The St.Emlyn’s Podcast

The Sintervenants Podcast: July Highlights - Game Theory, PTSD, Epinephrine Trials, and More Hello and welcome to The Sintervenants Podcast. I'm Simon Kelly, and today I’m going to guide you through the exciting developments in July. While we all enjoy the summer weather, there’s a lot more to discuss beyond vacations. Here’s what’s been happening in the world of emergency medicine. Game Theory in Emergency Medicine: Finite and Infinite Games This month, we delve into a fascinating post by my colleague, Craig Ferguson, about game theory and its application in emergency medicine. This concept revolves around finite and infinite games, an idea rooted in game theory, which you might recognize from the film A Beautiful Mind. The book it’s based on is also highly recommended for those interested in deeper insights. Understanding Finite and Infinite Games Finite games, such as chess, have known rules, defined endpoints, and players aware of their roles. Conversely, infinite games, like a soccer league, continue indefinitely. In these games, the objective is to stay in the game, continually evolving and adapting until resources are exhausted or other external factors intervene. Application in Healthcare In healthcare, particularly emergency medicine, Craig highlights the challenges posed by infinite games. Emergency medicine is an infinite game with no definitive endpoint. The objective is to keep going, continually providing care without a final goal. However, health service management often imposes finite rules, such as performance targets and time-based metrics. These finite measurements can clash with the infinite nature of healthcare, creating challenges and unintended consequences. For example, measuring patient flow and quality of care through finite metrics in an emergency department doesn’t account for the complex, non-linear nature of healthcare systems. Changes in one area can lead to unforeseen issues in another, complicating the overall performance and outcomes. Craig’s post has shifted my perspective on my shifts, especially during challenging times. It’s not about meeting arbitrary targets but understanding the infinite game we’re playing. Recognizing this can alleviate some pressure and help focus on continuous improvement rather than finite measures. Rusty Carroll's Insights on PTSD Another compelling post this month comes from Rusty Carroll, a clinician who has openly shared his journey with PTSD. His series, "Keep Walking: PTSD and Me," provides a candid look at the early stages of PTSD and the challenges of maintaining a facade of normalcy while dealing with underlying trauma. The Reality of PTSD in Emergency Medicine Rusty’s experience highlights the temptation and necessity for many clinicians to keep going despite severe emotional and psychological strain. The work-play-sleep-repeat cycle can mask serious issues, preventing individuals from seeking the help they need. This series aims to help those who haven't experienced PTSD understand the lived experiences of those who have, offering insights into coping mechanisms and the importance of addressing mental health openly. Emergency medicine professionals often face traumatic events, making Rusty’s story particularly relevant. Understanding these experiences can foster empathy and support within the community, encouraging those struggling to seek help without fear of stigma. The Controversy Over Epinephrine in Cardiac Arrest In July, we also reviewed a significant trial on the use of epinephrine in out-of-hospital cardiac arrest, published in the New England Journal of Medicine. This British-led trial by the paramedic two collaborators, spearheaded by Gavin Perkins, has been highly anticipated due to ongoing debates about the efficacy of epinephrine (commonly known as adrenaline in Manchester) in such cases. Key Findings of the Trial The randomized controlled trial involved over 8,000 participants and focused on patients who had not responded to initial defibrillation. The primary outcome measured was the survival rate at 30 days, showing a survival rate of 3.2% in the epinephrine group compared to 2.4% in the placebo group. While this suggests a significant benefit in terms of survival, the secondary outcomes raise ethical questions. Severe impairment, measured by the modified ranking scale, was more common among survivors in the epinephrine group. This finding complicates the interpretation of the results, as it indicates that while more patients survive, many suffer from severe neurological impairment. Ethical Implications The ethical dilemma here is whether increasing survival rates justifies the higher incidence of severe impairment. This question extends beyond medical practice into the realm of medical ethics and societal values. As clinicians, our goal is neurologically intact survival, aligning with public preferences for quality of life over mere survival. Despite the trial’s insights, it doesn’t provide a definitive answer. As practitioners, we must weigh these findings carefully, considering the broader implications for patient care and quality of life. Upcoming Events and Updates Teaching Power Course We’re excited to announce that the Teaching Power Course in October is almost sold out. By the time this post goes live, it might already be fully booked, which is fantastic news. This course, held in Manchester, promises to be a valuable learning experience for all attendees. Sintervenants Live Conference Tickets are still available for the Sintervenants Live Conference on October 9th. We’ve designed this event to be both affordable and enriching, featuring an international faculty that you won’t find at any other one-day course in the UK. Don’t miss this opportunity to join us for an exciting day of learning and networking. Practical Insights: Managing Paronychia Lastly, I’d like to highlight an insightful post by Natalie May on the management of paronychia. While not as high-profile as other topics, paronychia is a common and painful condition that we don’t always manage effectively in the ED. Effective Treatment Strategies Natalie’s review examines the formation of paronychia and the best treatment options. Our previous small randomized control trial suggested that lifting the nail fold is more effective than incision and drainage. Natalie’s findings support this approach, advocating for less invasive methods to alleviate pain and promote healing. Key tips include soaking the affected area and using appropriate tools to lift the nail fold gently. For more severe cases, inserting a small wick can aid healing by allowing drainage without creating a new wound. Natalie also advises on recognizing conditions that mimic paronychia, such as osteomyelitis or tendon injuries, ensuring comprehensive and accurate treatment. This practical advice can significantly improve patient care in emergency settings, providing quick relief and better outcomes for those suffering from this common ailment. Conclusion July has been a month of significant insights and developments in emergency medicine. From exploring game theory and its application in healthcare to understanding the complexities of PTSD and navigating the ethical dilemmas of epinephrine use in cardiac arrest, we’ve covered a wide range of topics. These discussions underscore the dynamic and challenging nature of our field. By continually learning and adapting, we can improve our practices, support our colleagues, and ultimately provide better care for our patients. Thank you for joining us on The Sintervenants Podcast. Keep an eye on our blog and podcast for more updates and insights. If you’re attending our events in October, we look forward to seeing you there. Until then, stay engaged, stay informed, and keep making a difference in the world of emergency medicine.

