FRCEM (Primary) – Done and dusted!

So I am happy to report that the results of the recent FRCEM (primary) exam were announced this evening – and I am proud (read ecstatic!) to share that I passed it! *takes a bow* (if you are interested in questions from the exam, read about that in a separate post here)

This is why I have been slightly out of the blogging scene for the past few weeks – prepping for the exam, juggling the ARCP for my first year of training and what has been very likely the hardest and longest and hottest summer stretch I have ever endured (and I am from Pakistan!) But I am back with the proverbial bang!

And I bring with it the novelty of experience.

It’s not a difficult exam per se – but it is an exam that requires commitment, and time and energy. Be ready to make that commitment. It’s a new exam, only started in Autumn 2016 I believe.

Back in the good old days when I was a (very) junior doctor back home in Pakistan, I had the luxury of having ‘many’ weeks off in lieu of exam prep – the job itself was intense but i had no other commitments; i.e training, portfolio, assessments, ARCP, etc. For this exam, I was working in your regular, run-of-the-mill A&E department in the UK, as a 1st year trainee. I decided to take the exam, decision was taken in January, I booked an online question database then, and I booked the exam in mid February, but I didn’t really get a good momentum going initially, and was still in 2 minds. Why? Because of the ARCP which is an assessment of all your competencies for a required year of training that you have managed to accumulate over the period of the past year, and a panel of judges basically sits and decides whether your performance (based on these signed competencies) is good enough to warrant your progression to the next stage/year of training. So this year was to be my first ever ARCP and coincidentally the exam fell on the exact same date as the ARCP, so in addition to the preparation of the exam, I had to focus on my assessments/requirements for ARCP – all to be juggled along side a full time job in the A&E as one of the juniors. It is doable folks.

So in bits and bobs I started my prep. I had that textbook of emergency medicine, but I must admit I never got beyond the first 5-7 pages of it! Doing the questions from the question bank is what helped me pass along with (as I said) youtube videos. I took a 4 month subscription for the FRCEM exam prep website – previously known as MCEM exam prep website. (‘tom-aye-to, tom-aah-to’). They have a good database of questions fortunately of the SBAQ type as well as the older true/false format. I have ready in many places that you could use any of the other websites/question banks as well.

On my days off, I aimed to do 50-100 question (see, I made you laugh there!) Who am I kidding, I barely got 30 done on a good day – these questions came with explanations, why this option is right, and why the others are wrong, along with a short description of the topic that the question deals with. I inevitably began making a habit of taking pictures of the explanations in my cellphone, and I went back to them again and again, for example before going to bed, or while waiting for my wife/son to wake up in the morning on my rare days off. I found this habit helpful, as you may not retain some of the information that you read, but if you go back and go through it again, or atleast if not all of it, then maybe just the major salient points, it is bound to stick to you.

On my days where I was working, I tried doing a few questions while at work, on my phone, between patient. That was a bad idea. Not only did I not have enough time to do even a single question justice – I also did not retain too much due to the lack of concentration in a busy A&E department. Ditched that idea fast. I did however vow not to waste any of the days I was working though, so after a busy shift, I used to come back, rest, recuperate or sleep (mostly slept) thanks to my wife who really upped her support game and banished me to a separate room in the house at all hours of day or night, waking or asleep – no diaper duty, no bath time no sleep time with the baby – just the books, fooding and my laptop. Where was I? Yes – days I was working, depending on what shift I had done, I still tried to get a good solid 3 plus hours of ‘mcqsing’ as I called it. On days that I was on morning shifts, I came home by 5 pm, straight to bed, slept for an hour and a half or 2 – woke up – tea/food/family time for an hour or 2 and then hitting the books (or laptop in this case) from 10 pm onwards up until 2-3 am – then 5+ hours of sleep and a repeat of this. Or on the afternoon shifts (2pm/4pm to 10 pm or midnight) similarly I used to come back home, freshen up, spend a minuscule amount of time with the family before they dropped off to sleep and then ‘mcqsed’ till the wee hours of morning, going to bed at 5 am or thereabouts, to wake up just in time for lunch and off to work. Night shifts were a bit more difficult, and I sort of gave up on trying to cram anything in my head during the 4-5 night stretch we have – the hangover like state I was in during the night shift stint was not really amenable for any further insult to the brain by forcing it to swallow any other bits of information/mcqs.

