Amalia Hussa
2013
Halb, Kingdom of Saudi Arabia
Dim but radiant. The operating room lights spotlighted the patient as the surrounding room remained faint. The singular OR light was a white star surrounded by an empty void of space. Amalia Hussa, age 38, was part of the surgical team in Operating Theatre 13. It was the Surgical ICU of the King Faisal Medical Centre.
The patient lay on his back on the OR table, with his upper body elevated and head turned to allow Dr. Bethmann surgical access. With scalpel in hand, the neurosurgeon cut along the patient's shaved head, making his first incision on the right side of the forehead.
Amalia walked to Dr. Bethmann's side and helped him lift off the skin. She held the forehead skin open, and he made another cut against the exposed, dark-red flesh. Blood began to seep from the exposed tissue. Amalia and Dr. Bethmann peeled more of the skin, along with the incised muscle underneath, folding both back to expose the skull bone. The pale skull was blood-stained, and the sight was not for the faint of hearted.
61-year-old male. Mamoon al-Moustafa. Type A negative blood. Brain tumor towards the front of the brain requiring a craniotomy. Operable, thank God. Dr. Bethmann and the surgical team were here to remove the tumor and save the man's life. Amalia had met Mamoon's kind family before surgery, before beginning to feel the rush of excitement. And being here now, she felt honored to be a part of it.
Amalia looked up at the hanging IV bag, its fluid translucent through the OR light that shined. This was nourishment for the anesthetized patient. Their water, their purifier. Medicine itself was the fountain of youth. That those who drank from it regained life. She thought, because where would this man be without today's science? He would not survive in any previous time in history. Amalia watched as the IV dripped, with its pool rippling circular waves.
Dr. Bethmann ordered, "Cranial drill."
The surgical technologist, responsible for handling surgical instruments, placed a cranial drill on a sterile tray between them -- called the neutral zone.
The surgical tech announced, "Cranial drill down."
The surgeon retrieved the drill and aimed it against Mamoon's exposed skull. He stopped. And pressed the drill's trigger as it howled -- its drill bit turning rapidly in accordance to the pressure-sensitive trigger. Dr. Bethmann slowly pushed the drill to meet against the skull – as it maimed the bone. But the drill was shaking along the surgeon's grasp.
The drill was not burrowing in a straight line. This broke a hot sweat on the back of Amalia's neck. Thank God Dr. Hadad was supervising. He stood on the edge of the area surrounding the surgical patient – the operating field. Dr. Bethmann was the new resident surgeon, and this first surgery of his was being supervised by a senior physician. Dr. Hadad stepped forward but stopped once Dr. Bethmann completed the burr hole in the patient's skull.
The surgeon lifted his finger off the handle and pointed the drill away from the surgical site. He aimed the drill again against the patient's skull and pressed the trigger. Drilling the second burr hole.
Dr. Bethmann finished. But did not move. What was he waiting for?
Dr. Hadad ordered the surgical tech, "Craniotome wire saw."
The surgical tech did not move and was waiting by the neutral zone. He extended his gloved hand, "I need the drill back, Doctor."
Amalia exchanged glances with Dr. Hadad as Dr. Bethmann reached to hand the drill back.
But the surgical tech kept his hands away, "No, in the neutral zone, Doctor --"
The drill went off, jolting Dr. Bethmann, as he dropped the drill on the sterile tray. The heavy instrument bashed against metal, sounding a dush and clang.
The surgical tech quickly took the drill, set it aside, and placed a fine wire saw in the neutral zone, "Wire saw down."
The surgeon retrieved the tight wire and held one end along the patient's forehead -- he made a slow back-and-forth motion as he pushed it inside the first burr hole. Some time had passed as Dr. Bethmann struggled to get the wire out through the second burr hole.
Amalia and Dr. Hadad looked at each other once more, and as he stepped forward --
Dr. Bethmann spoke, "I got it. I got it."
His technique is shit. He shouldn't even be here.
Everyone in the OR was dressed in personal protective equipment, PPE, including a scrub cap, surgical gown, latex gloves, shoe covers, and a surgical mask. They were colored azure blue, standard issue in the hospital. Amalia was the only woman in the OR, and she had long, dark-brown hair with slight curls. Her brown eyes glistened in the light.