The Evolution of IV Fluid Therapy: A Critical Review Welcome to St Emlyn's blog. Today, we explore the evolving landscape of intravenous (IV) fluid therapy in pediatric care. I'm Simon Carly, and I had the privilege of discussing this topic with Dr. Steve Playful at the Royal Manchester Children's Hospital. We delved into the historical context, current practices, and future directions of IV fluid therapy. Here's a comprehensive review of our discussion. Historical Context of IV Fluids in Pediatrics The use of IV fluids in pediatrics has undergone significant changes over the years. Approximately 20 years ago, the standard practice involved administering hypotonic fluids to children. This practice was rooted in research from the 1950s that misjudged children's electrolyte and fluid requirements, leading to widespread use of solutions like 0.18% saline with 5% glucose. However, this approach had its drawbacks. While individual practitioners might not have frequently observed issues, numerous instances of iatrogenic hyponatremia leading to cerebral edema and death highlighted the risks. This spurred a reevaluation of IV fluid therapy practices in pediatrics. Transition from Hypotonic to Isotonic Solutions By the late 1990s, concerns about the dangers of hypotonic solutions grew. In 2006, the National Patient Safety Agency in the UK formed a group to address these concerns. They concluded that most children could safely receive half-normal saline as maintenance fluid, except in high-risk situations, marking a significant shift from previous practices. The pediatric community started adopting isotonic solutions, such as normal saline. However, normal saline (0.9% sodium chloride) presents its own issues. Despite its name, it is not truly "normal" as its sodium content is slightly higher than plasma levels, and its chloride content is about 60% higher. Moreover, the pH of normal saline is around 5.5, far from physiological levels. Emergence of Balanced Solutions Balanced solutions have emerged as a promising alternative to both hypotonic and isotonic solutions. Designed to more closely mimic the body's natural plasma, solutions like Ringer's lactate and Plasma-Lyte have gained popularity in the UK. These balanced solutions are buffered with substances like acetate or gluconate to maintain a more physiological pH. Plasma-Lyte, for instance, is available with and without dextrose, making it versatile for different clinical scenarios. These solutions are typically better tolerated and associated with fewer complications compared to normal saline. The Debate: Saline vs. Balanced Solutions The debate over the optimal type of IV fluid for pediatric patients continues. Recent studies, including large international trials, suggest balanced solutions are associated with fewer complications than normal saline. These complications include hyperchloremia, which can lead to acute kidney injury and other adverse outcomes. Despite these findings, normal saline remains the most commonly administered IV fluid worldwide. This persistence is largely due to tradition and established practices. Changing these deeply ingrained habits requires substantial evidence and updated clinical guidelines. Key Studies and Evidence Several studies highlight the benefits of balanced solutions over normal saline. Research indicates that balanced solutions result in less acidosis and fewer chloride level shifts without demonstrated harm. However, not all studies show significant differences. The SPLIT trial, for instance, did not find a marked difference between the two fluid types, though this study had limitations, including uncontrolled pre-enrollment fluid administration and varying severities of illness among patients. Future Directions in IV Fluid Therapy As we look ahead, several areas of interest in IV fluid therapy emerge. One key question is which balanced solution is optimal for pediatric patients. Current options include fluids buffered with acetate and gluconate versus those buffered with lactate. Further research is needed to compare these solutions directly. Another potential development is the inclusion of bicarbonates in balanced solutions. Stabilizing bicarbonates in plastic containers has been challenging, but advances in technology may eventually make this possible, offering a more complete balanced solution. Practical Recommendations For clinicians, the decision on which IV fluid to use should be guided by the latest evidence and tailored to the patient's needs. Here are some practical considerations and recommendations: Review the Evidence: Stay informed about the latest research comparing saline and balanced solutions. Reflect on the pathophysiological basis for each type of fluid. Consider the Patient's Condition: For most pediatric patients, balanced solutions are likely safer and more effective. However, specific clinical scenarios may require different approaches. For instance, patients with pyloric stenosis or certain nephrological conditions may benefit from tailored fluid compositions. Monitor and Adjust: Fluid therapy should always be closely monitored and adjusted based on the patient's ongoing needs and responses. This includes considering electrolyte levels, acid-base balance, and overall clinical status. Educate and Advocate: Part of the challenge in shifting to balanced solutions is overcoming established practices and resistance to change. Educate colleagues and advocate for evidence-based practices within your institution. Conclusion The evolution of IV fluid therapy in pediatrics mirrors broader trends in medical practice: the quest for safer, more effective treatments, and the need to challenge established norms with new evidence. While much remains to be learned, current evidence strongly supports the use of balanced solutions over traditional saline in most pediatric scenarios. As clinicians, it's our responsibility to stay informed and adapt practices based on the best available evidence. By doing so, we can improve patient outcomes and advance the field of pediatric medicine. For those interested in further reading, many of the studies discussed are blogged about on our site. Explore these resources for more detailed discussions and links to original research. Stay informed, stay curious, and continue striving for excellence in your practice. Thank you for joining us on this deep dive into IV fluid therapy. We hope this discussion has provided valuable insights and practical recommendations for your clinical practice. As always, we welcome your thoughts and feedback on this important topic.

