The Painful Truth
The Iraq war is a new kind of hell, with more survivors — but more maimed, shattered limbs — than ever
By Steve Silberman
When Brian Wilhelm realized he'd been hit, he grabbed an M-16 and dove out of his truck to return fire. As he lay on the ground, another soldier in his convoy tied a tourniquet around his shredded leg to stanch the flow of blood, but it snapped. While bullets ricocheted around them, a gunner improvised a second tourniquet using a crowbar and field dressing. Wilhelm's buddies laid him out in the back of a supply truck, where he prayed and pressed his hands against a block of ice while they waited for the medics, afraid that if he passed out, he would die. He was 21 years old, a Fighting Eagle with the Army's Eighth Infantry, deployed northwest of Baghdad. Back home in Colorado, his wife had just given birth to their first child, a daughter. Wilhelm is among the more than 9,000 US soldiers who have been wounded in action since the war in Iraq began. The good news is that fewer GIs are dying of their injuries than in any modern conflict. In Vietnam, one out of every three soldiers hurt in combat was shipped home in a body bag. In Iraq, it's one in eight. Credit the use of body armor and a dramatic increase in the speed of the Air Force's evacuation chain — the relays of Black Hawk helicopters and transport jets that ferry the wounded from the front lines to Landstuhl Regional Medical Center in Germany, where soldiers receive care before being sent on to hospitals like Walter Reed Army Medical Center in Washington, DC.
The bad news is pain. The injuries suffered by those who survive are more severe than in previous conflicts. High—velocity bullets, rocket—propelled grenades, and so—called improvised explosive devices cause tissue damage that is particularly excruciating. Although Interceptor body armor and Kevlar helmets are highly effective at deflecting AK—47 rounds and RPG shrapnel away from the "kill zones" of the torso and head, soldiers' arms and legs are left unshielded for the sake of mobility. The success of body armor has had the unintended effect of creating a new class of survivable physical trauma. Operation Iraqi Freedom has become a war on the extremities — a litany of exploded muscles, shattered bones, and severed limbs.
While the process of extracting injured troops from combat zones has been streamlined, the methods for relieving their agony during evacuation has lagged. Until recently, the military's approach to pain control hadn't changed much since the days when the battlefield anesthetics of choice were rum, ether, and narcotics. "In the Civil War, the answer was general anesthesia and morphine," says Chester "Trip" Buckenmaier, an acute pain specialist at Walter Reed. "Two hundred years later, we can do things that doctors then would never have dreamed of — but the answer to pain is general anesthesia and morphine. We're still in the Dark Ages."
General anesthesia, which suppresses the activity of the entire central nervous system, is itself an assault on the body — a little death that requires constant monitoring of heart rate, blood pressure, and respiration, followed by hours in the recovery room. And when traditional anesthesia wears off, the pain returns, requiring patients to take massive doses of morphine or other addictive analgesics as they recuperate.
Now Buckenmaier is leading a group of army doctors and nurses determined, as he puts it, "to drag the military kicking and screaming into the 21st century." His team believes the future of wartime pain control is a new form of anesthesia called a continuous peripheral nerve block, which takes a more targeted approach by switching off only the pain signals coming from the injured limb, leaving patients' vital signs and cortical functions unimpaired.
Because nerve blocks affect a precise area of the body, they fall under the category of regional (rather than general or local) anesthesia. An elementary form of regional anesthesia is already widely used in maternity wards: the epidural block, employed to numb the pain of labor and achieved by injecting analgesics and narcotics along the spine.
Pioneered in experimental programs at Duke University and St. Luke's—Roosevelt Hospital in New York City, continuous peripheral nerve blocks could transform civilian medicine in the next few years by reducing the incidence of chronic pain, which currently afflicts more than 75 million Americans, according to the National Pain Foundation. The blocks already allow surgeons to perform major operations on patients who can't tolerate traditional anesthesia, such as frail seniors and those with severe cardiovascular disorders. And in an era when insurers often limit hospital stays, wider use of the techniques explored by Buckenmaier in Iraq will enable patients to take control of their own pain relief at home, with less dependence on addictive pharmaceuticals.
The blocks used by Buckenmaier and his team are made possible by the recent invention of small, microprocessor—controlled pumps which bathe nerves in nonaddictive drugs that discourage the transmission of pain signals. The pumps also can be used for weeks after surgery, enabling soldiers to adjust the level of medication themselves as they need it.
