Jack Howard, Nick Nudell, Alexander Olaussen, MD: CPR Induced Consciousness (CPRIC) (2/2/24)

All right everybody, welcome. It is February 2nd. It's Friday here on the East coast anyway at 11am and this is a very important topic. It's something that we have been following for a few years. We actually added it to our protocol.

Last year. And I've been following this group of authors because they're really driving the science on this. And I reached out to them and you'll hear in a minute from his accent. But we have Jack Howard coming to us all the way from Australia. It's 3:00am in the morning, so just thank you so much Jack for joining us. Great topic. I'll pass it over to you if you can make a further introduction and take it away. Thanks for coming on.

So guys, yeah, like I said, absolute pleasure to be here. I get a kick out of talking from paramedics from other states in Australia, let alone paramedics from overseas. So Peter, just an absolute honor to be here and thank you so much for having us talk.

Just a short introduction for me. Jack Howard. I'm intensive care paramedic from Melbourne, Australia.

Been a paramedic for the last 13 years. Primarily just a full time clinician, just dabbling in research here and there. We'll have Nick Nadal talk to you guys as well at the end of this presentation. Nick is probably pretty well known, I assume over there he in any case, I couldn't give his title justification. He's got too many achievements and titles for me to do accurately. So I'll let Nick do that when he comes on. We should have Dr. Don Rice, the ex head of Nebraska EMS Service. Unfortunately Don's undergone some medical issues of late and I don't think he's going to be even in on the call. He's just unavailable at the moment so here in spirit and I'll have to read out his slides for him. We also have Dr. Alexander Olson who won't be presenting today but will be available on the call should you have any questions for him. Without Alex, none of this project would have been possible. He's the driver, the preeminent author of Cipric in Australia. Definitely.

Used to be a paramedic and he joined the dark side, became a doctor and just an all round good egg.

So we by the way, Jack, sorry, Nick is on. Nick is on. So Nick, welcome.

Great. Good to see you Nick.

Thank you.

Yeah, we'll keep going. So this is Don's first slide. Don was presenting first so I'll just read them out. I can't do them justice. Apologies for that. But Don started With the problem that Cypric isn't really a new issue, it's just been misunderstood for many years. Movements back when people like Dr. Rice Train was simply thought to be autonomic dysfunction during CPR and because of the high efficiency of CPR was not being thought of nor practice. The concept of consciousness was not simply in the minds of those performing cpr.

He goes further to point Sometimes old data has some good information for addressing modern care dilemmas. So he points to a Lucas study device which was a porcine study in which pigs were placed into cardiac arrest and had hyper prolonged phases of CPR trialled on them. They divided into four groups and survival is quite mixed and survivor. The authors of the article felt that it was because of the length of the time that the pigs were undergoing cpr. But if you look at the appendix you'll see that the groups 3 and 4 were sedated not only with ketamine but also midazolam. And no one considered the time that the problem may have been the drug and not the direction of cpr. So sometimes it's good to have a look at old data with fresh set of eyes. Especially as we discussed management of Cipric in the more modern era. Reference to that article obviously down the bottom there as you can see. And we'll just press on to my slides here. So CPA induced consciousness, Cypric, a phenomenon like no other. It's one of those ones I think if you know, you know, if you've had Cipric at your scenes, if you've been there, you understand the burden and the cognitive burden it brings to scenes. I think pre hospital providers were pretty good at preparing and getting ready for any kind of difficulty at a cardiac arrest or any kind of pre hospital scene. But your patient coming alive, talking to you, choking you, hitting you, scratching you during cardiac arrest, probably one that you didn't expect.

Further compounding the problems that SIPRC brings to scenes, there's delays to treatment, delays to shocks, delay to cpr. All the things we know work. You'll see the teamwork of the team degrade communication goes away. It's very distracting, very confronting phenomenon. And as I said, this is, this is compounded by just a real lack of knowledge around the subject. Up until this study there was no definition of what Cypric looks like, no agreed upon definition.

We're not really, especially in Australia, this is really reporting cypric phenomenon episodes really all that well. And nor is it even in the UTSDEN guidelines, which is the gold standard of Data registries for catechrs data and this is further compounded. There's just a real positive literature around the topic. We're not learning anything from our presentations and so therefore there's very, there's not a lot of evidence surrounding and we're not releasing a lot of literature on the topic. If you go through the archives you can find scattered case reports, a lot of kind of.