Exploring the World of Emergency Medicine: Highlights from BadiM and Resuscitology Conferences Welcome to the St Emlyn's podcast! Today, we're diving into the exciting and insightful experiences from recent conferences in the world of emergency medicine. Join us as we explore the key takeaways and reflections from the BadiM Conference in South Africa and the Resuscitology Conference in Australia. These events not only highlighted innovative approaches to emergency care but also fostered a sense of community and collaboration among healthcare professionals. Setting the Scene: Weather and Warm Welcomes As is customary, let's start with a quick weather update. It was a pleasant 16 degrees in Verchester, and similarly, New South Wales enjoyed beautiful blue skies at 16 degrees. The crisp air and clear skies set a perfect backdrop for our discussions on the latest developments in emergency medicine. BadiM Conference: A Unique Experience in South Africa The BadiM Conference in Greaten, South Africa, was a truly remarkable event. Located about two hours east of Cape Town, the conference was set in the picturesque hills, creating a beautiful and serene environment for learning and networking. This residential conference was a blend of a festival and a professional gathering, fostering a sense of community among attendees. Building a Festival of Ideas One of the standout aspects of the BadiM Conference was its emphasis on community and co-creation. Attendees camped in tents, shared meals, and engaged in discussions in large TP-style tents. This setting broke down traditional power hierarchies and encouraged open and honest conversations. The conference aimed to build a festival atmosphere where learning extended beyond formal sessions to informal interactions over coffee or drinks. Addressing African EMS Challenges The conference kicked off with a focus on African EMS and the unique challenges faced in delivering emergency care in resource-limited settings. Haikert's talk on African solutions for African problems was particularly enlightening. She emphasized the importance of developing context-specific solutions rather than applying models from high-income countries directly to African contexts. This approach highlighted the need for mutual learning and collaboration, ensuring that solutions are relevant and sustainable. The Concept of Relief Porn A thought-provoking concept discussed was "relief porn," which refers to the well-intentioned but often misguided efforts of delivering aid without considering long-term sustainability. The idea is to avoid short-term fixes that may not integrate well into existing systems. Dave Drew's discussion on teaching BLS underscored the importance of building comprehensive systems rather than isolated interventions. Advocacy and Clinician Responsibility Nat Fertil's talk on the role of clinicians as advocates resonated deeply. Drawing parallels between working in a war zone and addressing complex health needs in urban settings, she emphasized the importance of standing by patients who cannot advocate for themselves. This advocacy extends beyond clinical care to addressing social determinants of health. The Gender Unicorn: Caring for LGBTQIA Patients Caleb Lachnitz's talk on the Gender Unicorn and caring for LGBTQIA patients was a highlight. He stressed the need for healthcare providers to understand and respect diverse gender identities and expressions. The Gender Unicorn graphic, which differentiates between gender identity, gender expression, sex assignment at birth, and attraction, was a valuable tool in fostering better understanding and care for LGBTQIA patients. Day Two: Workshops and Practical Learning The second day of the BadiM Conference was workshop-focused, providing hands-on learning opportunities. Feedback in Tricky Circumstances We conducted a workshop on giving feedback in challenging situations. This session aimed to equip participants with skills to provide constructive feedback, even in difficult scenarios. We discussed techniques for addressing behavioral issues and ensuring feedback is productive and empowering. Treating Pregnant Patients and Pediatric Emergencies Penny Wilson's talk on treating pregnant patients was reassuring, emphasizing that treating the mother is often in the best interest of the baby. Ross Fisher's engaging session on pediatric emergencies, specifically addressing foreskin issues, provided practical insights for managing these conditions in the emergency department. Tracheostomy Emergencies in Children A session on tracheostomy emergencies in children, led by James Booth and his team, highlighted the importance of patient education and family collaboration. In settings where community services may be limited, working closely with families is crucial to managing chronic health problems effectively. Ophthalmology and Trauma Care Ophthalmology in remote settings and trauma care were also significant topics. Innovative Ophthalmology Solutions William Mapperman's presentation on using the Vula app for managing eye problems in remote areas showcased the power of electronic media in enhancing healthcare delivery. This app has significantly improved the quality of eye care across South Africa and other African nations. Chest Trauma and Autotransfusion Tim Hardcastle's discussion on chest trauma and the use of drains for autotransfusion was enlightening. This technique, which involves collecting and retransfusing blood from a hemothorax, is a practical solution in resource-limited settings with high rates of penetrating trauma. Managing Coagulopathy and Intubation in Shocked Patients Debates on managing coagulopathy and intubating profoundly shocked patients provided valuable insights. Emphasizing the importance of doing the basics well, such as using TXA and maintaining temperature, was a key takeaway. For intubation, using low doses of ketamine and high doses of rocuronium, along with preparing for cardiovascular collapse, were highlighted as best practices. Human Factors and Emotional Resilience Human factors and emotional resilience were recurring themes throughout the conference. The Impact of Violence and Trauma Dom Pinnick's talk on gangs and domestic violence in South Africa shed light on the broader societal impact of violence. The discussion underscored the need for emergency departments to be prepared for the complex emotional and physical needs of these patients. Sleep Hygiene and Self-Care Natalie May's session on sleep hygiene was a timely reminder of the importance of self-care. Sharing personal experiences and practical tips, she highlighted the universal challenges of sleep deprivation in the medical profession and offered strategies to improve sleep quality. Super Bosses: Leading with Compassion Sardlery's talk on being a "super boss" resonated with many. Emphasizing the importance of amplifying the talents of team members and creating a positive environment, he highlighted the role of compassionate leadership in emergency medicine. Final Day and Closing Reflections The final day of the BadiM Conference was a half-day, focusing on simulation workshops and additional learning opportunities. Simulation Workshops and Major Incident Management Simulation workshops, including a major incident workshop, provided hands-on learning experiences. Discussions on managing major incidents, such as the Manchester bombing and a fuel tanker explosion in Mozambique, highlighted the importance of having a common language and system for emergency management. Venomous Plants and Animals A workshop on venomous plants and animals featuring actual snakes and spiders added a unique and context-specific element to the conference. Understanding local environmental hazards is crucial for providing effective emergency care in different regions. Organ Donation and Cruise Ship Medicine Dave Thompson's session on organ donation in South Africa and Caroline Lewis's talk on working on cruise ships provided diverse perspectives on emergency medicine. These sessions emphasized the need for specialized skills and adaptability in various medical settings. Personal Stories and Patient Safety Kirsten Kingma's personal story of crashing a paraglider and subsequent injuries provided a poignant reminder of the vulnerability of healthcare providers as patients. Her insights into the patient experience underscored the importance of empathy and effective communication in healthcare. Resuscitology Conference: Reflective Learning in Australia The Resuscitology Conference, organized by Cliff Reed, was another standout event. Held in the Blue Mountains of Australia, this residential course focused on case-based reflective learning. Case-Based Learning and Human Factors Participants brought challenging resuscitation cases, which were discussed in detail using the STEPS approach (Self, Team, Environment, Patient, System). This method facilitated deep learning and practical problem-solving. Fresh Air Life and Wellness The concept of "Friluftsliv" (fresh air life) was integrated into the conference, encouraging outdoor activities and wellness. This holistic approach to learning and self-care was well-received by participants. Breaking Bad News and Debriefing One significant takeaway was the idea that breaking bad news does not always have to be the responsibility of the treating clinician. This team-based approach allows for emotional support and cognitive load sharing. The importance of debriefing and support for team leaders was also emphasized. Looking Ahead: Future Conferences and Learning Opportunities As we reflect on these enriching experiences, we're excited about upcoming events. The St Emlyn's Live Conference on October 9th promises to be another exceptional gathering, featuring keynote speakers Natalie May and Claire Richmond from Sydney HEMS. Additionally, the Teaching Co-op Course will offer a masterclass in medical education, focusing on practical skills for bedside teaching and departmental learning. For those interested in Resuscitology, the next event is scheduled for November 15th and 16th. This innovative course will continue to build on the success of its inaugural session, providing a platform for reflective learning and collaboration. The Value of Conferences in Emergency Medicine While conferences can sometimes be seen as mere gatherings, the evolving quality and focus on interactive, participant-driven content have transformed them into valuable learning experiences. Events like BadiM and Resuscitology highlight the importance of community, collaboration, and continuous improvement in emergency medicine. Thank you for joining us on this journey through the world of emergency medicine conferences. We hope to see you at future events, whether in Manchester or Sydney and continue to learn and grow together. Until then, enjoy your practice, stay curious, and keep pushing the boundaries of emergency care.

