her. She entered the hospital with a smile, ready to birth as naturally as possible. her progress was slow so after a few hours they augmented her labor with pitocin which made it more painful for her. at 7cm they ruptured her membranes in an effort to speed things up. up till that point she was laboring without pain meds but once the membranes were ruptured her pain increased significantly (a well known reality is that the intact bag makes laboring more comfortable, a cusion effect for the mom). after an hour she needed an epidural for the pain, it slowed her progress down, she almost needed a c-section and in the end, the epidural wore off before the baby birthed so she wound up feeling most of the final labor.
her first words to me back in the clinic with a 3 day old baby were - "it was so painful." not, "it was so beautiful, look at my baby, what joy i'm feeling." this is a problem. more easily visible from outside the hospital than inside. the focus on rushing, on controlling every variable, and the ignorance of the subtle and deep personal issues of each case are a bad combination of factors that lead to excess intervention, dehumanized experiences, a focus on pain and suffering instead of enjoyment to achieve what we euphamistically call a "good outcome." the baby didn't die, the the mom had no physical complications, and she didn't sue.
there's no reason why a few different pathways couldn't have been activated successfully. she could have been sent home until her contractions were closer together but we use 4cm as the magic number for admission for everyone. there is no reason why she couldn't have walked and walked and walked inside the hospital until she was in true active labor. there is no reason why they had to rupture her membranes. babies can be born with the membranes intact and removed after birth. in some Native American cultures that is considered a very special, powerful omen for the person's life.
no doubt this patient was anxious, scared and eager to make the process happen faster. in a "karmic" sense, she got exactly what she wanted so this isn't so much a complaint against the system as an expression of frustration. the patient could have chosen to stay home longer, until her contractions were closer together. (i know many women who stay home until they can no longer tolerate it. they show up to deliver their babies fully dilated. it frustrates the heck out of nurses and doctors because they aren't then in control of every aspect of the labor but it means less interventions for the woman, which some prefer.) at the same time, docs and nurses in these big institutions could make sure that the patient is fully informed before each intervention. they never told her they were going to rupture her membranes. it was an ASSUMED decision by the doctor, not chosen by the patient. i remember when i was a resident that i would have been frustrated if someone told me that rupturing the membranes required informed consent, it seems like such a small detail in the BIGGER picture of hospital care, but when the bigger picture is patient comfort, patient-centered care, quality of care, it is front and center.
posted by andru | 7/15/2006 01:06:00 PM | (4) comments |
Monday, July 10, 2006
I'm finally a second year resident in family medicine (yikes!). 2nd year started off with a bang -- I'm on week two of working at a hospital in downtown Los Angeles, doing obstetrics/gynecology. That means I'm triaging women who are possibly in labor early or in labor on time, admitting women to the Labor & Delivery section of the hospital, delivering babies (YAY!), assisting in cesarean-sections, and caring for women for the 1-3 days they're in the hospital after deliveiring their babies. I'm working with both physicians and midwives, which is a great experience. I've got lots of stories from my past week, but yesterday I worked overnight, and my last patient in the early AM hours was a 17 year old girl who came into the hospital to be evaluated because she was having contractions regularly. She was 39 weeks pregnant, so contractions would make sense, she was in active labor and ready to deliver her baby. The only issue? Well, she hadn't told her parents until that morning that she was even pregnant. They were livid, but calmed down appropriately in time. But what? She lives with them, and they didn't notice that she had gained weight or looked different. And in the process of not telling anybody, she never got any prenatal care. A social work consult was in the works, and I hope everything ended up going well in her delivery, which happened after my 28 hour shift.
During this month, i'm improving my baby delivering skills but also observing how the senior residents and attending physicians and midwives "coach" laboring women and gain great rapport with them as they're going through some of the most intense pains any of us may ever feel. Humor during this process really helps, and as we're crouched in front of a woman's vagina, coaching her to push as if she's having a bowel movement (to push the baby out of the vagina), the first bit of the baby we obviously see is his/her hair. So some of the more recent hair comments by the physicians:
"Oh my goodness, your baby has hair! We're off to a good start"
"Hmm...mommy your baby has black hair, no highlights"
"No way, your baby has a mohawk!"
or "No way, your baby has dreds!"
So moving on from the hospital to the folks who make it run -- nurses. Right now a battle is being waged against them by Bush's National Labor Relations Board:
In a series of pending cases known as Kentucky River, the Bush board could strip what remains of federal labor law protections from hundreds of thousands-perhaps millions-of workers whose jobs include even minor, incidental or occasional supervisory duties. The pending cases involve charge nurses in a hospital and a nursing home and lead workers in a manufacturing plant, but these workers could be just the tip of the iceberg.(from Lawless Workplaces by Stewart Acuff and Sheldon Friedman of AFL-CIO
And more from AFL-CIO:
Have you ever shown a co-worker how to perform a task, or been asked to look over someone else's work? If so, your freedom to form a union and bargain collectively is in danger. The Bush-packed National Labor Relations Board (NLRB) is considering three cases that could alter the definition of supervisor—and that could mean hundreds of thousands of nurses, building trades workers, newspaper and television employees and others could be prohibited from forming unions...You can send a quick letter to your congresspeople here.
And from the California Nurses Association:
The National Labor Relations Board will soon issue a major ruling that could jeopardize the ability of RNs to receive the protections afforded by CNA/NNOC representation. At the request of healthcare employers and anti-union consultants, the Board is expected to make the absurd ruling that many thousands of RNs are "supervisors" under the law because they make clinical patient care assignments to other staff. Under federal labor law, supervisors have no protection. THEY HAVE NO RIGHT TO UNION REPRESENTATION.This coming Tuesday, CNA is organizing rallies in Los Angeles and Oakland. More info here.
