Alexandra Jabr, EMT-P, Ph.D: Ketamine & Mental Health in the Fire Service (9/3/2023)

What's the rationale for you doing this? You know, what did you find and then what are the limitations? Wherever then we can ask you questions. That's where it gets really interesting, I think.

Okay, well that does change a few things. So I guess I should ask this.

Is who's my audience.

There or people. They're all mostly army personnel for cadets. I'm just kidding. No, it's actually a fix. Peter can do it. Knows better than I because I'm not looking at the, the list right now, but generally it could be a wide range. It could be EMS chiefs, large percentage of EMS medical directors from the state of Florida. Again, these are all state of Florida, but we also have people piping in from North Carolina or from, you know, Oregon or whatever. You never know who's call. So it's. Anything else you'd add to that, Peter?

No, I think, I think you hit it. EMS leadership, medical directors. So it's kind of. That's, that's, that's who you got.

It's people mostly for medical directors. But we want the chiefs to hear it too. So we have EMS chiefs on with us and trainers and then there's a lot of people. It's been a good, good, good series. So you got CME for it. So we have people piping in from around the country sometimes, which has been nice. Okay.

And you have some, some pretty high level state folks. So I just saw jump down, the deputy Secretary of health for the entire state of Florida is here.

Oh my God. That's right.

Awesome.

Yeah.

50 cents still doesn't get you a.

Cup of coffee though.

Alex. Alex, what was that?

Oh no, I was just saying if it's 30 minutes total, then I'll make sure to. What I had planned for is about 20 minutes of me talking and then 10 minutes for questions. And then that little feedback gives me just enough to pivot a few things to make sure that I'm not doing too much of what we already. You guys already know and I'll just kind of glaze over that part. Those parts and then we'll just do my best to summarize some of those findings. But yeah, you guys will walk your way with, with something.

Yeah. And then the thing is, yeah it's supposed to be half an hour meeting but of course by the time we get going here we know we're all sometimes a lot of that's gone and we rather had that 15 minutes to ask you questions and out the other thing that we're really good about interrupting you saying so what's the reason for that? Or whatever. Or say that again. So we'll help you along here as well. The idea is to get communication across to everybody and not lose either. So some people actually have to go.

All right, perfect.

Perfect. And, Alex, are you okay if we record this session? Because we typically put it up on the YouTube.

Yeah, of course.

All right, so it is 302. So let's go ahead and get started, everybody. Another Tuesday. It is Tuesday, September 5th. You will see I put the CME code down here at the bottom of the chat. And today is a very special guest. Someone I've known for many years, and I've seen her growth, and I've seen her kind of just be a mentor to many and someone that we all look up to. And Alex Jabber is now Dr. Alex Jabber. She just successfully defended her PhD thesis just several months ago. And she is a paramedic, and she works out of in Southern California, but now currently living in Kansas City. And this is a very important topic. So, Alex, just so you know, many of us on this call have been involved in some sort of tragic event, whether it be Parkland or some other. And we are all dealing, as you know, with mental health issues. Someone's mic is live. Who's that?

It was Doug.

Doug, can you. Yes, you can. Mute. Thank you, Doug. Hey, Doug.

So this topic of mental health in the fire service in EMS is something that I don't think anyone's cracked a code on. And when I heard what Alex's defense was for a PhD, I thought, we all have to hear about it. She's been traveling around the country at many, many conferences talking about it. So without any further ado, Alex Jabber, thanks for joining us. If you want to make any further introduction, but then take it away, we're really happy to have you.

All right, well, go ahead.

And then, Peter, would you do. If she can. Let's see how this goes. But if we have time this afternoon, why don't you invite her over to the Eagle side? You can send information.

Okay. Okay, we'll do. That'll be awesome. Thanks, Paul. All right, well, it's all yours.

I'm gonna. I'm gonna kind of just start with giving you guys a background on my research. So I know you had mentioned. I. I'm. I have traveled around quite a bit, usually talking about death notification. So this is kind of a different.

