6 ms·

Emergency rooms are not okay

57 points by EndXA 2y ago

bradgranath 2y ago
Survey is no longer available
Subsentient 2y ago
They will not fix this. Indeed, regulation is required, but meaningful change requires a functioning, coherent government with institutions that are not fully enclosed in regulatory capture. The United States is falling apart, and it is no longer capable of solving its own problems. Now, inertia keeps legacy systems functioning, until fascism and/or balkanization a-la USSR takes over.
p51-remorse 2y ago
It’s safe to stop reading any article at the point they say something like this: > Year 4 of a pandemic
- throwaway346434 2y ago
  Ah, facts and accurate terminology are pesky. I wonder if the author of the article: - Is a doctor - With a PhD ontop of the medical degree - Who works in an ER setting - and is able to specifically know and understand what the word pandemic means ... In the context of a blog post about ER throughput. Let me just check for a second and, oh look at that: the author is all of those four points. COVID infected huge numbers of people, and variants of it continue to reinfect. Long term problems exist in a significant number of people - https://www.nature.com/articles/s41579-022-00846-2 https://www.nature.com/articles/s41579-022-00846-2 COVID has not magically vanished: https://www.idsociety.org/covid-19-real-time-learning-network/diagnostics/covid-19-variant-update/#/+/0/publishedDate_na_dt/desc/ https://www.idsociety.org/covid-19-real-time-learning-networ... It is very much still a pandemic, if for some reason you do not believe that. Otherwise I have to assume you are rejecting the entire article because you do agree it's still a pandemic, but for some reason can't picture why long term effects of COVID may have a relationship to hospital presentations and complexity of cases.
  - fifteen1506 2y ago
    The pandemic is a lie. It's actually a neoliberal disease worsened by a new virus. /s
- LorenPechtel 2y ago
  Being in denial of the problem doesn't make it go away. 2023 provisional data puts Covid at #10 at 50k/yr and this is undoubtedly an undercount as patients that die of a deadly clot due to Covid are likely to not be counted as Covid deaths.
timr 2y ago
The title should be changed. This has nothing to do with ER capacity (or the pandemic, for those commenters already leaping to that conclusion), and the author admits 3/4ths of the way down the article that ER capacity is not the problem: > The primary problem is not the number of patients coming to the ER. It’s the lack of open beds upstairs. She goes on to explain that most of the problem is that hospitals keep their beds full so as to maximize profits, with a variety of reasons ranging from nursing home shortages to hospitals' tendency to prioritize elective surgeries (these make more money). In fact, this entire article is very bad. The author asserts a problem, but provides no actual data to support the assertion, other than linking to some tweets of other people's opinions (edit: I shouldn't have said tweets; these are mostly links to pop journalism and editorials). Here's a paper quantifying the boarding problem in hospitals in the US, during the worst part of the pandemic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134/ to wit: > Occupancy rates and boarding time had a threshold association: when occupancy exceeded 85%, boarding exceeded The Joint Commission 4-hour standard for 88.9% of hospital-months (Figure 1). In those hospital-months, median ED boarding time was 6.58 hours compared with 2.42 hours in other hospital-months (P < .001). Across all hospitals, the median ED boarding time was 2.00 hours (5th-95th percentile, 0.93-7.88 hours) in January 2020, 1.58 hours (5th-95th percentile, 0.90-3.51 hours) in April 2020, and 3.42 hours in December 2021 (5th-95th percentile, 1.27-9.14 hours).
- SoftTalker 2y ago
  New hospitals are being built with fewer beds than the ones they are replacing. The current objective in hospital medicine is to get the patient home as soon as possible. There's a lot of good reasons for that, hosiptals are disease cesspools. Basically if you don't need intensive care they want to send you home.
  - timr 2y ago
    I don't know about the former part, but I agree with the latter completely. Turning people quickly from hospitals is a good thing. The longer you stay in a hospital, the more likely you are to die from something bad that happened to you in the hospital. But, it doesn't have anything directly to do with the so-called "boarding problem", which is what this article is about. That's mostly about the for-profit nature of our health care system, which is doing exactly what one would expect (optimizing profits).
SoftTalker 2y ago
It's also that so many people who go to the ER don't really have an emergency. Sometimes these are people who just don't want until the next day (or week) to see their regular doctor. Sometimes they are people who have nowhere else to go, and they know the ER can't turn them away. I avoid the ER unless I think I am putting my life at risk by not going. I cut my finger open earlier this year, it probably could have used stitches but I was not going to subject myself to the ER experience for that. I taped it up, kept it clean, and it healed. There's a scar, but I'm not a hand model.