Revision of data that's come out, but nothing really concrete, no trials or anything else like that. From what we do understand on the topic of Cipric, usually they're quite young, they're quite viable patients, they're of a cardiac origin with short down times and you explain that to any paramedics, they always light up, they're patients we know we can have a real win for, have a good story for and, and we try our hardest for so concerning and I'm creating a bleak picture here, but I promise it does get better. So in order kind of to adjust and to address this issue of just a course of literature, Alex and I got together, created a team with Nick and Don and a few others and we decided to undertake a scoping review of international Cypric guidelines. We found 23 international guidelines and of which there were 20 different ways of treating Cypric. We found this to be a real serious flow and consequences towards data collection. Therefore understanding Cypric. If you think about it, how can you compare the data points, how can you compare outcomes, how can you compare what our sedation regimes are doing to these patients if everybody's doing something differently? And as I said before, we're not even really collecting that data anyway, so we can't even learn anything from them. We've created this almost paradox where we need evidence to make a guideline, but we're not collecting any evidence itself and then everyone's doing something different anyway, so how would we even be able to compare that evidence? So this makes it more important as well. When you think about the modern era, our pre hospital systems are improving, our Cipric rates are improving with that. So we're talking about high performance cpr, bystand cpr, public defibrillation. We are becoming more efficient at treating cardiac arrest in the pre hospital system and therefore we're seeing increasing rates of Cypric. So like I said before, you've got this cohort of really viable young cardiac arrest patients that are not receiving optimal evidence based care. Everyone's receiving something different. We're not really learning anything from these presentations.

So the team and I decided to do something about that. And we created a Delphi study with Monash University in conjunction with Delphi study for those a bit unaware.

Multiple rounds, you get a group of experts together, you conduct multi rounds of questioning of that expert group until you whittle away, until everyone kind of agrees on a certain topic and you call that a consensus. And what we want to do with our Delphi studies, we wanted to create a definition for Cipric, a management plan for Cipric and a data reporting framework for Cipric. So we use a largely social media based recruitment snowballing technique. One person informs three people, who informs nine or six, 27, so on, so forth. And we agreed before the start of the study that consensus would equal a 70% agreement rate. So if 70% of our experts agreed on a singular topic, that would be counted as a consensus.

Now here's the demographics of the study. Of course everyone's going to look at this later on YouTube so I won't go through every data point and that's quite boring anyway. But I draw your attention to the last three questions here. Does your pre hospital service have a Cypric guideline? Yes, has and I've just got to move this. There you go. Yes, 38% no has 62%. Really quite interesting if you think about that. A majority of participants in our study didn't have a Cypric guideline to start with. Have you ever personally managed CIPRRIC? 82% said yes. So potentially of that 82%, 62% of those who have personally managed Cipric were doing so on the fly. And you think about those that have seen siprc, how difficult it is that are seen if you've got no knowledge of what it looks like, any definition or how to manage ciprq. I can't imagine what those people going through. So really difficult set of circumstances for pre hospital providers. Also just that last one witness Cipriq episodes you can see 85% of participants had seen at least one episode and it really kind of calls into question the rates of Cipric and how often they're presenting.

At the moment. Data is kind of saying about 0.9 to 1% of all Catego arrests have some Cipric presentation and perhaps these numbers lead elsewhere with that.

Now I could take you through.

The.

Study round for round but quite frankly that's just tedious and no one needs to hear me drone on like that for too long. So what I will do is just take you through the end result of those three domains. We're talking about the definition of management and data reporting framework. This is our definition domain. This is what we came up with with the participants. You can see that general cypric definition there. And further subgrouped into interfering, non interfering throughout the study. There was really no controversies with the definition. We had a large agreement rate throughout the study from rounds one through to rounds four. Really the only controversy here was you'll see the interfering cypric definition. The last dot point. Talking to rescuers. Early stages of the study it was. You can see all the other symptoms of interfering are quite physical. Talking to rescuers being more psychological. And there was toing and fro in the early rounds whether that was indeed non interfering or interfering. And it was eventually decided that the general psychological surprise of your patient getting up and having a chat to you in the middle of a cardiac arrest was interfering enough and probably warranted a larger sedation bolus.