For soldiers evacuated from the battlefield, the advantages of nerve blocks over traditional methods of pain control are clear. The wounded troops flying in and out of Landstuhl are often in misery or a narcotized stupor, while those treated with blocks remain awake and pain—free despite massive injuries.
This new war on pain is the brainchild of John Chiles, the Army's chief anesthesiologist. "Places like Duke were doing great things with peripheral nerve blocks, but they had fallen by the wayside in the Army," he says. "I wanted us to be on the cusp of these advances." The Walter Reed program is supported by grants from the Murtha Neuroscience and Pain Institute, founded by the US representative from Pennsylvania. John Murtha, who was wounded in combat in Vietnam, visits the troops once a week at Walter Reed.
Buckenmaier, a lieutenant colonel, is the first military anesthesiologist to train in a fellowship program at Duke focusing on groundbreaking applications of regional anesthesia. On the door to his office, he displays a photograph of the Three Stooges dressed as doctors mixing up a batch of mystery chemicals — he says he likes the looks of "concerned wonder" on their faces. Brash and blunt with a cleft chin and a bushy mustache, he projects a gruff, old—fashioned avuncularity. The grandson of a Rough Rider and son of an Air Force lieutenant colonel, Buckenmaier, 40, was born at Walter Reed just as the first planeloads of wounded started arriving from Vietnam.
Men who lost limbs in Saigon in 1968 still wander the halls of Walter Reed, alongside a younger generation learning to navigate the world with prostheses. Seventy percent of those who have lost arms or legs in combat report feeling relentless pain for years after being wounded. New research suggests that administering regional anesthesia quickly after traumatic injury may alleviate or even prevent certain forms of chronic pain, including phantom—limb syndrome. The most lasting impact of Buckenmaier's work may become obvious only decades from now.
Six months after the first wounded
started coming home
Buckenmaier flew to Baghdad with a laptop, a digital camera, a
satellite phone, a leatherbound journal, a 9—mm Beretta, and his bag of
The pilots and paramedics of the 54th Medical Company were watching Scrubs and playing the videogame Black Hawk Down on laptops in an air—conditioned hut when the distress call came crackling in — "First up!" Six minutes later, a Black Hawk was racing toward the site of Wilhelm's ambush. Less than 30 minutes after that, the infantryman was borne on a stretcher into the emergency room tent of the 21st Combat Support Hospital at Camp Anaconda, the major US base of operations in the Sunni trouble zone.
Buckenmaier had flown in a few days earlier. His first night, he was awakened at 3 am by cries of "Thunder! Thunder! Thunder!" — an alarm that insurgents had launched mortars at the base. This happened so often that most of the men in the tent went on sleeping.
By the standards of previous wars, the 21st CSH was well equipped. There were more than 300 active—duty personnel on call 24 hours a day, 90 beds, a digital x—ray, and two machines for administering general anesthesia. But by the standards of a civilian hospital, the working conditions were austere. The operating room was a glorified shipping container, and the recovery area was a cluster of tents connected by plastic tunnels.
Fortunately, Buckenmaier had a lot of practice working under less—than—ideal conditions. In 2002, he'd led a mission to Burkina Faso as part of a program funded by an anesthesiology group in Washington that provides medical care to developing nations. He and his colleagues set up shop in the remote village of Diébougou. Over the course of two weeks, they saw more than 3,000 patients, many of whom traveled hundreds of miles across the desert to get there. The team performed 110 surgeries, including 18 hernia operations on children, using only regional anesthesia.
Wilhelm had been given morphine by the medics who cauterized his wounds, but he was still in agony. His left calf muscle had been blown away, exposing a length of bone and pulped flesh, and blood was leaking through his field dressing. His foot was swollen with edema. When Buckenmaier asked him to estimate his pain on a scale of 0 to 10, he said 10, "the worst pain imaginable." Wilhelm had been carried into the OR for debridement, the harrowing process of removing dirt and dead tissue from a wound. Buckenmaier got out his bag and went to work.
First he used a millivolt stimulator to probe for leg nerves that were still functioning. The soldier's ankle flexed — a sign that the stimulator had found the nerves serving the injured area. Then Buckenmaier placed two blocks by inserting ultrafine catheters into Wilhelm's back and thigh to bathe his sciatic and lumbar nerves in a drug called mepivacaine.