Kevin McRey Jones, an esteemed editor and originator of the APEX course, joins to discuss the critical need for structured training in acute psychiatric emergencies. He highlights the significant gap in emergency medicine's approach to psychiatry compared to physical health crises. The conversation delves into the APEX course's innovative AEIOU framework, emphasizing the importance of integrated psychiatric assessments alongside physiological care. Jones also covers the challenges of managing psychiatric presentations and the necessity for mental health leadership in emergency departments.

St Emlyn's Podcast: April Review and Key Insights Welcome to the St. Emlyn’s podcast, your monthly source for insightful discussions and reviews from the world of emergency medicine. I’m Iain Beardsell, and alongside me is Simon Carley. In this edition, we're diving into the posts we’ve covered on our blog in April. After a grueling winter, we are finally catching up. We’re recording this in May, and it's a significant achievement for us. Let’s delve into the highlights and key takeaways from April. Catching Up with St. Emlyn’s Firstly, Simon and I are thrilled to be back on track. The sun is shining, signaling the end of winter here in the UK, and we’re embracing the spring warmth. Before we dive into the specifics, Simon, you’ve been traveling quite a bit recently. Can you share some of your experiences? Travels and Learnings from Graz, Austria Simon: Indeed, Iain. Recently, I had the privilege of visiting Graz, Austria, a beautiful city where I was invited by the NordDoc and the Austrian Society of Emergency Medicine. We attended the ninth Congress, or as they say in German, "Abit's Goermanneshaft for Notfallmedizin." It was an enlightening experience, despite my initial challenges with the language. The hospitality in Graz was exceptional, and the city itself is stunning. Emergency medicine in Austria is still in its nascent stages, but the enthusiasm and energy among the young physicians were palpable. The simultaneous translation during presentations was a unique experience. I also conducted sessions on feedback and ultrasound teaching, which were well-received. Iain: That sounds incredible, Simon. It’s always inspiring to see how different countries are integrating emergency medicine into their healthcare systems. Let’s move on to the main topics we covered in April. Key Highlights from April's Blog Posts Feedback and Coaching in Emergency Medicine Iain: One of the key discussions in April was about feedback and coaching, a topic Simon presented in Austria. Feedback is crucial for continuous improvement in emergency medicine. Simon, can you elaborate on your main messages from the talk? Simon: Absolutely, Iain. Feedback is essential for growth, and there are three main types: appreciation, coaching, and evaluation. One common issue is when these types are confused. For instance, after a challenging night shift, if a consultant gives a detailed coaching session instead of simple appreciation, it can be demoralizing. It’s crucial to match the feedback to the context and needs of the receiver. This ensures the feedback is purposeful and effective. Understanding Diagnostic Tests: Beyond Black and White Rick's post from April 10th delved into the nuances of diagnostic tests, emphasizing that results are not merely positive or negative but often fall into a gray area. Simon, can you shed more light on this? Simon: Diagnostic tests in emergency medicine are indeed complex. Take troponin levels, for instance. A troponin of 2000 is vastly different from a troponin of 15, although both might be labeled positive. Understanding the probabilistic nature of diagnostics is crucial. Rick's post does a fantastic job explaining this with examples, especially around acute coronary syndrome. We use a T-max calculator in Manchester to determine the likelihood of ACS based on various factors, including troponin levels. This probabilistic approach is vital for accurate diagnostics. Lessons from the War: Insights from Ashley Liebig and Noah Galway Another powerful post in April was Ashley Liebig's discussion with Noah Galway about their experiences during the Iraq war. Their insights provide a stark contrast to typical emergency department scenarios. Iain, what stood out to you in this post? Iain: The personal bond formed between Ashley and Noah through shared traumatic experiences is profound. Unlike the typical patient-doctor dynamic in emergency departments, battlefield medicine creates a deep, enduring connection. This post reminded me that the emotional and psychological impacts of medicine are just as significant as the physical treatments. Noah’s journey, from experiencing trauma to achieving remarkable feats like participating in the US version of Strictly Ballroom, is truly inspiring. Pediatric Trauma and the Use of Whole Body CT We also discussed the use of whole-body CT in pediatric trauma patients. Simon, can you summarize the findings from this journal club article? Simon: Certainly. Whole-body CT is a common practice in adult trauma but its utility in pediatric trauma is questionable. A multi-center cohort study from the National Trauma Data Bank in the US found that focused CT is often more appropriate for children. In Manchester, we rarely perform whole-body CTs on pediatric patients unless there's a significant mechanism of injury. The radiation risks and the lower incidence of severe injuries in children make focused CT a safer and more effective choice. Complications of Anticoagulation: Managing Bleeding Risks Dan Horner's professorial lecture on the complications of anticoagulation and how to manage them was another highlight. Simon, what were the key takeaways from Dan's talk? Simon: The sheer number of patients on anticoagulants in the UK, approximately 660,000, underscores the importance of this topic. Bleeding is a significant risk, and managing it, especially with the newer DOACs, is challenging. Dan provided practical advice on handling bleeding complications, including when specific antidotes are unavailable. Understanding these risks and management strategies is crucial for emergency physicians. Top 10 Trauma Papers: Insights and Innovations In another significant event, I presented the top 10 trauma papers at the Trauma UK conference. This talk was later featured on the Resusary podcast with Simon Lang. It's always a pleasure to delve into the latest research and innovations in trauma care. Iain: That sounds fantastic, Simon. For those interested, the blog post contains all the details and links to the podcast. If you have any suggestions or think we've missed some crucial papers, do let us know. Penetrating Trauma in Philadelphia: Lessons from the Frontline Zak Stein, who trained with us in Manchester and now works in Philadelphia, shared insights on penetrating trauma. Interestingly, patients arriving by police or private vehicle have higher survival rates compared to those transported by ambulance. Simon, what are your thoughts on this practice? Simon: The practice in Philadelphia highlights the time-critical nature of penetrating trauma. Quick transport to the ED, even by police or private vehicle, can significantly improve survival rates. In the UK, scene times can be prolonged, especially if the scene is unsafe. This practice makes us reconsider our approach to time-critical conditions. It's a balance between ensuring safety and providing timely care. The Resuscitationist’s Guide to Health and Wellbeing Our final post in April was the launch of "The Resuscitationist’s Guide to Health and Wellbeing," a comprehensive resource compiled from our blog posts. Simon, this has been a significant project for you. Can you tell us more about it? Simon: This book is part of our ongoing effort to promote wellbeing among emergency medicine professionals. It includes practical tips on managing night shifts, reflective pieces on coping with difficult situations, and much more. Wellbeing is one of the four pillars of St. Emlyn’s, along with the philosophy of emergency medicine, evidence-based medicine, and clinical excellence. We hope this book will be a valuable resource for our community. It’s available for