Eric Jaeger, JD, NRP: RSI/DSI - Looking Past First Pass Success (6/6/23)

Or Angus. I see. Can you record? There he goes. I know Angus is busy double, triple booked on meetings today. So we are recording. Alrighty. So let's get started, everybody. Welcome. It is 3:00pm, another Tuesday, June 6th. And just for a couple of announcements, as everyone knows, Eagles is next week. We have things happening every day of the week, Monday through Friday, Monday's Resuscit Academy, or Resuscitate Florida we're calling it. And then Tuesday, Wednesday is the first Air Force Care Thursday, Friday is Eagles. So we're really excited about it. So if you're on your way down, we're looking forward to see you. We also have tomorrow a webinar with the state of Florida's Houston park on medication assisted treatment for opioid use disorder. And then coming up next month, we have our third installation of our Whole Blood Florida Whole Blood Coalition, which is getting a lot of traction as well. So please make sure that you look at the WhatsApp channel for all that information. And let's get started. So today, if you've been following or been on our webinar for the last 117 episodes, you surely will have remembered Eric Jaeger, who I still think gave maybe the best talk when he gave a talk on implicit bias. And I talk about it everywhere that I go when I speak to my folks, my personnel. But Eric is also.

A highly expert in airway, specifically the Advanced Airway rsi. Dsi. I have asked him to come back today to talk about rsi, and his talk is entitled Looking Beyond First Pass Success. And so, Eric, I'll pass it over to you for a quick introduction. And we're here to the bottom of the hour when we switch over to Dr. Pepe. So welcome back to the show.

Awesome.

Hey, before you get on, Eric, Peter, did you get the CME number out for today?

If you have it, I'll type it in real quick. Go ahead.

Yeah, I'm trying to remember. I think it's 17374. I'll type it in or else I'll text you with it.

Okay, I'll find it. I'll find it. Okay. Thanks, Paul.

I appreciate it. You're welcome.

Thanks, Eric.

Forward to it. Okay, bye. Bye. Not a problem. All right, well, thank you so much again, Peter, for having me back. As I said before when we were chatting, I hope I can live up to the billing of being insightful and engaging. But we'll give it a shot. My name is Eric Yeager. I'm a EMS educator and RSI paramedic at Exeter Hospital up in Exeter, New Hampshire. I come to EMS through an unusual route. I was an attorney for 10 years representing healthcare clients in Boston before so switching gears to become a paramedic. And before that I went to MIT undergrad for computer science. I have no disclosures. If people are interested in any of the materials, feel free to contact me at my email address right there. And I want to thank Peter and the Florida chapter, the naemsp, for having me back.

So let's talk about rapid and delayed sequence innovation in the prehospital environment first. I want to acknowledge before going on that when I talk about this topic, I really am standing on the shoulders of giants. I appreciate Peter identifying me as an expert, but really I'm drawing on the expertise of so many other people who have come before. Jeff Jarvis, Jim DeCanto, Josh Stille, Steven Rahm, Peter, and many others. I do think it's important when we look at RSI and DSI, that we look beyond the ED and EMS literature, including at the anesthesia literature, and we won't have time to talk about it today, but the Project for Universal Management of Airways recently published some universal airway guidelines focused specifically on esophageal intubation and ensuring that we can recognize that when it occurs. And I highly recommend, if you haven't looked at that, that you pull it up and take a look.

The topics I am going to talk about today are Exeter Hospital's experience with RSI and doing cqi, looking at our data and and I've aggregated that data with some other agencies that we locally support. So our topics are looking beyond first Pass success and RSI grand rounds.

We recognize clearly as airway managers that first Pass success is incredibly important to preventing harm for our patients. And it's an important metric for EMS RSI DSI programs to track and look at as they're evaluating the safety and effectiveness of their programs. We know that with multiple attempts, risk of harm accumulates, hypoxia, esophageal innovation, bradycardia and cardiac arrest. And here's our aggregated RSI data for 2022 and when I first pulled it together I was pretty happy. We were hitting 94% first pass success. And I attribute a lot of that not just to the hard work of our providers, but to our use of video laryngoscopy, which we also strongly endorse. And our overall success was quite good as well. In 64 innervations, we used backup supraglottic airways on only two occasions, meaning on the other indications we were successful with intubation.

