<![CDATA[Gastroparesis Awareness Month: A Day In The Life]]>

My day starts when my morning caregiver arrives. I don’t just have gastroparesis. I have a variety of physical, cognitive, and developmental disabilities that make it so that I need help to do a lot of things to get through my day. So there are several times throughout the day when there is a caregiver here, the rest of the time there is one on call at short notice, and my day officially starts when the morning caregiver comes in the door.

My GJ feeding tube

The very first thing we do is start cleaning out my feeding tube. Nobody taught us to do this. This is something I learned how to do, in order to avoid having to keep getting it replaced due to clogs. I push water directly into the j-tube, then I pull it out again, over and over. Slowly, with the water come what we call “tube worms” — long wormy-looking pieces of food that have gotten stuck inside of the tube and would have caused a clog had we not got them out. We know the tube is running smoothly when we can push water through it without a certain amount of resistance pushing back at us. When we near that point, we stop and start concentrating on meds.

The first medication, and one of the most important ones that I take, is called Phenergan. I call it my butt pill — the medical term is suppository, but I always forget that word, so butt pill it is. They hand me the pill and a glove, and I turn around and stick it up my butt and wait for it to dissolve.

Me holding a “butt pill” — a Phenergan suppository — in a gloved hand.

Phenergan is one of six nausea medications I take to get through the day. Different people’s gastroparesis symptoms are different. Some people’s main symptom is pain and bloating. Mine is nausea, really bad nausea. So I am on no less than six nausea meds. The most important ones are Phenergan, Reglan, and Marinol. I also take Zofran, Benadryl, and Lorazepam for nausea.

Reglan works by making my digestive system move faster. The core trait of gastroparesis is that your stomach is partially paralyzed and moves too slow, failing to empty food into your intestines fast enough. Reglan is one of the few treatments that targets that slowness directly. Unfortunately I have intolerable side-effects at a full dose of Reglan, so I have to take a half-dose. I am hoping one day to be able to switch to domperidone, which I would have to order from outside the country. Domperidone is like Reglan, but it does not cross the blood-brain barrier so it has fewer side-effects. Not being FDA-approved, however, is a major obstacle to people with gastroparesis in the USA. It is approved in most other countries, though, so it’s possible to order it, according to my doctors anyway.

Marinol is derived from marijuana. I was highly skeptical of it at first because of that. But at the time they suggested it, I was on all five of my other nausea meds and still not able to come home from the hospital. Marinol often works where all other nausea meds have failed. It does not generally get you high, although it can have other unpleasant side-effects like anxiety and paranoia. I luckily have had few side-effects, no high, just a huge reduction in nausea.

Zofran is a nausea medication often given to people on chemotherapy. I don’t understand what the big deal is supposed to be, though. Unless I combine it with Benadryl or Lorazepam, it really doesn’t do a lot for me on its own. And I’ve heard the same from a lot of other people with gastroparesis. Zofran is a pill that dissolves under my tongue, so I don’t have to swallow it or put it through the tube. That’s the one benefit is it’s fast-acting and easy to ingest.

Benadryl and Lorazepam are more well known as an allergy medication and an anxiety medication. However, Benadryl is closely related to Dramamine, a well-known nausea med, and has anti-nausea effects itself. Lorazepam, likewise, has anti-nausea effects. These are medications I take for multiple reasons, both the nausea side and the allergy and anxiety side. I take a fixed dose, but I also can take them PRN, meaning whenever I have extra nausea and need more medication than I would normally take. Which happens most days.

My caregiver removes the drainage bag from my g-tube. Overnight, I always wear a drainage bag that drains the contents of my stomach into a bag. Before I did this, I my bile used to build up in my stomach because it wasn’t getting passed along down to my intestines. Then it would creep up my esophagus, into my throat, and I’d wake up choking on it. I’d cough it out for over an hour sometimes, sometimes having to call an ambulance if I had enough trouble breathing. I have bronchiectasis, a form of COPD that basically ensures any time I aspirate enough stomach fluid, I’m going to get aspiration pneumonia or at least some other lung infection. So this was a big deal, and it was happening several nights a week. With the drainage bags, and other drainage practices, I only get aspiration pneumonia a few times a year. Which is still too much, but it’s a drastic cutback and gives my odds of surviving into old age a much-needed edge.