free, so please read and share it widely. Conclusion and Future Directions April was a busy month for us at St. Emlyn’s, filled with travel, conferences, and insightful blog posts. We’re excited about what’s coming up in the future. We have a busy summer ahead, including the emergency surgical skills course with Caroline Leach in Manchester and our St. Emlyn’s live and teaching co-op course in October. Tickets are selling fast, so grab yours soon. Before we sign off, a quick mention of the Bad E.M. Fest, which was a spectacular event. We’ll discuss it in more detail in future posts and podcasts. For now, you can read the four blog posts we’ve published about it so far. Iain: It’s always fun to chat with you all. We hope everyone is enjoying the spring sunshine and looking forward to the summer. Simon, any final thoughts? Simon: Just one, Iain. Are we the only emergency medicine podcast that talks about the weather at the beginning and end of every episode? It seems like the most British thing ever. Iain: It's hugely important, Simon. Maybe next time, we’ll focus entirely on the weather! Until then, enjoy the sunshine and take care, everyone. Thank you for joining us for this edition of the St. Emlyn’s podcast. Stay tuned for more insights and discussions, and don’t forget to check out our blog for the latest posts and updates.

March 2018 Roundup: Evidence-Based Medicine and Exciting Announcements at St Emlyn's Welcome to the Centeminine's podcast monthly roundup for March 2018! This post delves into key highlights from our blog, discussing critical topics in evidence-based medicine and sharing exciting upcoming events. Let's dive in! Catching Up After Winter As the harsh winter fades, we’re catching up with several important topics from March. Despite the seasonal lag, there's a lot happening in the world of evidence-based medicine. Our blog has been buzzing with insightful posts, and we encourage you to explore the rich content we have curated for you. Exciting Upcoming Events Before diving into March's blog posts, let's highlight some exciting events on the horizon. We are thrilled to announce St Emlyn's Live and the Teaching Course in Manchester. If you're planning your study leave for the next 12 months, these are opportunities you won't want to miss. St Emlyn's Live St Emlyn's Live is shaping up to be an unmissable event. Scheduled for October in Manchester, this event promises a blend of learning and fun, with the added bonus of Manchester's unique charm—where the sun always shines (psychologically and philosophically, if not literally). Check our website for more details and secure your spot. We’re putting immense effort into making this event exceptional, ensuring it’s worth both your time and money. The Teaching Course in Manchester Alongside St Emlyn's Live, we have our renowned Teaching Course in Manchester. As you consider your professional development for the year, keep in mind the benefits of attending a well-structured, impactful course like ours. We're confident you'll find it a valuable investment in your career. Evidence-Based Medicine: The Great IV Fluid Debate One of the standout topics in March has been the ongoing debate over IV fluids in critically ill patients. This subject stirs significant anxiety and diverse opinions across departments and even within the same hospital. The Normal Saline vs. Balanced Fluids Debate The crux of the debate revolves around whether to use normal saline or balanced fluids such as Hartmann's or Plasmalyte. The evidence to date has been mixed, leading to differing practices. Our colleagues down under published the SPLIT trial a few years ago, finding no significant difference, but the sample size at the time limited the conclusions. Recent Trials in the New England Journal of Medicine Recently, two significant trials published in the New England Journal of Medicine have shed more light on this issue. These trials investigated the effects of balanced crystalloid versus saline in critically ill patients and emergency department patients admitted to the wards. Cluster Randomized Trials The trials used a cluster randomized design, where units were randomized to administer either balanced crystalloid (lactated Ringer's or Plasmalyte) or saline for a period before crossing over. With over 15,000 participants in each study, the findings are quite robust. Key Findings The trials revealed a small but significant difference in major kidney events in the critical care group (14.3% vs. 15.4%), suggesting a potential benefit of balanced fluids. While the mortality difference was not as pronounced, these results could have important implications for global intensive care practices. Practical Implications in Emergency Medicine As emergency physicians, how do these findings influence our practice? Over the past few years, there's been a shift towards more frequent use of balanced solutions, driven by a sound physiological rationale. Although the exact clinical significance of hyperchloremic acidosis from saline remains debated, the pathophysiological argument for balanced fluids is compelling. Local Practices and Preferences In our practice, preferences vary. For instance, our neurointensive care unit favors saline for patients with specific neurological issues, as explained in a podcast with Dr. John Hell from Southampton. For general use, Hartmann's is often the go-to solution. Teaching the Next Generation We emphasize the importance of fluids in emergency medicine to our new doctors. With only four main treatments—oxygen, analgesia, antibiotics, and fluids—it’s crucial to administer fluids effectively. While the choice of fluid might not be critical initially, ensuring the right volume is given can make a significant difference. The Teaching Course in Cape Town Another highlight from March was the successful teaching course in Cape Town. This course will be replicated later this year in Manchester, offering an excellent opportunity for hands-on learning and professional growth. Success in South Africa The Cape Town course was a resounding success, providing valuable insights and skills to all participants. The feedback was overwhelmingly positive, highlighting the course's effectiveness and the enriching experience it provided. Chris Weymouth’s Experience Chris Weymouth, a UK-trained physician, shared his experience working in a rural South African hospital. His story underscores the importance of structured and well-supported international placements. Such experiences not only enhance clinical skills but also foster personal growth and resilience. Cardiac Arrest: Predicting Outcomes with Pupil Responses Our final major topic for March revolves around predicting outcomes in cardiac arrest, specifically through pupil responses. This topic, close to our hearts, is critical for making informed decisions during resuscitations. The Study from France A recent study from France, analyzing over 11,000 cardiac arrests, examined whether early pupil responses could predict outcomes. The findings were intriguing but not definitive. Sensitivity and Specificity The study found that the absence of a pupillary light reflex is a poor prognostic sign, but with only 72% sensitivity and 68.8% specificity, it’s not conclusive enough to base critical decisions on. The Gray Areas in Resuscitation Deciding when to stop resuscitation remains one of the most challenging aspects of emergency medicine. While some cases are clear-cut, many fall into a gray area, making it difficult to determine the right course of action. ECPR and Prolonged Arrests With emerging technologies like ECPR (Extracorporeal Cardiopulmonary Resuscitation) and reports of remarkable recoveries from prolonged arrests, the decision to stop becomes even more complex. In young patients with no prior morbidity, the stakes are even higher, and the decision requires careful consideration and often consultation with colleagues. Upcoming Events and Final Thoughts As we wrap up our March roundup, we look forward to several upcoming events and ongoing discussions. The St Emlyn's team will be speaking at the Retrieval Conference in Scotland in April, and we have a variety of summer events lined up. Join Us at St Emlyn's Live Don't forget to join us at St Emlyn's Live in October. This event promises to be a highlight of the year, offering a blend of cutting-edge medical insights and networking opportunities. Check our website for all the details and secure your spot today. Stay Tuned for More We'll be back in May with updates on April's posts and more engaging content. Until then, keep enjoying your emergency medicine practice, take care of yourselves and your patients, and stay connected with the St Emlyn's community. Conclusion March has been a month filled with significant developments in evidence-based medicine, exciting course announcements, and thought-provoking discussions. As always, our goal is to provide you with the best possible insights to enhance your practice and support your professional growth. Thank you for being part of the St Emlyn's community. We look forward to engaging with you through our blog, podcasts, and upcoming events.