I was online on Twitter and I noticed that Cliff Reed had published some RSI statistics from his emergency department. And for certain he looked at first pass success and there it is, 92%. But then he published some other statistics. He was looking at hypoxia, peri intubation, hypoxia and a post intubation hypotension. And the statistics look pretty good. But I realized we hadn't actually. Well, for sure we look at individual calls and do CQI and individual calls if there's an episode where there's hypotension or hypoxia. We hadn't actually aggregated the data in this way to look at whether there were systemic issues that were hiding behind our fairly good first pass success statistics.

When I was putting together this talk, by the way, I noted Dr. Jarvis had published an article on this topic. He said, and I thought this was the perfect quote. First pass success by itself is not a patient oriented metric. It is a surrogate measure. Patients don't give a damn how many attempts it takes to innovate them. What they care about is avoiding harm during those attempts.

So I went back to our data and I scoured through every single RSI and what I found was a little bit startling. Despite our phenomenally good first pass success numbers, on 20% of our RSIS, we had patients experiencing desaturations. On a quarter of our patients, they experienced post intubation hypotension. And 14% of our patients experienced post intubation cardiac arrest. Now let me be clear. This isn't all due to the RSI. These are incredibly sick patients that were RSIing or DSI ing out in the field. And it's not surprising that some of them would experience significant desaturations or hypotension or even cardiac arrest. But I wasn't sure that all of these statistics were explained by the simple fact that they were sick patients.

We know how to address this, right? I mean, all of you, as airway managers could in your sleep or site resuscitate before you intubate. We focus on pre oxygenation with a nasal cannula or non rebreather of 15 liters per minute. We tell our providers that if you've got a shocky patient with poor hemodynamics to give them fluid to do push dosepi to ensure that before they proceed with RSI that their patient has been adequately resuscitated.

And yet when we looked at the data, we found that our Providers were already very focused on resuscitate before you intubate. They can repeat that mantra in their sleep. We did simulations where they were focused on doing that, and yet we were still seeing some of these adverse consequences and wanted to understand it better. I'm going to pull them apart a little bit and talk briefly about peri, intubation, hypoxia and what we found and what we did to address it. And then post intubation hypotension, what we found and what we did to address it.

So the question we went back and asked was, were we really maximizing pre oxygenation? We often articulate that 98 to 100% pulse ox before proceeding with RSI is the goal. And we saw that on some calls that wasn't being achieved in. And of course, these patients are being intubated in part because they're maybe suffering from a respiratory complaint. So it's not necessarily achievable all the time. And we saw that. We saw that there were some patients where the providers were getting the patient up to 92% with a nasal cannula, or the patient was agitated and they couldn't get them settled down enough to get them much above 92 or 93%. What we did when we saw that, and these providers were then going on to proceed with the RSI, believing that this was the best they could accomplish under the circumstances. In looking at it, though, we went back and said, what can we do to help enable these providers to actually change the equation to get that pulse ox up higher before proceeding with rsi? And in simulation and in training, we've now urged them to consider if they're not getting adequate oxygenation with a nasal cannula or non rebreather, can they reposition the patient? Can they swap out CPAP or BVM ventilation for the nasal cannula or non rebreather? Do they need to add PEEP to the equation? Or if they're already using 5 of PEEP, do they need to turn it up to 10 or to 15?

Part two, we found, was ensuring that providers understood that the goal wasn't just a high pulse ox, because some of the patients they would encounter already had a pulse ox of 98 to 100%. Perhaps this was a trauma patient that wasn't having any difficulty oxygenating and they were proceeding fairly rapidly with the RSI failing to recognize that the true goal isn't just a high pulse ox, but real denitrogenation. And so we asked them to focus on the fact that they need to do a full three minutes of pre oxygenation, regardless of pulse ox.

And then the last thing that we've come to realize, that the DSI is an underutilized tool or modality. And I know that, for example, some of the agencies that Peter supports, DSI has become the default way to approach these. And of course I'm talking about delayed sequence innovation where we're pushing the induction agent and then waiting before pushing the paralytic. And as time has gone on, we found this is a really important tool for ensuring adequate pre oxygenation and for ensuring adequate monitoring where you've got an agitated patient who may be moving about. Giving the induction agent first allows the patient to relax and ensure that your providers can adequately monitor those patients when they proceed to push the paralytic and proceed with the laryngoscopy.