After we’ve removed my tube feeding pump and cleaned out my tube, we mix up my medications. Most of my medications are in liquid form, the best form for a j-tube because j-tubes are easily clogged. We use a syringe to put the medications in. The j-tube has two syringe ports, one for a small syringe and one for a larger one. You hold closed whichever one you’re not using, or you can get sprayed in the face.

Inserting medication into the small port on my j-tube.

After meds, put Diet Coke into both of the tubes and let it soak for ten minutes or so. This helps dissolve any clogs. Hot water is supposed to be as good as coke, so we flush it with hot water afterwards.

Then we do something that polite people call ‘venting’, but the nurse that taught me calls it ‘burping’ and the idea fits. You open up the g-tube over a cup. We have a designated green Burp Cup. I recommend yellow or green cups to camouflage the color of the bile a bit. What nurses teach you to do, is put the cup under the tube, unclamp the tube, and unscrew the cap. What’s supposed to happen then is all your stomach fluids flow out of the tube and into the cup. But it’s not that simple.

My burp cup with some liquid in it, and a syringe in front of it.

Here are some of the things I have to do in order to properly burp enough air and fluid for it to actually empty properly and prevent aspiration. Some of these things could damage the wrong kind of tube. So don’t just do something because I wrote about it here. But here are the kind of things I do during a burp:

Understand that some of these are things that no doctor would ever recommend you do to your tube. And since each tube is different, what I’m doing above might destroy another type of tube. So my advice if you have a tube, is get to know your tube really well before you do anything unusual to it, and get to know your body, too. Some of the things I do could also make a person really sick in the wrong circumstances. In fact it sometimes makes me sick, if for instance I swallow a lot of air but I can’t get it to come out the tube.

Then we dump the contents of the Burp Cup in the toilet (which is every bit as gross-looking as it sounds), rinse it out a few times and keep dumping that in the toilet, and then fill it up with soapy water and set it on the back of the toilet to soak. Without the soapy water, it starts to really reek after awhile.

Soon enough it’s time for more medications. Those work the same way the original ones worked: They go in through the j-tube. And this is also where my tube feeding starts.

I’m fed a formula called Osmolite. It’s basically a pre-mixed formula, it’s the same every day. It’s beige and it smells and tastes gross, but luckily I don’t have to smell and taste it. It looks exactly like what we used to feed the baby birds at the wildlife rehab center I used to work at. Anyway, a j-tube is different from a g-tube in some important ways when it comes to feeding.

A bottle of Osmolite hanging inside of its backpack.

A g-tube goes to your stomach. Your stomach is designed to take in large quantities of food at once. That means that your stomach is capable of stretching to accommodate your food. People who are fed by g-tube can often be fed simply by pushing lots of food in by syringe, all at once.

But a j-tube goes to your intestines. Your intestines are not able to stretch to accommodate the food you need to eat. So you need to be fed extremely slowly. For me, this means I’m on a feeding pump. It gives me 45 milliliters of food per hour. Ideally, I would get 90 mL per hour, but that made me really sick, so I use 45. This means that it takes 24 hours to feed me the whole container of food. So I have a backpack the feeding pump and the Osmolite live in, so if I have to go anywhere, I can just wear it on my back.

The feeding pump itself is just a little box that attaches to a tube going out from the Osmolite bottle. The pump slowly moves the food into my intestines, keeping it at a constant rate day in and day out. I sometimes give myself a few hours of break in the morning, but other than that I am constantly eating, and feel neither full nor empty.

An Enteralite Infinity feeding pump, inside its backpack.

The only time I’ve felt hunger has been since going on steroids for severe adrenal insufficiency. Steroids can cause such intense food cravings that I end up eating small things and having to drain them out of my g-tube to avoid aspirating them. I’ve talked to my doctors and they say I’m not to blame for this, because it’s a known side-effect of dexamethasone. I just have to be careful.

The feeding tube has to be set up properly. The tube is connected to the Osmolite bottle, wound through the backpack and into the pump, then wound out through another hole in the side of the backpack. Then it’s plugged into my j-tube. The settings have to be cleared so the pump knows it’s a new bottle, and not the same old one. If it thinks it’s the old bottle, it will stop feeding me early. Then we have to make sure it’s still set to the right feeding speed. Then we “prime” it by pressing a button to move the food through the tube quickly. And then we plug the tube into my j-tube and turn it on.