Passion project of mine, something that I always intended to do. I didn't know that when I went into my PhD program that I was going to come out researching and advocating for psychedelic therapy for. For first responders. But here's where we ended up. And I will admit that when I first started my dissertation clock, so two and a half years in, you start your clock about two years. And I was determined to finish within those two years, one way or another. And I did at the cost of my nervous system. But that's okay. We made it there. But my intention was actually, I had the ignorant idea that maybe this was well known about. And a little going backwards a little bit. Ketamine is actually more of a hallucinogen. It's not considered a classic psychedelic, but it behaves like one, and it's showing very promising therapeutic results, similar to things like MDMA and psilocybin, which is in mushrooms and ayahuasca. Now, the difference with ketamine that is very appealing is It's a Schedule 3. So it's something that is available right now legally, for anybody to participate in, should they go through an actual practice that has a physician that's prescribing it, that has medical professionals that are administering it, and so forth. So this is where it's a little bit more unique than, say, some of the other psychedelics that are not so much available, even in areas that they're decriminalized, like Colorado. It's not easy to access, to act. It's not as easily accessible. And then there's a lot of question of whether or not it's even something somebody can participate in off duty and not compromise their status with being employed. Right. So that's where I picked ketamine. I did not want to invite any uniformed personnel to open up about topics that would implicate them for anything illegal. So that's where ketamine was my preferred drug of choice or treatment of choice. Now, when I had initially sought out to do this, I wanted to actually find. I wanted to find firefighters to put through ketamine therapy and then interview them about their experiences with it. My school promptly said, absolutely not. We're not gonna allow that. And the lawyers said, no. So I thought, okay, well, let me. They said, how about you find some firefighters that have actually done it? And I went, okay, that's a great idea. It was crickets for about eight weeks. Finally, I went back to my chair and I said, hey, look, I don't know why there's been no response. I'm assuming that this is just that novel of a treatment option. I'm going to interview union leaders instead. I'm going to interview them about the idea about this treatment, Because I have a suspicion that that's how new and how low the awareness is of this to begin with. And they said, okay, go for it. And I got my eight participants. So I really finished this thing in the 11th hour. I think I got my participants in December. I finished my. My rough draft in January, and I submitted it for review at the end of February. So it was like, I'm finishing this or I'm not finishing it all kind of thing. And I was really, really pleased with the results because it helped me understand just how unknown this therapeutic option is. And so what I'm going to talk about, I'm going to briefly talk about ketamine. I'm going to briefly talk about the theorized mechanisms of action with. With what we think that it does or what we know about it so far. And then I'm going to talk about what the general consensus was of these eight union leaders about implementing this within their own fire departments in California. So these were all union leaders throughout the state of California, representing about 5,000 members. So I thought that it was a really good idea to just get the discussion going.

Let's see, where do I want to start with this? So the thing I asked my participants was one of the first things I asked was, what is the first thing you think of when you think of ketamine? And it really fell into one of two things, which was they either knew of it as a drug of abuse, recreational drug, a party drug known as special K or horse tranquilizer, or if ketamine was in their protocol to administer for things like pain, then they knew of it for its clinical indications, but only one person had heard about it for psychotherapy. So what I'm asking you guys to kind of keep in mind is that we're now looking at it from a completely different lens. We're looking at it from the lens of its potential benefits for mental and behavioral health. And this is really where this education strives to rewrite a narrative that has plagued this drug for a very long time. It's an old drug that's asking us to don a new lens, to see it for what its potential can be to benefit Are really all uniform personnel. I did decide to go with firefighters because I have a little bit more connections with them. And so even though I didn't know my participants, the fact that I worked for the fire department, the fact that I was a California paramedic, really opened them up to talking to me about some of this stuff, Because Some really sensitive things came up during this interview, as you can imagine, and they were all anonymous. Okay. So that just gives you a little background on that. So moving forward. So ketamine has been a medication that was introduced to the market as dissociative anesthetic in the 1960s. And about 1990s is when research started turning to ketamine for its potential action or its potential role in mental health. But it was really a study that was published in 2006 that launched the research that we're still in the middle of today. And so I want to make something very clear. There is a lot we don't know about ketamine yet. And I think we have to be careful when looking at some of this research, even some of the most rigorous studies that still leave a lot.

To be wondered because of the fact that we don't have any long term data to show what the long term results are. What we do know about ketamine right now is that it has rapid with IV administration for depression and suicidal thoughts. It has rapid effects within hours for some of them. What we don't know is how long those effects last. How many sessions of ketamine does it take to create a substantial long term benefit. What we do know is it works fast and it works effectively for those two conditions. But it's also shown promising results for other conditions such as anxiety, obsessive compulsive disorder, intrusive thoughts, addiction, substance abuse. All of these things have shown some promising results one way or another. But for depression and, and suicidal ideation, it's shown the most promising ones with your.

Those are the ones that have studies that are double blind, randomized active placebos. So they're using placebos like Versed because it's pretty obvious when you take ketamine you can't just give them a sugar pill and expect the placebo to be very reputable. Right. But considering what we don't know about ketamine, it's pretty.