- mejutoco 2y ago
  In many places (different countries), the appointments are further and further into the future, so I do not blame them. ER does triage too.
- fifteen1506 2y ago
  Time is money Wellbeing improves productivity
- rPlayer6554 2y ago
  That's where urgent cares come in. I did the same thing to my finger and they stitched it up no problem. They even took X-rays with a remote doctor checking the imagines. 50$ in and out. No clogging up emergency rooms.
  - SoftTalker 2y ago
    It was a Sunday, as tends to be the case with these things, urgent care not open. I could have gone to the ER and spent the rest of the day there in a queue for service, or wait and go to urgent care on Monday, but if you wait that long they won't stitch up a cut anyway. I didn't have any loss of feeling or movement so I decided to just clean it out, bandage it up and let it heal.
- btach 2y ago
  Most ERs have a fast track area dedicated to this kind of thing.
erulabs 2y ago
Hospitals need to be BIG. Basic logic does something like “population * sickness-rate = mean required beds for hospital budget”, but this is logical for lossy services, not mandatory ones. Not to get political, but when a service goes from being a luxury to being considered a human right, our tolerance for failure changes immediately. Anyone who works in reliability knows that the budget for “will never fail” is exponentially higher than “almost never fails”. As we transmute more services to “fundamental right”, we need to expect costs to grow non-linearly, regardless of who is paying. None of this is a bad thing, we just need to be building freakin’ massive hospital buildings!
- throwaway346434 2y ago
  There's a point where the vertical integration of services doesn't scale up with demand - and you get what is happening here, which is effectively kanban, a pull based model for patient flow. The scale out cost for hospitals are in the order of billions and decades to become available. The US needs significantly more diversionary, urgent care resources - a cut or fracture below a certain threshold does not need to be in the same emergency room as a stab victim or crush victim. Going back further, preventative care absolutely needs to be in place so chronic illnesses do not progress to the point of emergency. The Australian model is simple enough: for medications, for the most common treatments, these are on a pharmaceuticals benefits list. The government guarantees the price is kept low, even if the manufacturer is charging ridiculous amounts. This works, because paying $600 extra a month for someone's pills from taxes saves $1200+ of them not rocking up to hospital on death's door 12 times a year.
- listenallyall 2y ago
  I don't see how healthcare can be considered a "fundamental right", like freedom to practice religion or ability to own property, because it relies on (and therefore places a burden on them) to deliver that service. If healthcare is my fundamental right, how can you, who is providing care, take a day off or quit the job entirely? Am I entitled to every possible test as frequently as possible plus every potential drug or medicine even as my prospects for regaining health diminish towards zero? Government's should have some system for providing "pretty good" healthcare to the largest percentage of its citizens as possible, but raising it to a "fundamental right" is not sustainable or possible or fair.
quacked 2y ago
It is unprofitable to provide "perfect service", because in order to provide perfect service you need people on hand that aren't doing anything that can spring into action during surge events. Someone's going to stand around when there's an imbalance between demand and labor supply. At our local grocery store, they overhire high school kids to stand around waiting to check people out. I've never waited in line for more than 3 minutes there. If they cut costs by firing the extra labor, I'd have to stand around and wait for the "optimized" labor force to attend to me.
- solidsnack9000 2y ago
  Is it so unprofitable to provide perfect service? Consider your grocery store example... The incentives of hospitals are much more complex than those of grocery stores, because of how different their business is. One of their major customers, for all patients, is the government -- which rewards some things and not others. Unlike the grocery store, then, the hospitals have to be quite attentive not only to the experience of people coming the door but the metagame of quality measures -- what the government thinks the experience of those people is. The article hints at a reasonable solution, which is for the government to include surplus capacity as part of their incentive structure.
  - LorenPechtel 2y ago