I also youtubed a lot of videos – specially anatomy ones, and one or two for physiology and microbiology. There are a lot of good ones out there. I focussed on upper and lower limb anatomy the most, along with the plexuses. You can just search for them under ‘anatomy, mcem or mrcem’.

My strategy towards the middle/end of my prep was to focus mostly on the maximum yield subjects – broadly anatomy and physiology which carried the most weightage in the actual exam, with 60 questions from each subject (out of a total of 180 questions!) Followed by significant input from microbiology/pharmacology/pathology. I used to do 3 sets of 20 questions in a row – the first set being anatomy, second physiology and the 3rd annoys the others, but I kept the first two sets the same, due to its weightage. Anatomy threw me, as it was basically learning a new something I had learnt almost 13-14 years back in the early medical school years! I think it was safe to say I had forgotten most of it, despite having a refresher course during my stint at the USMLE exams. But I digress. I found the following topics high yield, and got an inkling from my various forays into the question banks that these were important enough to be tested and warranted more attention (or repetitive attention) from my end.

ANATOMY

– Upper limb (muscles -attachments and function, nerves, bones, blood vessels) -Lower limb (Same as above) – brachial plexus – abdominal wall layers – blood supply of the heart – borders of the heart – contents of spermatic cord/inguinal canal – Sacral plexus – Optic nerve lesions – cranial nerve basics – triangles of the neck – foramina of the skull and their contents – diaphragmatic openings – Facial nerve – spinal cord lesions based on presentation – stuff going on at T4 level – brain blood supply

PHYSIOLOGY

Lung volumes – cardiac cycle – hormones (renin, angiotensin, mineralocorticoid, cortisol, adrenal medulla, pancreas, PTH, calcitonin, Vit D and its metabolytes) – renal physiology – 

MISCELANEOUS 

Vaccination program – Drugs that induce/inhibit cytochrome p450 – broad microbiology – allergic/hypersensitivity reaction types – types/examples of vaccines – immunoglobulin types – 

I also attended a course arranged very kindly by our deanery for candidates interested in the FRCEM primary. It was purported to be a tough exam, as the previous attempt had had a passing percentage of 43 percent. Yes, only 43 % of the candidates who appeared for the previous attempt passed. We gulped down our fears, and while the course gave us a broad idea of what wee needed to be doing (which was a lot!) it served no greater purpose than to tell us that we were not alone in being scared and that everyone seemed to be equally stumped by their performance in the questions – slightly reassured by the fact that during practise mcq sessions, when the consultants tried to solve the questions they were mostly unable to. Slightly reassuring, and mostly horrifying, as how were we supposed to pass the exam?! Yikes. What threw most people was that the exam format had been changed – from the previous true or false format, to the  Single Best Answer Question or SBAQ format. All options in a given question may be correct in different ways, but select the answer which is most appropriate according to the stem. Which basically translates to “guess what the examiner was thinking when he/she made this question” – so no pressure!

By the last few weeks, I was about to pull my hair out – the amount of mcps I was doing wasn’t too much, and I didn’t seem to be ding all that well if you calculated the number of questions I was getting right – overall a 52-55 percent of correct answers. Abysmal. I did not let that disappoint me, however, knowing full well that practicing questions was the way to go in such an exam format.

I used up all of my 2 weeks of annual leave and 3 out of 5 days of study leave for this exam, which brought me to just about 20 days of uninterrupted preparation (coupled with MANY visits to the department for ARCP related issues). That I feel was the single best thing in way of preparation – the time off was focussed, and I wasn’t tired from running around – preparation is mentally exhausting as it is, coupled with the physical exhaustion of day-to-day ED life – it takes a toll. All I did was sleep, eat and study. Lather, rinse, repeat.

But I will reiterate here what I have said before as well – you can never do enough questions as practise – just keep doing as much as you can, every waking minute make sure you are doing questions. Whether its 5 or 50 questions, make sure you stay consistent and do not get laid-back and forget to do questions – keep doing them, whether right or wrong, as long as you are also focusing on the explanations of those questions, its a learning experience.