So then we looked at post intubation hypotension and we wondered if people were ignoring the signs of a poor shock index. Shock index, of course, asks us to look at heart rate divided by systolic blood pressure. We, we recognize that a patient's vitals might look okay. A heart rate of 114, a BP of 110 over 68 doesn't look that awful if you're proceeding with RSI until you put them together and see that the shock index is over 1. And we've been telling our providers for some time that a high shock index pretends badness.

But we found people were not ignoring the shock index, they were calculating the shock index. And if they had a shocky patient, hypotensive patients were getting fluids push. Dosepie was being prepared. They weren't proceeding cavalierly before they had adequately resuscitated these patients. So what was going on? What we found was that while some of the patients that ended up with post innovation hypertension and cardiac arrest were hypotensive beforehand, some of the patients were actually normotensive or hypertensive no more. And that that had led providers maybe to anticipate that they wouldn't experience a problem with hemodynamics.

There's been a couple of studies out in the last couple of years that have reinforced the danger of hypotension in the context of RSI. This study, published in JAMA in 2021 looked at over 3,000 patients getting RSI'd in multiple centers around the world. They found 4, 45%, this was a startling number for me, experienced major adverse events. And most of that 43% of that was hemodynamic. Instability in the context of RSI.

Even more recently and more pertinent to our environment. This study, published in the BMJ in 2022, looked at post ROSC patients that were RSI in the prehospital environment, and they found that 50% of those patients experienced hemodynamic compromise.

In our data, we found that while many patients suffering hemodynamic collapse had been hypotensive, more than a few were normotensive or hypertensive before proceeding with intubation.

Our conclusion, and this has had a pretty profound impact on how we train and simulate and ask our providers to operate in doing rsi, our conclusion was that while hypotension and a high shock index does portend badness, the reverse is not true. Or the converse normal tension and a low shock index does not offer any protection necessarily against post intubation hemodynamic problems.

So here's what we changed and there are multiple things that I go through. Our first was to say that you should anticipate hypotension in every single patient. Resuscitate before you intubate is lovely. I live and breathe that concept, but it does nothing for those patients who are normal or hypotensive and still in shock. Right? Shock does not necessarily equal hypotension for certain. We can have patients that are compensating sufficiently for a short period of time and yet still are at significant risk of hemodynamic collapse when we push that induction agent and when we switch from negative pressure ventilation to positive pressure ventilation.

Part two was sure give a bolus of fluid, but we now recognize from other recent literature that a fluid bolus in and of itself offers little protection. And I think this is the other area where our providers were getting.

Were struggling. They would give the fluid bolus, they would see the patient's pressure increase. They would feel as though they'd adequately resuscitated the patient out of the danger zone and proceed with the rsi. And studies in the last couple of years have shown us that fluid boluses offer little if any protection against post RSI collapse.

So the next thing we asked providers to do was push dose EPI prepped for every single patient. We don't care whether the patient's hypotensive beforehand or shocking beforehand. They could have perfect set of vital signs, not be tachycardic, not be hypotensive. You mix that push dosepi and you have it labeled and ready to go by your side, regardless of their hemodynamic status.

And then the last or the second to last part of the concept was start low dose norepi for any patient with even a whiff of hypotension. This last one, these last two concepts, they sound straightforward, but they've been a little difficult to get providers comfortable with. We did some RSI sim this morning working with the rts here in the hospital and, and it was interesting, as we talked about it, people were lamenting how much waste we typically have. Mixing up the push dose EPI and not using it on calls, mixing up the norepi and not using it on calls. And the obvious answer to that is even a single patient who suffers profound hemodynamic collapse or cardiac arrest is worth the investment. Mixing up push dose EPI for every one of these patients. Why push them though? If they've got that push dosepi in hand, why push them to also think about actually getting the norepi started? I'll tell you why. I do CQI in every single RSI that gets done. And I saw multiple RSIs where they had the push dose epi ready post RSI, they start pushing the push dose epi when the patient begins to, their hemodynamics begin to suffer and at the same time they document they're trying to get the norepi mixed up and the pump started and the tubing primed and in the back of an ambulance. Unlike in the hospital environment where you can just look at a nurse and ask them to go get the norepi and put it on a pump in the back of the ambulance, it can be challenging for a couple of providers to not only manage that patient, which is now deteriorating, as well as get the pump set up. And so we found it works much better if there's even a whiff of hypotension at the outset before proceeding with the rsi, you, you've got your push dose epi, mix up your norepi, maybe even start your norepi at really low dose and then if they start to deteriorate post intubation, it's a simple matter of turning up the dosage.

