Tanner Smida: NAEMSP 2025 Abstract Preview (1/3/2025)

Okay, welcome everybody. It's January 3rd. Happy New Year 2025. Let's make it a great year. This week we have Kenner Smita, who's taken the time to give us a Preview of the 2025 abstract. As you know, all of these abstracts are published in tec, so you get a chance to look at them before you get out to the meeting. But Tanner's going to take us through that. So Tanner, thanks so much for putting this together. And first of all, how are you doing?

Doing good, doing great. Yeah. Looking forward to the meeting next week.

All right, my friend, take it away and thanks for doing it.

No problem. Yeah. And I will say that I definitely did focus on most of the poster abstracts, left most of the oral abstracts alone. A couple of them might have slipped in. Also, there was some overlap between the abstracts that are being presented here at NEMSP and the ones that were presented at the Resuscitation Science Symposium that we covered previously. So any ones that I covered in that previous video, which is now on the YouTube, I've also left out of this presentation. Presentation.

I've also kind of grouped these into small thematic groups. I think it ended up being about 17 abstracts. I'll try to get through those in about as many minutes. So first we're going to talk about some heat related or abstracts related to heat related emergencies. The first of these was a NEMSIS study. So between 2020 and 2022 they included all EMS responses that had a heat related emergency defined by the use of a heat exposure protocol, provider impression, symptoms, the dispatch reason, or the deployment of a cooling procedure like cold water immersion. So it ended up being a kind of a very rare patient population. So it accounted heat related emergencies accounted for about 0.4% of all encounters nationwide. Of course, this varied by region, it varied by season. But overall, lumped together, heat related emergencies were about 1 per every 259, 1:1 calls or per 250 encounters. There was a small increase observed in 2022 relative to 2020. So the odds ratio there was about 1.09. So it's a pretty small increase. And the biggest increase when they broke it down by region was in the west south central United States.

And so kind of branching off of that. And I really like this abstract. It made me smile when I read it. You know, it's been established that for kind of the most severe heat related emergencies for heat stroke, cold water immersion is kind of the gold standard in management. It's an effective technique. Lower body temperature by as much as 0.2 degrees Celsius per minute. However, when it comes to deployment of this therapy, a lot of agencies are using kind of ice water slurries in body bags or cold groundwater in body bags. However, no one studied, you know, what's the optimal bag to use. And so these authors bought seven different commercially available body bags. And then they simulated a cold water immersion with a weighted dummy and about 40 liters of iced water.

They basically filled a body bag with this water. They put the weighted dummy in there. They oscillated the bag on the ground for about 10 minutes. They moved the bag to the EMS stretcher, oscillated it for 10 more minutes. Then they evaluated them for structural failure. They looked at how much water leaked out of these bags. They found that five out of seven of these body bags experienced some structural failure. They specifically mentioned two. The North American Rescue Human Remains pouch lost about 30 liters of water. The majority of the water that you put in that bag would have ended up on the floor of your ambulance or on the ground where you were doing this procedure. They also specifically mentioned the DoD body bag didn't experience any failures. Maybe something that the government got right there. I thought this was kind of a pragmatic paper or pragmatic abstract and could influence kind of the body bags that you stock if you're in an area that has a cold water immersion protocol that uses the body bag.

All right, so moving on to cardiac arrest care. Wouldn't be any MSP abstracts without a ton of cardiac arrest abstracts.

And this first one looks at the delivery of telecommunicator CPR instructions to patients. And so, you know, we know that CPR prior to the arrival of EMS is associated with survival. It has a number needed to treat for telecommunicator CPR of something somewhere close to 15. So this is a very effective intervention, and we need to make sure this is being delivered to as many patients as possible.

Importantly, some recent literature has suggested the way telecommunicator CPR instructions are delivered has an influence on whether or not CPR is actually initiated by bystanders or family members. And so this study looked at six different public safety access points in Missouri or answering points in Missouri. They looked back at the previous year and randomly selected out of hospital cardiac arrest calls. And then they analyzed these calls. They listened to the audio recordings and analyzed them using a standardized template. They ended up with 272 out of hospital cardiac arrest calls. And they found that dispatchers who used kind of more of a direct or assertive instructional strategy that led to increased odds of the patient actually receiving bystander cpr. So when I say direct or assertive, that means saying things like we are going to do CPR or they, you know, you need to do CPR now on this patient rather than saying something like do you want to do cpr? Do you think you're able to do cpr? The direct assertive instructional strategy was also associated with shorter time to initiation of cpr. And interestingly, they did a subgroup analysis looking at just callers who were deemed to be emotionally distraught. And they found that if you use that assertive strategy, you multiplied your odds of having CPR initiated by about six times. I think this is another great study. If you are the medical director of these PSAP sites, it might be beneficial to make sure that your dispatchers are trained in this assertive assertive strategy. If you're using scripts, making sure that the scripts are reflective of the assertiveness that's being described here.