And that brings us to the management domain. Boy, oh boy. Controversy. So not as easy to agree upon the management domain as the definition of the data reporting framework. But here you can see our first line medication. What was evident from the start of the study was that ketamine was absolutely preferred to treat both interferon and non interfering ciprric. Some larger controversies erupted around firstly the decision to treat non interference. So initially at the start of the study, non interfering and interfering cypric were treated with the same dose of ketamine which was 0.5 to 1 milligram per kilogram. It was a real split between the camps. Yes. Wanting to treat non interference at BRIG felt it was humane to do so. The NO campaign they didn't want to go near a patient that wasn't interfering with management. And that risk reward profile of introducing a sedation agent into the cardiac arrest and perhaps causing some cardiovascular compromise was probably not there. So we had to come up with a bit of a compromise there. And you'll see the non interfering ciprg quite a reduced ketamine dose, 0.3 milligrams per kilogram. That really got a lot of people over the line. They felt the risk kind of profile had righted itself and were much happy to give a smaller dose for that. Increased signs of awareness in that non interfering cohort. The other kind of controversy we're having was the dosage. I mean 1 milligram per kilogram is an anesthetic dose of ketamine. It's quite a large dose. 0.5 milligrams per kilogram is as well. There was large conjecture around.

Sedation Profiles and cardiovascular collapse, which is obviously a bit of a vogue topic as well at the moment in critically ill patients. So there was some compromise. Originally it was 1 milligram per kilogram was reduced to 0.5 to 1 milligram with a real emphasis on clinician gestalt in terms of thinking about your patient, their frailty, where they are, in terms of how much sedation they need and those kinds of things.

And this is just the last part of the management domain. The second line medication was probably the most controversial. If ketamine doesn't work, what do you use next? And we could have had 200 rounds and it would have been the worst study in the world and we probably still wouldn't have come to an agreement on the second line medication. And it's really dependent on as a service, what do you want to use, what can you use, what do you have available, what are you comfortable with? We couldn't split between paralytic, midazolam, fentanyl between all of our participants. So in the end we just said up to you. So depending on local preferences, if ketamine doesn't work, you can use whatever you feel you are comfortable with or have access to as a second round sedation.

And onto the data reporting domains, broke those down to subcategories and, and put in more points. These are all the things that if you collect these in terms of what Cypric looks like, who's who's presenting with CIPRQ and how our sedation regimes are affecting their outcomes. Is there a quick point to make here that many of the BLO data points are absolutely already included in the category S data registries and new extend guidelines. It's not an exhaustive list and it's just purely a starting point to collect meaningful data around Cypric presentations.

Especially in Australia, this probably needs to be done really a lot better. I don't know how it goes over there Peter, but yeah, we're not collecting our data fantastically well on the SIPRIC in Australia. So that brings us to our discussion points.

Basically we had a definition, we've got a guideline, we've got a reporting framework. We set out to achieve those three things. When we achieve them, emphasis. This is the building block. It's a consensus opinion, but it's something, it's better than nothing and we hope that off this guy, off this study we can build more evidence based practice, stronger guidelines.

We also found another discussion point that ketamine is king, but how much is too much? So clearly a lot of people worried about sedation profiles and cardiovascular collapse. Clearly we need to build a lot more evidence around this topic. I will point out that there's a lot of new stuff coming out at the moment in the critically ill patient and sedating them there seems to be Shock indexes are clearly.

Indicators of cardiovascular collapse. Pretty hard to do in the cardiac arrested patient. But another indicator.

That you your patient will have some kind of cardiovascular collapse is clinician gestalt. You guys know what you're doing. You know which patients the catecholamine depleted. You know the ones that are not going to do as well with sedation.

And that predictor itself and using either the minimal the maximum amount of sedation that you need. Rely on that feeling that you get in your stomach that your experiences and bring them to the table because they are important and clearly they do predict where your patient's going in terms of perfusion and cardiovascular collapse. When you're introducing sedation into this critically ill cohort. Another point to discuss is Ciprg more common than we think? Obviously our data is there are a lot of sorry participants had seen Cipric had managed Cipric. As we get better at collecting our data especially off the basis of paneer and at all and all the great stuff they've been doing around consciousness and cardiac arrest. Clearly consciousness is far more common than we actually think in catecher s it really leads to the thought of do we need just basic sedation profile and all cardiac arrests for those higher consciousness that we're starting to see. Also a bit of a mindful it's can happen at scenes but language use. You don't think anyone else is in the room but perhaps your patient is. Perhaps your patient actually is showing a huge amount of consciousness and hearing everything that you're saying. So watching what we say at those scenes as well and I think our last point here just Cipric needs to be mandatory reported from now on. We just need to learn more about this phenomenon and build really strong guidelines and just build our knowledge and understand what our sedation profiles are doing to these patient cohorts. Now that is it for me. Peter. Nick is this is his slide. Are you there Nick?