Dr. Bethmann used the saw to cut an outline of a bone flap. Amalia retrieved forceps and used them to lift open the perforated bone. The surgeon pulled on the wire saw's handles -- slowly pulling out a portion of the patient's skull.
Amalia tightened her grip on the forceps hard. There was a crunch, and the portion cracked away from the rest of the skull. She turned to drop the flap in a sterile bowl. The hard bone fragment clinked as it danced inside the metal bowl.
The patient's dura, a slick, tissue membrane that covered the brain, had been exposed. Dr. Bethmann placed the craniotome saw back in the neutral zone. The surgical tech took it off and waited.
Dr. Hadad ordered, "Suture scissors."
The surgical tech retrieved them and placed suture scissors in the neutral zone, "Suture scissors down."
Dr. Bethmann grabbed the scissors and angled it towards the dura -- stopped -- and changed his angle. He held the scissors there for a moment, only to reposition it once more.
Amalia stepped forward, "Here, angle it this way."
She slowly adjusted his elbow, allowing the surgeon to cut along the dura in a u-shape -- so that it would fold back towards the patient's face. Dr. Bethmann began cutting until he exposed the patient's brain. And there it was. Neurons, glial cells, neural stem cells, blood vessels. All that medically composed of a person's consciousness.
You only ever experience time and space within your own physical body. That you could never live the billions of lives that have ever existed. Each unique with their own past, ancestry, personalities, and futures. That yours would be so unique, not even 7 billion souls will live one exactly like it. And here you are, at this moment, with your brain exposed hoping that you can live the longest life possible. One that has been entirely of your own.
These were ethereal moments. Amalia loved the mystery of one's consciousness because it made her wonder, if the brain's electrical impulses dictated one's existence in the form of consciousness -- was one's soul a part of that? Or does consciousness only exist within these impulses?
She looked away from the surgical site and at the patient lying on the OR table. Was his being only explained by bodily function? Or was there an eternal soul which transcended the physical body even after death? Trillions and trillions of stars in the universe. Trillions and trillions of neurons operating in just one person's brain. All to make up who they are, the love they feel, the heartache that hurts them.
It was a work of art. God's work of art.
*
The surgery was ultimately successful. Amalia had changed out of her PPE and was in her navy-blue scrubs. She was on her way to the nurses' station of the Surgical ICU floor. The wood walls were a luxurious brown, its surfaces coated with a glossy finish -- spotlighted by the cool white ceiling lights. Amalia was stepping over spotless white flooring, and the entire hospital was accented with exotic florals. Pink tulips and surrounding sunrays of dark green spiked flowers. And in almost every corner were tan leather chairs.
Dr. Bethmann was the new neurosurgeon from Germany. He was handsome, with shiny black, side-parted hair and a charming, white smile. It seemed the whole nurses' station was in love with him. But Amalia did not buy his act. Even the surgical team meeting beforehand had been short, and Dr. Bethmann skimmed major details. The dullest knives are the most dangerous.
Amalia figured Dr. Bethmann would be gone soon, and she would not have to see him in again in the OR.
***
At the nurses' station, Amalia pressed the side button of her phone to check the time. Her wallpaper was a 1969 Mustang Mach 1 in racecar red. The Mustang was her dad's car. She always asked him if she could have it when she was a kid, but even until today, she was not allowed to drive it as a woman. Her dad still gave her the car for graduating from nursing school, but only her husband could legally drive it.
Occasionally, she and her husband would take the car to an empty parking lot at night, and he would teach her to drive it. Manual shift and all. But if they were ever caught, the consequence could range from a mere warning to jail time or even a lashing.
It was Friday the 13th, and the American expat workers were superstitious that this was always the day more patients came in than any other. More injuries, freak accidents. Amalia was anticipating her 3rd surgery with Dr. Bethmann, set to start within the hour. Their second surgery days ago had gone well. Maybe he just had a bad first day. If it's your first neurosurgery, who wouldn't be? We're only human, right? Amalia just wanted to believe that he deserved to be here. Perhaps he is still here because he is actually a good doctor.
*
Back in the OR, everyone was positioned within the operating field, which was as far away from doors and human traffic as possible. No senior physician supervised Dr. Bethmann this time. The hospital council must have had their faiths restored after just one simple surgery. But hospitals, after all, are a business. And having your own surgeons supervised shouted incompetence.