This next one is a retrospective study from a high quality single center cardiac arrest registry. It aimed to establish the prevalence of signs of life during cardiac arrest resuscitation as well as the association of signs of life with survival. So in terms of signs of life, they defined signs of life is respiratory effort, eye movement, body movement, or verbal response or verbal engagement during CPR. During 2022, they treated 617 cardiac arrest patients. Of those, about 13% had signs of life. When they looked at factors associated with signs of life, they found that witness cardiac arrest, having a cardiac arrest in a public location and having a drug associated cardiac arrest were associated with having signs of life. I think that's interesting, especially in the context of our previous discussion of naloxone and cardiac arrest and signs of life potentially being a modifier of who does or does not get naloxone thought that was an interesting secondary finding of their analysis.

Not surprisingly, they found that patients with signs of life were more likely to survive. The odds ratio there was 9 confidence interval ranging from 4.2 times as high to 19.5 times as high. They found that in their population the signs of life that they saw most frequently included spontaneous respiratory efforts that was in 86% of cases, eye opening in 71% of these spontaneous signs of life cases, personal movements in 63% and then verbal communication in just over 50% of the cases with signs of life, which I thought was pretty surprising.

This next one is actually more about prevention of cardiac arrest. It's from the Pittsburgh group a couple abstracts describing this crashing patient care bundle have been presented previously at nemsp, but essentially the city of Pittsburgh has this crashing patient care bundle and it's basically aimed to stabilize critically ill patients as soon as it's recognized that they're critically ill. The protocol basically says if you encounter an unstable patient on the floor of their home, correct their physiologic abnormalities if they're hypotensive, get vascular access, start fluids, maybe even invasive if that's indicated. If they're in respiratory failure, don't wait to move them to the truck to put an airway in or establish non invasive positive pressure ventilation. Correct physiologic abnormalities when you recognize them. These authors wanted to see if this bundle of care Implementation of this bundle of care was associated with decreased odds of EMS witnessed cardiac arrest.

They looked at all of the cardiac arrests treated by city of Pittsburgh paramedics and they looked at the percentage of these cardiac arrests that were 911 responder witnessed. They also looked at it was a subgroup analysis looking at patients who had EMS witnessed cardiac arrest more than five minutes after EMS arrival to kind of give EMS providers a window for intervention. They found that so this all started in 2015. And they found that post EMS contact cardiac arrests were about 12.4% of the total system cardiac arrests in 2015 compared to only 5.8% of the system wide cardiac arrests in 2023.

The difference in proportions there was statistically significant. They also found that more of the EMS witness cardiac arrest patients had vascular access prior to cardiac arrest. That went from 30% in 2015 to almost 60% in 2023. When they looked at that subgroup so the crashing patients who were basically in the presence of EMS for more than five minutes, they found that the cardiac arrests among that subgroup decreased from 10% in 2015 to about 5% in 2023. Also statistically significant. They also found in that subgroup that survival there was a trend toward improved survival over the study period, although that didn't reach statistical so I look forward to kind of more data characterizing this bundle of care and hopefully a forthcoming manuscript from this group.

So this next one looks at what happens after resuscitation is successful. So after return of spontaneous circulation, it was basically a retrospective review of cardiac arrest patients treated by a single urban EMS system. They leveraged both cardiac monitor defibrillator file data as well as electronic health record data. This group of patients or this group of investigators defined rearrest as a non pulsatile rhythm following return of spontaneous circulations. That was either asystole VF or resumption of chest compressions. They looked at 217 patients. Of those, 44% experienced rearrest. But the interesting twist to this paper is that this group of investigators, they noticed that in their service area during patient movement, patients frequently had their electrotherapy pads disconnected while patients were being extricated from their homes. They found that 16% of the rearrests that were observed in the study occurred during that monitor disconnect time, which of course might have relevance to whether or not the rearrest was detected and how quickly that rearrest was treated, which might have an influence on patient outcomes. Not surprisingly, rear rest was associated with lower odds of survival to admissions. The odds ratio there was about 0.29. It was statistically significant. I think this data goes to show that we should probably be making every effort we can to keep our patients connected to cardiac monitors while we're extricating them so we could recognize that shockable rearrest and correct it and perhaps improve outcomes by decreasing the ischemic burden suffered by our patients.