Putting the Osmolite tube into the large port of my feeding tube.

Putting the tube from the Osmolite bottle into the large port on my j-tube.

The Osmolite tube connected to my feeding tube.

If anything goes wrong with the feeding, there are a bunch of different, loud alarms that will go off. There’s two separate alarms for problems with food flow, one for trouble with food flowing into the pump, one for trouble with food flowing out of it. There’s another alarm for if it runs out of food, and another alarm for when the feeding is supposed to stop. And an alarm for if you plugged it in but forgot to turn the pump on. The main thing they have in common is that they are very loud, annoying, and impossible to ignore.

After my feeding is set up, the next big part of my routine is another butt pill. I have an alarm clock set for that. The alarm clock is out of my reach, so in order to get to it I have to move out of my bed. This is enough of a prompt that usually I can go get the butt pill and insert it into my rectum with no problem. My problem is with initiating actions, and the alarm clock placed out of my reach helps me initiate.

Standing in the kitchen holding up a butt pill (Phenergan suppository) in its wrapper.

At some point, a different time each day, a licensed nursing assistant (LNA) comes in to help me bathe. The first thing she does is clean the mucus, and sometimes blood, off of my stoma site (the area where my feeding tube enters my body). And then we decide how much else of me to wash. Washing is very painful for me, so I often opt to only wash the most essential parts and put medicated lotions on, and deodorant. I need help washing because of a movement disorder, although even as a child I was never good at bathing and I went through a lot of pointless and humiliating training about bathing in mental institutions as a teenager.

I don’t have daily mealtimes, because I am eating literally all day and all night. The closest I have is a series of medication routines, and there are people here who help me perform those. They involve mixing up medications and putting them into my j-tube in a certain order. That kind of thing is too complicated for me to do on my own. I can do maybe one medication, if I’m lucky, but I can’t do the huge number of meds that are required for my daily routine.

The people who come to help me out basically do nearly everything for me. They either help me do the thing entirely, or they help me get started. For instance, there are many things that I can’t do on my own, but that I could do if you handed me the materials to do it with. Like I would not be able to go into the bathroom and pick up deodorant and put it on, but if you hand me the deodorant I can put it on. This is because of problems initiating associated with my movement disorder. So I get anything from assistance with starting things, to total assistance, and it all depends on what I need that day.

I wear a drainage bag on my g-tube during afternoons and evenings. It collects everything from inside my stomach. It has an accordion that you press down, and as the accordion pulls itself out again, it pulls the liquid and gas out of my stomach. As long as I keep pressing the accordion as it comes out, it will keep sucking in bile. Then when someone gets here, they can dump all the bile in the toilet and wash out the drainage bag with vinegar and water. I have devised a number of ways to keep the drainage bag in good shape so that I can use it over and over again for months at best, even though they are single use only. They cost $80 and aren’t covered by insurance, so we have to be creative.

Drainage bag connected to my g-tube, contents pretty full.

The evening routine is much like the morning routine, including burping the g-tube manually, and a lot of medications at different times. There’s also a bunch of things, like physical therapy, that don’t have much to do with the gastroparesis or feeding tube at all. I’ve needed services to survive for longer than I’ve had gastroparesis, and I’d still need them even if I didn’t have gastroparesis. It’s just that right now, a good deal of my daily routine does revolve around gastroparesis.

Night is the scariest time for me with gastroparesis. This is the time when I am most likely to aspirate. What happens is usually that something goes wrong with the drainage bag, and it isn’t draining as much as it should. This usually means a blood clot or something is stuck in the tube, preventing bile from exiting my stomach. So the bile goes up into my esophagus. I have central and obstructive sleep apnea and sleep with a bipap machine that blows air into my lungs. When the bile goes into my esophagus, the bipap blows it down into my lungs. I wake up choking and coughing.

Me wearing my bipap mask at night.

Then, I usually spend at least an hour coughing up bile. If it’s bad enough that I can’t breathe, I have to call 911. But often I just sit on the bathroom floor with a wad of tissues and cough up bile and throw them away as fast as humanly possible, trying to get it all out of my lungs. I have a condition called bronchiectasis that makes it easy for me to get lung infections and hard for me to clear lung infections. So every time I have a bad enough aspiration, I have to go on antibiotics immediately. The goal is to prevent aspiration pneumonia, although usually I get aspiration pneumonia anyway and the antibiotics just help me fight it off in the end. Right now, as I’m writing this, I have aspiration pneumonia for the second time in the past year. But I’m doing better than ever because I’m able to treat it properly now.