Advice about the exam itself: Time management – 180 questions, 3 hours. The way I did it was divided it into 3 parts, so I needed to have completed 60 questions in 1 hour, and preferably even faster than that, since I needed to allow some time at the end to go back and tackle the more difficult or confusing questions. Keep track of time as well – if you seem to initially be on track, keep checking the clock every 10-15 minutes and make sure you are on track. If you feel you need to think more than 20 seconds for an answer and are still unable to do so, then mark the question and move on, return to it later. Do not waste minutes on a single question, causing a delay and jeapardising multiple other questions. Read the stem carefully – often we do not read the ‘except’ ‘all’ which’ ‘most appropriate’ next step’ gold standard’ ‘not included’ bits of the stem and inadvertently end up selecting the wrong option. In case of long stems, read the last bit/question and the skim over the rest of the stem, to gauge what they are looking for. If you don’t know the answer, go through the options by the process of elimination. Eliminate the blatantly wrong options. Think about the rest, if possible eliminate another 1 or 2 till you are left with one. If you read the stem and know the answer, look for that in the options, if you see it, select that. Always attempt all questions, no use leaving a question blank and lose an opportunity of a lucky guess. Feel free to draw, make flowcharts, write things down in the margins of the question paper if it helps you remember, calculate, reach a conclusion (I remember I drew the whole optic nerve/tract/radiation diagram to help me diagnose where a lesion was based on the hemianopia referred to in the question paper!) The questions may be easier than your practise question bank – don’t worry!

And I had the support of good friends. I don’t know, there is something about prepping for an exam (or anything in life for that matter!) and knowing that there is someone else going through the exact same thing as I am – it creates an interestingly unique bond. I had 2 such colleagues and friends, and I am pleased (and incredibly proud) that they have passed as well. We used to work together in the same ED department back home in Pakistan, and are now in different parts of the UK pursuing careers in emergency medicine. Onwards and upwards!

The world is indeed your oyster – always work to improve!

Always set goals for yourself, it is never too late to improve yourself, or hone a skill. Add to your already accumulated skill set, or improve pre-existing ones. There is always room for improvement. Always another star you can aim for.

If you find yourself saturated (or the environment around you saturated, and you can’t get a foothold) move to greener pastures – if you are the best at something in one place, chances are there will be something new to learn in a different place, even if you do the same thing.

Get another degree (something which I am trying to do), study a new culture, learn a new language (something I am currently working on!) get a new hobby (like photography? cooking? Blogging!) Move to another town, another city, another country – see how another part of the world does it’s business. Read a new book – finish it and pick up another one, go through a personal list, then go through someone else’s list – make new friends, meet new people. Make a mistake. Learn from it, move on. Do not be afraid to make a mistake. Share your knowledge (yes, you have it!) Pick someone up from where they have fallen. Help them if you can. Surprise yourself with how good it feels, and how easy it is to make someone happy (or just less sad).

Be the best you can be, and then strive for even better than that.

Always improve. Always be open to change. Always be open to suggestion to make yourself better. Always be humble enough to know that there is always room for that little bit of change, however hard you try to fight it – you will end up being a new ‘you’, very likely for the better. You are your own best investment. Do right by yourself.

An interesting lump, courtesy of Warfarin – a dilemma in clinical management

59 Year old female came in to ED due to a painful lump that she had noticed overnight in the right side of her abdomen, associated with pain in the right half of her abdomen, back and upper part of her hip. This was the vague and slightly confusing history on the card as I went to review her. She was a very pleasant lady, who walked into the cubicle without assistance, no support required – and clearly no hip pain?

She reported she had had a cough x 6 weeks – not continuous, but had had a chest infection initially, and was still recovering from that about 3 weeks back when she began to have productive cough and fevers again – and had to complete a second lot of antibiotics, the last of which finished yesterday. She still had bouts of cough though, even though it had improved considerably – one of which had happened last night just as she was going to bed. She couldn’t sleep all night due to the continuous coughing, but this wasn’t the reason why she was here that morning. She woke up in the morning feeling quite sore in her upper abdomen, and put that down to her constant coughing. She tried to ignore it, and took some paracetamol, but as she tried to dress herself, she felt that she required help with undressing and dressing, which was a concern. To top it off, she also noticed in the shower that morning that she had a palpable tender lump under her ribs, in the upper part of her abdomen on the right side. This concerned her enough to come to the hospital. Oh, and she was on warfarin – that lovely blood thinning medication that’s given for clots in the lungs or in the legs, or if you have a heart rhythm disturbance that makes you prone to throw clots to your brain – for recurrent PEs (clots on the lung) and her last INR was 2.6 (a test to see if the warfarin is doing what it is supposed to be doing, and whether it was doing more or less than it was supposed to be doing – recommended range for her condition was between 2.5-3.5)