Dr. Bethmann ordered, "No. 15 scalpel."
The surgical tech did not move. He looked at the doctor, "No. 15 may be too broad for these narrow cuts, you want a --"
"Don't you think I know what scalpel to use? Don't question me during surgery. Give me what I ask for."
The surgical tech retrieved a No. 15 scalpel and placed it in the neutral zone, "Scalpel down."
The patient lay face-down on the OR table with sterile drapes covering his whole back except for the surgical site. They were operating on the lower back, performing a spinal fusion. Qasim Rabbani. Age 51. He developed a spine deformity that grew more severe over the past year, which was very painful and disabling to his daily life. If Dr. Bethmann was who Amalia wanted to believe he was, Mr. Rabbani could live problem-free.
Dr. Bethmann operated, though taking more time than he should, to expose the patient's spine. Amalia could see through his wound crevasse and gazed into his neural network wrapped around his spine. And what an experience it is to realize you are these thin, pink neural tendons wrapped around bone, wrapped around by flesh, and encased in this sack of meat and skin.
How much different would we live our lives if our appearances truly represented our nervous system? If we were but brains, eyeballs, and neural spaghetti positioned upright in body form and freely exposed. That the faces and bodies we so cherish only distract from the organ which truly represents us. And is our face truly our face?
To realize we are but souls having a human experience.
This was not a sprint, it was a marathon. But Dr. Bethmann had trouble every step of the way. Amalia stood opposite the surgeon, using forceps to keep the patient's kidneys out of his way within the surgical site. Dr. Bethmann's hands kept nudging blood vessels. And so did the tip of his scalpel.
And as Dr. Bethmann held the blade inside the patient's exposed spine -- the scalpel nicked the segmental medullary artery.
Mr. Rabbani flexed his glutes. Amalia heard lumbar vertebrae crack like knuckles as they repositioned themselves. His nerves spilled out like thin pasta. Amalia's eyes widened at the horrific site – holy fucking shit.
The stat monitor alarmed as the wounded artery bled massively -- spraying along Amalia's PPE as she pulled away from the patient.
Dr. Bethmann ordered, "Get me RF-seven!"
The surgeon spent the next half-hour filling the bleeding area with rFVII coagulants. Amalia figured that Dr. Bethmann believed this was the best option to stop the bleeding. But coagulants were a Band-Aid to the problem. The rFVII would only create blood clots to help stop the bleeding but not repair the arterial damage. It was only a short-term solution.
"You have to re-operate, Doctor." Amalia turned to the surgical tech, "Get him a catheter, suture needle, two needle holders, and ligating suture --" she turned back to Dr. Bethmann, "Doctor, you have to suture him up now!"
"Do you need to go back to nursing school? I am the surgeon. Your country's laws enforce that. I am qualified, and you're not... I lead this team and my orders are final. Now get me a coagulation test on his blood."
Amalia stepped back. You're no surgeon.
She turned away from the operating field as he shouted behind her, "Nurse!"
Amalia ran out of the operating theatre. Her gloves were stained with blood, but she kept her hands up, and elbows tucked to her sides. Where's the nearest neurosurgeon? This patient needed to be stitched up -- and fast. Amalia ran down the hallway and towards the nurses' station, where she found Dr. Yassin.
"Dr. Yassin!"
He turned, and his eyes widened at the sight of bloodied gloves.
"You have to come right now!"
Dr. Yassin ran with her down the hallway, "What's going on?"
"Spinal fusion," Amalia had to slow down her breaths, "Dr. Bethmann nicked the segmental medullary artery. He's packing the patient with RF-sevens. Won't perform anastomosis."
The two ran inside Operating Theatre 13, but Dr. Yassin still needed to be prepped. Dr. Bethmann looked up from the patient's spine.
His eyes darted at the other surgeon, "I have this under control, Doc!"
Amalia snapped back, "No, you don't!"
They had to do this quickly. Several minutes to scrub-in might cost the patient his life. Dr. Yassin and Amalia began washing their hands in the double-scrub sink by the door. The shelf beside it held face shields, masks, scrubs, and sterile OR gloves. Amalia prepared Dr. Yassin's PPE for him as he turned off the sink with his elbow, kept his hands upward, and then dried his hands.
Dr. Yassin put on his PPE and entered the operating field as Amalia replaced her own.