But the good news is that with the feeding tube, I’ve gone from aspirating several nights a week, to aspirating several nights a year. Any aspiration is too much aspiration, but with the feeding tube I have the chance to live a lot longer than I was going to live without it.

The very last thing that happens in my day is a very early-morning phone call and alarm clock. It’s the Phenergan suppository again. That Phenergan suppository is the bedrock of my anti-nausea regime, and it’s vital that I get every single dose. The Phenergan, Reglan, and Marinol are the most important nausea meds and I never skip a dose, ever. It gets to the point that I look forward to sticking that Phenergan pill up my butt because I know how much better I’ll feel afterwards. And as someone who doesn’t like anything put up any orifice where it doesn’t belong, that says a lot.

Gastroparesis is a really weird disease in some ways. One of the weirdest parts of it, is that the severity of your symptoms has no correlation to the severity of your delayed stomach emptying. So someone can have a severe stomach emptying delay but barely any symptoms. Someone else can have a mild stomach emptying delay but very severe symptoms. I’m someone who has (as far as we could determine) a mild to moderate stomach emptying delay, but severe enough symptoms that I require a feeding tube both for the nutrition and to avoid aspiration.

Also, different people have different symptoms. Here is a description of gastroparesis taken from one of the common gastroparesis awareness ribbons:

Paralysis of the stomach that is estimated to affect 5 million Americans with no cure and few treatments. Foods eaten take hours or even days to leave the stomach leading to nausea, pain, vomiting, malnutrition, bloating, weight issues, and more. It does not mean that you are not hungry… it means that you are starving but cannot eat the food right in front of you.

Gastroparesis is a rare, debilitating disease that literally means paralysis of the stomach. When someone with Gastroparesis eats, the food stays in their stomach for hours or even days. Symptoms of Gastroparesis include = Severe abdominal pain, gastro reflux, vomiting, nausea, feeling full after eating very little, bloating, heartburn, unintentional weight gain, unintentional weight loss, malnutrition and much more. There is currently very few treatments and no known cure for Gastroparesis.

But even within those lists of symptoms, different people experience different things. Some people lose a lot of weight. I lost a total of 70 pounds overall. Other people gain a lot of weight, or lose weight and then gain it back again as their body enters starvation mode and tries to hang onto what calories it can. Some people’s main symptom is pain and bloating. My main symptom is nausea and loss of appetite. I had such severe nausea that even before I got the feeding tube, I couldn’t make myself drink enough Ensure to survive, until they put me on six different nausea medications.

Something I see very often in the online support groups, is people getting substandard care for gastroparesis. Their doctors don’t understand gastroparesis, so they don’t understand how to treat it.

One of the biggest mistakes doctors make is to assume that the person’s symptoms will only be as bad as the delay in stomach emptying. As I mentioned earlier, severity of symptoms is, for reasons not entirely understood, not well-correlated with the delay in stomach emptying. It may be that there are other things, like problems with the vagus nerve, that cause the more severe symptoms some people report even when their stomach is emptying relatively fast for a person with gastroparesis.

But at any rate, I see way too many people struggling to keep enough food down to maintain a healthy weight, but being told by doctors that everything is okay because their emptying delay is not very severe.

I also see a lot of people whose doctors give up on nausea medication before they even start. Just to give you a clue, this is what my nausea medication looks like.

Every day, I take six different nausea medications. I take Reglan (which is not just a nausea medication, but also speeds up your stomach), I take Zofran, I take Phenergan suppositories, I take Marinol, I take Benadryl, and I take Ativan. You may not know that Benadryl and Ativan treat nausea, but they do. And it is the combination of those medications that got me out of a five-week-long hospital stay a couple years ago. Marinol was the final addition. I had been afraid to take it because it’s derived from marijuana, but it doesn’t get me high and I have no real side-effects from it. Marinol often helps people with nausea who can’t be helped by any other medication, and I fell into that category. I was already on five medications, which were helping somewhat, but only the addition of Marinol allowed me to leave the hospital without a feeding tube, and stay home without a feeding tube for several months.