The Physician Response Unit (PRU) is an innovative service in East London that takes the emergency department to the patient. The PRU is led by Tony Joy, consultant in emergency medicine and prehospital care and is a fairly unique service to the UK. In this podcast our very own Richard Carden interviews Tony for an in depth understanding of how the service is supporting the entire emergency care system in London. You can read more about the PRU here https://londonsairambulance.co.uk/our-service/news/2017/10/remodelled-pru-to-be-a-seven-day-service-for-the-first-time and look out for a blog post on the St Emlyn's blog site very soon.

Monthly Update from St. Emlyn’s: Insights into Emergency Medicine Welcome to the St. Emlyn’s podcast blog! I’m Ian Beardsell, and alongside Simon Cully, we're here to bring you our monthly update. This post will delve into February's content, upcoming events, and the latest discussions in emergency medicine. Winter Challenges and Patient Updates Winter has been relentless this year, and we're still feeling its impact. The influx of patients hasn't slowed down, and our departments are buzzing with activity. Up in Manchester, we continue to see a high volume of patients, while down south, the weather has been kinder, though no less busy. As a Yorkshireman, I can empathize with the challenges faced in the North. Hang in there, and let's get through these cold evenings together! Upcoming Events: St. Emlyn’s Live and Teaching Course Before diving into February's posts, let's talk about the exciting events we have lined up. This October, we're hosting the St. Emlyn’s Live conference and the Teaching Course in Manchester. St. Emlyn’s Live Conference The St. Emlyn’s Live conference is a one-day event focused on our philosophy's four pillars: clinical work, evidence-based medicine, wellbeing, and the philosophy of emergency medicine. With international speakers, this event promises to be an enriching experience for all attendees. Spaces are limited, so make sure to book your spot early via our website. Teaching Course in Manchester Following the conference, we have a three-day Teaching Course designed to develop you as an expert teacher in emergency medicine. This comprehensive course covers all aspects of teaching and is an excellent opportunity to enhance your skills. All bookings can be made through the St. Emlyn’s website. Insights from February’s Blog Posts February was a month rich with valuable insights and studies. Let's delve into some of the highlights: Intranasal Ketamine and Fentanyl for Children One of the standout studies we reviewed in February focused on the use of intranasal ketamine and fentanyl for managing pain in children. Pain management in pediatric patients is always challenging, especially when IV access is difficult. Traditionally, we've used intranasal diamorphine, but there's been a shift towards using intranasal ketamine and fentanyl, particularly in the US. Study Overview This randomized controlled trial compared 1 mg/kg of intranasal ketamine against 1.5 mcg/kg of intranasal fentanyl in children aged 4 to 17 with suspected isolated extremity fractures. The primary outcome was pain reduction, and both drugs performed similarly in this regard. Side Effect Profiles The key takeaway was the difference in side effect profiles. Ketamine is known to cause dysphoria, vomiting, and dizziness, while fentanyl has fewer unpleasant side effects. Therefore, fentanyl emerged as the preferred choice not because of superior pain relief but due to its more favourable side effect profile. Practical Implications The study underscores the importance of having a streamlined protocol for intranasal medications in emergency departments. While some departments might still use syringes, investing in mucosal atomizer devices can simplify administration and improve patient care. Engaging Medical Students in Emergency Medicine We had a guest blog from Claire Bromley, a medical student working with us in Manchester. Claire shared her experiences and insights into why she chose emergency medicine as a career, despite the occasional negativity she faced from other specialties. Building a Career in Emergency Medicine Claire's blog is an inspiring read for medical students considering a career in emergency medicine. She highlights the importance of engaging students in the department and ensuring they see the undifferentiated, unwell patients that characterize our specialty. Her experiences as a SMACC volunteer and her early involvement in FOAMed (Free Open Access Medical Education) are testaments to the value of early engagement and online education. The Role of Educators One of the significant challenges we face is balancing the educational needs of students with the operational demands of the department. However, investing time in student education is crucial. These students are our future colleagues, and their early exposure to emergency medicine can shape their career choices and prepare them for the challenges ahead. Aromatherapy with Isopropyl Alcohol for Nausea A fascinating study we reviewed involved the use of isopropyl alcohol for nausea relief. The concept of sniffing alcohol swabs to alleviate nausea isn't new, but this study provided robust evidence supporting its effectiveness. Study Design and Results The randomized controlled trial compared the effects of isopropyl alcohol sniffing to oral ondansetron in adult patients presenting with nausea in the emergency department. The results were surprising: patients who sniffed isopropyl alcohol swabs reported greater relief from nausea than those who took ondansetron. Implementation Challenges While the study's findings are promising, implementing this practice consistently in emergency departments can be challenging. Ensuring that alcohol swabs are readily available and that staff are trained to use them effectively is key. Additionally, clarifying whether a Patient Group Directive (PGD) is required for this intervention could streamline its adoption. Reflections on Historical Practices One of the lighter yet insightful pieces this month was a video from the 1970s showcasing a casualty department in Liverpool. Watching historical medical practices can be both amusing and educational, offering a perspective on how far we've come and what future generations might think of our current practices. Educational Value While humorous at times, the video also highlights the core principles of emergency medicine that remain unchanged. It reminds us of the importance of continuous learning and adaptation in our field. Looking Ahead: SMACC 2019 and Beyond As we look forward to the year ahead, we’re excited about the upcoming SMACC conference in Australia in 2019. Planning for study leave and participation in such international conferences is essential for continuous professional development. These events provide unparalleled opportunities for learning, networking, and sharing best practices. Conclusion February has been a month filled with valuable insights, studies, and preparations for future events. The emphasis on pain management in children, engaging medical students, and innovative approaches to nausea relief reflects our ongoing commitment to improving patient care and education in emergency medicine.