I'm here Jack. Thank you.

Sure. Thank you for having us on today, Peter. This is a really important topic. I am Nick New Dell. I'm a paramedic scientist with the Paramedic Foundation. I also work my full time job is doing trauma research in a level one trauma center in Colorado and I serve on a number of state and national boards related to advancing the profession of paramedicine. So thank you for having us on today.

Jack did an excellent job going over the data that we collected. And what the future holds is more data to come. Any good research project is going to end with a statement that more research is needed. And that's essentially what we've determined here as well. Whether that research is necessarily academic level research or just.

Data that's collected from our clinical practices that will inform our future.

We hope that there will be an uptake based off of our findings in the different data registries and that maybe the international standard setting bodies will also take an interest in this and.

Take it serious. Because as paramedics, we see this as Jack described, we see it, we experience it, we have to manage it. And we're doing that without internationally standardized guidelines today. So it would behoove our colleagues in those standard setting bodies to carry that over the finish line in really help us.

Take this research and move things forward there. There are also other kinds of research that might inform this in the future. I mentioned reanimation and Arctic hibernation science. There's a lot of interest right now in this, in the science related to hibernation.

I met with and presented with the University of Alaska in Fairbanks in their Arctic ground squirrel research program where they're looking for different enzymes that might contribute to ground squirrels hibernating during the wintertime there. And so it's really fascinating to start looking at translational science between the animal world and the human world that might help inform future medications. So maybe it isn't sedation that's needed, maybe it's in essence giving a medication that might allow somebody to have an experience similar to hibernation. Humans don't hibernate, but maybe there's something we can do to improve their.

Their outcomes by not making them aware of what we're doing. And also maybe that will feed into all of the other science that we, that we see going into the post resuscitation phase of care.

Jack, could you go to the next slide please?

So I just want to drop a little plug for this new concept of the Global Paramedic Research Alliance. This effort that we undertook here was among the first of hopefully many future projects where paramedics from different countries, different continents, many different time zones and different cultures, languages, etc. Would be able to work together to collaborate to bring our unique experiences forward and contribute to the science of what we do internationally.

This particular project was a lot of, it was a lot of fun for me because I learned a lot about how paramedics in Australia provide care, how they interact with the physicians that they work with and how everybody works together as a team in the Australian model. And then we were able to contribute the US model of care to the conversation. And I'm involved in other projects now where we're joined by our colleagues from many other nations. So it's a new time, a new paradigm for paramedic led research. And any of you that might be interested in paramedic research.

Feel free to reach out to us and get involved and learn how to carry forward that research. So that really is the message I wanted to share here. This was, this was kind of the first time for us to try to make this happen. Putting out a survey using the right words that would resonate with us paramedics and also paramedics from Australia and other countries that did participate in the survey was a unique part of that experience and.

It was a lot of fun. It made it an enjoyable experience. So thank you for listening to this study today.

Jack. I'm not sure if you want to close it out with your references or if you are just ready to move into any kind of discussion.

Awesome. Well, we appreciate it, Jack And Nick, amazing presentation. Nick, thanks for all you've done here stateside. We follow your work very closely. And Jack, amazing presentation. A lot of people on this call are probably.

Looking and seeing why this is an entire new aspect of cardiac arrest care. I know that we have Dr. Oleson on and I'm going to read from Don Rice's email who said you'll probably have to coerce him to answer questions and he's probably the most prolific author on the topic of CPRK in peer reviewed literature. So Alex, we have you on. Would you mind saying a couple of words before we end the show and go over to Dr. Pepe's webinar?

Sure. Thanks a lot for the opportunity to talk about this, Peter. And thanks to Nick and Don and the team in the States. Great presentation, Jack. This is very interesting topic. When I started with this just 10 years ago now, there was no definition. There's a few case reports and yeah, the work that we've done and you've pushed forward now, Jack, this has really brought it into the practical domain, you know, like what are we going to do about it? And I think, yeah, ketamine seems to be the way to go at the moment. But I'm interested in what you have, Nick, about hibernation. That sounds, that's pretty novel.