Six different nausea medications of various types

All of my nausea meds: Dronabinol (Marinol), Q-Dryl (Benadryl), Metoclopramide (Reglan), Lorazepam (Ativan), Phenadoz (Phenergan), and Ondansetron (Zofran).

What I see happening to other people, though? Their doctor offers them a little Zofran or Reglan, maybe both if they’re lucky. Then, if they don’t improve sufficiently, they’re told they are out of luck, and there’s nothing more the doctor can do. I understand the risks of prescribing six different medications that are all sedating in their own ways. But it’s also a huge risk to allow your patient to starve to death because they can’t keep food down. Many times these are people who won’t need feeding tubes, people who won’t need any drastic interventions, all they need is something to keep the nausea under control. And their doctors won’t experiment with combinations of drugs for that. They just give up after the first one or two fail.

I also see a lot of people whose doctors simply don’t know much about gastroparesis and won’t do much to find out about it. So they won’t get referred for the best treatments, or they’ll get referred to a specialist who also doesn’t know much about gastroparesis. And they’ll get passed around in circles by doctors who don’t know what to do with them, getting sicker and sicker along the way.

People who have multiple health conditions tend to have the most trouble getting good healthcare, and gastroparesis is often the results of another health condition. Diabetes is a common cause of gastroparesis. Some eating disorders can result in gastroparesis. In my case, we suspect it’s caused by an autonomic neuropathy that runs in my family. But we don’t know. When I was diagnosed with severe secondary adrenal insufficiency, we had a lot of hope that the gastroparesis symptoms would go away, because adrenal insufficiency can mimic gastroparesis. But the symptoms didn’t go away. I gained a little weight back on steroids, but that’s all. Now we’ve found out through single-fiber EMG testing that my mother and I have a neuromuscular junction disease, probably something like myasthenia gravis. We also have some form of hypermobility syndrome, which can sometimes be tied to a connective tissue disorder, which sometimes can be tied to gastroparesis.

And I’ve noticed among the support groups that most people with gastroparesis are like me: They have a complicated medical history with a good deal of diagnoses that are connected in ways that aren’t fully understood. There’s people with mitochondrial disease, there’s people with Ehlers Danlos and related syndromes, there’s people with eating disorders, there’s people with adrenal insufficiency, there’s people with diabetes, there’s people with neuromuscular junction diseases, there’s people with autonomic dysfunction, and there’s even people with several of these things at once. And the more things we have, the less our doctors seem to understand what’s going on. I’m lucky to have a dedicated team of specialists for all of my conditions, who are willing to work together to keep me alive. Without them I wouldn’t be here right now.

There have always been some doctors who felt like my life wasn’t worth saving, or that things weren’t as bad as they actually were. The doctors I’ve kept are the ones who have done the lung x-rays and CAT scans to prove I had pneumonia and bronchiectasis, the ones who did the gastric emptying studies to prove I had gastroparesis, the ones who did the blood tests to prove I had adrenal insufficiency, the ones who did the EMG to prove I had a myasthenia-like syndrome. Basically, the ones who have gone out and gotten the proof to fight anyone who says either “This kind of patient isn’t worth keeping alive,” or “She’s exaggerating her symptoms, it can’t be that bad,” or “She’ll never be able to take care of a feeding tube anyway.”

I’m not usually a big fan of awareness days, awareness months, and that kind of thing. But there are things I make an exception for, and gastroparesis is one of them.

I went for years with gastroparesis symptoms before I was properly diagnosed and treated. In fact, the first time I was hospitalized for gastroparesis, was something like five years before I was diagnosed. They put me on medications for “chronic nausea” and didn’t do any further looking for the source of the nausea.

If I had been diagnosed and treated earlier, there’s a chance that it would never have gotten as bad as it is now. There’s a chance that I wouldn’t need a feeding tube, that I wouldn’t have gotten aspiration pneumonia eight times in one year, that I wouldn’t have entered adrenal crisis from the illnesses that followed that.

Because for someone with a complex medical history, one thing is never just one thing. Gastroparesis causes me to have bad reflux. The treatments I use for sleep apnea cause me to aspirate that reflux at a higher rate than normal. Bronchiectasis causes that aspiration to result in pneumonia pretty much every time. Adrenal insufficiency means that getting sick with pneumonia puts me into adrenal crisis without treatment. Everything builds on each other until it’s actually pretty surprising that I’m alive at this point.