And then the last concept that we struggled with too was are some patients too sick to rsi?

So take this patient, for example, a construction worker hit by a loader and thrown several feet. He's unconscious with snoring respirations, his heart rate's 134, BP 7634, pulse x 90% on room air. There's no question he needs a Definitive airway. There's no question he's eventually going to get rsi. But is he too sick to RSI in the field? And by that I mean is his hemodynamics so poor that notwithstanding attempts to resuscitate him with normal saline impressors, at least until Peter gets all of his whole blood programs up off the ground and we can conduct resuscitation with whole blood, Is this patient so sick from the standpoint of hemodynamically compromised that we need to recognize that notwithstanding the fact that we have the tool to establish definitive airway, it's just too dangerous. The risk of causing hemodynamic collapse, even if I manage to fluff this patient up, is just too high.

I want to make one more observation about the post intubation of hypertension, because one of the interesting things that our providers were noting is immediately post intubation, we saw little hypotension. Often when it was occurring, it was happening 10 to 15 minutes post induction. And that was another thing that seemed to catch our providers by surprise. Occasionally, they would conduct a very careful RSI or dsi. They would monitor the patient closely immediately post intubation. Great end tidal CO2 waveform, good pulse ox, good blood pressure, because they know to hit that blood pressure button repeatedly. They'd get the vents set up, they'd begin to relax, they're doing their patch into the hospital. That's when the patient becomes bradycardic and hypotensive. And again, when we looked at the data in the aggregate, we noticed this. This was a trend.

The other topic I want to talk about in the brief time I have remaining is our RSI Grand Rounds process.

Our old CQI process. We reviewed every single call, as I said, and if we found a call that had problems where the providers had struggled or where the patient had suffered some adverse consequences, we'd review with the crew, we'd pull the crew in, our medical director would come in, our director would come in, I'd sit down with them, and they were awesome conversations. We would learn lessons that we could apply to the future. But I struggled with how to share those lessons with the larger RSI team. I tried emails. People didn't read the emails or didn't take them to heart. I built some of these scenarios where the patients suffered these adverse consequences into simulation, but it didn't really have the same impact as discussing a real live call. Think about Peter's real emergencies video, where you see it unfolding in real time. So we said, we want to do RSI grand rounds where we would bring everybody together and have crews present their own cases. But that presented some risk.

Because we're asking people to come in and present on cases where things went poorly. That's one thing to do in the context of a private CQI conversation, with a different thing to do in the context of a larger meeting where their colleagues may be peppering them with questions, pointing out mistakes they made and asking what went wrong. And that seemed not what we wanted to try and accomplish. So we spent a lot of time thinking about how to do this effectively. And what we came up with is to be super clear in all of our communications about the RSI Grand Rounds process that we were not interested in looking back at what went wrong. I often say I can't go back and change the past. I can't go back and fix what happen on that call. I don't care about what went wrong. What I'm interested in is forward looking. What did you learn from that call? What would you do differently if you had a similar call in the future? And this by itself seemed to make a dramatic difference in how we approached RSI grand rounds. People came in presenting their cases, eager to share with people the lessons they had learned that they were hoping to apply in the future. And seeing it happen on real life cases just had the impact we were hoping for. The other piece of the equation was we didn't just in the past when we did cqi, we tend to focus on just those calls where things had gone wrong. And instead in our RSI grand rounds, we try and ensure there's balance. Where a significant focus is on cases where things went really well. I pull out calls that reflect great clinical decision making. A team of paramedics, for example, began to RSI a patient, pulled up all the meds, prepped all their stuff, and then concluded the patient was too sick to intubate, that they weren't going to go ahead and push those meds, they were going to manage the patient's airway effectively in another way. We pulled that case into the grand rounds to highlight their great decision not to proceed with the rsi. So the combination of these two things has made the RSI Grand Rounds hugely successful. Where our concern had been that it could have had a negative impact, instead, I have just been shocked at how successful it has been in giving a positive impact on our RSI practice, helping build a shared mental model. And I now see practices that we've been trying to encourage through training and simulation being widely adopted by the team. I Think in large measure due to this RSI grand rounds process where the crews are sharing the lessons they've learned with the one another.

I'm going to summarize.

I think it's incredibly important if you're responsible for an RSI program to look beyond the first pass success numbers. I think they're great to celebrate and a lot of us have learned how to use training and video laryngoscopy to achieve great first pass success. But I think if you haven't looked deeper into your data to analyze and understand safety and effectiveness and it is very worthwhile doing, we've just found it's made an enormous difference in our program. What we've asked people to do based on our review of the data is maximize pre oxygenation, anticipate hypotension and I would urge people to consider developing their own form of RSI grand rounds.

