Treating Kids Like Little Adults: Challenging the Dogma of Pediatric Cardiac Arrest with Peter Antevy

Welcome to another episode of mracast, the podcast for residents by Residents. I'm your co host Chris Riley. Thanks for joining us. Now let's get to today's episode. Mracast is supported by Vapotherm, a leader in ventilation innovation. Find their latest research and advancements@vapotherm.com hey everyone. Welcome to another episode of Mracast. I'm Chris Reilly, one of your co hosts and today I have the pleasure of Speaking speaking with Dr. Peter Antevi. Dr. Antevi is currently the medical director of Davie Fire Rescue, Coral Springs Parkland Fire Rescue, Southwest Ranches Fire Rescue and MCT Express, all in South Florida. He is also the founder of Hand Tevy Pediatric Emergency Standards where he is currently CMO. He currently practice out of Joe DiMaggio Children's Hospital. Dr. Antevi, thank you so much for coming in. Why don't you tell the listeners a little bit about yourself?

Awesome, Chris, thanks for having me. Hi everyone. I have just been privileged in my life to have a journey where I started in pediatrics at AN la, went to Pittsburgh for my pediatric EM fellowship, came back to South Florida and then five years after I got started, I became an EMS medical director somehow or another. And it's just been an incredible journey. I realized that really where I belong is in the pre hospital world and it's something that has really changed my life.

That's awesome. When thank you again for being here. It's an honor to have you on the show. Why don't you tell the listeners a little bit about yourself from a personal aspect. Why don't you tell us one fun fact about yourself?

A fun fact about myself. I love listening to podcasts and really ingesting a lot of information from many different sources. I find myself nowadays trying to learn from fields that are completely different than mine and try to bring it all together to see if we can master the craft that I'm in now, which is really as a really an entrepreneur. Right. I started off as a doctor who then created something and now you have to bring that thing to the world. And believe it or not, they don't teach any of this in medical school. So it's been an incredible journey and learning every single day.

And speaking of medical school, I just found out you went to St. George's which is where I'm from. So really cool to see SGU alumni doing their thing out here.

I love it. Great school. Great, great school. Great memories from that school.

Yeah, absolutely. So today we're going to be talking about a topic that scares a lot of emergency physicians and emergency residents out there, and that's going to be pediatric cardiac arrest. And Dr. Antevi is an absolute expert in this field and he has a great talk for us today that we're going to be discussing. So, Dr. Antevi, you want to set the scene for everybody?

Absolutely. You know, I've been doing this for over 22 years, and I can't tell you how many times, Chris, they would come into the emergency department and the five minute ETA we'd have a, let's say two year old that was pulled out of the water is coming in in full arrest. And over the years, I just kept seeing more and more kids coming in in full arrest. And it hit me that we could get these kids back. But oftentimes it was all for naught. They would end up either dying 24 to 48 hours later, or they would end up with a trach and a G tube, et cetera, and go to some nursing home or having to be cared for at home. When I became a medical director in 2010, it became very clear to me that we weren't doing enough on scene so that we can bring these kids into the hospital with a pulse. For anyone who's kind of worked in EMS or been in ems, you understand that you're there when it's hitting the fan, right? The scene is oftentimes there's a lot of anxiety, a lot of tension, and if you can't control that scene, you end up going along with this, hey, let's get out of here. And then we end up bringing these kids to the emergency department, where, by the way, the resuscitations aren't nearly as good as they are in a very high functioning EMS system. And when you look at the data, Chris, where you have 20,000 pediatric cardiac arrest every year in this country, and if you look at the guidelines, what they'll tell you is that they have data saying 11.4% of those patients, those children, survive to hospital discharge. But you have to read the small print there, right? Survival to hospital discharge doesn't mean that they're playing soccer and running around in the field anymore. It turns out that only 5% of those children are neurologically intact. So quick math, 20,000, 5%. That's only 1,000 children.

Wow.

So here we are in 2022, almost into 2023, and we have 19 out of 20,000 children who have a bad outcome from their cardiac arrest. And if you just digest that information for a second from 1980, 90, the 2000s, that number has not moved at all.

Wow.