When I examined her there appeared to be no bruising to the area in question, and her abdomen was soft, though there was definitely a palpable tender firm swelling in the right upper quadrant, sort of jutting out of the lateral aspect of her liver – my thoughts immediately went to a spontaneous hepatoma/bleed into her liver because of her being on the warfarin – I quickly ticked off in my mind a checklist of things that would signify severe ongoing bleeding internally, like pulse and blood pressure (both within normal ranges for her) and she appeared nice and ‘hemoglobin-y’ – adequately perfused! I decided to request a quick ECG (which was normal sinus rhythm) and did some baseline bloods on her including a clotting screen (to check her haemoglobin and INR today – both were normal, though a slightly raised white cell count and CRP) as well as a chest x-ray (I felt there were two reasons for this: 1) cough for 6 weeks gradually worsening, warranted radiographic evidence and 2) in someone presenting with tenderness of right upper quadrant, it is very relevant to be thinking about problems with the lower part of the lung above, rather than just focussing on the abdominal complaint – she may well have a pneumonia sitting in her right lung base, causing pain in her right upper quadrant! In this case, however there was nothing nasty on the chest x-ray on the right, though you could argue the left lung base looked slightly more hazy than I would have liked; at any rate, she needed treatment for an LRTI)

I spoke to my consultant, who quickly magicked an ultrasound machine within the ED and did what is called a ‘FAST’ scan, an ultrasound to quickly rule out free fluid within the abdominal cavity, usually done for patients of abdominal trauma to look for bleeding, etc. The scan was negative for free fluid within the abdominal cavity (we both breathed sighs of relief!), however we did find what seemed to be a collection of blood within the abdominal wall in the area of pain – she seemed to have bled into her abdominal wall, probably due to the coughing, which caused a tear within the muscle wall, and due to her being on the warfarin, caused her to bleed internally but contained within the wall of the abdomen – causing her presentation of a tender painful lump in her abdomen. Mystery solved. Now to the management of said mystery.

The dilemma we faced was this: We couldn’t stop her Warfarin due to the indication for which she was taking it in the first place – it could prove fatal if she had a clot on the lungs again. We couldn’t just leave her bleeding on the warfarin and do nothing. We needed to treat her cough as well, because even if it wasn’t life-threatening at this point, if she went on coughing, who knew how much worse this bleeding might get? And we had limited treatment options for her cough-slash-chest-infection, because many drugs including some antibiotics interfere with the action of warfarin, and the patient was allergic to penicillin (of course, we wouldn’t want this to be too easy!)

So we requested a formal ultrasound from the radiology department – much more detailed than our very ‘FAST’ scan. They agreed with our preliminary findings, with the very valuable additional information that there seemed to be no evidence of ongoing bleeding – the hematoma was contained and was not likely to worsen. Her INR was within the limits appropriate for her, maybe slightly on the higher side, so we decided to advise her to skip the next dose of her warfarin, and to liaise with the anticoagulant monitoring service to monitor her INR in the next few days to make sure it was still within the prescribed limits for her. We sent a sample of her sputum for culture and sensitivity, and based on the haziness in the left lung base and the raised inflammatory markers (CRP and white cells) we decided to start her on some antibiotics – she was allergic to penicillin, and so the next best option was clarithromycin which unfortunately interacted with warfarin so we couldn’t go down that route; we decided on doxycycline being the best line of treatment for her. We explained to her any of the red flag signs, if she experienced any concerning symptoms, to come straight back for review. We advised some analgesia, and some cough medication as well, and the patient was very happy to go home. Fingers crossed, she has neither returned nor have I heard of any problems coming to light following her ED visit.

This served as a learning experience for me – coming to a diagnosis in this case when the presentation was completely different from what was actually going on, and then connecting all the dots in the history (warfarin, chronic cough) and the physical examination (presence of a tender palpable lump in the absence of trauma) and ultimately finding out the mystery of the sudden lump, and then reaching a management plan that should have been so easy and straightforward, but really wasn’t due to the patient’s unique situation.