Understandable why people are still willing to participate in it, myself included. I'm going to talk a little bit about my experience with it towards the end of this because traditional antidepressants take what, two to eight weeks to take effect. And then when you compare the effectiveness to the placebo group, they tend to be anywhere between 20 to 30% more effective than the placebo group, which isn't. I'm not one to say anything bad about antidepressants. I took them myself. I do not discourage anybody from taking them. But given that in mind, it's understandable to know why people are willing to turn to a treatment that still has a lot left to be determined. Does that make sense?

All right, so the working theories of ketamine, the big one is NMDA antagonist. So by binding to the, by being an NMDA antagonist, what it creates is a increase in something called brain derived neurotrophic factor or bdnf. And BDNF is a protein that's found throughout the central nervous system. And what it does is it's responsible for the development, maintenance and synaptic plasticity of the brain. So this is where the neuroplasticity happens. So it induces this ability for the brain to heal itself. Now, Dr. Anteby, when you mentioned some of the traumas that people have been through, things like an acute traumatic event, post traumatic stress disorder, an acute depressive episode can cause damages to the synapses of the brain. That is theorized to be one of the factors that contributes to this. And ketamine is thought to go in there and actually heal these things. They don't just repair the damaged synapses, they will actually create new routes around the damaged synapses to create that connectivity again, which is very exciting. The other part is its effect on the opioid system, which is a little bit newer. In fact, this wasn't even on my radar when I did my literature review, so it's not in my dissertation. But what they found in 2019 was that when they administered a placebo and ketamine with participants, 7 out of 12 of them had a 50% reduction in their depression the next day, very next day. Didn't mean the other ones didn't have, they had some sort of response as well. But 7 out of 12 of them had 50% reduction in their symptoms the very next day. The ones that got naltrexone, which I think I'm saying that wrong, but naltrexone, which is a longer lasting opioid antagonist, none of them had any effects, none of them had any resolution of their depression effects, which is really, really fascinating to learn because historically we knew that ketamine in terms of pain didn't rely on the opioid system alone to create the analgesic effect. And so that was really interesting. But again, some of these things are just still theories. We don't 100% know.

When they're most, which one's most prominently at play here. The third one is reducing activity in what's called the default mode network. And the DMN is really the part of our brain, it's kind of these multiple parts of the brain that are networked together. And if you've ever had a traumatic event or a really bad falling out, really bad breakup, you had an abusive person you were working with at work kind of thing, and you play that story over and over and over again in your head. That's called rumination. And that inability to turn that off and that intrusiveness of that thought and.

That over identification or that replaying of it, that's the role of the dmn. And when ketamine is administered, it actually can bring down the activity in the DMN to the point where it's like lowering the volume and it induces a light sleep. And for me, it feels like a chemically induced meditative experience that if I'm in acute place of stress, I. I don't have an ability to tap into myself like that. Yes, you can reach this with very.

Seasoned practice, or someone who is a seasoned meditator can absolutely reach this. But for some of us it's a little harder. And this really does help assist that. Now I share the part about the DMN to share this, which is that what's fun about this medication is I find myself playing in two different disciplines. So, so I've got medicine and neuroscience, and then I have psychology and a little mysticism. And that's the part where you lose a lot of medicine when you start talking about the mystical side of things. But this is where it gets really cool. Now this has been researched pretty heavily and theorized by Dr. Carhartt Harris since about 2008. So it's widely accepted in the field of psychology. But he believes that the default mode network is where consciousness and our ego resides. So he believes that when ketamine has an effect to bring the activity of the DMN down, it actually has. It's that classic psychedelic experience of dissolution of ego, which dissolution of ego is this feeling of oneness. It takes away.

This sense of duality or separateness. And this is where people who, particularly with things like mdma have these very heart opening experiences where they feel this love for people that they hated going into it, right? And it's really easy to hate people from far away. This is where, you know, right versus left and you versus me and you know, the poor versus rich, like all these things come into play. But under these chemical states, with the DMN coming down, it's creating this place where our ego dissolves and this oneness occurs. And so one Thing I want to bring up, which I know is a little bit of a side note, but it is. It is another topic that we do need to pay attention to is the fact that those of you who are administering ketamine in a clinical setting, for whatever reason, whether you realize it or not, are creating this effect in your patients. And the problem with that, when given with that lack of awareness. And again, this is another topic for later, but I just want to make sure I bring it up here, is that you're dissolving that patient's ego anytime they're receiving this medication. Ketamine is unique in so many ways. There is not one other medication that you carry that's going to create the same effect as this. And what happens when that ego is dissolved is you open up the portal to the unconscious. And it's not just about what goes in. It's about what comes out. Our unconscious, and I should say subconscious with this crowd, because unconscious has different implications. But the subconscious mind is where we store repressed memories. It's where we store childhood traumas. It's where we store deeply buried emotions. And when we're administering ketamine to reset someone's shoulder injury.