Throughout the 85—minute operation, Wilhelm remained awake and talking. At one point, a technician lifted his wounded leg to clean it, and the weakened tibia fractured with a sharp crack that sent shudders through the surgical staff. But the blocks were so effective, Wilhelm didn't even feel it.
The typical scene in the recovery tent is a somber one: friends touching the sides of the bed around an unconscious soldier in a silent show of support. By contrast, when Wilhelm's operation was over, 15 of his buddies crowded around, laughing and joking with him.
Later, Wilhelm's catheters were connected to pumps, each about the size of a TV remote control and weighing only about 6 ounces, with tiny LCD screens. Hooked up to a supply of ropivacaine, they would provide continuous anesthesia for 48 hours on two AA batteries. The entire apparatus fit in a fanny pack.
That night, the anesthesiologist and his patient boarded a Black Hawk for the hop to Baghdad, then a C—141 jet for the six—hour flight to Landstuhl. Since block pumps are electronic devices, the crew was reluctant to allow their use, just as commercial airline attendants require passengers to turn off cell phones, but Buckenmaier won over one of the flight nurses. For the rest of the trip, Wilhelm's pain level remained at zero.
By the time they arrived in Germany, Wilhelm was wondering if he still needed both blocks. "I wasn't hurting and I could still move my toes," he says. The doctors in Landstuhl were concerned that the anesthesia might be masking the onset of a potentially serious complication called compartment syndrome, caused by the compression of tissue after a high—impact injury. So they switched off the blocks. Wilhelm's pain level jumped back up to 8 before they could turn the blocks on again.
Buckenmaier remained at Wilhelm's bedside until the soldier was transported to Walter Reed two days later. Though he didn't have compartment syndrome, Wilhelm developed complications caused by massive blood loss — the shrapnel from the grenade had blown out the veins in his leg. An avid athlete, he elected to have a below—the—knee amputation.
After Wilhelm returned to the US, Buckenmaier considered heading home to his family. He had already broken a pledge to his wife that he would never volunteer to go to a combat zone. But in Wilhelm, he'd found his index case — the first patient that proved nerve blocks could be effective all the way through an evacuation. Buckenmaier wrote in his journal:
Seeing Brian off was a seminal moment in my life. Years of effort came together today.
Then he jumped on a transport and flew back to the war.
Buckenmaier stayed for three months, becoming as hardened to the surreal conditions of life at Camp Anaconda as the men who snored through incoming mortar rounds. A 15—square—mile warren of tents and trailers, the base occupies the former site of the Iraqi Air Force Academy near Balad, protected by a buffer zone of razor wire and earthen berms. Buckenmaier returned just in time for the holy days of Ramadan, when the ferocity and frequency of ambushes increased. Rockets fell outside the mess hall. The attacks soon became daily occurrences, and few of the residents ventured "outside the wire" unless they had to. Buckenmaier chose a bunker near the runway so he would know when the wounded were incoming.
The fate of an arm or leg often depended
on some twist of
circumstance, such as the decision to dangle an elbow out the window
while driving in the triple—digit heat. The soldiers' injuries were
aggravated by strange infections. When a bomb detonates under a Humvee,
septic muck from the chassis and road surface — carrying native strains
of bacteria for which US troops have no resistance — is blown deep into
the ravaged tissue. Buckenmaier emailed the notes in his journal back
to Walter Reed, where a research assistant loaded them into a database.
To boost morale after what Buckenmaier describes as "a little mass—casualty exercise every morning," the staff took dips in the old regime's swimming pools and ordered small indulgences online, like their favorite flavor of jelly, or games from Amazon.com. Nurses exhausted by 12—hour shifts bought fancy underwear they could slip under their uniforms, delivered to the base by yellow DHL vans. (FedEx came only as close as Kuwait.) Each day at sunset, the anesthesiology crew smoked cigars out by the razor wire and spoke frankly about the progress of the war. Buckenmaier wrote:
Every time a convoy leaves Camp Anaconda, flares go up warning that the Americans are out — come ambush.