Firecracker

So I was in Minors, and the next card I pick up is of a 68 year old male and I read the triage nurse’s notes and…I can not understand what she means by “linulated banger wart af n left hand, wounds to thumb and index finger”. So something happened in a different language that resulted in wounds to the thumb and forefinger of this gentleman. He did something to a banger? Did she mean a badger? This should be interesting. Could she have written it in a more confusing manner? Doubtful.

I called his name and he walked into the cubicle, with a blood-stained (soaked?) dressings wrapped around his left hand. I introduced myself and admitted downright that I had no idea what had happened to him, so could he tell me in his own words? He told me he was a farmer, and essentially to scare away birds and small animals, they light up this firecracker type thing at the end of a long rope, and with the help of the rope swing it up into the sky and it lands far away into the field, and explodes with a loud bang (hence called a banger!), acts as a sort of loud scarecrow, if you will. And what had happened today? “Well I have been doing this for years: I never use the rope, I just take it and light it in my hands and then lob it off into the distance. And I just have been very lucky these past 45 years!” So he basically miscalculated the timing this time, and it exploded in his hand before he could lob it. It now dawned on me what the triage nurse’s writing meant. lighted banger went off in left hand, wounds to thumb and index finger.

So anyway, I exposed his wound after donning some gloves. As I began to unravel the dressings my nose detected the heavy smell of burnt gunpowder/spent explosive caps in those toy pistols we used to play with as children. His thumb had born the most of it, with the nail literally split down the middle, the edges flaring up and out; the soft tissue of the pulp of the thumb was shredded, and all I could think of was how I was meant to stitch the nail back together, with no rest-of-the-thumb left to hold the sutures together.

His sensations were still remarkably intact, and the wound was oozing, but not profusely bleeding. He had a similar but smaller, less extensive wound on the index finger of the same hand, and a few other small spots that had singed or burned. He had full range of motion, surprisingly, of all interphalyngeal joints; nevertheless I realised I needed to get an x-ray done to rule out any bony injury, before progressing to the matter of how to fix this.

x-rays were requested, and they showed as expected a comminuted (read shattered) fracture of the distal phalynx of the thumb (an open comminuted fracture, since the skin/flesh was denuded over the fracture segment) and a simple fracture of the distal phalanx of the index finger as well.

Orhthopedics! My job was done! I bleeped the orthopaedics registrar (with half of my brain telling me it might get shoved on to plastics) but he very kindly agreed to come down to review the patient, and that was that. I decided to go take a break after this. But he had other plans in mind for me. He requested I do a ring block around the base of both the injured digits, so the finger and thumb would become anaesthetised and he could give it a good clean. A ring block is essentially local anaesthetic injected into the base of the finger or thumb in question, on either side, which numbs the nerves supplying the finger and you achieve localised sensation loss (temporarily) used mostly for nail bed injuries or nail-related procedures. I injected his thumb, not a problem, two jabs and all was amazing. I then moved on to the index finger, first jab was alright (3rd in total, including those of the thumb) but the second (or 4th?) as I was injecting it he said oh I feel a bit hot, and i feel a bit sweaty and I feel like I maybe am about to pass out and…oh here I go. And off he went. *kerplunk* fainted right in the chair. We quickly moved him onto a trolley, he came round quickly, very embarrassed. I re-assured him, even though I had just almost shit my pants thinking please be ok please be ok. My external facade was calm and cool, you gave us quite a fright sir, but you’re alright, don’t worry about it, these things happen  while on the inside I could feel my teeth clenched so hard I thought the muscle in my temple would pop out. The orthopedic reg was still stood in a corner, and he looked like he had shit his pants. I reminded him to come forward and continue. We administered the rest of the local anaesthetic, and the ortho reg happily cleaned the wound of any debris that may have collected in the wound(s), washed it with copious amounts of saline. He then cleaned the wound and dried it and applied an impressive dressing to the hand (the thumb and index finger were deemed best to heal this way). The rest of the plan of management involved IV antibiotics stat (he opted for gentamycin and flucloxacillin), and oral antibiotics to go home with (co-amoxiclav x 7 days), and we all remembered the tetanus toxoid, which was administered, and the patient went on his way. He was to return to orthopaedics fracture clinic the following week.