So in 2010, it hit me, why aren't we treating these kids the same way we're treating adults? And what do I mean by that? Well, why aren't we staying on scene? Why aren't we doing high performance cpr? The same mechanics? Why aren't we talking to the family members, telling them that we're staying for a reason? And I got a lot of head scratching and people telling me, well, that's just not how we do things. And I realized I was part of the problem. Someone here in the ivory tower as an ED doc saying, you bring me those kids and we'll handle it. I then flipped the script and I said, wait a minute. We're gonna show the emergency department that they want us to stay on scene. They want us to perform CPR in a very well organized manner. And then when we bring them a child who does have a pulse, we can then pass the baton and then that kid has a fighting chance. There is now data to prove without a shadow of a doubt that lives are saved by EMS when it comes to pediatric arrest. And that's the beauty of this field.

Wow. Those numbers are staggering that you're talking about. And I can see why that would be disturbing to pretty much anyone.

Yeah. So when you start to look at adult cardiac arrest, you know, in 2015, I became medical director with Dr. Schepke of a very large agency, Palm Beach County Fire Rescue. And we came in in January 1st of 2015, and by the end of the year in the adult population, we already doubled ROSC survival to the ed. So then when we turned around and said, hey, what about the kids? Everyone again was like, ah, we're not really sure if we can do this. When you look at the disparities between adult care and pediatric care, it's very interesting. The true reason why people EM residents, EED docs, paramedics, nurses, why people get nervous when they hear that it's a kid. It turns out that there's one very simple reason. And it has nothing to do with the medicine. It has nothing to do with the anatomy. It has to do with the fact that when you Chris, hear that you have a 65 year old cardiac arrest in bed one, before you even take two steps, you already know exactly what you're going to do. You know, the dose of all the medications, you know, the monitor, defibrillator, joule dose you're going to put, you know, the airway size, you know it all just by hearing the word 65 year old cardiac arrest. So when I say to you five year old cardiac arrest, a wall more than likely just got built right in front of your brain. And if you think of where that wall gets built, it happens right when you hear the age. So the adult age never stopped you, but for some reason the pediatric age did. What I learned from a great book called Thinking Fast and Slow by Daniel Kahneman is that there's something called system one thinking and System two thinking. When you think of system one, if I told everyone who's listening today, close your eyes, you have a 60 year old male clutching his left chest, short of breath, he has chest pain radiating to his left arm. Everyone exactly knows what to do, right? That's, that's called system one. Your brain just automatically is hearing this information and is a million miles an hour in front of you already knowing what to do. That's pretty much all of adult emergency medicine. But then for pediatrics and pediatric emergency medicine, they've told us that you have to have a child's weight. And unfortunately, in order to get to the child's weight, you have to have measured this child, right? So this whole thing about using a length based tape that was developed in the mid-1980s by a wonderful and very smart doctor, Dr. Broslow. What Dr. Broslow did back then, he said, these kids come into me, I don't know any information, but if I, if I measure them, I can start to figure out dosing. So he was already in the emergency department, he had a length based tape that he could put right by this kid. But that one thing of forcing a length based tape, what it does is that that lane face tape now forces you into a huge pause. So whether you're the resident, the ED or the attending, or the paramedic en route to a scene, you now have that five to six minutes where you know what's coming but you cannot prepare for it because you cannot do a system one evaluation. Meaning you can't just say five year old. I know exactly what to do. And that was the aha moment where I said, well, why don't we just use age? Which is what they did in LA Children's where I trained, Bob Hickey, my mentor in Pittsburgh, Children's in Pittsburgh, he's one of the co authors of Pals, by the way. He only uses age. And we never use a link based tape at both of those institutions. So now I come to the hospital here in South Florida and I'm being told, you shall use a link based Tape. So it turns out that if you can figure out a way to use age to jump off and understand the epidose, the equipment in this case we use an eye gel or the tube size, whichever one, and then the dual dose, just by hearing the age, you could then put your brain in the same motion as you were when you were thinking of the adult, that 65 year old. And it turns out it's nothing more than just a behavioral change to have your brain start thinking along a different pathway. If I gave all of you on this call the case of a seven year old patient who's septic and I said, I need an ET tube, an NG tube, I want a norepi drip, or let's say I want a milrinone drip, right? All of a sudden I'm giving you information, I'm asking you questions that you do not have the answer to. Why? Because it's all system two. And system two is that item that needs to be removed from what we do for a living, whether you're an emergency medicine physician, emergency nurse, or you're a paramedic. And that's for me, where it all starts.

