Journal of Medical Engineering & Technology
ISSN: 0309-1902 (Print) 1464-522X (Online) Journal homepage: http://www.tandfonline.com/loi/ijmt20
Medical and scientific equipment maintenance — to be or not to be! R. E. Trotman To cite this article: R. E. Trotman (1979) Medical and scientific equipment maintenance — to be or not to be!, Journal of Medical Engineering & Technology, 3:2, 57-59, DOI: 10.3109/03091907909161609 To link to this article: http://dx.doi.org/10.3109/03091907909161609
Published online: 09 Jul 2009.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmt20 Download by: [137.189.171.235]
Date: 28 March 2016, At: 23:48
bmment Medical and scientific equipment maintenance - to-be or not to be! by R.E. Trotman
Downloaded by [] at 23:48 28 March 2016
Dr. R.E. notman is a Consultant Editor of the J o m l of Medical Engineering and Technologv, and is in the Bio-Engneering Department at St. Mary’s Hospital Medical School, London W2
Following its introduction in the United Kingdom, the Health and Safety Commission considered the application of the Health & Safety at Work Act (1974) to some work activities that were covered by legislation for the first time. In consequence, the Health & Safety Executive (HSE) carried out pilot studies in certain work activities, to identify the hazards and the kind of safety problems likely to be encountered. One such study was undertaken of the hospital services by inspectors of the Factory Inspectorate, and their report [ 11 is now available. Their study was of hospitals in one National Health Service (NHS) region, the North West Thames, although a number of visits t o hospitals in Scotland were made and account taken of the differences in organisation of the health services in Scotland and in England and Wales. One of the most important statements made in the report was that the principal concern of medical and technical staff is the observed interference or ‘do-it-yourself ’ repairs on equipment mrried out by staff without electrical or electronics training. The statement referred to both patient connected and laboratory equipment. This is not the first time such concern has been expressed. There is many a scientist and engineer working in the NHS, and in other countries, who must be saying, or certainly could be saying, words to the effect that “I have been voicing my concern about that for years”. It is quite evident from this study that they have now been joined by their medical colleagues in expressing grave concern about the lack of properly organised servicing and routine maintenance facilities for all categories of medical and scientific equipment. It is well known that, in recent years, controversy has been raging over who should be responsible for organising and implementing such a scheme for sophisticated clinical and laboratory equipment: hospital engineers, who have always had responsibility for servicing and maintaining plant and ‘hotel’ equipment, some of which is very complex; or medical physicists and/or bio-engineers, many of whom have been actively involved in servicing and maintaining a variety of categories of equipment, particularly clinical measurement and radiation physics equipment, for several years. No doubt this controversy, which now seems to have died down because it has been realised that both categories of staff must, of necessity, play a part in the forseeable future at a n y rate, has resulted in delaying the introduction of effective schemes in some hospitals. But, I doubt very much if that has been the overriding factor in most cases. As is so often the case, a major cause of delay is lack of finance. The infuriating thing is that it is widely recognised that an efficient, in-house organised servicing and preventive maintenance scheme can save a lot of money. I say in-house orgunised scheme, because it probably is neither wise nor practical to completely dispense with manufacturers’ Volume 3 No. 2 March 1979
maintenance contracts and break-down servicing assistance. But, alas, in order to introduce even limited and rudimentary maintenance schemes, health authorities have to commit themselves to some new expenditure for the additional manpower and equipment necessary. They must actually spend a substantial sum of money some months or possibly a year or so before the financial benefits begin to accrue. In the present fiancial climate it takes courage to commit oneself, particularly when other equally essential improvements in the quality of service to the patient require similar commitments. The Department of Health & Social Security (DHSS) is taking this problem very seriously, as, indeed, are many Regional and Area Health Authorities in the United Kmgdom. The DHSS has recently circulated a draft Health Service Management document entitled ‘Management of Equipment’ for comment. The document discusses such matters as: choosing suitable equipment; acceptance testing; calibration, breakdown servicing and routine maintenance; planned replacement; and dissemination of information to user and manufacturer. This appears to be an extremely valuable document, and one can only hope that the process of consultation, final publication and implementation will be completed speedily. There is an urgent need for a formal policy on all facets of the management of equipment.