For wounded Iraqi civilians, the litmus test for admittance to the 21st CSH was whether medical intervention could save life, limb, or eyesight. POWs needing treatment were segregated in their own tent under armed guard; after surgery, they were sent to detention camps. An infantryman would arrive on a stretcher with his legs blown off, and the man who planted the bomb that maimed him might be carried in a few minutes later.
At first, Buckenmaier would place blocks only on American soldiers. He didn't like the idea of probing for nerves on patients whose language he didn't speak or understand. To him, the Iraqis at Camp Anaconda seemed "like people from the Middle Ages who suddenly showed up in Star Wars." Word went around that one POW told his doctors that he wanted treatment so he could kill more Americans.
Then one of the prisoners began to show signs of complex regional pain syndrome, a degenerative disorder that can be brought on by even a minor injury. Afflicted areas of the body burn at the slightest touch, the skin turns blue and erupts in lesions, and bones and muscles waste away. Pain specialists theorize that CRPS is caused by neural feedback run amok: The pain of the initial injury creates inflammation, which causes more pain, triggering further inflammation and pain. One of the only ways to avert the onset of CRPS is to place blocks on the nerves connecting the injured area to the spinal cord, interrupting the feedback loop. Buckenmaier, using a translator, administered the blocks. He ended up performing regional anesthesia on more than a dozen Iraqis — civilians and POWs alike. Employing blocks instead of general anesthesia for routine procedures like dressing changes freed up the OR for major trauma cases.
One day, rumors circulated that a car bomb had detonated inside the wire. It wasn't true: The tire of a Black Hawk had exploded, killing 19—year—old specialist Paul Bueche and wounding Peter Damon, a 31—year—old National Guardsman who lost his left arm and part of his right. Because Damon's limbs were severed, Buckenmaier couldn't depend on motor function like the flexing of an ankle to indicate when his stimulator found the nerve pathway serving the area. Instead, he probed with the needle until his patient felt sensation flooding back down his arm, as though his missing fingers had returned.
For Buckenmaier, the challenge wasn't over once Damon's blocks were in. News of his patients had drifted up to Air Force command, which responded by issuing a specific ban on flying with block pumps. The pumps are designed to function accurately in the stable environment of a civilian hospital; Air Force staff were concerned that by running them at high altitudes and subjecting them to cold temperatures and heavy vibration on medevac flights, the planes' navigation systems, as well as the patients themselves, might be endangered. Buckenmaier knew better. Because his first military assignment was as a flight surgeon in Panama, Buckenmaier says, "I felt confident that I understood the technology of the jets and the operation of these devices enough so that my patients could fly without harming either themselves or the planes." He succeeded in obtaining a waiver so Damon could maintain his pain control en route to Landstuhl. Adopting the philosophy that it was better to beg forgiveness than to ask permission, Buckenmaier told the rest of his patients to hide their pumps in transit.
The larger hurdle was resistance to change. "Anesthesia is very tribal," says Geselle McKnight, a nurse—anesthetist on the team at Walter Reed. "We all tend to practice the kinds of anesthesia used by the group we're with. The traditional model of taking the patient to the OR, putting them to sleep, letting the surgeon go to work, and then you're out of there — that's very hard to overturn." Placing blocks requires detailed knowledge of neuroanatomy that anesthesiologists don't need to know to perform traditional methods of pain control. It's hard to tell military anesthesiologists they need to retrain, because they can always command bigger paychecks and work under less demanding conditions in the civilian world.
Use of blocks also requires new ways of thinking about patients — such as the notion of giving them control over their own postoperative pain relief. As in civilian medicine, pain control is often a secondary consideration; for war planners, it can seem like a luxury.
Regional anesthesia, however, is perfectly suited to the Pentagon's plans for the leaner, meaner future of war fighting. A dozen pain pumps can fit in a duffle bag, while general anesthesia requires massive infrastructure, including bulky compressed—gas machines, mechanical ventilators, and tanks of oxygen and volatile anesthetics. The compact self—sufficiency that makes blocks ideal for small mobile units could also be useful in the aftermath of a major natural disaster or a domestic terrorist attack, McKnight points out. "If, God forbid, we suddenly had to work with less, regional anesthesia lends itself to low tech environments." The Special Forces, whose modus operandi is doing more with less, has discussed with Buckenmaier the possibility of developing self—administered blocks, so that a Green Beret could turn off the pain in a mangled limb with an injection and keep fighting.