    The basic problem is that demand is unpredictable. From a patient care perspective you overprovision so that pretty much any surge doesn't exceed capacity. But note that the cost to the hospital is pretty much based on what they provision for, not what they actually do. You're not paying the hospital the big bucks for actually doing, you're paying for the capacity to do it. From a profit perspective you overprovision only to the point where the marginal value drops to zero, a point far below the peak of a surge. Unless mandated otherwise no business provisions to the biggest surges.
    - solidsnack9000 2y ago
      Then it should be mandated; but that's not really a public versus private issue. It would have to be mandated in the public context, as well.
rdl 2y ago
How is discouraging people who don't actually need an ER from showing up at an ER a bad idea? If I have something urgent but not an emergency, I could either do ER or Urgent Care. If I'm pretty confident Urgent Care can handle it, it might make more sense to do 1-2h to go to an urgent care option vs. 10 minutes to ER and 4h wait (for care which exposes me to lots of other risks). There are a bunch of things where I'd rather wait 8-24h at home, even in pain, than go to an overloaded emergency room.
- advisedwang 2y ago
  This article is not about that at all. It's about patients that need to be admitted (ie they DO need hospital treatment) being stuck in ERs because the hospital has no beds.
- greentxt 2y ago
  You have s home snd a nice one most likely. The typical ER "frequent flyer" does not. Many are unhoused or members of the renter class, or living with parents/caregivers/etc... I think it would he interesting to compare teal estate prices and rent with ER overcrowding. My guess is few of the surplus patients own nice homes.
- harimau777 2y ago
  In my experience, urgent care charges extremely high and unpredictable prices. However, I agree with you that there should be some way for people to get routine things addressed quickly without going to the ER.
- deleted 2y ago
  [deleted]
djoldman 2y ago
> Prioritizing elective surgeries. Elective surgeries bring in more money, so sometimes hospitals prioritize beds for surgeries instead of sick patients waiting in the ER. Why aren't there facilities out there that just specialize in the elective surgeries and don't have ERs and other things that are money-losers? Seems like you could provide all the money-making services without the money-losing ones.
- rootusrootus 2y ago
  > Why aren't there facilities out there that just specialize in the elective surgeries There definitely are. But I wonder if the main sticking point may be access to an ER in case something goes terribly wrong during surgery. I know that gets used as a bludgeon against abortion providers, but I imagine the same basic regulations apply to any clinic offering surgical services.
mastax 2y ago
I’m surprised to see no mention of Certificates of Need: https://en.wikipedia.org/wiki/Certificate_of_need https://en.wikipedia.org/wiki/Certificate_of_need. In most of the US hospitals need to have a license for their number of beds, the idea being that regulators don’t want there to be too many beds because hospitals tend to find ways to fill them unnecessarily. I’m not familiar with the literature about how good of an argument that is. Intuitively you can see how that could be an impediment when there is a greater need for hospital beds.
- FireBeyond 2y ago
  That's the idea. In reality other hospitals in the area get to have a significant say in new facilities to ensure that they are not either operating empty beds (non-maximal revenue) or filling them with delayed discharges. Remember that hospitals and hospital owners lobbied the Nixon administration heavily to get this process put into law, and it becomes a bit clearer.
- bsder 2y ago
  Please do also remember that law dates to a time when everybody was on indemnity health plans covered mostly by the mills and manufacturing plants.
teeray 2y ago
> The emergency room (ER) is the front door of the hospital. Patients come and are quickly seen by a physician, who addresses medical emergencies and other needs. There it is. The ER, even with its shortcomings, is a better user experience. You have a medical concern, and you get it addressed in a reasonable time— not the weeks or months you need to wait for your primary care or a specialist to be bothered to see you.
- n8henrie 2y ago
  The worst part is teaching people that their experience might not reflect the quality of care. People want to eat fast food (immediate gratification) but not necessarily good for them in the long term, in particular if that's all the ear. Similarly, seeing an EM physician for "what ails you" might check the "got seen in under 24 hours box," but I try to be very up front with my patients that "unless you have a heart attack, a stroke, a car accident, have cut off a body part, etc. you might be getting second or third-rate care from me." I usually try to phrase it as "I didn't get any training in non-emergency problems, and I think you deserve to see a doctor which the right expertise, so I think waiting for that scheduled appointment is worth it, even if it takes a while." It is hard to help people understand that no matter how bad the alternative is, that doesn't make me any better at dealing with non-emergency conditions.
luna4151 2y ago
[flagged]