Allocation of funds The authors of this report indicate that a recent estimate of the total value of NHS equipment is €100,000,000 and suggest that the allocation of ‘modest resources’ to keep it in good repair “is not unreasonable, neither should it be too long delayed”. Modest may be assumed to be something of the order of €5,000,000 a year, since it has been found that on average the annual cost of in-house organised servicing and maintenance schemes is approximately 5% of the replacement cost of .the equipment (compared with an average of approximately 10% when one is entirely dependent on manufacturers). No doubt some people will say the DHSS often gives such helpful guidance, but since it rarely, if ever, forwards the cheque to make implementation possible one might as well forget it. Unfortunately the recent statement by the Department [2] that no additonal resources can at present be made available for general administrative costs arising from the Health & Safety at Work Act, will not remove their scepticism. Furthermore, there are those who are arguing that serious accidents due to faulty equipment are rare, so we need not worry too much. Fortunately, it is a fact that there are few serious accidents, but, in view of the state of some of the equipment one sees in use in hospitals, and of the way it is used, that is pure luck; many an unreported minor incident could so easily have been a serious accident, as could many unobserved incidents. But, make no mistake about it, serious accidents d o happen, and in recent years there have been two that were so serious that formal inquiries were held. Both reports commented on the poor way that servicing of equipment was organised. There is another aspect of the problem. It would appear that the HSE has indicated that inspectors do not intend (initially at least) t o concern themselves with medical or nursing care of patients, except so far as may be necessary when dealing with certain systgms of work or the fitness o f plant or equipment. [ 3 ] Furthermore, in the report referred to in the first paragraph [ 1 ] there is a statement to the effect that the lack of proper servicing and maintenance schemes may be ‘an area in which further guidance and consideration by the HSE will be required’. There is, therefore, ample
57
Downloaded by [] at 23:48 28 March 2016
Here, from Philips, are five answers to the problems of providing cardiac stimulation. Five All these instruments have been built such that you instruments that cater for just about every can use them quickly requirement, and also give you information and easily. And with vital to further treatment. The CMD 400 monitor defibrillator and SD 420 complete confidence. defibrillator are versatile, mains-operated units Because each one has been.thoroughly primarily intended for use inside the hospital. tested to ensure the And to help you deal with any emergency, no matter where or when it occurs, we’ve a choice utmost operational safety and dependability. If you’d like to know more about the Philips of portable monitor defibrillators, the BD 400 answers to the problems of cardiac stimulation, and BD 500. The fifth, and smallest instrument write now for our new cardiac resuscitation is a handy, easy-to-operate, external pacemaker, the TP 300, with many therapeutic brochure. It may have the answers you’ve been looking for. and diagnostic facilities.
@ 58
Medical Systems
PHIllPS Journal of Medical Engineering and Technology
Downloaded by [] at 23:48 28 March 2016
evidence that the matter of servicing and maintenance of equipment, both medical and scientific, is something with which the HSE is going to concern itself. Presumably, therefore, those employees within the service that have equipment in their control, and that may well include the doctor and nurse, will be held legally responsible for ensuring that it is properly maintained, because they have a duty to take reasonable care for the safety of themselves and any person who may be affected by their acts or omissions.They may well find themselves in a very similar position to that of a surgeon who operates in unsatisfactory conditions. Thus, some employees may find themselves in the unenviable, indeed impossible, position of not having the finance to enable them to undertake their legal obligations. As always, it is a matter of priorities. One can argue that if a patient is connected to a faulty machine it may be a matter of life or death. Similarly if one is unable to connect a patient to a renal dialysis machine because a machine, and/or supporting facilities and services are not available when the need for dialysis is imperative, that also is a matter of life and death. This, of course, leads to a discussion on the monetary value of a human life. Card & Mooney [4] estimated values of life based on several unrelated public policy decisions, such as legislation on tractor cabs and the decision not to introduce child-proof drug containers. The values varied between €50 and €20,000,000. One would like to think the decisions were right, although one cannot help but ask why there is such a wide range of values! But the question for consideration now is, should one spend €5,000,000 a year on creating good equipment servicing and maintenance schemes? To put this sum in perspective, it is negligible compared with the Office of Health Economics estimate of the cost of the Health Service in 1978 - €8,000,000,000 - or even with the cost of the nation’s drugs bill. It is very small compared with the sum of money spent now on the chaotic, ad hoc breakdown servicing that is undertaken. I well remember one manufacturer’s