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and cool eso welcome, everyone. Um, thanks for the introduction. Show you, um, Miami serum, a neurosurgery training, working in Cambridge on over the next hour or so we'll go through at the principle of managing patients that have, um neurotrauma, which is something that you might know learned to not about. Getting that full though some of you may have a mobile do is in the next half an hour, so we'll cover that principles and that theoretical principle behind managing the stations. On down after that will be some cases to discuss into the breakout rooms where you can try and apply those cases, um, and make use of those information to solve what's going on. So what we'll talk about today in the next half an hour will be sort of describing what neuro trauma is on trying to get a bit of a definition drug I do on specifically, we'll talk a bit more in detail about what traumatic brain injury is, which is a kind of a subtype of neurotrauma that's actually quite common on. I think it's important to understand the principle of its management. We'll talk a little bit about how you will approach a patient that present with TBI, or traumatic brain injury, and little bit about how the injury develops and kind of the pathophysiology around it on down. We'll talk a little bit about what you can do for these patients in terms of investigations and also kind of immediate level of fat mint. So just to start off with some definitions, what is in your room, I might, you know, we'll probably end up having one understanding of it. But really, if we think about it in a broad sense, sort of neurotrauma means any kind of injury to the head or the spine that occurs secondary to trauma, often from some kind of external force that is applied to a head or spine that results in injury. Um, and as you can tell, this is a very broad definition. A lot of things can come under this umbrella term, and so lots of this thing includes mail conditions all much more severe. End of the spectrum, Um, and for example, on the mild end of the spectrum of Neurotrauma is something called concussion, which is a sort of minor head injury were often the patient is fairly well but still can create some problems underlying on the more so the end of the spectrum. There's different types of traumatic brain injury, whether brain itself is injured, and often we can see bleeding or different types of pathology within the brain tissue itself. This'll be accompanied by skull fractures due to trauma that can be isolated or associate it to underlying brain injury as well. And we also come to get about the spine on derms five drama on. In the context of your extra, we can have fractures within the spine at any level. So from the cervical spine and all the way down to the sacred. And we can also past spinal cord injuries, where fractures or ligament injury cause disruption of the spinal call on the stitches here of kind of highlighted in the mouth. And so, you know, here you've got just a kid that looks pretty well, but the bruise on the head that's still part of neurotrauma, they have a head injury, even though they probably fine with it. Um, here is something we don't see very often in the UK, which is a penetrating had injury. So you might believe that this patient had a bullet or something go through their head, which is something that people see more often, for example, in North America, other countries. But we don't see that much. Here. You can see it. A CT of someone's head that shows you the bone on Deacon. See here where there's a fracture, Um, alongside the outline of the skull. And finally, here there's a CT scan that shows us a fracture in the lumber spine on Be here looking more of their survival spine level. This now in MRI, where we have a fracture that is put putting pressure and compression on the spinal cord. Um, and you can see that by these areas are very bright within the spinal cord itself, causing damage. And so this now makes understand that neutral makes that was a huge topic. It's not something we can cover in half for now. Today, one of the sexual bit and so what I thought. Well, focus on today. Specifically, it's traumatic brain injury, which is one of the areas in your trauma that is very important to get right away on, because I want to, you know, from learning about strokes. For example, and other brain conditions. We know that time really matters when you deal with injured brain on. So the important thing for you to learn as a medical student is not to deal with the super details on their specialist aspects of managing this patient, but learning how to recognize these patients on learning about the simple things that can be done early on to give them the best time they have at making a good recovery, as if we think a little bit more in detail about traumatic brain injury itself. Again, let's think a little bit about a definition, because I think it helps us to understand the process is that go on to cause this entry. So as reset traumatic brain injury is usually caused by drama or some some kind, So it's something that it's not a degenerative condition. It's not a congenital condition. Um, it's often do to some kind of external mechanical force. Apply to the head and the brain, and that could be a penetrating force like a bullet. It can be a blunt injury, such as hitting your head on the floor, but some kind of forces usually involved um, it usually lead to some kind of either temporary or permanent impairment off some urological function, and that could be coming to function. Let your ability to think make decisions. Um, use your brain in ways that you normally would to speak and understand physical conditions or physical processes so you could have things like Weakness is, for example, or difficult to using