57 points by EndXA 2y ago

Survey is no longer available

They will not fix this. Indeed, regulation is required, but meaningful change requires a functioning, coherent government with institutions that are not fully enclosed in regulatory capture. The United States is falling apart, and it is no longer capable of solving its own problems. Now, inertia keeps legacy systems functioning, until fascism and/or balkanization a-la USSR takes over.

p51-remorse 2y ago

It’s safe to stop reading any article at the point they say something like this: > Year 4 of a pandemic

throwaway346434 2y ago
Ah, facts and accurate terminology are pesky. I wonder if the author of the article: - Is a doctor - With a PhD ontop of the medical degree - Who works in an ER setting - and is able to specifically know and understand what the word pandemic means ... In the context of a blog post about ER throughput. Let me just check for a second and, oh look at that: the author is all of those four points. COVID infected huge numbers of people, and variants of it continue to reinfect. Long term problems exist in a significant number of people - https://www.nature.com/articles/s41579-022-00846-2 https://www.nature.com/articles/s41579-022-00846-2 COVID has not magically vanished: https://www.idsociety.org/covid-19-real-time-learning-network/diagnostics/covid-19-variant-update/#/+/0/publishedDate_na_dt/desc/ https://www.idsociety.org/covid-19-real-time-learning-networ... It is very much still a pandemic, if for some reason you do not believe that. Otherwise I have to assume you are rejecting the entire article because you do agree it's still a pandemic, but for some reason can't picture why long term effects of COVID may have a relationship to hospital presentations and complexity of cases.
- fifteen1506 2y ago
  The pandemic is a lie. It's actually a neoliberal disease worsened by a new virus. /s
LorenPechtel 2y ago
Being in denial of the problem doesn't make it go away. 2023 provisional data puts Covid at #10 at 50k/yr and this is undoubtedly an undercount as patients that die of a deadly clot due to Covid are likely to not be counted as Covid deaths.

timr 2y ago

The title should be changed. This has nothing to do with ER capacity (or the pandemic, for those commenters already leaping to that conclusion), and the author admits 3/4ths of the way down the article that ER capacity is not the problem: > The primary problem is not the number of patients coming to the ER. It’s the lack of open beds upstairs. She goes on to explain that most of the problem is that hospitals keep their beds full so as to maximize profits, with a variety of reasons ranging from nursing home shortages to hospitals' tendency to prioritize elective surgeries (these make more money). In fact, this entire article is very bad. The author asserts a problem, but provides no actual data to support the assertion, other than linking to some tweets of other people's opinions (edit: I shouldn't have said tweets; these are mostly links to pop journalism and editorials). Here's a paper quantifying the boarding problem in hospitals in the US, during the worst part of the pandemic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134/ to wit: > Occupancy rates and boarding time had a threshold association: when occupancy exceeded 85%, boarding exceeded The Joint Commission 4-hour standard for 88.9% of hospital-months (Figure 1). In those hospital-months, median ED boarding time was 6.58 hours compared with 2.42 hours in other hospital-months (P < .001). Across all hospitals, the median ED boarding time was 2.00 hours (5th-95th percentile, 0.93-7.88 hours) in January 2020, 1.58 hours (5th-95th percentile, 0.90-3.51 hours) in April 2020, and 3.42 hours in December 2021 (5th-95th percentile, 1.27-9.14 hours).

SoftTalker 2y ago
New hospitals are being built with fewer beds than the ones they are replacing. The current objective in hospital medicine is to get the patient home as soon as possible. There's a lot of good reasons for that, hosiptals are disease cesspools. Basically if you don't need intensive care they want to send you home.
- timr 2y ago
  I don't know about the former part, but I agree with the latter completely. Turning people quickly from hospitals is a good thing. The longer you stay in a hospital, the more likely you are to die from something bad that happened to you in the hospital. But, it doesn't have anything directly to do with the so-called "boarding problem", which is what this article is about. That's mostly about the for-profit nature of our health care system, which is doing exactly what one would expect (optimizing profits).