Very interesting. So this concept of looking at age that started in your training in LA and it started in fellowship in Pittsburgh. How did you incorporate that into South Florida? Because you said at first, you know, they were like Brazilotape, Brazil tape. How did you incorporate that?

Yeah, so it's interesting, the very first month I was in attending, you know, listen, after six years of training, PEDs and PGM, that first day you're on the job, you're still nervous and your heart rate is going fast because you know, everyone's looking at you. The nurses are like, hey, who's this guy? He's a new doc. And they're all trying to make that evaluation. And where they evaluate you the most is in the code room. So my first month we have, you know, it was that 7am Shift change and that's when the kids who had been probably dead for a couple of hours, the parents find them. You have a dead baby. So I remember, I'll never forget, I walked into that room and a nurse handed me. Cause they took the Brazil tape and they encased it in like a six foot piece of wood so nobody would steal it. So here I was, never having ever used this tape before and the parents were in the room and someone hands me this six foot board and I can't even tell you that the fear on my face when I knew that everyone was looking at me and I'm thinking to myself, what am I supposed to do with this? And so one of the nurses comes over and she says, okay, we measured the kid. And he comes up to here. Now you have to tell us what you need from here. And I'm thinking to myself, well, in Pittsburgh and in la, I would just say, hey, let's get epi, let's get ready to intubate. And next thing you know, they'd come on a silver platter. So after that experience, my stress level went really through the roof. And I said to myself, I have to figure this out. So in. In the ensuing months and over the next year, I was making phone calls to Bob Hickey of Pittsburgh, and I said, bob, I really need to understand what are we doing differently at this children's hospital, level one trauma center that we weren't doing really at the academic facility? And he says, pete, I. I don't know what to tell you. I said, but, Bob, you never used a tape. He says, I know. I just have a way of doing it by age. And I went back to the desk and I took out a piece of paper, and I said, okay, let me. Let me start putting down some ages on a piece of paper. And I did. I put 1, 3, 5, 7, and 9. And then I was looking at all the formulas I could find, looking at how to convert an age into a weight, because there's a lot of articles on that. And I came to a really complicated formula that when I plugged in those ages, 1, 3, 5, 7, and 9, the weights came very close to 10, 20, 25, and 30 kilogram. And I said, okay, it's a good start. And then I listed seven medications that I would need in the code room. And this goes way back, like, we were still using atropine, we still using bicarb, whatever. But I ended up figuring out the volume dose based on the kilogram weight. And I quickly realized that it was very easy for me to use the age to get to the epidose for cardiac arrest, the atropine dose, bicarb, D25, even epi, 1 to 1000 for anaphylaxis, amiodarone. So till today, if you just give me any weight within seconds, my brain will now go through those seven medications in a heartbeat. And that's what I did. I ended up, like, after about a year, the nurses were like, pete, for the past year, we were, like, nervous about you. And suddenly you're doing incredible in the code room. You're calm, you're relaxed. What did you Do. And I said, no. I just. You know, it just. I think it just hit me. I'm getting more confident, which was not true at all. I just didn't want to tell them that I had to use a different system that I had to make up. After talking to Bob, I. And two years goes by, I still didn't tell a soul. And I'm about to give a talk about pediatric shock, and the nurse says to me, pete, do me a favor at the end of the talk, can you teach everyone the little trick that you use? Because I had told one nurse about it, And I had two slides with this one. 3, 5, 7, 9. And I taught people how to do it. And I had 50 people line up after a lecture, and they said. I'm like, well, is the lecture that good? And they're like, no, we just want those last two slides. And. And I. That was the day I came home to my wife. And I'm like, it's not just me. And I felt vindicated. And so my wife helped me make these little badge buddies. And I came to work with the badge buddy. And within an instant, people like, I'm begging you, I want those badge buddies. So I brought a. Like, literally a box, a couple hundred of them that I got made at the printer. Literally, within days, that entire box was gone. And I would walk around and people wearing the badge, the badge buddy. I go up. It would be a year later, I would. The anesthesiologists were wearing it, and the nurse in the PACU was wearing it, and the fourth floor pediatric nurse. I'm like, what's up with that? I started getting asked around the country to give this talk, and I would bring boxes of these cards. And over the years, I must have given away tens of thousands of these little badge buddies. And that's when. In 2010, because I started it in 2005, by 2010, I kind of knew that I had something. And I just became an EMS medical director. And one of my medics said to me, Doc, there's seven drugs here on this card, but we have 40 drugs. And I said, aha. So I ended up going in age by age from preemie all the way to adult. And I just said, these are the 40 drugs. And instead of only having 1, 3, 5, 7, and 9, 5 ages, I ended up having, you know, 19 different ages from preemie all the way to adult. And that. That was the moment where things really started to turn. Meaning I was getting asked by agencies locally, agencies regionally, saying, like, we want exactly that. And that was the moment that I said, you know what? Maybe I do have to create something for the masses. But interestingly, Chris, normally if you come out and say, I've developed something and people see that it's working, they're like, you keep going. You're doing a great job. It turned out that my physician colleagues were the exact opposite. I had so many people come and tell me how stupid this was, and how could I even think of using age and my own hospital? There were people who wouldn't look me in the eyes anymore. National conferences. I would walk into room, people would walk out of the room. But I knew in my heart that we really just have to use a different method, not different medicine, but just a different mental process to get to the promised land, which is being in the code room. Your heart rate, it's always going to move up a little bit, but your heart rate, at the point where you could still look people in the eyes, you could have mom and dad stand right next to you. You could manage the room without yelling. You could ask the room, am I missing anything? You can go back to the parents, update them, and that is when you know that you're running a really good code. And it turns out, and I'll end with this part, if system two creeps into your brain, meaning if people are asking you for a dose, an ET tube size, how do I mix that medication? Once system two gets ignited, you're done. Your heart rate goes through the roof, Your hands start to sweat, you start becoming agitated. People could see that you're not focused in on them, you're not looking them in the eyes, and that's when you lose the room. And the same thing happens in ems, and that's why people leave the scene in the emergency department. You just have total chaos in the code room. And many of us have seen that before. It turns out it's. It's something that's not related to medicine at all, that fixes the resuscitation for pediatrics. And that's why I go back to what I said earlier, which is you can learn from other fields how to be a better practitioner. And that's exactly what happened to me, and that's how I ended up in this position.