Dr. Bethmann kept his hands in the surgical site, "Doctor, I am in the middle of repairing this operation. I am the one most familiar with this patient, his condition -- so it's best you let me finish."
Amalia re-entered the operating field and looked to the surgical tech and anesthesiologist, "Is he stitching the artery?"
Dr. Bethmann shook his head with a flinch, "That's not necessary nurse, we would all know that if you had performed the coagulation test like I asked."
She watched his eyes staring into the surgical field. Dr. Bethmann was not necessarily smiling behind his mask. But the skin around his eyes wrinkled and his eyes were glistening.
Amalia looked around at the surgical team. Their eyes agreed with her -- Dr. Bethmann did not belong here. The surgical tech and anesthesiologist grabbed Dr. Bethmann's hands, carefully pulling him away from the patient. They pushed him out of the operating field, his shoe covers sliding against the OR floor, as his leg kicked a back stand. Its instruments flung upward and crashed along the OR floor with metal clangs.
The two brought him to the operating theatre's double doors, opened them with one hand, and pushed Dr. Bethmann out with the other. They immediately lunged to close the doors against him — the surgical team had locked their surgeon out. And the anesthesiologist turned off the door's automatic function to manual.
Dr. Bethmann smashed his fist against the door's vertical windows, "That is MY patient! I am the designated surgeon. You all take orders from me!"
All human lives are equal inside and outside the hospital. And they are all entitled to the best possible care available. And in this moment, for Mr. Rabbani, that was not Dr. Bethmann. Amalia turned to see Dr. Yassin's face as he prepared to operate in the surgical site. It is awful.
*
In just the few minutes Amalia had gone, brought Dr. Yassin back, and had him prepped -- the patient's condition had turned for the absolute worst. Dr. Bethmann had not ordered a blood transfusion, and Dr. Yassin had to ligate the artery, which required operating above the initial incision. Amalia held two forceps with both hands but had to wrap an arm around Dr. Yassin – allowing him an unobstructed view of the surgical site.
Amalia's arms were aching, but she had to keep Mr. Rabbani's kidneys out of the way. 30 minutes had passed since they locked Dr. Bethmann out. And Amalia had finally started the blood transfusion through an IV.
Amalia's PPE was a bloodbath. The two were operating atop a pool of blood as the patient continued to bleed through the severed artery. And it would not stop spilling.
Then the stat monitor beeped to a flatline.
Everyone turned their heads. Both Amalia and Dr. Yassin held their hands where they were -- and then surrendered. Amalia took out the forceps, and Dr. Yassin dropped his bloodied tools on the neutral zone tray.
Dr. Yassin had already gotten up, but Amalia could not move. She stood still, staring but not staring at the patient. This was biological death. But where did that man's soul go?
Amalia was paralyzed to know that everything you have ever experienced, and will experience, only existed within the contents of your brain. A brain that feeds, moves, drinks, and fights for its own survival. That all your thoughts, feelings, joy, anger – the electrical synapses that flashed like city lights all switched off as your brain went into neural decay. And became nothing. Was death like flipping off a switch? Was his soul gone and gone forever?
Amalia was in the locker room changing into new scrubs. Somehow, blood had gotten onto her scrubs underneath all the PPE and was about to put them into plastic bags – but stopped. Amalia stood up from the bench and walked over to the trash can, throwing them away.
The intercom sounded, "Dr. Bethmann to surgical nurses' station. Dr. Bethmann to surgical nurses' station."
Patient deaths were inevitable in this job. But not in these surgeries. A person died when they never should have. Dr. Yassin said he would file a report to the hospital council. He was a senior physician, and even he could not believe what he saw.
Amalia left the Surgical ICU's locker room and found Dr. Yassin by the nurses' station. She raised a brow and shrugged her arms, "Have you paged Bethmann?"
Dr. Yassin nodded, "No answer. Mr. Rabbani's family is still in the waiting room… Maybe you should come with me since they don't know me."
Amalia winced at the thought but realized he was right.
They began walking down the hallway as he asked, "What are their names?"
"The wife's name is Sajiya, and the brother is Munir."
The two entered the Surgical ICU waiting room, and Amalia glanced at the mounted TV displaying the floor's surgical updates, Rabbani - Wait for surgeon.