Gastroparesis can be pretty bad even if you don’t have a complicated medical history. But as I said above, most people I know with gastroparesis do have a complicated medical history. Whether it’s eating disorders, diabetes, mitochondrial dysfunction, adrenal insufficiency, Ehlers Danlos, autonomic dysfunction, or some unholy union of many of these things, people with gastroparesis rarely seem to come with just one disease. And that makes it even more important that people know what gastroparesis is, and what it looks like, so they can do something about it.

By the time I was diagnosed, I had been living on grits, crackers, and broth for weeks and had lost forty pounds. They didn’t believe me about how little I was eating until they saw me fail to eat anything at all for weeks in the hospital. In their eyes, a fat person must be eating, even if that fat person was losing catastrophic amounts of weight. It’s even worse for people with gastroparesis who experience weight gain as part of the symptoms, because anyone who has eating problems and is gaining weight has less likelihood of being believed by doctors, even though medicine knows perfectly well why this happens.

There were a few things that should have been big red flags for me, but I simply didn’t know enough to understand their significance.

One of them was that when I threw up, I would often throw up food from a long time ago. Like from up to three days ago. I just kind of assumed that the food was coming from somewhere really far down my digestive tract, but it was actually sitting in my stomach all that time.

Another one was that I always felt better if I didn’t eat, or barely ate, for days at a time. There were times when I’d live on small amounts of broth, oatmeal, and grits for weeks or months at a time, and I always felt much healthier afterwards. Most people don’t feel healthier after barely eating anything for a long time.

The constant nausea should have been a red flag, too. But I was so used to weird symptoms that I honestly didn’t even think to classify that as especially weird.

Also, I had motility problems in other areas of my gut. Ever since childhood, I had bad constipation, sometimes to the point of bowel impaction and blockages requiring emergency room trips and hospitalizations. As an adult, they found that my esophagus had reduced motility as well, that it didn’t move food as fast as it should. So my bowels move slowly, my esophagus moves slowly, it shouldn’t be a surprise that my stomach moves slowly as well. But for some reason they never looked at that until that five-week hospitalization.

And what happened during that five-week hospitalization? I’d aspirated again and gotten pneumonia. I was very weak from not eating, from myasthenia-related reactions to vomiting, and from an impending adrenal crisis. And I demanded that they keep me in the hospital until they figure out why I couldn’t eat, and figured out a way for me to get adequate nutrition again.

They got serious about it then. They diagnosed the gastroparesis, although they wouldn’t do the final testing for another couple months. They started me on that intense nausea medication regime. They tried a bunch of antibiotics that are supposed to speed up your gut, but they just made me more nauseated. And they started seriously considering a feeding tube. Marinol is the only reason I didn’t get a feeding tube right then and there, from what I’m told.

At any rate, if you want to know more about gastroparesis, I’d urge you to visit the G-PACT (Gastroparesis Patient Association for Cures and Treatments) website, which deals with gastroparesis and related motility disorders and digestive tract paralysis. If this sounds like you or anyone you know, please get help, because the longer you go without treatment, the less they can do in the end. There aren’t a lot of treatments for gastroparesis, and the more extreme the gastroparesis, the more extreme and invasive the treatment is. So you want to know if you have it, as early as possible. The treatment I have — a feeding tube — is actually middle-of-the-road for gastroparesis treatments. It’s invasive, but it can be removed, and you can still eat if you have one. The most invasive treatments involve things like a stomach pacemaker, or removing your stomach entirely. So you don’t want it to get that bad before you get treatment.

And it’s one of those diseases nobody seems to have heard about. Which is one reason that I think awareness is important. I know that the disability rights movement has a million different critiques of awareness, including the idea that it pits different diseases against each other. But if I had simply known a few years before, what I learned when I was diagnosed, I could have been spared a lot. I’m lucky to be alive, given the combination of diseases I have, and I’m far from the only person with gastroparesis whose health is fragile like that. So I think it’s more important to get the word out than to do what the disability rights movement tells me to do about awareness months. For things like this, awareness months are really important, because we haven’t got any other way of spreading the word to people who need to hear it. If any of what I’ve written here, or in my last post, helps even one person, that will be enough.