Surviving a Relentless Winter: Reflections and Insights from St. Emlyn's Welcome Back to the St. Emlyn's Podcast Welcome to the St. Emlyn's podcast. I'm Iain Beardsell, and I'm Simon Carley. We are delighted to be back with you after what can only be described as a rather tricky winter. The winter season has always been challenging for emergency departments across the UK, but this year felt especially relentless. In this blog post, we will reflect on the past few months, share key insights, and look forward to exciting events on the horizon, including the St. Emlyn's Live conference. The Winter Struggle: A Nationwide Challenge Down south in our emergency department, we have faced significant challenges. Iain shared his experiences: "We have been having a heck of a time. It has been a real struggle. I'm utterly exhausted, and it has only been in the last couple of weeks that it felt like we could breathe again." The situation has been similarly difficult up north. Simon echoed these sentiments: "It's been a bit grim up north, to be honest. This winter felt different, harder. The emergency departments in the UK have always had problems over winter, but it has felt more relentless this year." Unprecedented Pressure and Relentless Demand We didn't have much of a summer to recuperate, and the winter was relentless day in and day out. Our department saw unprecedented pressure, with patient numbers pushing us to our limits. Interesting statistics from our department showed consecutive days of being over capacity, creating concerns about patient care and safety. Despite the exhaustion, we managed to maintain a high standard of care, with complaints remaining at normal levels and even receiving more compliments than usual. Coping Strategies and Positive Outcomes Maintaining patient care while looking after ourselves has been a challenge. We have implemented various strategies to keep on track, from educational events to incredible clinical work. Reflecting on our achievements, Simon highlighted the importance of continuing education and maintaining healthcare standards even under pressure. "We have done some amazing things over the winter, and it is something we can be really proud of," he said. Understanding Public Perception and Political Activity The public's understanding of the pressures in the healthcare system has increased, although tolerance for the challenges faced remains limited. Political activity over the winter saw clinical leads writing to the Prime Minister, and emergency medicine frequently made the front pages of newspapers. However, recent events, such as the nerve agent attack in Salisbury, have shifted the focus away from A&E crowded corridors, providing some relief. Looking Forward to St. Emlyn's Live We have many exciting events coming up this year, including the highly anticipated St. Emlyn's Live conference. Scheduled for Tuesday, the 9th of October in Manchester, this one-day conference will bring us out from behind our microphones and keyboards to present live. The event promises to be hugely cost-effective, with an incredible lineup of speakers from around the world, including Claire Richmond from Sydney Hems, Natalie May, Salim Rezy from the US, and Kat Evans from South Africa. Interactive Learning and Cost-Effective Education We have designed St. Emlyn's Live to be an interactive conference, reflecting everything we aim for in our podcasts and blogs. The conference is priced at £150 for consultants, with discounts available for trainees, registrars, doctors in training, allied health professionals, nurses, and medical students. Given the limited venue size, we expect tickets to sell out quickly, so we encourage early booking. Post-Conference Teaching Course For those looking for more in-depth learning, we are hosting a teaching course on the 10th and 11th of October, directly after the conference. This course focuses on practical education techniques, helping clinician educators improve their teaching skills. It has been highly acclaimed by previous participants, offering a transformative learning experience. Reflecting on Clinical Medicine and Evidence-Based Practice At St. Emlyn's, we value reflection and evidence-based practice. In January, we covered several important topics on our blog, including devastating brain injuries, dizzy patients, and the adrenal trial. Let's delve into these discussions and see what we can learn. Devastating Brain Injuries: Updated Guidance One of the critical topics we discussed was devastating brain injuries. Historically, decisions about the prognosis of patients with severe traumatic injuries or subarachnoid bleeds were often made too quickly, based on initial CT scans. However, recent guidance suggests that we should not make precipitous decisions about patient outcomes solely based on early imaging. In summary, it's essential to give these patients at least 24 to 72 hours before making a prognosis. This allows time for clinical outcomes to become more apparent. In our hospital, we transfer these patients to neuro-intensive care and have a proactive organ donation program, ensuring patients and their families receive the care they deserve. Differentiating Dizziness: Central vs. Peripheral Causes Another challenging area in emergency medicine is dealing with patients presenting with dizziness or vertigo. Differentiating between central causes, such as posterior circulation strokes, and peripheral causes can be difficult but crucial. We highlighted the importance of understanding the difference and utilizing tests like the HINTS exam to aid diagnosis. As emergency physicians, we must continue to educate ourselves on these diagnostic tools. Utilizing resources like the St. Emlyn's blog, YouTube, and FOAMed can help us stay updated and improve patient care. It's essential to be comfortable revisiting and revising our knowledge to ensure accurate diagnoses and appropriate treatment plans. The Importance of Reflection in Medical Practice Reflection is a powerful tool for lifelong learning and self-improvement. Despite recent controversies, such as the case involving a junior doctor in Leicester, we must not abandon reflection. It helps us increase self-awareness, think critically about our practices, and improve our clinical skills. Natalie May's blog post on reflection emphasizes that it's not just about ticking boxes but about purposeful and structured thinking. Her insights from Sydney Hems highlight the importance of integrating reflection into our daily practice to enhance our growth as clinicians. The Adrenal Trial: Steroids in Septic Shock The adrenal trial, reviewed by Dan Horner, examined the use of steroids in septic shock. Published in the New England Journal of Medicine, this trial aimed to determine whether steroids improve outcomes in these patients. The results showed no significant difference in mortality, although some secondary outcomes, such as vasopressor use and ICU days, showed variations. The trial highlights the complexity of medical treatment and the need for continuous learning and evaluation. It reminds us that while some treatments may show promise, their benefits might not always be clear-cut. This underscores the importance of evidence-based practice and staying informed about the latest research. Embracing Continuous Learning and Collaboration Emergency medicine is a dynamic and ever-evolving field. At St. Emlyn's, we are committed to continuous learning, sharing knowledge, and improving patient care. The challenges of winter have tested our resilience, but they have also shown the importance of collaboration, education, and maintaining high standards of care. We encourage our readers and listeners to stay engaged with our content, participate in upcoming events, and continue striving for excellence in their practice. The St. Emlyn's Live conference and the teaching course are excellent opportunities for professional development and networking with peers from around the world. Conclusion: Looking Ahead with Optimism As we move forward into the spring and summer, let's take a moment to reflect on the lessons learned and the progress made. The past winter was tough, but it also demonstrated our ability to adapt, innovate, and support one another. With exciting events like St. Emlyn's Live on the horizon, we have much to look forward to. Thank you for being part of the St. Emlyn's community. Stay connected, stay curious, and let's continue to learn and grow together. Here's to a bright and hopeful future in emergency medicine.