Terrible. What a terrible thing to see. Amalia brought Dr. Yassin over to the patient's family. And she slowly asked Munir, "Has… Dr. Bethmann come to see you?"
Munir and Sajiya raised their eyebrows and looked to one another, then shook their heads. Munir answered, "… No, what's going on? No one can tell us any new updates."
Amalia's shoulders fell, where the fuck is he? He should be here to explain himself.
Dr. Yassin cleared his throat and held his hands in front of him, "I am sorry, but I have some bad news to tell you. Despite our best efforts, Qasim did not survive the surgery."
The wife and brother held onto one another as their eyes broke contact and began to seep tears. Sajiya began to lean back, and Munir helped her sit down. They bowed their heads and wiped their eyes.
Sajiya spoke through tears, "I thought this was a simple operation…"
Munir's brow was raised at Dr. Yassin, "Where is Dr. Bethmann? I thought he was doing the operation?"
Amalia exchanged glances with the doctor, and Dr. Yassin answered, "Unfortunately, there were unforeseen complications that required the knowledge of a senior physician. Which is why I stepped in."
Amalia's eyes burrowed at him. But she stopped herself, the family is here. They needed to grieve, and it was not the time for them to be furious.
Dr. Yassin continued, "As a surgeon, you hope everyone you come across does well, but unfortunately, it does not always happen. But your dear Qasim is with God in heaven. Inshallah, he will rest in peace."
The family repeated, "Inshallah."
God willing.
*
Amalia walked back to the nurses' station on her own. She checked the time on her phone and realized she was only half-way through today's shift. Amalia took a surrendered breath and saw Naseem Hamed approach the station. He was the husband of her best friend, and one of two cardiac surgeons at King Faisal Medical Centre.
A Saudi-Lebanese man who always dressed in a suit. His Saudi father married a Lebanese woman and they lived in Beirut which was where Naseem completed medical school. Naseem was in scrubs as he dropped off a patient folder to one of the nurses, his smile was wide as he turned to see her, "Surgery was a success. Boom."
Amalia snapped, "What is it with you surgeons? Don't you ever know when to quit?"
The nurses at the station looked up at her, luckily Naseem was the most laid-back person she knew.
With an arm resting on the stating, Naseem asked with sympathetic attention, "Everything okay?"
Amalia just needed to vent. He walked over to her and the two began walking down the hallway. She explained, "Today has been the blackest day."
Naseem pushed up his tortoise-brown eyeglasses, "I'm sorry to hear, anything I can do?"
Amalia pondered, then shook her head, "You and Faryal are still coming over tomorrow night, right?"
The two passed by offices, glass doors of frosted glass. Non-transparent and with metal handles. Metal plaques displayed the names of the doctors they belonged to. Amalia began to breathe more comfortably as they approached the floor's unpopulated break room. No doctors, no patients.
Naseem nodded with a smile, "Game of Thrones night. Wouldn't be the same without you guys. I do have a consultation, so I thought I'd just walk you to your favorite spot."
"Is it with Dr. Nasiri? I heard he had a patient come in this morning, a toy stuck up his ass."
They both laughed as Naseem joked, "Don't tempt me with a good time now."
Naseem began to walk away as he turned back once more to quote the TV show, "-- And if you think this has a happy ending, then you haven't been paying attention."
That always cracked her up, and she appreciated the brief moment of distraction. But then the thoughts had returned to her. That magic in neurosurgery was as good as gone. She could not look at another person's spine without being brought back to Mr. Rabbani's blood-spilling surgery. Amalia entered the empty break room and sat on one of its cozy, tan chairs. The humming of the A/C and the electrical churning of the vending machine was not enough to quiet her thoughts.
Everyone knew of Naseem's perfect record, the lowest number of medical errors, even compared to the younger surgeons. From what she heard from the cardiology nurses was that he had the gift of steady hands -- and attention to immaculate detail. Such a low death stat for someone who performed invasive surgeries. Naseem was in cardiology. Perhaps she could transfer.
Sitting by herself, the adrenaline had begun to wear off, and was replaced with a rush of thoughts about the surgery. Amalia could not help but feel like crying. Her elbow was on the arm of the chair and her head rested on her hand.
The intercom called, "Amalia Hussa to surgical nurses' station. Amalia Hussa to surgical nurses' station."