Potentially opening that portal up to them. And so this is where it makes sense that sometimes our patients wig out when they take this. And so I think a lot of times ketamine can have this negative connotation because there's this idea that, well, I had a patient that had a really bad trip with it. How can this be therapeutic for me? And it comes down to being in a safe environment with the right setting, with the right sitter, with a mindful intention and informed consent for what they're getting into. And I can tell you experience.

Yeah, I'm just going to stop you. Only because we. We lost your picture. So I'm looking at a blank screen. We've been hearing you perfectly. I'm not sure if others are experiencing same thing. Try turning your camera on and off.

There you go.

Okay, you're back.

Hey, beautiful. Seeing her. Okay, I'm seeing her.

Maybe that was just me. Sorry, I can see you now.

No, no problem. And so, really I just wanted to share that from. And I'm not going to talk about my personal experience too much here, other than I did start using ketamine assisted psychotherapy, or cap, for my conditions, which I'm more than happy to talk about at another time. But I'll spend the next couple minutes just talking briefly about what my findings were.

Generally speaking, what my research was Doing was. It was a phenomenological research. So it wasn't this clinical controlled or anything like that. I just wanted to have a discussion with these union leaders to find out what their perception of ketamine assisted psychotherapy was. What their.

Now she seems to.

Yeah, I think we lost you, Alex. You're on mute. You're on mute yourself.

It said someone, me.

Oh, I don't know. I don't know how that happened. Sorry about that.

No, it's okay. So the general consensus was that they were all for it. Now, there were some conditions involved, especially with the ones that didn't really understand it. And they said, well, I'm for it as long as it wasn't abused. I'm for it as long as it took place in a clinical therapeutic setting. So all things that are innate to CAP anyways. But I understood where those concerns came from. And then there were members who said, if there is something that could potentially prevent my department from having another suicide, I am 100% a yes. They said, we'll do it. We want to see this happen. And that was very promising. Now, one thing a few of them brought up that was a theme was that they said, well, if this is something that is available to our firefighters right now, why has the IFF not said anything about it? Why haven't we heard about it at seminars? Why haven't we, you know, in our networks of things going on, why have. Why is this not being discussed? And so this really brought to light the importance of awareness and then followed up by education and the re education. So there's a different. Not even a different narrative, because I get it. Ketamine in different or different settings produce different results and different experiences and conditions that you need to think about. But we need to add this additional lens to it. We need to expand our understanding of it so that people know that this is an option to them. But I'll tell you really quick about the iaff, and this isn't to pick on them in any way, but I had an opportunity to sit down with a few of them at a lunch a couple of weeks ago. And I was sitting with members who were in charge of wellness and behavioral programs. And somebody brought up my dissertation. And I said, you know, I said, it's real funny. I said, a couple of the members that I interviewed said that they hadn't heard anything from the iaff. Like, is there any reason. I said, what do you guys know about ketamine assisted psychotherapy?

And you would have thought I spoke French to them. In that moment, because nobody said a thing, it was complete crickets. And it was in that moment that I realized they don't know what those words mean. They don't know what they mean put together. They've never heard of this before. So the fact that you, Dr. Antevey, have brought me here and everybody here that's participating to talk about this, is that, like, far in the forefront of this discussion yet? This has been a therapeutic modality that's been available for at least a decade. And so.

But Alex, how many. Are there any studies? I mean, you started off by saying that you couldn't find anyone, any firefighters who would at least admit to have gotten ketamine therapy. Do you think that before, let's say, an agency would agree to this, that they would want to see that data? Does that data exist in the layperson category, if you will? Because I know that when you travel through California, and I was there recently in la, there's ketamine clinics everywhere. Is this what they're using the ketamine for?