This next one was actually a quality improvement. Abstract and so it's from a group of investigators. They practice in an area where protocol requires paramedics to contact direct medical oversight for all cardiac arrest cases. And then the direct medical oversight, they're supposed to order push dose epinephrine for all patients that had a systolic pressure less than 90 millimeters of mercury or an unobtainable blood pressure despite a palpable pulse. But they noticed that this intervention was not being delivered very frequently in the pre hospital setting. Frequently or previously on this webinar we discussed a publication looking at implementation of a postdoc bundle of care and the Post Ross bundle of care did not influence the prevalence or incidence of rearrest. And we hypothesized that part of the reason for this may have been that the actual deployment or the actual delivery of interventions such as push dose epinephrine, fluid bolus, et cetera was very low. So adherence to the bundle was very low. And so this quality improvement abstract they basically set out to increase adherence with this kind of component of that bundle of care. It involved a targeted education initiative for the medical oversight nurses and physicians. They distributed newsletters they had in person training visual aids in the dispatch center. They were all focused on increasing awareness of this push dose epinephrine protocol and they found that they were able to improve administration of push dose epinephrine for this patient population from 25% in kind of the pre intervention group to 42% in the post intervention group. And so I look forward to kind of more publications from this group, seeing if that has any influence on patient outcomes.

All right, so in this next group of abstracts looks at patients who present to EMS refuse and then present to EMS again later, these repeat encounters or frequent utilizers of ems. I kind of included these, these abstracts in a separate group because I think this is incredibly relevant to our practice as EMS clinicians. And we certainly encounter these patients a lot more frequently than, for example, cardiac arrest patients. So I think it's great that this is population that's starting to be studied a little bit more intensively. This first study is from the ESO data collaboratives. They use the 2021 annual data set, and they set out to describe on a nationwide level, EMS patient utilization patterns Using demographic fields, using name and date of birth, and these patient identifiers, they created a masked patient id. And then they determined over the course of that year basically how many times Those patients encountered 911. They classified patients as either being low utilizers, the patients that use the EMS one time within a calendar year, moderate utilizers, so 2 to 4911 calls, 5 to 11 calls, or the very high utilizers, that's the 12 plus call group. They ended up analyzing over 7 million encounters for over 5 million individual patients. Single patient encounters accounted for about 50% of all the encounters in the data set. And interestingly, about 0.3% of patients accounted for 5% of the total encounters. Right. So again, 0.3% of patients are accounting for about 1 in 5 of the 911 calls made in the United States every year, which I think is pretty interesting. They also looked at what are predictors of being a high utilizer in this sample. And so they found that so being an adult who is less than 65 years of age and patients who were male and in socioeconomically vulnerable areas, all those three things predicted being a high utilizer of ems. They also found that in comparison to a reference group of patients with cardiovascular or respiratory complaints, odds of being a very high utilizer was increased for patients who presented with an index diabetes related impression. And then I don't think this is necessarily surprising, but the odds were decreased for the patients who presented with altered mental status in patients who presented with injury.

This next one is somewhat similar. So it looks at repeat EMS utilization, except focused specifically on patients who receive lift assists. Right. So, you know, we've all been on a thousand of these calls, right? Elderly patients who fall in their home they request EMS are helped up and decide not to be transported to the hospital. There's some literature out there that suggests that falls, especially in elderly patients and liftocyst, can kind of be sentinel events that may indicate underlying pathology for a significant percentage of patients. And so this patient basically describes patients who are encountered within seven days of an index lift assist. It was conducted in a single EMS system. It was based on a retrospective review of electronic health record data. They included 574 repeat encounters for 480 unique patients. 76% of these patients were transported on the repeat visit. And interestingly, over 60% of the repeat primary impressions indicated some medical pathology. Right, so these were not repeat falls. This was not musculoskeletal pain related to kind of the initial fall. These were kind of medical complaints, things like chest pain, respiratory distress, sepsis, etc. Which is interesting and suggests that maybe things were missed during assessment. At the, at the time of the initial lift assist, only 1% presented in cardiac arrest within seven days, which I think is honestly probably pretty low considering how elderly this, this patient population is and the degree of comorbidity. The median time to repeat call was about one day and the majority of calls, repeat calls, happened within three days. There was no association between the odds of transport on the repeat visit and the initial assessment. So there was no association between, for example, abnormal vitals on the initial assessment and the odds of repeat.