If nerve blocks fulfill their promise of reducing or eliminating chronic pain, the thousands of veterans of this war on the extremities will come home to more normal lives. Long—term pain is highly correlated with the development of post—traumatic stress disorder, depression, anxiety, panic attacks, and substance abuse. Researchers at Northwestern University recently discovered that lingering pain may reduce the density of gray matter in the cortex. It is also a factor in veteran suicide.
Soldiers are not the only ones in Iraq
who would benefit
smarter, more efficient pain management. Half of the US contractors who
filed federal workers' compensation claims in the first months of 2004
were injured in Iraq. The civilians lucky enough to receive treatment
at the 21st CSH represent only a small fraction of the total number of
Iraqi wounded. By last summer, the largest prosthetics clinic in
Baghdad was turning away 10 times as many patients as it could treat,
even with 70 technicians cranking out new limbs six days a week.
Battlefield physicians like Buckenmaier have always led the way in understanding how the body works, and much of what we know about pain was learned in the terrible laboratory of war.
Modern surgery was invented in the 16th century by Ambroise Paré, a lowly barber—surgeon in the French army. When he joined the ranks, guns were the latest upgrade in weapons of mass destruction, bullet wounds were washed out with boiling oil, and the standard practice for relieving a soldier's pain was to slit his throat.
Paré improvised a prototype of the tourniquet, launched the field of prosthetics by designing the first flexible artificial leg, and dispensed with the boiling oil. He also listened closely to his patients, noting a "strange and prodigious phenomenon" among the amputees. "Many months after the cutting away of the leg," he wrote, "[they] grievously complained that they yet felt exceeding great pain of that leg so cut off." Paré even made a careful distinction between stump pain and feelings that seem to emanate from limbs that are no longer there, which he called faux sentiments, or "false sensations." The medical establishment didn't acknowledge the existence of phantom—limb pain for another 300 years, but the notion that an amputated arm or leg could leave behind a doppelgänger made its way into Moby Dick, where Ahab tells a carpenter carving him a new prosthesis:
Look, put thy live leg here in the place where mine was; so, now, here is only one distinct leg to the eye, yet two to the soul. Where thou feelest tingling life; there, exactly there, there to a hair, do I. Is't a riddle?
While civilian physicians attributed these eerie hallucinations to mourning for lost limbs, it took another surgeon—in—arms, Silas Weir Mitchell, who served in the Civil War, to correctly identify their source. He speculated that phantom pain came from complex interactions between the brain and the spinal cord, and he proposed a networked model of the nervous system that anticipated mainstream neuroscience by a century.
Neurologists now know that even a small injury, such as stubbing a toe, puts the body's entire pain network on alert. In the case of a stubbed toe, this has no more consequence than the leg becoming unconsciously vigilant for a day or two so that the toe doesn't get stubbed again. In soldiers who sustain major combat wounds, sensitization of the pain pathways in the brain and spinal cord — a process known as windup — can go too far, so that just the prick of an IV needle can make a GI howl with pain, even after rounds of morphine.
When an arm or a leg is wrenched from the body by trauma or surgical amputation, torrents of signals from the severed nerves travel up the spinal cord and converge in the cortex. In the weeks following the loss of the limb, the brain redraws its map of the body by growing new neural connections. Pain specialists theorize that windup creates glitches in this new map, causing acute pain from the injury to be hardwired into the body as chronic pain. A 2001 brain—imaging study in Germany found a strong correlation between disturbances in the process of cortical reorganization and the development of phantom—limb syndrome.
A brain under general anesthesia is still bombarded by frantic pain signals; it just can't do anything about them, therefore the patient is still susceptible to chronic pain. Nerve blocks intercept the cascades of bad news before they sensitize the central pain pathways. Blocks also dilate capillaries in the damaged tissue, improving blood flow and accelerating healing.
By the time a soldier typically sees an anesthesiologist, the windup process has already begun, but several studies have shown that use of regional anesthesia before, during, or after the removal of a limb may reduce the incidence of chronic pain. Danish patients given epidural blocks before surgical leg amputation showed a dramatic reduction in postoperative discomfort. Other research has shown that even the short—term administration of a block reduces the need for narcotics in the recovery room.