And that's a really interesting story. And I feel like we kind of hear those stories from a lot of people who are trailblazers yourself, someone who saw a problem and tried to make a solution. And you're going to have naysayers, and you're going to have People that are believers. And you're going to see, you know, mixed reviews of that. But you stuck to your guns. You stuck to what you believed and what you saw that worked and you kept pushing forward with that.

Yeah, I appreciate that. I think anyone, like you said, who has a really good idea, if it's an idea that everyone can do, and people are like, oh, yeah, that's a great idea, probably other people have thought about it. If you have a great idea that you know is great and everyone is telling you you're wrong, those are the really special ideas. Now, I can say in retrospect, after having a lot of black and blue from years and years of trying to prove this to be true, now we're on, we're just finishing up 12 years of this. Now there's, you know, 2,500 cities around the country who use our program. It's nice, you know, kind of looking back to say, hey, everything that you thought was true really is. But you know what, Chris? You could look all around you in the emergency department. There's so many things that we today that are completely wrong. So many things, sure, that have to be fixed. But we are trained that you, you watch one, you see one, you do one, whatever that whole thing that you're being taught, things from people who have been doing it for so many, so many years that when a new idea, specifically in healthcare, comes up and bubbles up, your immediate inclination is to say, nope, I'm not doing that, because I have never done that before and therefore it can't be true. So I just think that we owe it to ourselves to say, if there's something that doesn't feel right, maybe we should be doing it differently.

Yeah, of course. Obviously what you've been talking about this whole time with the 1, 3, 5, 7, 9, this is the hand tevy technique. Why don't you tell our listeners a.

Little bit about that?

For anybody who hasn't heard about this technique for pediatric emergency medicine and resuscitation.