Wow, Eric, that's incredible. Another great talk and I already see that there's a hand being raised. So let's go to Dr. Pepe first and then we'll go to Dr. Landry after that. Go ahead, Dr. Pepe.

Is he, is he on the line? Dr. Pepe, I thought the name, what's.

The name on Leonard Skinner baby.

From the Skinner box. I put the PhD up there for the psychology folks there. Hey, so the great talk, of course, and, and I like that you brought up all the stuff you have to be thinking about. It's not like, you know, one thing works or doesn't work. One thing I want to really reiterate though, and you know this and everybody on the call knows this, but I think the number one reason why people crash afterwards is that, you know, people start overzealously ventilating, especially if they have, including the respiratory therapist, you know, because, you know, it just, it is that there's, that tube is in there. And a lot of the bad problems we've had in the past in outcomes in various areas with, and you know, with endotracheal tubes has been related to that overzealous ventilation and particularly in people who have high risk like hypotension that we, we literally knock them off with when they're, when they have hemorrhage, you know, that kind of thing, severe hemorrhage and then to the same thing with the people with auto peep or whatever else that might occur. And people are severely hypovolemic, like children, you know, that kind of thing, who go into cardiac arrest because they're had a lot of insensible Loss. So I just want to reiterate that people really have to get the tube in, give them a couple good breaths, but that's basically then back off on it at that point because I think that's where most of our badness comes in, including the emergency department and the operating room.

Okay.

It was just my comment, for whatever it's worth. Right?

No, that's great, Paul. And one of the things we've done is made use of the vent standard of care. So we've told our providers be really careful with the bag and post tube, but then switch them over as soon as they can to the venture. Because we. Our transport times are up to 30 minutes or longer. We recognize bagging the patient for an extended period of time is prone to some of those risks. Thank you all.

I'm just going to say also, you know, the protocols for that are basically not. Sorry about the background noise here. The back the. I was going to say that even some of those protocols are a little bit too much. For example, if you like, if you follow Peter Anteby's the lead on what the Heart association has recommended for children. Some of that same applies for adults as well. And sorry if I cut into your time, Kim, and I got to switch over to the other meeting.

Anyway, Paul, thank you so much. Let's go over to Dr. Kim Landry from the Panhandle. Kim, hey.

Excellent. This really kind of feeds information for me to use in my protocols. But I also recently in reviewing RSI cases, have noted several recent peri intubation cardiac arrest directly related to the low pulse ox prior to the administration of the paralytic in particular. And to the tune that I have actually refined my protocol and almost restricted the use of these drugs until these criteria are met. One of which is the pulse hoc needs to be above 94% prior to administering any of the drugs.

And.

And you know, so I guess it's safe to assume that some of the research you're producing could actually be translated into the protocol itself to where you actually restrict the use of drugs and intubating patients unless these criteria are met, including the blood pressure and etc. So my crews are aware that, you know, these are problems that could lead to peri intubation and post intubation cardiac arrest. But I, I think just making them aware of that is one thing, but actually putting it in protocol that restricts them from practicing until these problems are corrected makes a big difference.

Great. And I think you make a good point, Dr. Landrieu. We actually, I didn't have a chance to mention it, but we just rewrote our New Hampshire protocol and built it around what we call principles of safe and effective RSI and shock index. I don't know that we limit them, but we call strong attention to not proceeding if the shock index hasn't been adequately addressed. And I guess the other thing I'd say is we found that.

We'Ve been able to give people tools when they're struggling to get the oxygenation pre oxygenation up above 92, 93, 94% tools like repositioning and PEEP and CPAP and BVM where they've actually been able to be successful moving them beyond thresholds where they get stuck.

Awesome. Great question, great answer. And our friend Dr. Marv Wayne coming from Bellingham, northwest corner of the country. Go ahead, Marv.