Transport to the hospital on repeat assessment. Or interestingly, they looked at incomplete assessment. So if some vital signs were not documented that had no association with the odds of repeat presentation or transport.

So this next one is another nationwide ESO study using the 2018-2022 annual data sets. Similar to the study we discussed before, they created that masked patient ID. They looked at all 911 encounters that ended in non transport. And then they looked at the proportion of these cases that had kind of repeat ems encounters within 72 hours. Because about 20% of all transported patients within the ESO data set have linked emergency department and hospital ALPH outcome data. They also looked at characteristics associated with hospital admission versus ED discharge for patients transported for after their kind of repeat EMS encounter. Of the over 21 million index encounters, about one in five patients were not transported. Of those patients who were not transported, about 6% of them basically represented to EMS within 72 hours. At the representation, 1% of those patients were dead on scene, 28% refused again and were not transported. 71% were transported. Looking only at those transported patients with outcomes, 56% were sent home from the emergency department, 41% were admitted, 3% were transferred, which probably suggests some pathology that either needs specialized care or immediate intervention, and then 0.4% died in the emergency department. They looked at factors associated with increased odds of admission after that repeat encounter. Right. So trying to identify those patients who perhaps were at higher risk following that initial refusal of care. And they found that factors associated with admission included male sex, increased age and clinical impressions that included cardiac or pulmonary complaints, neurologic complaints, as well as infection or sepsis. Not surprisingly, they also found that abnormal vital signs on initial presentation were associated with ED admission at a later time point. Once again, in terms of operationalizing this from a pragmatic standpoint, it suggests that if you're on scene and a patient is trying to refuse, you know, maybe have a little bit more caution, maybe try a little bit harder to convince patients to go to the hospital if they have one of the chief complaints listed here, and, you know, goes without saying, if they have abnormal vital signs.

There were also a cluster of abstracts looking at patient sedation for agitation. So the first of these compared the safety and efficacy of droperidol versus midazolam for agitation management in the pre hospital setting. It was a review of electronic health record data from a single large EMS agency. So within this EMS agency, so the protocols for these two drugs, so it was 0.2 mgs per kg for menazolam or 5-10 mg for droperidol, in addition to a bundle of care that included continuous monitoring with ECG and pulse oximetry and nasal capnography, as well as calculation of the Richmond Agitation Severity Scale. And so they found that there was a between these two agents, there was a similar degree of reduction on that scale. So RAS reduction was -4 from inazolam vs minus 3 points for droperidol in terms of their outcome of hypoxia. So more patients who were treated with midazolam had hypoxia. So SpO2, less than 90%, 14% in the midazolam group versus only 7% in the droperidol group, and that difference was statistically significant.

Similarly, this additional analysis so also was a retrospective review of electronic health record data from a large urban EMS system compared the prevalence of adverse events between patients who received dropperidol, minazolam or ketamine. They included patients who received these IM drugs for agitation. They excluded patients treated for seizures, patients who were treated with these drugs to facilitate airway management and also cardiac arrest. Patients, their primary outcome, it was a composite outcome actually. So they defined new or worsening post sedation hypoxia as an SpO2 less than 90% or 20% lower than the initial SpO2 hypotension as an SBP less than 100 millimeters of mercury or 20% lower than the initial SBP or the need for post sedation airway management. So bbm, any BLS airway adjunct and of course advanced airways. So in terms of the kind of epidemiology of administration of these drugs, about 1 in 3 patients received midazolam, about 63% of patients received troperidol and then a very small proportion received ketamine. And they found no association between what drug was received and the odds of any adverse event.

All right, so moving on to pre hospital airway management, of course there were a ton of abstracts looking at airway management in the pre hospital setting.