SoftTalker 2y ago

It's also that so many people who go to the ER don't really have an emergency. Sometimes these are people who just don't want until the next day (or week) to see their regular doctor. Sometimes they are people who have nowhere else to go, and they know the ER can't turn them away. I avoid the ER unless I think I am putting my life at risk by not going. I cut my finger open earlier this year, it probably could have used stitches but I was not going to subject myself to the ER experience for that. I taped it up, kept it clean, and it healed. There's a scar, but I'm not a hand model.

mejutoco 2y ago
In many places (different countries), the appointments are further and further into the future, so I do not blame them. ER does triage too.
fifteen1506 2y ago
Time is money Wellbeing improves productivity
rPlayer6554 2y ago
That's where urgent cares come in. I did the same thing to my finger and they stitched it up no problem. They even took X-rays with a remote doctor checking the imagines. 50$ in and out. No clogging up emergency rooms.
- SoftTalker 2y ago
  It was a Sunday, as tends to be the case with these things, urgent care not open. I could have gone to the ER and spent the rest of the day there in a queue for service, or wait and go to urgent care on Monday, but if you wait that long they won't stitch up a cut anyway. I didn't have any loss of feeling or movement so I decided to just clean it out, bandage it up and let it heal.
btach 2y ago
Most ERs have a fast track area dedicated to this kind of thing.

erulabs 2y ago

Hospitals need to be BIG. Basic logic does something like “population * sickness-rate = mean required beds for hospital budget”, but this is logical for lossy services, not mandatory ones. Not to get political, but when a service goes from being a luxury to being considered a human right, our tolerance for failure changes immediately. Anyone who works in reliability knows that the budget for “will never fail” is exponentially higher than “almost never fails”. As we transmute more services to “fundamental right”, we need to expect costs to grow non-linearly, regardless of who is paying. None of this is a bad thing, we just need to be building freakin’ massive hospital buildings!

throwaway346434 2y ago
There's a point where the vertical integration of services doesn't scale up with demand - and you get what is happening here, which is effectively kanban, a pull based model for patient flow. The scale out cost for hospitals are in the order of billions and decades to become available. The US needs significantly more diversionary, urgent care resources - a cut or fracture below a certain threshold does not need to be in the same emergency room as a stab victim or crush victim. Going back further, preventative care absolutely needs to be in place so chronic illnesses do not progress to the point of emergency. The Australian model is simple enough: for medications, for the most common treatments, these are on a pharmaceuticals benefits list. The government guarantees the price is kept low, even if the manufacturer is charging ridiculous amounts. This works, because paying $600 extra a month for someone's pills from taxes saves $1200+ of them not rocking up to hospital on death's door 12 times a year.
listenallyall 2y ago
I don't see how healthcare can be considered a "fundamental right", like freedom to practice religion or ability to own property, because it relies on (and therefore places a burden on them) to deliver that service. If healthcare is my fundamental right, how can you, who is providing care, take a day off or quit the job entirely? Am I entitled to every possible test as frequently as possible plus every potential drug or medicine even as my prospects for regaining health diminish towards zero? Government's should have some system for providing "pretty good" healthcare to the largest percentage of its citizens as possible, but raising it to a "fundamental right" is not sustainable or possible or fair.

quacked 2y ago

It is unprofitable to provide "perfect service", because in order to provide perfect service you need people on hand that aren't doing anything that can spring into action during surge events. Someone's going to stand around when there's an imbalance between demand and labor supply. At our local grocery store, they overhire high school kids to stand around waiting to check people out. I've never waited in line for more than 3 minutes there. If they cut costs by firing the extra labor, I'd have to stand around and wait for the "optimized" labor force to attend to me.

solidsnack9000 2y ago
Is it so unprofitable to provide perfect service? Consider your grocery store example... The incentives of hospitals are much more complex than those of grocery stores, because of how different their business is. One of their major customers, for all patients, is the government -- which rewards some things and not others. Unlike the grocery store, then, the hospitals have to be quite attentive not only to the experience of people coming the door but the metagame of quality measures -- what the government thinks the experience of those people is. The article hints at a reasonable solution, which is for the government to include surplus capacity as part of their incentive structure.
- LorenPechtel 2y ago
  The basic problem is that demand is unpredictable. From a patient care perspective you overprovision so that pretty much any surge doesn't exceed capacity. But note that the cost to the hospital is pretty much based on what they provision for, not what they actually do. You're not paying the hospital the big bucks for actually doing, you're paying for the capacity to do it. From a profit perspective you overprovision only to the point where the marginal value drops to zero, a point far below the peak of a surge. Unless mandated otherwise no business provisions to the biggest surges.
  - solidsnack9000 2y ago
    Then it should be mandated; but that's not really a public versus private issue. It would have to be mandated in the public context, as well.