Take-home message: 1) Lie patients down when injecting them with things. However macho or well-adjusted to the pain or the trauma the patient might seem, you would be surprised at what a needle and the sensation of local anaesthetic being injected into any part of your body can do for your consciousness. *kerplunk*
2) never use ‘bangers’ or any explosives in your own hands, you may think you have it covered, but a firecracker in your hands might just be a case of having too much on your hands.
3) never question a triage nurse’s writing. or any nurse’s for that matter. Karma will hit you back with such a vengeance you won’t ever forget it.

Pearls of Wisdom – what I have learnt, the hard way

  • NEVER request a chest x-ray JUST to rule out rib fractures. It won’t change your management, unless the patient is short of breath or there are concerns for a pneumothorax, then request a chest x-ray to rule out PNEUMOTHORAX – but I repeat, NEVER for a rib fracture. If you put those words in the request form, that may well be the one (and only) time a radiologist will leave their dark dungeons and come out into the light, TO HUNT YOU DOWN AND KILL YOU.
  • ALWAYS have a chaperone present, or atleast offer the patient one, in cases of intimate examinations (PR, breast, pelvic and/or genitalia). Document – name of chaperone, or when the patient declines having a chaperone present, make sure to state that in the notes clearly. A chaperone is for your protection, and not for the patient’s only.
  • NEVER request x-rays for (suspected) broken toes. If it looks and sounds and feels like it is fractured, it probably is.  Before you x-ray it (which you should never do!) you will neighbour strap the affected toe to the next toe, sort of to act as a splint and reduce the pain. THAT is the management for a fractured toe. If you request an x-ray (once again, something you should never do!) you will find that it is indeed fractured, and then proceed to tell the patient that yes, it is indeed fractured but I have already buddy-taped (another name for neighbour strapping) your toe and the x-ray doesn’t really change my management. I will now run away because the radiologist is probably going to kill me now.
  • Always reduce an ankle fracture BEFORE x-raying. If it’s clinically requiring it, you won’t change the management by wasting time with x-rays; you don’t want the patient to lose their blood supply or stretch out their nerve to point of no return while they’re waiting in the x-ray department, do you?
  • NEVER discharge someone from the department on behalf of someone who has given advice over the telephone. They need to physically see the patient and make a judgement. You can ask for advice, but active management issues, and discharge from hospital on someone’s advice, doesn’t stick in a court of law. If they didn’t come down and document they saw the patient and THEN recommended this and that, then IT DID NOT HAPPEN. They will backtrack faster that a patient on furosemide will need a wee. Well, probably faster than that!
  • ANYONE presenting with abdominal pain, or loin pain, or back pain, above the age of 40-45, PLEASE CONSIDER AAA. It is never a good idea to miss anything, but it is a scary-ass thing to miss a AAA when you have been sitting on it for 3 hours.
  • LISTEN to your gut feeling.
  • Ask for advice BEFORE sending the patient home. No shame in asking for an opinion or running it by someone more experienced. But no forgiving the thing you missed that your ego didn’t allow you to question or ask someone for advice.
  • ALWAYS x-ray pelvis in elderly patients presenting with a fall, I have seen patients walking in to the department with a slight limp, found to have impacted femoral neck fractures. Specially patients with dementia or learning difficulties or any sort of cognitive impairment.
  • Be that extra bit more thorough in patient with cognitive impairment of any sort, delirium etc, they are the ones with hidden signs/symptoms that they sometimes can not express in usual ways of communication. Not every patient who is in pain will tell you (or will be able to tell you) that they are in pain. They may be agitated, or fidgety, or moaning, or distressed, or literally crying out every 2 seconds “Help me!” yet when you ask them what they require help with, they wouldn’t be able to tell you. Pay extra heed to them and be very, VERY vary of what you may miss in these cases.
  • Whenever doing bloods/putting a cannula in, always make sure you have a trolley near by or at least a comfortable chair in a private cubicle – patients have a tendency to faint/go vasovagal on you at the touch of the needle, you don’t want them to be flailing around while you have a cannula/needle in them.

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    WATCH THIS SPACE FOR FURTHER LOVELY NUGGETS OF INFORMATION THAT I HAVE GLEANED IN THE PAST. AND I HAVE LEARNT THE HARD WAY. DO NOT MAKE THE SAME MISTAKES I DID.