The first of these examines laryngoscopy challenges that are associated with ketamine only endotracheal innovation. And so I think that this is practiced in order to minimize adverse events. So to kind of maintain patients spontaneous respiratory effort which would be taken away if a paralytic was administered. But the extent to which that is successful is unclear per these authors. They used electronic health record data, cardiac monitor files and importantly they used video laryngoscopy recordings from a single large urban EMS system that deployed ketamine only innovation. They reviewed cases where ketamine only innovation was attempted. They ended up with a sample size of 46 patients and they had some, I'd say troubling findings. So first best success was only 54% and at 10 minutes post intubation over 40% of patients were hypoxic and over 58% of patients had post intubation hypotension.

Based on the video review. So the review of the video laryngoscopy attempts incomplete relaxation was attributed as a cause of failed innovation in 68% of failures. And so this might shed some doubt that ketamine only innovation decreases patient complications and might actually be associated with increased complications.

Another similar study. So this looked at sedation assisted innovation or ketamine only innovation for sedative assisted innovation in a single state. So this used NEMSIS data from a single state. They stratified their cohort by the type of sedative that was used in sedative only innovation. They compared etominate versus ketamine and they found that automata was associated with better first pass success, so 84% versus about 55% and overall innovation success in comparison to ketamine. And those differences were statistically significant. Interestingly, the first pass success with ketamine, so about 55% here, was very similar to the first pass success with ketamine in this a different EMS system.

And so again shedding some doubt that ketamine only innovation is a good idea in the pre hospital setting.

This next paper and two of the authors. So Jeff Jarvis, apparently some of his brilliance is also rubbed off on his daughter Sydney Jarvis, who is also a co author on this manuscript. They use the 2022 annual data set from the ESO Data Collaborative to look at the drug assisted airway management approach and innovation first pass success. So they classified non cardiac arrest patients who are undergoing pre hospital innovation as receiving either rsi. So that's a sedative plus a paralytic sedative assisted innovation, which is a sedative only, paralytic only, or no drugs at all. They ended up with a sample of about 13,000 patients. Of those, about 1 in 5 were innovated for trauma. About 43% were innovated with a video laryngoscope. And overall in this cohort, first pass success was 75%. Drug assisted airway management approaches included RSI about 50% of the time, no meds about 30% of the time, and then the rest were a mix of sedation assisted innovation and paralytic only. They found that compared with no medications, using that no med group as a reference category, patients who received RSI had higher odds of first pass success. And patients who received paralytic only also had higher odds of first pass success. Compared to sedative assisted innovation. RSI was also associated with higher first pass success.

This next one's pretty interesting. It's the use of a soft robot as an innovation adjunct. So I was able to find a picture of what this kind of robot looks like on the Internet. It was a prospective study of the usability ability of this soft robot to perform endotracheal innovation among EMS clinicians. So they recruited four paramedics and four EMTs to attempt to use this soft robot to innovate mannequin models and human cadavers. So in the models it had 100% success. The median time to innovation was 7.4 seconds. So it works great on the kind of mannequin heads that we're all familiar with. And it also worked pretty well in cadaver models. So when the robot versus video laryngoscopy went head to head. There was 87% first pass success with the robot versus only 63% with video laryngoscopy. This robot and I wasn't able to find a ton of information about this online, but it was basically these types of robots were designed to navigate the lumens in medical context. This could be used to facilitate things like endotracheal innovation, as it was used here during endoscopy or surgeries, navigating the gastrointestinal intestinal tract. And so I'm looking forward to talking with the authors of this abstract during the meeting and see, hopefully they bring the device and you know, maybe, maybe let some of us play around with it, but, you know, just kind of a taste of what might be on the horizon for the trachea innovation.

Hey, Tanner.

Yeah?

Would you mind going back one, because we have one of the authors here on the call, Marvin. Marvin Wayne. A little bit. A little bit better.

Yeah. Well, these guys brought me along. I convinced them that this wouldn't work, so they convinced me it would. And part of Dave Miramani's crew down in San Antonio brought the folks in. This is an interesting concept where you take a supraglottic airway. You know, they always talk about sliding something down so you can innovate, which is incredibly impossible. And then you combine them with the luminal tube and you build it with soft robotics. So essentially superglotic goes in and you just push. It's already preloaded. You push through the oral tracheal tube and it works. And we played around down at Scotty's lab with quite a few different cadavers, fresh frozen cadavers, all variety of ages and formats of body habitus. And it just worked. And we trained EMTs in five minutes and got this incredibly high percentage. Now does that mean it's ready for prime time? Don't know yet. So we need a lot more opportunity. But I think physically building it will be again, probably somewhat semi robotic.