any of your lens or sensory disturbances on ball. So psycho social functions so more sort of higher function relating to you. Psychology, how you interact with others and how you can function in society. And this could be a temporary so within the hours, days, months after the injury. But also it can be permanent a types on. Usually when a traumatic brain injury happens. It's associated with some degree off, out of state of consciousness on deal talk a little bit later on about how you might you go by assessing the state of consciousness and these patients and the thing to remember. It's that the UK it's not the hugest country in the world. But if we think about in a global scale, TBI is really prevalent. It's a condition that affects loads of people worldwide. across all walks of life across all countries. About 69 million to the ice happen in the world every year on diseases both in highly countries like the UK but also low income countries on. So the this is really important to get right no matter when you're working, know massive what patients you end up seeing on and there are differences. For example, in the UK, we know that the majority of patients that we see with TB eyes now are starting to get older. And so perhaps those patients have more milder traumas, but still resulting significant brain injury because they may have more communities or risk factors that make them at higher risk of, for example, a bleed in their head. But we also know that to be I can affect young people s So, for example, people your age that are young in their twenties and, uh, you know, engaging in there is activities they might you know. Often we see patient that have, for example, of impossible for a traffic accident and they really young and they were completely well before the injury on. So this is something really that effects everyone across all ages, And that's why I think it's really important to just get an understanding what you do with this group of patients, and you might even injuring itself. So we talked about umbrellas and umbrellas it in, um, breathless and the Trump New York rumor is a big scheme, and then t b I's one of the substance of it. But within two by itself, there's also different pathologies on Go. What have tried to describe here with this sort of series of five CT scans is really the range of conditions or different types of brain injury that can represent TBI is holding the same all in the same patient or in different patients. And so if you go through them in in line, you might have seen some of this camp before you might have recognized the type of pathology we're talking about, and so TV I mean's, for example, on the standard they're very left inside of the screen. A patient that has an extra during bottom are so we can all see here. There is a bright, acute bit of blood that's toward the outside. So not really inside the brain were just outside to it. underneath the bone. Um, and the shape of it looks like a, um, sort of a bit like a lens there, and it's, ah, type of bleeding that was outside the US, so it's an extra during the tumor that's often caused by arterial bleeding. Um, and at your bleeding has pressure. And that's why the she is aware that you're on from the periosteum underneath the bone on bone wide expanse. Often it's up a bleeding is associated with spinal with, um, fracture in the bone around the air of the bleeding. On it is just one type. The second scan along is still blood still bright, still acute blood we can see here, but now this is distributing all away this all along, the subject of space on the left inside of the patients got a scan, and so this is an acute subdural hematoma, where the blood is often venous in nature rather than arterial, and it's Friday across a subdural space, so he has a wider areas Teo run across on but usually follows the outline of the brain itself. But again, it can put lots of pressure underneath, and we can see both here and here, where the midline off the patient's head is not right in the middle anymore but has been shifted to one side on go. These type of traumatic brain injury often require removal of this big Aaron of clot. The scan in the middle looks a little bit different on, but you can see here is now lots of small areas of high hyperdense or acute blood on that scattered all the way around the frontal lobes on bees are hemorrhagic contusions, so basically bruises within the brain tissue. It's south, and this is a little different cause now this bleeding and it's bruising is within the brain tissue. It's not on the outside, it's not on the lining, but it's within the brain itself. And so, as you can imagine, it's very difficult to go and remove this type of clot or bleeding because it's in dispersed within a normal brain tissue. Eso. The way we treat this patient very, very slightly based on the pathology they have on the right inside. The This scan over here shows some blood within the subarachnoid space, which actually you'll know about some record hemorrhage in the context off having aneurysms or sort of weakening of the blood vessels that can bust and cause. It's a direct a hemorrhoid, but also these vessels can rupture when there is trauma on. And so here, on the right inside of the patients scan, you can see some acute bright blood around around the fishes and around the so okay, which is consistent with some traumatic subarachnoid hemorrhage. And finally, the last one on the right hand side, you may think, looks quite good. You may think there's nothing wrong with it on you would not be wrong on first look. But if you look a bit more close, as you can start to see that this scar and compare to, for example, the one next to it looks a bit fuzzy in general. You can't really see the silk, right? Very well. So if you look here, you consult to see the