Yeah. So it started off with this on your hand. You know, you say the 1, 3, 5, 7, 9, 10, 15, 20, 25, 30. And then from that weight. So let's say the 1 and the 10 go together. So one year old is 10 kilos. Well, if you want to know the cardiac arrest EPI dose, which is EPI 1 in 10,000, you take the 10 kilogram, you move the decimal point over once and you get one that's 1 milliliter of epi. It turns out it's also 1 milliliter of amiodarone if the kid is in fib, right? Or pulses btach. So you end up having one number. You could walk into a code room and you can bag, bag, bag, push, push, push, drill. You give 1mL of epi if you needed the Meo. Probably not, that's 1mL as well. And all of a sudden it was a very quick and easy, simple way of doing that. Now fast forward now, almost 13 years later, we now have recognized that the hard part of pediatric dosing is when you have 40 meds, right? A typical code room there is about 35 to 40 different meds, plus all the different drips that you could potentially use. And no one wants to ever have to memorize that. And there's no quick way to do that. So we created an application on your phone that we then customize. So if you're an EMS system, we take all of the meds on your vehicle, the dose from your protocol, the route you want, and we kind of put it into this software that we built and then it spits out a very simple customized dosing image, if you will. And the cool thing about it is that you can click on one year old and you can click on atropine and it gives you the volume you say I gave it, it turns green. And then everything you're doing on the phone then can be transmitted into like for example, if you're a paramedic, it transmits into their ehr. So now you're giving them a tool that provides them information before they get to the scene, right? Because now two year old in cardiac arrest, they open the app, they say 2 year olds, 12 kilos, epidose is 1.2amiodarone doses, 1.2 milliliters. They know the joules. Let's say we're going to go to 30 Joules because there is no 24. So all that information, they know the EPI, they know the Igel size, that's the supraglottic airway we use. They know the joules during that six to eight minute ride to the patient. Hospitals use our system for that five minute pre game, right? When you know that EMS is coming and we have a five minute eta, then they pre game and say, okay, med nurse, this is what you need for epi. Respiratory therapist, this is the ET tube size you're going to get, you're going to need whoever's on monitor is, this is the jewels that you're going to need. All of a sudden we've given people an opportunity to pre game and then we give them the entire dosing algorithm, if you will. And then we added a pretty cool metronome where we have five different things going on at the same time. So once you're in cardiac arrest, what people don't recognize is you want a metronome at 110, you want one breath every six seconds. And then if you're going to go from 15 to 2, then the airway goes in, you have to go to continuous. And then you have to know when to charge the monitor at a minute 45. This is all high performance CPR metrics I'm talking about, which is what we practice heavily in ems. And then at two minutes you have to hover, check the rhythm, either shock or dump the charge. And then when you give epi, then at the next EPI is every three to five minutes, that's another timer. So all of a sudden you start to realize that we can create a tool that instead of someone having to remember all these things that are happening at the same time, those are all hard to do now we allow it to just be done seamlessly and then we add a checklist on top of that. So you could be, let's say in the RSI checklist while someone's intubating. And instead of trying to figure out what your mental RSI checklist is, someone could be reading it to you right from the same screen as the CPR metronome is going on, right from the same screen as you're looking at the drip, how to mix that norepi drip, so forth. So we've really come a long way, the collaboration with Electronic Health Records so that all the information you're doing on your phone or on an iPad can then just go right into your electronic health record and then saves you a lot of time.

That's amazing. And that keeps you on that level one thinking that you're talking about as opposed to that panic that level two can bring. This helps you overall treat kids like adults and you don't have that kind of panic that that sets in. I think that's incredible that you've done that and you've, you've continued to push for this to be accepted. And I know personally some of my co residents who use the hand tevy method and myself, I use it, I think it's fantastic method and I think it does keep you calm in those situations. And when you think about pediatric cardiac arrest, there's nothing scarier in my opinion, that I deal with in the emergency department because again, like you said, adult comes in, you know what to do, you know what to do. That's level one thinking. And then when the kid comes in, there's a lot of different factors there. Dr. Anteve, any last minute thoughts or advice when dealing with pediatric cardiac arrest?