It's.

It's fascinating. I am going to ask David to bring some models of this to the meeting. We are kind of in a. An advanced position because the paper is at science and. But the abstract is going to be at nmsp.

Excellent. All right, thanks, Mark. Appreciate it.

The question came, how is it different from the innovating lma? You have to see it. The emanating lma, you have to add a second tube. This one is all preloaded. Thank you.

I see. Thank you. Thanks, Tanner. Back to you.

No problem. Yeah, just one left. So we'll finish off here with this. It's a study of. It basically characterizes nationwide protocols related to the practice of transcutaneous pacing in the United States. I wanted to throw this one at the end because this is of kind of personal interest to me. So we know that we've discussed transcutaneous pacing on this webinar before. We know it's associated with dismal outcomes. There are a number of reasons why that might be, including things like false electrical capture and the challenges of palpating pulses and confirming mechanical capture, the way this therapy is deployed now in the United States. So these authors basically used two large repositories of EMS protocols. They identified 585 across the entire United States. They randomly selected two protocols from each state. They also included states that only had one protocol. They ended up with a total sample of 111 protocols. But due to some feasibility constraints, they only ended up actually reviewing 27 advanced life support protocols.

I thought there was some interesting data here. There's a randomized controlled trial out there that shows that pad position on the thorax has pretty significant implications for whether or not mechanical capture is able to be achieved with anterior posterior pad placement, leading to a higher probability of mechanical capture. But 11 of the protocols that were found did not mention pad placement. So over 40% of the protocols that were kind of reviewed. In addition.

A fair number of these protocols did not mention sedation or pain management. In a paper our group authored, we found that a very small proportion of patients with a GCS of 15 actually received any pain management for what is certainly a painful procedure.

Fifteen of the protocols did not mention electrical capture settings. So they didn't mention, for example, what a typical range for electrical capture should be for an average human patient.

Ten of them described a method to confirm electrical capture. Only 16 suggested confirming capture with a matching palpable pulse, which I found was pretty interesting. And only three describe the phenomenon of false electrical capture.

And so I just thought this was kind of an interesting study design in going to publicly available EMS protocols and seeing, you know, what is the letter of the law for paramedics and advanced EMTs who are out there actually performing this procedure on a daily basis. And I think it found that the protocols that exist are lacking. But, yeah, again, that's all I have for you today. Thank you very much for listening. I'm happy to talk about any of the. Go back and talk about any of the abstracts I've already breezed through or if there's any others that you want to discuss from the published abstracts that are online. Happy to do that as well.

Awesome. Great. Amazing job, Tanner. This gives everyone a preview of really what NMSP is all about. You end up getting research that has not made it to publication yet. Everything that Tanner went through today is only an abstract form, meaning that these departments, these agencies did their research. They put together a 350 word abstract they submitted to NMSP. Small team of people reviewed it and said, yeah, this looks pretty good. We'll put it in for the meeting. Now, all of these authors, the next task is to actually go and write the paper and go through the peer review process. So what I love about NMSP is that you end up getting to see hundreds of research papers that are not going to get into the main circulation for maybe a year or two or more than that. That's a great opportunity to meet the authors, talk to them and see what's coming into the future. So NMSP is kind of like a short look into the future of what's coming and what you'll find in the publication. So I have the link for the Eagles webinar Canada. That was amazing. You are going to be at nmsp, right Tanner?

I will, yes.

Awesome.

I will be helping people put up their posters. If they need to find the location of their poster, I'll be available.

If you see Tanner, make sure you say hi to him. If you see any of us, please be sure to say hello again. If you're part of the Florida chapter, we'd love to see you at the dinner. Chapter meeting is at 6:30 on the 10th followed by the dinner right across the street. We'll be giving everyone like an armband because we're maxed out, we're capped out and Zol is sponsoring. So we're very appreciative for them. And with that being said, we'll head over to Paul's webinar. The CME codes unfortunately were not given to us yet. So you'll have to wait until Candace provides them and when they do, I will put it in the chat in the multiple chat. Good to see everybody. Let's make it a great 2,025. Get to San Diego safely and Happy New Year. Thanks everyone.