So, yeah, Look, I think clinically the key thing first is just to be aware of it, to not sort of have this go unrecognized. And then second, secondly, we can start talking about how to best manage it.

You know, as Jack was saying, these are the people that we have a chance to really save, so they deserve every event.

Well, again, thank you so much. Before, before we move off, let's see if anyone has any questions. My comment is, you know, based on your research, it looks like the dose that we use is way too high. We have a dose of 200 and we just, we just threw that against the wall kind of thing. But it looks like ours needs to be a lot lower, especially since ketamine does cause some coronary vasospasm, to my understanding. So we are going to be modifying it based on your research. So thank you for that. And I see Andrew Schmidt had your hand raised. Go ahead, Andrew.

Yeah, to piggyback on that comment, with the ketamine dosing, for those who might not be super familiar with ketamine, we do need to be a little careful because once you're getting down to 0.5 mgs per kilig, you are getting into your partial dissociation, which you can actually see worse neurologic events from in terms of emergence phenomenon stuff. So if we are worried about the mental health of the patient experiencing scary events during cpr, we might consider that at low dose may actually exacerbate that. So just something to think about in future research.

That'S interesting and that will only be known to us if we, like Nick mentioned, go to the folks who have these registries and all the data. So for example, cares, which I gave a presentation on last week, is something that. This has to be added into that, right? Nemsis. It has to be added into that because even today some of those data points are very confusing even for us who are looking at that data very, very frequently. So.

Nick or Alex or Jack, do you want to comment on. Are there folks looking at modifying those data elements yet or just too early? I know that ILCOR just, just added CPRIC into their, into their discussion without a dose or without a drug. But can you, can you tell us where we are at this point with that process? Is it just starting?

Yeah, I couldn't comment. Maybe Nick might know a little bit more than I, but at the moment. No, you're 100% right there, Peter. There's not a lot of evidence. So that's where we're at at the moment. We've just Got to collect this data.

And we need to find out more about what our sedation profiles are doing. Nick, do you have any further on that?

Yeah, that's actually an important aspect of emerging evidence is to ensure the dissemination and implementation of it. So I would say that's the phase we're moving into now. Now that we have this published, we do need to work towards implementation. And with the CARES Registry, with nemsis, with nfirs, with whoever has these different data sets, it's not easy to change a data set. Usually those cycles are quite long. They might be one or two year cycles in order to get changes made and through all the processes needed. So I would expect that those conversations will be happening shortly.

Some of us, however, can add into our EPCRs those of us who have the ability to make the modification, to add a closed call rule for CPRIC and then medications used for that specific purpose. As an example, we had a gentleman who had a cardiac arrest several days ago on the tennis court. We got him back with double sequential. He had cpric, he got ketamine and he's actually knocking on wood. He's going to be extubated today. So.

You know, I can't wait to speak to him to say, you know, do you remember any of that? But I think to the points mentioned about consciousness and remembering, et cetera, that's also another fascinating topic to delve into. So go ahead. Dr. Marv Wayne, Bellingham, Northwest Corner.

Hey Peter, you know, I've been around this stuff for 50 years and I have a concept this was more common or more recognized years ago, which seems strange that we would have. But I, I interview every one of our resuscitations that wake up and that's significant numbers now. And I always ask them, what do you remember? Do you remember the process? And I seems to me, and again, this is a study of, with no validity that I can prove that. We see this less often and I'm not sure why, especially with more high performance CPR and with things like Lucas. The corollary question is that we've debated this issue. Is it midazolam or is it ketamine we should be using? And I see some comments on the chat related to this. Why would you not use midazolam, Jack? And by the way, say hi to Steve Bernard for me. And why or why would you use midazolam?

Fantastic question.

There is really no evidence. Don't be sorry. That's. It's a great question. I, I would use ketamine. I'm happy to use ketamine.

I, I would shy away from bedazolam. Not based on anything scientific, just more personal. I don't think the evidence is out there really to differentiate between everyone, I mean, between ketamine, fentanyl and midazolam. I think at the start of the presentation we had that kind of point from Don about those groups in the Lucas study and the groups that had in deadline didn't do as well. There's also some evidence out there against ketamine. There's also evidence out there against fentanyl. Until we learn more about acidation profiles, really nothing to go with my, My preference is to go to ketamine because I know it works quickly. I know it has all the pain relief issues that I, I want. It has the analgesic, the so amnesia issues that come in from ketamine. And it just works really well and really quickly. My issue with midazolam is more.