service engineer telling me, several years ago, that if I called him during the night it would cost €50 before he’d even got his trousers on! It is the same order of magnitude as the cost to the NHS of skateboarding accidents. Despite all the difficulties and the competing requirements, the inescapable conclusion to be drawn from the above discussion is that it is imperative that medical and scientific equipment be kept in good repair. This can only be done by means of effective in-house organised servicing and maintenance schemes, and an outlay of €5,000,000 a year for up to 2 years, by which time the schemes will be saving money, is really a very small price t o pay. The DHSS has recently indicated that it will be reveiwing with the HSE those findings of their pilot studies which could have significant capital expenditure implications for the NHS. [ 2 ] If the HSE suggests that major expenditure is required to bring a particular activity up to an acceptable standard, the Department “should be informed at once”. In view of the fact that, as mentioned above, servicing and maintenance of equipment is an area in which the HSE is going to give further guidance and consideration, one might expect that a statement to the effect that major expenditure is required to bring that particular activity up to an acceptable standard will be made and communicated to the DHSS: one could argue that the HSE has already done that! One hopes that possible future intervention by the HSE will not be used by the DHSS to delay pressing ahead. On its own admission in the draft Health Service Management document ‘Management of Equipment’, it is already well aware of the need to allocate what it considers to be ‘modest’ funds for this purpose without delay. (One has a sneaking feeling that it has in mind Regional and Area Health Authorities re-allocating their existing funds rather than it allocating additional funds for the purpose). Unfortunately Volume 3 No. 2 March 1979
many other ingredients of delay are there. The Health Service Management document is only a draft, and the mind boggles at the thought of the time it might take to decide if what is required is ‘modest resources’ or ‘major capital expenditure’; they are doubtless provided from different allocations.
Quite clearly, medical, scientific and technical staff from all regions, not simply the North West Thames, will have t o continue to express their concern about the interference or do-it-yourself repairs on equipment being carried out by staff without electrical o r electronics training, in the hope that the appropriate authorities will be persuaded to make available the finance required to overcome the problem. They will hopefully succeed before the laws governing the effects of electrical currents on the human body, and also the laws governing fire and explosion, infection and immunity, and so on, catch up with the unfortunate patients, and before the Law catches up with the unfortunate members of staff concerned. REFERENCES [l] Working conditions in the medical services. Pilot study. Health & Safety Executive, 1 Chepstow Place, London W 2 4°F [ 21 Health Circular HC (78) 30. Department of Health & Social Security, 157 Blackfriars Road, London SEl 8E1. [3] Lancet (1978),II, 586. [4] Card, W.I. and Mooney, C.H. (1977). BriffshMedical Journal, 2,1627.
Medical and scientific equipment in the UK National Health Service by J.C.A. Raison Some remarks on a briefing / I / published in the British Medical Journal. Dr.Raison is the Deputy Director (Medical and Scientific) at the National Radiological Rotection Board, H m l l , O x m He was formerly the Chief Scientific Officerat the Department of Health and Social Security.
Expenditure by UK Health Authorities on medical supplies and equipment in 1976-7 (exluding medicines) was of the order of E170m [2] Somewhere between 1/3 and 2/3 of this was spent on non-consumables which are of key interest to doctors and scientists. Very few are satisfied that the means for consideration, decision and purchase are sensible. The BMJ Briefing presents a clear ample description of the confusion of procedures, committees and persons involved: it deserves a full reading. Two questions must be in the mind of any would-be user of scientific equipment “What do I want?” and “What are they doing about my getting it?” It is a paradox of health care that the doctor usually insists on a redundancy of clinical data for decisions on his patient’s management but is usually woefully lacking in information to aid medical services management, including equipment provision: the same may be said of scientists. NHS reorganisation and the growth of professionalism in various administrative subdisciplines have only served to increase the viscosity of the decision-making mire of persons and committees involved. The reader may ponder whether his difficulties are any greater than those of someow in another region where the deliberations on equipment purchase, and the limits within which these must be couched to be treated as revenue or capital, are seemingly entirely different. The Briefing comprehensively surveys the wide variety:interestingly it
59
ISSN: 0309-1902 (Print) 1464-522X (Online) Journal homepage: http://www.tandfonline.com/loi/ijmt20
Medical and scientific equipment maintenance — to be or not to be! R. E. Trotman To cite this article: R. E. Trotman (1979) Medical and scientific equipment maintenance — to be or not to be!, Journal of Medical Engineering & Technology, 3:2, 57-59, DOI: 10.3109/03091907909161609 To link to this article: http://dx.doi.org/10.3109/03091907909161609
Published online: 09 Jul 2009.