I think it's just important to set up some sort of sequence where your hospital or your emergency department is, is, is doing some type of routine training. What I've learned when I compare EMS to the ED is some very, very big differences that the hospital cannot overcome. You're on shift with someone different every single day. Today you had these four nurses, tomorrow you're going to have these four nurses. And by the same token, the nurses have the same problem. They're going to have Chris today, Pete tomorrow, Julie the next day. And that what happens is when you walk in for your shift at 7 o' clock in the morning or at 7 o' clock at night, you're looking at each other and you're thinking, either that's a hell yes, I see who my team is, or you're like, oh God. Right. And if it's an adult code, I mean, I think, I think most people can kind of figure that out pretty simply, but if they throw a pediatric code in there and you haven't trained and practiced, then all of a sudden it ends up becoming an upside down feeling. And people leave those scenarios feeling that they didn't give the child the type of care that they would have wanted their own child to get. What I push everybody to do is to look at this item called high performance cpr. And I know it sounds like everyone's like, oh, yeah, of course we do high performance cpr. But it turns out that unless you actually see high performance CPR being performed, usually that's on the EMS side because it's the same crew every third day and we really drill really hard on it. Unless you're doing high performance CPR where the room is quiet, everyone's got a role, everyone knows what they're doing. The mom is next to you, the mom and dad are next to you, and you're keeping them informed, you're not kicking them out of the room. That's the kind of thing that I think everyone in the hospital needs to work towards so that when that next kid does come in, it doesn't ruin your career. And I've seen many careers being ruined, not in the sense of people being sued. As an example, it's people come into that room, it's like a grenade just blew up. And then people just kind of Shuffle out, having to go see the next patient. And a lot of people go home and cry. And they go home and they say, was it something that I did wrong? So we all have to work together to make it so that the system at the hospital that we work at works and something very simple that you can do. And I did this for many years. I came in once a month and I invited all the nurses and doctors. The doctors never showed up, but the nurses did. And we just went through code after code after code, just mock scenarios. And what I did was I told the nurses, there's going to be a nurse who's going to act like the doctor. And then we have respiratory therapists, we had a med nurse, we had a procedure nurse, and we had a documentation nurse. And we over time, we just kept cycling everybody through each of those positions so that when the real code came in, the nurse who was in any one of the positions knew exactly what the doctor was thinking because he or she had been practicing that, you know, in our monthly sessions. And there have been many times where someone would say, hey, doc, do you want to do whatever? Fill in the blank. How about we start an EPI drip on this patient? Or do you want me to turn that EPI drip up? The blood pressure is a little soft. That type of mentality of collaboration, bringing everyone together, that doesn't happen just because you went to the best medical school and you're the all star resident. You have to know how to do it the right way and work as a team. So it takes a lot of work, it takes a lot of practice. And having the right tools to actually help you get to that point is very valuable. But the tools don't work unless there's a system where. And someone's managing that system to make sure that you're practicing and doing it the right way.

And I was going to say, it seems like the overall theme here is if you don't like something or you don't think something's working the best way that it should be working, put in some effort to actually go forward and use your ideas or collaborate with others to try to make things work better, it seems like you did exactly that, especially with running these mock scenarios. I think that's invaluable. Dr. Antevi, any last minute thoughts for.

All the residents out there? I would say that some of you may know the world of ems, but most often the ER doc sees EMS as just another patient that they're bringing them. What I've learned since 2010, when I became an EMS medical director is that they really have a very difficult job, but they're really, really good at what they do, especially if they have good training and good CQI, etc. Oftentimes when they get into the hospital, they're not really, you know, treated the right way. Right. It's just, oh, I've got another EMS call. I would say if you see EMS walking into your department, stand up, go greet them. Hey guys, what do you got? I'm Dr. Antevi. And you introduce yourself and then give them their moment, listen to what they have to say, don't just shoo them away. And I'm reminded by a very important case. I'll end with this. This is a case that happened in another state. It was a five year old boy who choked on the little pink bouncy ball. And apparently EMS was on the scene. They were trying to get his sats up. Someone had said something about that they think that this kid choked on a bouncy ball, but when he got into the emergency department, they just kind of shooed EMS away. And that information never got translated over. What happened was they kept looking and looking and looking and they finally saw that this kid had a pink, you know, flesh colored ball in his trachea. It was finally pulled out and the kid ended up having an oxygen brain injury. I think that the lesson there is give EMS their moment, treat them with respect, listen to what they have to say and maybe even go another step. Work with them, go to the firehouse, ask them when their training is be involved, get on their calendar, let them know who you are so that when they come to the hospital like, oh, that doctor cares about me. And then you'll start to get more patients coming back to life. You'll have EMS who wants to come to your hospital. And so my biggest, my biggest point to everybody out there is get to know who your EMS system is and then collaborate with them. You may even find yourself in a career in EMS one day like I did, which has been the best thing for me. So. And that's it. So thanks, Chris, so much for having me.

That's amazing. And if you guys want to learn a little bit more about Dr. Antevi and the Han Tevi method, what his business does, you can check it out in the show notes. I'll put, put a link to his website and some other links in there for you to check out. Thank you guys for joining and we'll see you next. And Emracast, thanks again to our sponsor, Vapotherm. Visit them@vapotherm.com to learn more about their advancements in high velocity mask, free ventilation therapy.