Well, actually I'm in Maui, Hawaii, but I won't say that too loud. So as Peter knows. I'm sorry. As Peter knows, we've done two things that I think everybody should think about. One, we threw out the footballs. Our BVMs are eight 900 cc's. They all have a manometer. They all have a timing light. They all have the option for peep valve. And you can't squeeze in too much if there isn't something you can squeeze that hard because the person that squeezes the bag is least trained usually. And it's like a bilge pump. Scared man in a bucket is the best bilge pump in the world. And then the second thing we have done is also, you all maybe have seen every intubation is video recorded. We've been using video for 16 years and I've got probably a picture of a little bit of anything. And we've actually done some work with Peter's wonderful real ems. He's been very kind to allow us to be part of it. I'm just impressed that we're talking about something that doesn't help patients but kills patients. And yet we have so much overlooked this in the past. So thank you, Eric and everyone for bringing this to everyone's knowledge base. And this is just some of the few things we've done. Are we perfect? Absolutely not. Do we have growth and improvement? Absolutely, yes. But do we have a basis to start from?

Yes. And I think RSI has grown tremendously in the last decade. By the way, I want to make a plug. My pitch is we should have a national EMS Airway Conference that focuses on exactly these topics and brings together so many of these stories for us all to Learn from one another.

So let me throw a pitch back. National association of EMS Physicians does the our airway class, which is going to significantly expand in Austin. We use cadavers, but we also have Dan Spate who talks about death by ventilation. He talks about the epic trial and welcome you all to come. Although we've always been over subscribed, we think we're going to be able to enlarge it. So I'm sorry, Eric, you gave your pitch. I got my pitch, but I could put you. Hey, I get this on the basis of age. I completely agree. We have national discourse and national that course, as Dan said, we don't have a course on national hyperventilation. And this is so true and we can only teach so many. But this would be a great thought, Peter, and all your other wonderful gurus of programs.

Thank you.

Agreed. Yeah, Marv and Eric, I think that from the NAMSP level, I would love to see all the courses come under the umbrella and the guidelines as well. Acls.

We're working on it.

Yes. Okay. Last but not least, before we move over to Paul's show. Lou. Lou Steinberg. Welcome. Hi.

Thanks.

I just had a quick question for Eric. Did you track what agents were used.

And was ketamine used at any point.

Which I would think would help enhance the pressure?

You would think so. We almost exclusively use ketamine Iraq, although with the national ketamine shortage we're rapidly being forced to switch back to etomidate. I think if you look at some of the more recent, and I think we've long thought ketamine as hemodynamically protective. But if you look at some of the more recent near data and others, it seems to suggest that it's not quite. Quite as protective or have as quite a significant advantage over automated as we had previously assumed. Right.

Thank you. Excellent question. And then Eric, I'm going to end with a question that probably half the people on this call or more don't do RSI or dsi. We've had speakers on this program who have said let's just use the supraglottic airway and there's no dai. There's no drug assisted intubation at all. What's your comment on that? And again, consider that there's people on this call from the largest of the large urban suburban to also rural areas. What's your overall 30,000 foot view on that topic?

When you say drug assisted innovation abation, you're talking about not full RSI with a paralytic or you mean Full rsi DSI with an induction and paralytic.

Right. I'm talking about full RSI DSI in your protocol. You got the whole kit and caboodle. I see around the country it's either you do that or you just have a supraglottic that you put in when the patient can accept it.

Yeah. And I would support either one or the other, not a middle ground. And I have to say I have mixed feelings about rsi. I think that if you're going to do it, it requires an enormous amount of effort and support and I do sometimes worry that it takes away. We ultimately we're doing performing RSI both in the field and in the hospital so we get more opportunities to practice. But I see some smaller systems that they're doing a great job with rsi. But are they not paying as much attention to some other topics, whole blood, for example, that could potentially offer enormous benefits. So I wouldn't. I think our program is a great program that saves patients lives. And I think for agencies that can invest in it and do it properly, it's a. I strongly believe paramedics can do safe and effective rsi achieving great first pass success and safety for their patients. I have no question about that in my mind. But I do recognize that it's a resource intensive undertaking.

So I vote that you take on the National Airway course.

And again, another great talk again. I love all the tactical items that you brought forth and I think a lot of us who do this should be looking at more than one metric as you described. So Eric, thank you. We will see you hopefully. I know we'll see you at the EMS World and I'll definitely hit you up after this webinar in the future. So thank you my friend. Appreciate you.

Take care. Thank you very much, Peter, for the invitation.

You got it. And hang on everybody. The CME is in the chat and I'm going to, I'm going to be the one moving us over to Dr. Pepe. So let me just do that real quick.

Please hold until I figure this out. In a second.

Okay. Join with computer audio.

And.

Show that never end here for the first meeting.