passion of the brain. But here is much more difficult to see on we can to some small errors off sort of hyper acute or maybe small areas of bleeding around the brain scattered on. So this top of injury Usually it will be called a diffuser tunnel injury, which is a type of TB I caused by often shearing forces so often high velocity, high impact incidents where the brain is a little shaken on the accidents that cross the greater white matter tend to become disrupted. And this causes lots of small hemorrhages but also swelling on. So this brain starts to look a bit tighter. And that's why you can't see the differentiation between the So okay, much more on you at this point any more. And so this is just really to show you The TBI and XL can include a number of pathologies, um, all of which we treat partly in the same way, but also sometimes partly in different ways. Um, I think it's important to bed. It's in mind and just don't think that maybe I just one simple condition. The other important thing about it is that we've talked about trauma. We've talked about people, they get injured by external forces. And so, as well as some of these scans are showing you before, can coexist. They can exist when a patient might have two types of bleeding or two type of interest, but bring together, they may also have other types of injuries elsewhere. Um, and important thing that we need to remember is when somebody Assad an injury that caused him to have a scan that looks a little bit like this. We can't do anything to reverse that injury. We can't go back in time and make sure that this isn't happen. But we'll we can do is to try and prevent any further injury from happening on. That's really important because brain that is injured is not happy. Brain is brain that is not functioning very well on do further injury test happen. And this is the thing we need to stop. And to understand this is a little bit used to turn this down the pathophysiology. So in very simple term, we talked about head trauma. We talked about some kind of injuries, Some kind of force affecting the patient may have been hit on the head. Maybe days they've been involved in an RTC, they be in front of their bike. Maybe they fall and understand any of those things could happen on. That's a bit. We can do too much about that. What we call the primary injury either Primary insults what happens at time? Zero. But what happens after times. Here is what we really need to focus on. Um and that's because the brain that is injured and swollen on dtaps bruised. It's not happy lots of things happen down the line. Um, Andi, what we all these things that happen result in is in what we call the second group of an injury. And that's the thing that we can try and stop on bavencio happening with the treatment that we give our patients. So, for example, the brain that injured it's bruised means that we've lost some accidents. We've lost, um, urine's. The cells are damaged, not happy. That center leaves a lot of inflammation and sell toxicity, which causes the brain to swell. And similarly, when we have bleeding, we have ruptured blood vessels on disk Um, you to reup too. Damaging all opening off the blood brain barrier, which is we know, is what normally keeps the brain within its own safe space on. Therefore, this can also cause inflammation, and this can also lead Teo fluid shifts and also more swelling and more edema. And so there are lots and lots of processes that are involved in what happens after the initial injury. Ischemia, cells being damaged or dying, inflammation in general. And all of those things can lead to swelling within the brain and the intracranial cavity. And that's not something we want to happen. And the reason when that's not something we want to happen is that we all know that the brain is living in their clothes box. I yes, go! A school has two openings, really. One other form of Magnum at the very bottom and to the very front will go, Oh, I sockets those. The eye sockets are very small on the brain comedy. Squeeze through that, just the optic nerves going through that. But the main opening, or the only opening for that the school really has is from a magnum where the brainstem runs through and brain is connected to the spinal cord. Um, so if you think about the box that's closed, this can mean there any kind of changes in volume. A. Whatever is inside this close box on cause a great deal of changes in pressure and the relationship between the intracranial pressure on the intracranial volume is describing a doctor in which is called the morning Locally doctrine which you may have heard of before. And basically, this doctor describes that we normally, when we're healthy and don't have an injured brain, live in a state of homeostasis where we have an amount of brain within the skull and amount of arterial blood on amount of Venus, blood and amount of CSF. And these four components all live within their own percentages within within a store. But if one of these increases, for example, a hematoma or just swelling within the brain tissue itself, then the books doesn't change its size. And so something else has to be squeezed out on the first thing that tends to be squeezed out to make room is the CSF, and then followed by that some venous blood. Um, but this can only happen for a certain amount of time. A zit can see sort of the graph here to the left. Normally, we have a lowish pressure on the volume that looks a bit like this. If we have a mass or in denial, something that's in there that's trying to put increase in space inside and volume, we can squeeze out some of this fluid sites that have components or what's inside the skull, but actually was soon Richard Point, where we've squeezed out all that can be squeezed out in terms of CSF and almost venous blood. And now we've