Submit your article to this journal
Article views: 1
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmt20 Download by: [137.189.171.235]
Date: 28 March 2016, At: 23:48
bmment Medical and scientific equipment maintenance - to-be or not to be! by R.E. Trotman
Downloaded by [] at 23:48 28 March 2016
Dr. R.E. notman is a Consultant Editor of the J o m l of Medical Engineering and Technologv, and is in the Bio-Engneering Department at St. Mary’s Hospital Medical School, London W2
Following its introduction in the United Kingdom, the Health and Safety Commission considered the application of the Health & Safety at Work Act (1974) to some work activities that were covered by legislation for the first time. In consequence, the Health & Safety Executive (HSE) carried out pilot studies in certain work activities, to identify the hazards and the kind of safety problems likely to be encountered. One such study was undertaken of the hospital services by inspectors of the Factory Inspectorate, and their report [ 11 is now available. Their study was of hospitals in one National Health Service (NHS) region, the North West Thames, although a number of visits t o hospitals in Scotland were made and account taken of the differences in organisation of the health services in Scotland and in England and Wales. One of the most important statements made in the report was that the principal concern of medical and technical staff is the observed interference or ‘do-it-yourself ’ repairs on equipment mrried out by staff without electrical or electronics training. The statement referred to both patient connected and laboratory equipment. This is not the first time such concern has been expressed. There is many a scientist and engineer working in the NHS, and in other countries, who must be saying, or certainly could be saying, words to the effect that “I have been voicing my concern about that for years”. It is quite evident from this study that they have now been joined by their medical colleagues in expressing grave concern about the lack of properly organised servicing and routine maintenance facilities for all categories of medical and scientific equipment. It is well known that, in recent years, controversy has been raging over who should be responsible for organising and implementing such a scheme for sophisticated clinical and laboratory equipment: hospital engineers, who have always had responsibility for servicing and maintaining plant and ‘hotel’ equipment, some of which is very complex; or medical physicists and/or bio-engineers, many of whom have been actively involved in servicing and maintaining a variety of categories of equipment, particularly clinical measurement and radiation physics equipment, for several years. No doubt this controversy, which now seems to have died down because it has been realised that both categories of staff must, of necessity, play a part in the forseeable future at a n y rate, has resulted in delaying the introduction of effective schemes in some hospitals. But, I doubt very much if that has been the overriding factor in most cases. As is so often the case, a major cause of delay is lack of finance. The infuriating thing is that it is widely recognised that an efficient, in-house organised servicing and preventive maintenance scheme can save a lot of money. I say in-house orgunised scheme, because it probably is neither wise nor practical to completely dispense with manufacturers’ Volume 3 No. 2 March 1979
maintenance contracts and break-down servicing assistance. But, alas, in order to introduce even limited and rudimentary maintenance schemes, health authorities have to commit themselves to some new expenditure for the additional manpower and equipment necessary. They must actually spend a substantial sum of money some months or possibly a year or so before the financial benefits begin to accrue. In the present fiancial climate it takes courage to commit oneself, particularly when other equally essential improvements in the quality of service to the patient require similar commitments. The Department of Health & Social Security (DHSS) is taking this problem very seriously, as, indeed, are many Regional and Area Health Authorities in the United Kmgdom. The DHSS has recently circulated a draft Health Service Management document entitled ‘Management of Equipment’ for comment. The document discusses such matters as: choosing suitable equipment; acceptance testing; calibration, breakdown servicing and routine maintenance; planned replacement; and dissemination of information to user and manufacturer. This appears to be an extremely valuable document, and one can only hope that the process of consultation, final publication and implementation will be completed speedily. There is an urgent need for a formal policy on all facets of the management of equipment.