rdl 2y ago

How is discouraging people who don't actually need an ER from showing up at an ER a bad idea? If I have something urgent but not an emergency, I could either do ER or Urgent Care. If I'm pretty confident Urgent Care can handle it, it might make more sense to do 1-2h to go to an urgent care option vs. 10 minutes to ER and 4h wait (for care which exposes me to lots of other risks). There are a bunch of things where I'd rather wait 8-24h at home, even in pain, than go to an overloaded emergency room.

advisedwang 2y ago
This article is not about that at all. It's about patients that need to be admitted (ie they DO need hospital treatment) being stuck in ERs because the hospital has no beds.
greentxt 2y ago
You have s home snd a nice one most likely. The typical ER "frequent flyer" does not. Many are unhoused or members of the renter class, or living with parents/caregivers/etc... I think it would he interesting to compare teal estate prices and rent with ER overcrowding. My guess is few of the surplus patients own nice homes.
harimau777 2y ago
In my experience, urgent care charges extremely high and unpredictable prices. However, I agree with you that there should be some way for people to get routine things addressed quickly without going to the ER.
deleted 2y ago
[deleted]

djoldman 2y ago

> Prioritizing elective surgeries. Elective surgeries bring in more money, so sometimes hospitals prioritize beds for surgeries instead of sick patients waiting in the ER. Why aren't there facilities out there that just specialize in the elective surgeries and don't have ERs and other things that are money-losers? Seems like you could provide all the money-making services without the money-losing ones.

rootusrootus 2y ago
> Why aren't there facilities out there that just specialize in the elective surgeries There definitely are. But I wonder if the main sticking point may be access to an ER in case something goes terribly wrong during surgery. I know that gets used as a bludgeon against abortion providers, but I imagine the same basic regulations apply to any clinic offering surgical services.

mastax 2y ago

I’m surprised to see no mention of Certificates of Need: https://en.wikipedia.org/wiki/Certificate_of_need https://en.wikipedia.org/wiki/Certificate_of_need. In most of the US hospitals need to have a license for their number of beds, the idea being that regulators don’t want there to be too many beds because hospitals tend to find ways to fill them unnecessarily. I’m not familiar with the literature about how good of an argument that is. Intuitively you can see how that could be an impediment when there is a greater need for hospital beds.

FireBeyond 2y ago
That's the idea. In reality other hospitals in the area get to have a significant say in new facilities to ensure that they are not either operating empty beds (non-maximal revenue) or filling them with delayed discharges. Remember that hospitals and hospital owners lobbied the Nixon administration heavily to get this process put into law, and it becomes a bit clearer.
bsder 2y ago
Please do also remember that law dates to a time when everybody was on indemnity health plans covered mostly by the mills and manufacturing plants.

teeray 2y ago

> The emergency room (ER) is the front door of the hospital. Patients come and are quickly seen by a physician, who addresses medical emergencies and other needs. There it is. The ER, even with its shortcomings, is a better user experience. You have a medical concern, and you get it addressed in a reasonable time— not the weeks or months you need to wait for your primary care or a specialist to be bothered to see you.

n8henrie 2y ago
The worst part is teaching people that their experience might not reflect the quality of care. People want to eat fast food (immediate gratification) but not necessarily good for them in the long term, in particular if that's all the ear. Similarly, seeing an EM physician for "what ails you" might check the "got seen in under 24 hours box," but I try to be very up front with my patients that "unless you have a heart attack, a stroke, a car accident, have cut off a body part, etc. you might be getting second or third-rate care from me." I usually try to phrase it as "I didn't get any training in non-emergency problems, and I think you deserve to see a doctor which the right expertise, so I think waiting for that scheduled appointment is worth it, even if it takes a while." It is hard to help people understand that no matter how bad the alternative is, that doesn't make me any better at dealing with non-emergency conditions.

luna4151 2y ago

[flagged]