Art and Labor
On a very related note, I'm hoping to check out the "At Work: the Art of California Labor" exhibit at Pico Gallery, Downtown Los Angeles, sometime in the coming month. Details below and more information here, comment below or email me if you're interested in joining me or if you've already checked it out! Looks good...
The story of labor - which comprises passionate struggles and triumphs as well as dehumanizing forces - has figured largely in the art of our time. At Work: The Art of California Labor exhibition opened at the Pico House Gallery at El Pueblo de Los Angeles Historical Monument on June 13, 2006. It is the first exhibition to explore this important topic through the eyes of artists who witnessed or were inspired by some of the most significant trends and events in the history of the 20th Century...
And lastly -- Manual Labor
Ending on an upbeat note (pun intended), join me for some manual labor, aka dancing, each of the next 3 thursdays, at the Root Down party at the Little Temple in the silverlake area of Los Angeles. I've got each of the next 3 fridays off and I'm working each of the next weekends, so it's party time each thursday night, and this party/movement is where it's at.
(cross-posted at Los Anjalis)
posted by Anjali Taneja | 7/10/2006 01:22:00 AM | (0) comments |
Saturday, July 08, 2006
Gall Bladder Emergency;
about a month ago a woman entered the clinic jaundiced and feverish. no abdominal pain, no vomiting. her vital signs were normal so we felt safe to order some lab tests and figure out what was going on. we did the usual liver and hepatitis tests. the results were very concerning for gall bladder disease. the patient was still relatively asymptomatic so we continued with an outpatient workup, ordered an ultrasound and results showed a markedly diseased gall bladder with a dilated common bile duct (indicating a stone stuck in the duct system). Even though she was still relatively asymptomatic, the reality of her labs and ultrasound demanded an immediate surgical consult.
at this point my stomach always lurches a bit because the usual reality is anything but pretty for uninsured patients, especially undocumented immigrants.
i called the publid hospital, and for those who have read my posts before, guess what the response was.
WE'd LOVE TO HELP, SOUNDS LIKE SHE NEEDS SURGERY BUT WE HAVE NO BEDS.
Okay. Texas is a big rich state, perhaps i will start sending my patients there... Another idea that crossed my mind was to buy her a ticket to Canada. Years ago i had a roommate who was doing a musical tour in Canada. He was in a car wreck, not too bad, but was brought to an ER and evaluated with x-ray and CT scans. On the way out the door he tried to pay and the doctor said, "don't sweat it, we have national health insurance here, it's basically paid for, there is no bill for you."
check out this irony. another roommate at the time was Canadian. she was here in the USA as a student. she got sick, abdominal pain, and wound up in the ER at our local public hospital. everyone assured her there would be no cost to her, she was savvy enough to ask before being seen. after a few weeks the bills started arriving and she had to pay $800 for the visit. guess how mucha round trip ticket to Canada is. under $800. she could have flown home, gotten free healthcare in Canada and taken two weeks of vacation and come out about even.
okay, so it might be difficult to put a very sick undocumented immigrant on a plane to Canada. i assume it breaks alot of governmental laws, even though it honors human rights and the laws of ecnomics and free trade, but that's another story.
so lately i've been offering the option to my patients to go to other hospitals in albuquerque, names Presbyterian, which is the only other non-profit hospital in town. they have been known to disocunt bills significantly for working poor uninsured patients.
i called the surgeon at Pres and was treated a rare medical miracle. The surgeon was amazing on the phone. respectful, thoughtful, supportive and eager to see the patient. Most times docs ask the insurance status of the patient. She didn't. when i offered to her the social and financial issues, she shrugged her shoulders and said to send the patient right over.
the hospitalization turned out to be fairly complex with a 9 hour surgery. while the patient didn't look sick by her symptoms, she was actually on death's doorstep. this surgeon saved the patients life. i have already written a letter of gratitude to the surgeon because i was so touched by her compassion and perspective and desire to help someone who needed help.
while the patient is also super appreciative, and has already started to pay her bill, the total came to about $50,000. gulp. out of the frying pan, into debtors prison. perhaps Canada wouldn't be such a bad place after all for this patient and her entire family... Pres is a non profit and offers some discounts so my volunteers are helping her fill out the paper work. we'll keep you posted.
posted by andru | 7/08/2006 04:24:00 PM | (0) comments |
Wednesday, July 05, 2006
first off - welcome SRI! thank you for that deep and insightful sharing of wounds, history, medicine, internship and healing. i am humbled and touched by your words and i look forward to more of your writings.
the other day in my clinic there were four people waiting to be seen. we see people first come - first served, but there are occasions when medical necessity dictates a change in order.
a young woman was in the clinic waiting to be seen. she was missing a leg from an accident years prior. i had talked with her on the phone earlier in the day and let her know that when she arrived i would skip her ahead of the rest of the patients because of her particular problem.
when i called this young woman back out of order, an older hispanic woman scowled at me. she wasn't fuming mad but she was clearly irked that i was skipping over her daughter who was waiting with her to be seen. they had been there for almost an hour already.
it took about 15 minutes for the visit. afterwards the older woman came in with her daughter, they were next, and the first thing shedid was offer an apology. she thanked me for seeing the other woman first, recognizing that it was a clinic, not a bank or a restaurant, and sometimes others have deeper needs. i let her know that the reason i saw the patient first was that she had arrived by bus and it had taken her 2 hours to get to the clinic, plus she had the ride back, all with a handicap that made it just that much more complicated.
it was an interesting exchange and i was glad for it. i had broken the order out of compassion for a patient with a disability and a long bus ride and my other patient came around after a few moments to share that compassion with me.
posted by andru | 7/05/2006 03:40:00 PM | (0) comments |