Allocation of funds The authors of this report indicate that a recent estimate of the total value of NHS equipment is €100,000,000 and suggest that the allocation of ‘modest resources’ to keep it in good repair “is not unreasonable, neither should it be too long delayed”. Modest may be assumed to be something of the order of €5,000,000 a year, since it has been found that on average the annual cost of in-house organised servicing and maintenance schemes is approximately 5% of the replacement cost of .the equipment (compared with an average of approximately 10% when one is entirely dependent on manufacturers). No doubt some people will say the DHSS often gives such helpful guidance, but since it rarely, if ever, forwards the cheque to make implementation possible one might as well forget it. Unfortunately the recent statement by the Department [2] that no additonal resources can at present be made available for general administrative costs arising from the Health & Safety at Work Act, will not remove their scepticism. Furthermore, there are those who are arguing that serious accidents due to faulty equipment are rare, so we need not worry too much. Fortunately, it is a fact that there are few serious accidents, but, in view of the state of some of the equipment one sees in use in hospitals, and of the way it is used, that is pure luck; many an unreported minor incident could so easily have been a serious accident, as could many unobserved incidents. But, make no mistake about it, serious accidents d o happen, and in recent years there have been two that were so serious that formal inquiries were held. Both reports commented on the poor way that servicing of equipment was organised. There is another aspect of the problem. It would appear that the HSE has indicated that inspectors do not intend (initially at least) t o concern themselves with medical or nursing care of patients, except so far as may be necessary when dealing with certain systgms of work or the fitness o f plant or equipment. [ 3 ] Furthermore, in the report referred to in the first paragraph [ 1 ] there is a statement to the effect that the lack of proper servicing and maintenance schemes may be ‘an area in which further guidance and consideration by the HSE will be required’. There is, therefore, ample
57
Downloaded by [] at 23:48 28 March 2016
Here, from Philips, are five answers to the problems of providing cardiac stimulation. Five All these instruments have been built such that you instruments that cater for just about every can use them quickly requirement, and also give you information and easily. And with vital to further treatment. The CMD 400 monitor defibrillator and SD 420 complete confidence. defibrillator are versatile, mains-operated units Because each one has been.thoroughly primarily intended for use inside the hospital. tested to ensure the And to help you deal with any emergency, no matter where or when it occurs, we’ve a choice utmost operational safety and dependability. If you’d like to know more about the Philips of portable monitor defibrillators, the BD 400 answers to the problems of cardiac stimulation, and BD 500. The fifth, and smallest instrument write now for our new cardiac resuscitation is a handy, easy-to-operate, external pacemaker, the TP 300, with many therapeutic brochure. It may have the answers you’ve been looking for. and diagnostic facilities.
@ 58
Medical Systems
PHIllPS Journal of Medical Engineering and Technology
Downloaded by [] at 23:48 28 March 2016
evidence that the matter of servicing and maintenance of equipment, both medical and scientific, is something with which the HSE is going to concern itself. Presumably, therefore, those employees within the service that have equipment in their control, and that may well include the doctor and nurse, will be held legally responsible for ensuring that it is properly maintained, because they have a duty to take reasonable care for the safety of themselves and any person who may be affected by their acts or omissions.They may well find themselves in a very similar position to that of a surgeon who operates in unsatisfactory conditions. Thus, some employees may find themselves in the unenviable, indeed impossible, position of not having the finance to enable them to undertake their legal obligations. As always, it is a matter of priorities. One can argue that if a patient is connected to a faulty machine it may be a matter of life or death. Similarly if one is unable to connect a patient to a renal dialysis machine because a machine, and/or supporting facilities and services are not available when the need for dialysis is imperative, that also is a matter of life and death. This, of course, leads to a discussion on the monetary value of a human life. Card & Mooney [4] estimated values of life based on several unrelated public policy decisions, such as legislation on tractor cabs and the decision not to introduce child-proof drug containers. The values varied between €50 and €20,000,000. One would like to think the decisions were right, although one cannot help but ask why there is such a wide range of values! But the question for consideration now is, should one spend €5,000,000 a year on creating good equipment servicing and maintenance schemes? To put this sum in perspective, it is negligible compared with the Office of Health Economics estimate of the cost of the Health