lost the ability to compensate for more volume. And at this point, what happens is that we can maintain a low pressure because if more volume has to be in, put it into the into the skull. Then the intracranial pressure starts to rise exponentially on the graph here on the right for presents, same concept without the description of the percentages of volumes on Go. We normally are in a state down here where we have low pressure, normal volume, and we can compensate a little bit. But we soon reach a point where we can't squeeze out and eat. Um, it's possible, and so suddenly, Ah, pressure of that within the school rise is really, really high. And the problem of that is that we need a low or normal amount of pressure within the skull for the base for the brain to be able to refuse by blood on. But the problem is that if the pressure keeps rising, the brain will not receive enough blood supply on also a some point. Eventually the brain itself will push out off the box threw the Roman Magnum, which is the only opening on the unfortunate needs to bring their on. But what we need to happen is to intervene to make sure that we never reached this point here or the very top of the graph on that concept. And that principle of the more early doctrine and pressurizing within the head is what is related to how are patients present on. So when we stop about patient presented with things like had true marked for my sleep or an injury, we can sometimes see patients that have signs and symptoms of pressure. And, for example, a patient that has a scan that looks a little bit like the one here on the left inside May presents clinically with the finding off unequal pupils with the dilated pupil on the same side of the bleed on, we'll talk a little bit more about why that happens in the cases, so you can think about it now. The other thing that we can see is because of swelling and because of pressure building in the head, patients may have an altered liver consciousness, and the way we normally assess the level of consciousness in our patients is through, um, assessment of the class of coma scale, which I'm sure you've heard of before, which assesses patients responses Teo voice and to pay on. We can assess how patients open the rise, speak on, move their limbs. Um, can go from the 15, which is the highest normal number of GCS, then 23, which is the minimum when somebody is completely unresponsive and not responding to anything we do to them on as pressure rises, usually the GC schools lowers on some patient because of that ends up end up in this situation like the patient here on the right, inside being really sick in an intensive care unit, needing help with their breathing because I'm sure you'll know parts of the brain control breathing functions on. So some patients are too sick to maintain their airways breathing their own, and they need lots of monitoring and interventions to make sure that they kept safe. So after all of that, you might think, How do you approach a patient that comes in with a traumatic brain injury? It all sounds very complex. Well, I don't think the nation assessment should be, um the things to remember is that this patients come in and they're acute. Yeah, well, and so your normal principles off acutely and well patient management that you've all learned about 80 80 assessments, um, and in this state is no real difference. The only addition to that is that this patient often drama patients. And so there are other consideration to add on to your age of the assessment. The spaces are often also not managed in isolation. So you normally have a team. We do with different expertise. Often this patient will come to the emergency department where you have emergency doctors. There'll be a niece itches around. If people are worried about that, always there might be other specialties deal with truma. They often would call the neurosurgical team if they're worried about a sort of severe TBI. And so they depend of people around to help with. But the important thing is that you need to make sure that there was a safe and there was We all know if the brain is injured, airways can become unstable and looking for not protect their own airways on breathing, circulation, disability and at this point is really important to really make sure that we assess their disability or the neurology to see how alert or not alert a are on day. Finally, anything else is there any other things you can see unusually in trauma? We split this assessment into your initial acute um, well, a tree assessment, which is what we call off in the primary survey. So the things and where we focus on the things are really life threatening. So you're eight weeks and that system doesn't really go wrong. And following that once in a relaxed, we found out the things that are really, really difficult and really important, and we should deal with. First, we can go back and look at all the systems in more detail, and that's what we call the secondary survey. We can look for minor injuries, other things that we may have missed before. And that's a time to try and gather more information, for example, from who witness and, for example, the trauma or any family members, anyone else, I can help you identify who the patient is, what's going on them what the medical history waas and the only addition to your atria specimen is something about the cervical spine. So you know, you know, normal entry assessment of a non from our patients. You don't really think so much about the spike was fine. But when somebody's had an injury to the head, the head is connected to the rest of the body through your cervical spine on, so the cervical spine itself can also be injured. And it's really important to remember that we should be careful about this because, as I'm sure, you know, the spinal cord