Yes, yes, they are using it for. There are some ketamine practices that are using it for chronic pain, but the ones that you're probably referring to are using it for mental health. So a lot of times they're paired up with therapy, a psychiatrist, sometimes it's run by an md and to answer your question about studies, there are plenty of studies, like I said, when it comes to depression and anti suicidal or I'm sorry, suicidal thoughts, those are probably the most rigorous clinical trials that you can find out of all of them. But yes, there is an abundance of studies. As far as studies specific to firefighters, there is only one study in regards to psychedelic therapy for PTSD that exists with the firefighter population, and that was done in 2017 by Maps, which is like the aha of psychedelics. But that was done in 2017, I believe, with MDMA. And it was mixed population between. It was police officers, firefighters and military. But outside of that, firefighters are completely absent from. From the literature, other than this, I guess.

So I would be curious. You know, we only have a few more minutes left, so I'm curious, is there anyone in the group here? We have people from. We have people from all across the country here today. Is there anyone with. His is absolute no. And if the answer is no, why. And I just, I would love to hear, because it sounds to me like, you know, we know ketamine very well, right? In our services, and at least I see value in it. The question is, does. Does the EMS leadership Kind of see, see the value there and if so, why hasn't it taken hold and what are the obstacles for it to take hold?

Let's see. Doug, Del Coupez would love to hear your, your opinion, Dr. Pepe, of course hear your opinion. We have Brendan Marchetti.

Nothing in your opinion, but Joseph Zalkin, but Dr. Ken Shetty from the state of Florida. What are your thoughts?

Yeah, and Peter, let me know because I'm going to have to go obviously in a couple minutes, so. Okay.

If I don't, if you don't mind, let's start with Ken, since he has a great appreciation for the receptor action actions and of kept mean. He's got it. The guy's kind of brilliant that respect. So. That's okay, Ken.

Well, I know Chris Caldwell and I have had this, this debate for a long time. You know, ketamine versus tropera. But clearly ketamine is the best medication in the world. And I, I use, I've put slides up many times for my talks. You know, ketamine for everything. So I'm not surprised to hear that ketamine is, is being proposed for this as well.

So.

Yeah, and you know me, I'm perfectly willing to try new things in areas where traditional therapy does not work very well.

And that, that actually brings up a great question. So, Alex, would you comment on this? Is this for the run of the mill type of therapy or are you reserving ketamine only for kind of maybe a more severe category, if you will?

You know, there is a.

There is a mindset that you have to fail so many therapies before ketamine is considered. That is a recommendation. That is not a hard and fast rule. So it's going to be very individual between the patient and their practitioners to decide. And so I am not one to propose that you have to suffer for years before you turn to this. I think the stigma associated with that tells us we have to. But that's ultimately a question for the practitioner and the individual. I don't believe you have to wait.

Great. Great answer. Now let's get Dr. Kupas, who is maybe a malfunctioning microphone from the great Commonwealth of Pennsylvania. Doug, what are your thoughts?

Peter, can you hear me?

Oh, okay, great.

I thought my microphone was malfunctioning. You know, I think that when you say, what's the holdup? Or what are the worries? I think that, you know, really, I found it interesting, your statement that you said this in front of the IAFF and they were met with crickets. I think that if you said this in front of most groups of emergency physicians, EMS physicians and even to some degree psychiatrists and some of the folks in, in mental health, you would get crickets too, because I don't think this has become widespread in many, many areas. I think there are pockets of areas where there has been general acceptance. And, you know, I did follow some of the information just for general depression. And I know of some people in the emergency department who, if they had a patient that had depression and also had back pain, that would be like their reason to give them ketamine, knowing that maybe it's going to help their depression too. But within their health system, there's not a, you know, it's not generally accepted by the psychiatrist. It's not. I have found that, you know, some of the general mental health professionals have, I think, not really been as excited about it because it does require something they're not used to. You know, it's not a pill they can order and just have somebody pick up and start requires this infusion. And they're not comfortable with the infusions. You know, I don't think in most places they're sending people to the ED specifically for the infusion. If there's an infusion center in the community.

You know, they try it, but, you know, so I don't think it's mainstream even among all of those folks. So I think that's the real issue at this point.

I agree, I agree. And I think that was the eye opening part for me that's continuing to bring awareness to me is how few people know it.

Alex and Dr. Kupe, so here's my question for you. I know someone recently in my circle, if you will, who was using. He went to the doctor and they had him come into the office twice or three times a week for an intranasal dose. And that's how it was administered. So is it truly going using infusions or have they moved to the less invasive and easier way of doing it? I don't know the answer to that.

Kind of.