Two leading pain specialists, Joel Katz at the University of Toronto and Allan Gottschalk at Johns Hopkins Hospital, believe that regional anesthesia could be a powerful tool in averting chronic pain. But they worry that progress in developing so—called preemptive analgesia has been hampered by scant amounts of research, with sample sizes too small to be definitive. "The model is valid, but we need to run more controlled studies," says Katz. He adds that regional anesthesia should be used on the battlefield "not only because it might forestall pain in the future, but because it's certainly much more humane."
Buckenmaier's database now contains one of the largest samples of traumatic amputation cases focused on pain. During a recent lecture, someone asked him, "How do you feel about doing experiments on soldiers?"
"I didn't go to Iraq to do a randomized trial," he replied curtly. "I went out there to treat my patients."
Many of the rooms at Walter Reed overlook a lush garden — a glimpse of heaven for those who have been evacuated from hell.
Brian Wilhelm and Peter Damon were brought here, to ward 57, where those whose lives have been permanently changed in combat undergo the grueling process of recovery and rehabilitation. Most of the soldiers on the ward try to accept their fate with equanimity. Some say they want to return to the front lines as soon as possible so they can help their buddies who are still there. Others are profoundly bitter about the war.
They're all still soldiers: They bitch about the hospital chow and call the physical therapists "physical terrorists." A stream of celebrities has come through, from Ozzy Osbourne to vice president Dick Cheney. Last fall, US senator John McCain and radio host Don Imus made the rounds as I interviewed a young sergeant whose arm was fractured in a dozen places. They chatted with him and thanked him for his service. Once they were back out in the hall, a member of their entourage whipped out a bottle of hand sanitizer and passed it around — a ritual to ensure that microbes from the desert don't spread beyond the walls of the hospital. One 22—year—old booked for surgery the following day had lost both of his legs above the knees, his right hand, and his left thumb, and required a ventilator to breathe.
Damon, whose forearms were blown off in the tire explosion, has gone home to his wife and two children in Boston, but he's still in significant pain, for which he takes a daily regimen of drugs, including methadone. "I've always worked with my hands," he says. "I went from being a mechanic and an electrician to where I am now. The simplest tasks have become difficult in ways that you can't imagine. But I'm proud of my sacrifice."
Wilhelm says he felt phantom sensations in his leg for a month after he was injured, but they have mostly subsided, and he has stopped taking the medications he was given to relieve them. Now he's considering a career as a drill sergeant and is thinking about training for the pentathlon at the 2008 Paralympics in Beijing.
While both men were evacuated with nerve blocks, there were significant differences in the circumstances of their injuries. Damon's amputations were traumatic and instantaneous, while Wilhelm's was surgical and delayed. Untangling the variables in hundreds of case histories like theirs is the next assignment for Buckenmaier's team as it analyzes the effectiveness of regional anesthesia on the front lines.
Their war on the military's resistance to change is going better than the war itself. The Air Force has rescinded its ban on pain pumps, reclassifying them as safe—to—fly. The team just locked down another $6 million from John Murtha's institute, pending the signing of a defense appropriations bill by President Bush. Last July, the Army launched a regional—anesthesia fellowship program, and its first fellow, Cynthia Shields, is serving at Walter Reed. Early this year, two anesthesiologists with postgraduate training in administering blocks will be deployed to field hospitals in Iraq.
Buckenmaier now spends more time in the air than in the OR, lecturing at trauma conferences and meetings of the combat developers and officers who will determine the Army's approach to pain in future wars.
"I always hated politicians and salesmen, and now I've ended up being both," he tells me. "But someday, regional anesthesia will just be there for the Army, and no one will remember that it was ever any different, because I will have done my job."
Contributing editor Steve Silberman (firstname.lastname@example.org) wrote about virtual combat training environments in issue 12.09.
Killing the Pain
After a traumatic injury, the brain and spinal cord are bombarded by pain signals, laying the foundation for chronic pain that can linger for decades. A new method of anesthesia ends the pain — perhaps even permanently.
Peripheral Nerve Blocks
Nerve blocks intercept pain signals before they're delivered to the brain. A battery—operated pump connected to catheters implanted alongside the nerves administers periodic doses of anesthetics like mepivacaine, relieving the agony of the injury and preempting chronic pain. Pumps also provide pain relief for weeks after an injury via analgesics such as ropivacaine.
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