The Importance and Practice of Debriefing in Emergency and Critical Care Debriefing is a crucial process in healthcare settings, particularly in emergency and critical care units. It involves structured discussions following critical events to help teams learn from their experiences and support each other's psychological well-being. This process is not just about operational reflection but also about addressing the emotional impact of challenging situations on healthcare professionals. Understanding Debriefing Debriefing can take two primary forms: hot debriefs and formal debriefs. Hot debriefs occur immediately after an event and focus on operational aspects, such as what happened, what went well, and what could be improved. They are concise and do not delve into the psychological aspects of the incident. These debriefs are valuable for capturing immediate lessons and determining if further, more comprehensive discussions are necessary. Formal debriefs, on the other hand, are conducted five to seven days post-event. This delay allows participants to process initial emotions, making it a more suitable time for in-depth discussions. Formal debriefs cover both operational details and psychological reactions, providing a safe space for staff to express their feelings and thoughts. They are essential for long-term learning and emotional healing, ensuring that the team can move forward positively. Timing and Setting The timing of debriefing is critical. While hot debriefs capture immediate reflections, formal debriefs should not be rushed. Conducting them too soon can be ineffective, as participants might still be too emotionally charged to engage constructively. In our hospital, formal debriefs are usually organized when an event causes significant distress among the staff, whether due to a clinical situation, a tragic incident involving a colleague, or a complex ethical dilemma. The setting for a debrief should be carefully chosen to ensure a conducive environment for open communication. We often use teaching rooms, which are formal enough to maintain the seriousness of the discussion but comfortable and private enough to encourage honesty and confidentiality. Facilitators and Structure Selecting the right facilitators is crucial for a successful debrief. Typically, a social worker, like Liz, and a senior medical consultant co-facilitate. The consultant provides a comprehensive overview of the clinical aspects, while the social worker manages the psychological and emotional discussions. This balance ensures that all relevant facets of the event are covered. A formal debrief generally follows a structured format: Introduction and Ground Rules: The facilitator sets the stage by explaining the purpose of the debrief and establishing ground rules, such as maintaining confidentiality and focusing on constructive feedback. Narrative of the Event: A detailed recount of the incident is provided, clarifying what happened and why certain decisions were made. This helps participants understand the context and avoid misunderstandings. Operational Discussion: The team discusses the operational aspects, identifying what was done well and what could be improved. This is critical for learning and improving future responses. Emotional and Psychological Impact: Participants share their emotional reactions, providing a space for acknowledging the psychological effects of the event. This aspect of debriefing is vital for team support and individual well-being. Closing and Follow-Up: The debrief concludes with a summary and any agreed-upon actions. Facilitators also provide information on additional support resources, if necessary. Challenges and Considerations Debriefing can be challenging, especially in navigating sensitive topics or when there are conflicting opinions. It's essential to create a safe space where all participants feel comfortable sharing. Facilitators must manage the discussion to ensure that dominant personalities do not overshadow quieter voices, encouraging everyone to contribute. In some cases, separate debriefs for different groups involved in the event—such as pre-hospital staff, nurses, and doctors—may be necessary. This approach ensures that discussions are relevant to each group's experiences and prevents unnecessary exposure to distressing details that may not be directly applicable. Broader Implications and Benefits Debriefing should not be limited to negative or critical incidents. Regularly debriefing both positive and challenging events fosters a culture of continuous improvement and support. It helps normalize the practice, making it an integral part of the workplace rather than an extraordinary event. It's important to recognize that not all staff may want to participate in debriefings, and that’s acceptable. Debriefing should always be voluntary, with alternative support mechanisms available for those who need them. The long-term benefits of debriefing are substantial. It helps prevent burnout by providing a space for staff to process their experiences, supports continuous learning, and improves patient care outcomes. A well-implemented debriefing process can enhance team cohesion, reduce staff turnover, and foster a positive workplace culture. Conclusion Debriefing is a vital component of healthcare practice in emergency and critical care settings. It provides a structured approach to reflect on critical events, offering both operational and psychological support to healthcare teams. While it requires time and effort, the benefits for staff well-being and patient care are invaluable. We encourage healthcare professionals to integrate regular debriefing into their practices, not just for critical incidents but as a routine part of their work. This approach helps build a resilient and supportive workplace culture, where staff feel valued and heard. Sharing experiences and learning from each other strengthens the team and ultimately leads to better care for patients. We invite you to share your experiences with debriefing in your hospital. What strategies have worked well? What challenges have you encountered? Connect with us through the St. Emlyn's blog or Twitter, and let's continue the conversation about improving our practices and supporting each other in this challenging yet rewarding field of healthcare. Stay tuned for more insights from St. Emlyn's as we explore the complexities of working in emergency and critical care. Until next time, take care and keep supporting each other.