Globally I do. They changed molecule, they changed one molecule in the molecule in the original formula. And I think it's esketamine now or it's Faro something is the brand name of it. And they charge about a thousand dollars a nasal spray for it. So it was a way, I mean, and again, here's the benefit of it is it can actually be prescribed for depression. Where is ketamine being used in these clinics? Is being used off label, which is not a foreign practice. Amongst physicians. But that, that's the play with that. I'm not saying it doesn't work. I'm just saying.

Right. Let me, let me, let me bring in Dr. Pepe since he's got to switch over to the next webinar. Go ahead, Dr. Nails.

In the next 35 seconds. Okay, so two things. One is why not accept it? First of all, ketamine has been attacked by for our use in general where we know it's really important general for various things.

And it's been opposed by anesthesiologists who are the pain people and by psychiatrists when we had to deal with people who are out there who were very agitated and dangerous in some respects. And, and so that's part of the deal that that's become a very controversial situation and almost to the point where they wanted to remove ketamine from us altogether. So there's that aura in the background. Okay. That thing. So part of it is to go to people like those groups to make sure they're convinced. But they're going to be less convinced. I think so. But that's, that's part of the issue why you're not seeing it as mainstream. Having said that, in our stream we are very happy with the drug for a lot of reasons. And one of the things along your lines that we're happy about is having to do with. We have good data coming out of military, for example that when people when ketamine was used versus other drugs for intubation or pain control, there is less ptsd. So you probably found that in your research as you went through there. But we have a very specific incidence where in traumatic situations like injuries that it seems to be very effective of controlling things that we have pretty good data along those lines. So that's one thing to keep in mind that might lead us right direction here to get it get better accepted. And I think as you'll see people like. And by the way, this is a sidebar talking about the dma. The is that it's been Molly is being popularized movies like the Long Shot, you know, and so you unwind people and, and actually last night on last week's version of Billions had it on as well that they had to do that sort of get oneness together as you were saying. So we'll leave it at that. Right. So just a connection so to catch.

Up on those shows.

Yeah, but I mean it's, it is interesting because it does have those effects. And I think the other thing is to keep in mind the untoward effects that one might have as it brings out certain areas. But overall, there's a lot of reasons why we really like this drug and we probably would be more of a supporter of this, but we have to sort of approach it in a scientific manner as well. So that's why iaff, that's why a lot of other places happen here, because they're waiting for scientists or the medical community to have.

This, you know, that kind of thing. So we'll have to see your thesis.

Well, a lot of that starts right here because, you know, with. With Paul and his ability to distribute via the Eagle. So hopefully you can. We can, you know, get Alex on the next show. So why don't we do that?

Okay, bye. Bye.

As far as far as getting over. So, awesome. Thanks, Paul. We'll see you in a little bit. So. Well, Alex.

Alex, did you have any.

Reaction to what I just said? PTSD thing from military experience and trauma experience.

It's a fascinating part of the conversation. Yeah. And I'm glad that you were able to bring that up in this short time period.

Okay, see you later. Take care. Bye bye.

Thank you. All right, so, Alex, thank you so much. I'm going to give you a last word. You have people here from around the country listening in.

What do you propose are the next steps to get this type of therapy into the mainstream? Even to just to be considered for those folks that we all know we.

Have in our department?

I think that we need to source more professionals that understand the benefits of this and the risks, because this is not for everybody, and that we need to make space for it in our symposiums and our conferences and our online things like this and start just putting the information out there on one hand. I think it's normal to wait for entities like the IAFF to kind of put out their position on it. And I think that I just heard about another suicide this morning and I'm tired of waiting. Like, let's just do something about it.

So that's where I'm at, 100%. All right, well, I don't see any other hands raised, but let's see, I'll give another couple of minutes, a couple of seconds here so we can. I'll start to restream Eagles in a minute. And then, Alex, I sent you a separate link so you can get on to Paul. Probably calling you on this on the Eagle side if you have a moment to do that. That'd be wonderful. Yes. And then, Alex, can you also put in the chat how people can get in touch with you. What I failed to mention is that and you had mentioned it. But for those of you who don't know, Alex has developed an incredible course on death notification in ems. It stemmed from a personal story. I personally watched it and I recommend my agencies, I sent that out to my agencies as a primer from which we then speak about the topic so people can look you up where how can they find you and find more about what you do.

Alex.

My name Alexandra Jobber on LinkedIn. And then social media is emergency resilience. You can find me mostly active on Instagram, but I peek in on Twitter and Facebook on occasion.

So awesome. All right, so I'll see you on the other side. I'm going to restream Eagle, so everyone on the call, please hang on. Alex, thank you so much for joining us. We'll stop the recording and then we'll post this on YouTube.