***
Hussa Residence
Amalia had dinner prepared atop her dark-marble kitchen as she switched off the oven on her stainless, Thermador double electric. She wiped the sweat of her hands along her colorful blouse. Hot steam was rising from their main course of kabsah. This was long-grain basmati rice, chicken, and vegetables. Circular lights shined underneath the cupboards along the marble countertops.
Her first child, 3-year-old Raha, sat in her high chair beside the counter watching her childproof-cased tablet. Amalia checked to make sure she was still drinking her milk. The sound of "Baby Shark" would often send Amalia running to stop the video and change it to something else. She never wanted to hear it again.
Amalia opened her dark-wood cupboard for cardamom and saffron. She opened the spice containers and topped them along the main course, mixing them in with a ladle, and lastly sprinkled them with dark-green bay leaves.
Her nostrils inhaled the herbal scent as Amalia turned back to the stovetop. Naseem had let Amalia sit-in on his morning surgery, just before her shift. It was a shame surgeries were too violent for most people to spectate. Naseem was a cowboy with a scalpel. She had never seen anything like his surgical performances.
Naseem was a graduate of AUB's surgical school. Amalia learned from the senior surgeons how Naseem and his university professors in Beirut developed a modified bicaval antastamosis technique for heart transplants. Their technique decreased the time a patient was on a heart-lung machine. Because the longer they were on it, the more likely complications occurred.
The front door rang. Naseem and her best friend were here.
*
Amalia, her husband, Naseem, and her best friend Faryal had all eaten dinner. They just finished watching TV in the living room. It was decorated with carbon grey, modern couches; a large artwork of a Bengal tiger in the dark jungle. Faryal hung her long, dark-brown hair along her shoulders, and sat with Amalia in the living room. She admired her friend's beautifully arched eyebrows, as if made by thick brush strokes by an artist, where the ends softly fade.
Faryal had graduated from AUB'S physician program, which required ER rotations where she saw combat wounds from civil conflict. Amalia and Faryal sipped from their tea cups. Amalia's husband was showing Naseem the new modifications he made to her Mustang in their garage.
Amalia confided, "Honestly, it was the hardest day on the job I ever had."
She held her cup in her hand and stared at Raha, who sat comfortably in her crib by the coffee table.
"You did the right thing forcing him out, I would rather have a patient that's alive and face losing my job."
Amalia broke her gaze, "But he's not alive… Just makes me wonder how many Bethmann's there are in hospitals."
"So, what do you think? Was he just cocky? A psycho?" Faryal shrugged and raised the corner of her lip, "Or a normal surgeon having a bad day?"
"Multiple bad days. But why should I be the one worrying? He was the one that did this, not me."
Faryal agreed, "He was the surgeon. He was in charge. But just because it's the law doesn't mean it's right. You wanted to believe he was qualified… But what about the family? Do they know the truth?"
Amalia looked away, "… Dr. Yassin covered for him. Was probably covering the hospital by avoiding a lawsuit."
"Do you think the family deserves to know what happened?"
Amalia kept her distracted gaze, "… Yes…"
"And do you think Dr. Bethmann made errors so egregious, that he should be punished for them?"
"… Yes…"
"It's never too late to do the right thing. So, what do you think? Incompetent? Or maybe he was drinking?"
"I would be surprised, honestly…" she shook her head, "I don't think he's stupid. I think… I think he meant to do it."
"What?"
Amalia sat back in her seat and with a deep breath, "I don't know… The way he just looked… Like a kid that dissected a frog. You know, the one kid that's too excited about it."
Faryal leaned in closer to her, "Girl, let me tell you Naseem was that kid, too… And I think, the most horrible people never realize when they do wrong. That's why they do it. He may have done it, but if no one else is going to do the right thing -- it has to be you. So, he doesn't hurt anyone else… Our imam was talking earlier, about how terrorists dilute the world's perception of Muslims… And that the religion of Islam is easy. Peace. Justice. Truth… You need only to live by what they truly mean."
Amalia remained surrendered along her couch, she looked away to think about it. And smiled as she shook her head, "… What is life?"
"Ball is life."
Faryal cracked a smile, the women laughed as Amalia softly slapped her, "Girl, stop."
The two continued to laugh as they sat alone in the living room. Faryal made a playful smile at Raha as the toddler reached her hand out -- and smiled back.
End of Chapter 1.