Service in 1978 - €8,000,000,000 - or even with the cost of the nation’s drugs bill. It is very small compared with the sum of money spent now on the chaotic, ad hoc breakdown servicing that is undertaken. I well remember one manufacturer’s service engineer telling me, several years ago, that if I called him during the night it would cost €50 before he’d even got his trousers on! It is the same order of magnitude as the cost to the NHS of skateboarding accidents. Despite all the difficulties and the competing requirements, the inescapable conclusion to be drawn from the above discussion is that it is imperative that medical and scientific equipment be kept in good repair. This can only be done by means of effective in-house organised servicing and maintenance schemes, and an outlay of €5,000,000 a year for up to 2 years, by which time the schemes will be saving money, is really a very small price t o pay. The DHSS has recently indicated that it will be reveiwing with the HSE those findings of their pilot studies which could have significant capital expenditure implications for the NHS. [ 2 ] If the HSE suggests that major expenditure is required to bring a particular activity up to an acceptable standard, the Department “should be informed at once”. In view of the fact that, as mentioned above, servicing and maintenance of equipment is an area in which the HSE is going to give further guidance and consideration, one might expect that a statement to the effect that major expenditure is required to bring that particular activity up to an acceptable standard will be made and communicated to the DHSS: one could argue that the HSE has already done that! One hopes that possible future intervention by the HSE will not be used by the DHSS to delay pressing ahead. On its own admission in the draft Health Service Management document ‘Management of Equipment’, it is already well aware of the need to allocate what it considers to be ‘modest’ funds for this purpose without delay. (One has a sneaking feeling that it has in mind Regional and Area Health Authorities re-allocating their existing funds rather than it allocating additional funds for the purpose). Unfortunately Volume 3 No. 2 March 1979
many other ingredients of delay are there. The Health Service Management document is only a draft, and the mind boggles at the thought of the time it might take to decide if what is required is ‘modest resources’ or ‘major capital expenditure’; they are doubtless provided from different allocations.
Quite clearly, medical, scientific and technical staff from all regions, not simply the North West Thames, will have t o continue to express their concern about the interference or do-it-yourself repairs on equipment being carried out by staff without electrical o r electronics training, in the hope that the appropriate authorities will be persuaded to make available the finance required to overcome the problem. They will hopefully succeed before the laws governing the effects of electrical currents on the human body, and also the laws governing fire and explosion, infection and immunity, and so on, catch up with the unfortunate patients, and before the Law catches up with the unfortunate members of staff concerned. REFERENCES [l] Working conditions in the medical services. Pilot study. Health & Safety Executive, 1 Chepstow Place, London W 2 4°F [ 21 Health Circular HC (78) 30. Department of Health & Social Security, 157 Blackfriars Road, London SEl 8E1. [3] Lancet (1978),II, 586. [4] Card, W.I. and Mooney, C.H. (1977). BriffshMedical Journal, 2,1627.
Medical and scientific equipment in the UK National Health Service by J.C.A. Raison Some remarks on a briefing / I / published in the British Medical Journal. Dr.Raison is the Deputy Director (Medical and Scientific) at the National Radiological Rotection Board, H m l l , O x m He was formerly the Chief Scientific Officerat the Department of Health and Social Security.
Expenditure by UK Health Authorities on medical supplies and equipment in 1976-7 (exluding medicines) was of the order of E170m [2] Somewhere between 1/3 and 2/3 of this was spent on non-consumables which are of key interest to doctors and scientists. Very few are satisfied that the means for consideration, decision and purchase are sensible. The BMJ Briefing presents a clear ample description of the confusion of procedures, committees and persons involved: it deserves a full reading. Two questions must be in the mind of any would-be user of scientific equipment “What do I want?” and “What are they doing about my getting it?” It is a paradox of health care that the doctor usually insists on a redundancy of clinical data for decisions on his patient’s management but is usually woefully lacking in information to aid medical services management, including equipment provision: the same may be said of scientists. NHS reorganisation and the growth of professionalism in various administrative subdisciplines have only served to increase the viscosity of the decision-making mire of persons and committees involved. The reader may ponder whether his difficulties are any greater than those of someow in another region where the deliberations on equipment purchase, and the limits within which these must be couched to be treated as revenue or capital, are seemingly entirely different. The Briefing comprehensively surveys the wide variety:interestingly it
59