Nothing against midazolam, but.

Personally, from my anecdotal evidence, I have a lot of issues with cardiovascular issues and compromise post midazolam in my conscious patients. I feel uncomfortable giving midazolam in large boluses to my category S patients. So to me it just makes sense to use ketamine. It has all the effects that midazolam have and more.

So it's a great question and I don't think anyone's wrong for going any other way. Clear studies identified ketamine is the way to go forward. But it depends on what your service uses and what you guys are comfortable with as well.

So that puts an exclamation point. I was gonna say mar. That puts an exclamation point on the fact that we need more data.

Thank you.

We have to file this right? Go ahead, Marv.

No, what I was exactly say that. So the cardiology people say, oh, it's, it's ketamine has cardiovascular issues, vasospasm, midazolam has maybe a little less cerebral or rapid onset. Probably you could flip a coin and get the same answer. And that's the problem. And I would agree this is great study. I just. My concept. And again, we're not doing a good job of putting CIPR in our, in our ehr. And we actually do need to create that field on a mandatory basis. But medics are aware and do commonly make. Make comments. I don't know. I don't. You know, I've seen this for a long, long, long, long time. I've had patients reach up and try to take their endotracheal tubes out. So I don't know the right answer. I. My concept is less common, but maybe it's not. Maybe we're just not documenting. So I guess it sounds like we all need to become more aware and we need to make this a mandatory field and then somehow collect the data. It'd be nice if CARES would add this in.

Yeah. Yeah. Good luck.

Yeah, go ahead, Nick. Yeah, go ahead, Nick.

I was just going to add on top of that that although we're. When we're describing Ciprric, we're describing a.

Visible appearance of consciousness, it may not necessarily be a true consciousness. Like we are thinking in terms of somebody is aware or is creating a memory that they're going to remember later, versus it may also contribute to a catecholamine response, a stress response, a pain response in that moment, and then other mechanisms are preventing the memory from forming. So there's a lot to be learned here still. And I think it's going to be many years before we are able to answer all of these questions.

That's a perfect way to end it because I do think that this is the beauty of research and beauty of clinical care. I will say that what I've noticed, especially in the videos that are online, is that as soon as the person starts moving, everything stops. The CPR stops and people looking and they're wondering. It's just bad for the patient. So for the people out there who are like, there was someone on Twitter who came on Twitter and said, why are you even giving these people anything? Right? And I think the answer is because if you watch the videos and you read the case reports, as soon as the patient moves, hands go off the chest and people start like tapping them on the shoulder, say, hey, are you awake? So, well, well, Jack, you made a great presentation. I'm going to give you the last word. Take us away. And you have a lot of people here who, you know, following the research, may or may not have it in their protocols. Give us your final. Your final comments and then. And then you can go back to bed. So thanks. I know it's so late there and I really appreciate you again.

Thank you so much for having. Yeah, just exactly kind of what you indicated there, Peter. I mean, that's anecdotally. I've had some had patients Game of Thrones style, trying to claw out my eyes with their thumbs. I've had them choke me, scratch me, tell me to go away with four letter words rhyme with duck.

It is.

It's an incredibly confronting.

Phenomenon and psychologically impacts not just paramedics, but the patient, but bystanders. So sedation profiles probably definitely needed at the moment and just we need to build evidence that we need to collect data. And I really stress that point going forward, collect as much data as you can and we'll go from there. Like Nick says, this process is probably going to take a few years to get and perfect. But yeah, we're certainly very excited of where we're heading at the moment.

Awesome. Well, I'm going to. I just put in the, in the chat. I just put in the chat. Your, your paper, the link to the paper and above that is a link to now join the Eagles webinar. So to Jack, Alex, Nick and I know Don was not here, but we're thinking about him and hope that he, he's doing well. Thank you guys for contributing to the evidence base and for showing us what the future of EMS care and cardiac arrest care looks like. So thank you all very much and we'll see you next week. Have a good day, everybody. Thanks again, guys.

See you guys.

And I'll stick around until people join the other webinar or exit. I'll give it another minute or so and then we'll do that. Thank you.