runs through your cervical spine all the way down to the rest of the spine. But actually a low enough control. Breathing functions, for example, are also this level. And so we must protect the cervical spine to make sure that our patients don't end up with worsening injury in the lower limbs, for example, and upper limbs. Because because we haven't protected the cervical spine. And so, for example, when you do new entry assessment, if the patient is not well enough to tell us that they have no pain and they can move all the limbs absolutely fine, we normally put patients in a color, and that looks a bit like this. So survival Call it that protects the neck on deacon protect things, for example, like this fracture here. So on the left inside, you can see a CT scan, a sagittal view of a CT scan or someone cervical spine that has a fracture at C five level. On this fracture could be potentially putting the spinal cord under pressure. And so we need to protect it until we know that it's safe. Do not do that anymore. This could be done through imaging, but also through asking the patients how they're doing. On top of that, the main of principles of managing TV. I really on our to do the basic things. Well, as we said, we focus on the Atria Cess Mint on. Important thing to that is that the brain likes to stay in its own normal environment on, so we really need to try and maintain normal physiology. That's really the key principal eso Things like initial initial resuscitation say the patient is unstable hemodynamically. All those things should take priority because in the body is not perfused at the brain is definitely been perfumes? Well, either. Um, so you know, brain, it's a high level of not supply constantly, and so we need to make sure that we avoid periods or, for example, pull hemodynamic stability and poor blood supply going to the brain. We need to make sure the process someone's areas. Because, of course, if the brain is to injured, they may lose the ability to protect them on their own. On. We don't want people to be hypoc sick. We need to make sure that the oxygenation is very good, that the brain is refused, that the BP is maintained, that there's no anemia, so that again oxygen carrying capacity is good and also that people are well on allergies. Because this this thing can be really painful. And then we can do things that we call overall newer protective measures. And I'll talk a little bit about that in a second. And that's basically again making sure that the brain doesn't suffer anymore any further, and we need to again keep monitoring, then urology. So keep monitoring how allergic this patients are on. We can do so usually through, um, the classical must get a settlement just something I talked about before. So we asked regularly patients Teo respond to us in terms of the first speaking to them. And if they don't respond to speech, then we usually cause them a painful stimulus on. We wanna just this religiously on, actually intervals to make sure that any changes detected very early. The other things we monitor is pupils. The people of response we want to see it in the pupils are reacting to light on. We want to check the size of them. And so these are really are clinical ways in which we morning to the brain. There are investigation we can do so we started the bedside with simple things like blood gases. Azam. Sure, you know all the patient that usually are you doing well on the trauma will change the bloods. We'll check the the not anemic. We normally check their clotting because, as you can imagine, any of the monitors in closing mean that bleeding it in the head would be much more severe. And as we said before, there's not a little space it within the cranial cavity and so correcting any kind of abnormal grafting is really important. We usually once patients to have a group and saves and, you know, in case they need surgeries and transfusions. And the other test that we often do is a CT scan off the head. And so Michael Spine, for the reasons that we mentioned earlier on and that sort of your key boxes of investigation, you would do really for managing the stations. And the other thing that I think in this kind of setting, usually it's more red. Investigation. Is collateral history so often, especially coming? Is a trauma on there no alert enough to tell you much about their history? And so we may not know who the people are, and so we have no way of knowing their past history and records on so part of collecting. Those information is kind of doing investigative work. Often the police and they may have been involved or paramedics that may have been involved in that it's in the injuries. The accident can help us, but that is kind of doing, you know, going a little bit backwards, not doing the standard history examination later, but actually doing the acute assessment and then going back to taking some more information there's a few practical things to consider on. We'll discuss these in the cases more in depth. So when you have a patient that comes in with the TBI and we said that can be failing well, But they can also be really well. And so the questions that you should be asking yourselves are, you know, where does this patient need to go? Um, who needs to be involved in managing them? And so if you think about this two statements, the first one is a patient is 23 years old, the cardiology says 14 because they're a little bit confused. There were hit at the pub on Do have some small front or confusion on the CT scan. So if you think about what this patient could go and you need to be involved, you can say, Well, this patient could probably be safely managed on award with some nursing stuff that can assess the GCS and the neurology. And who needs look after him? Well, probably, perhaps, if you have capacity for it and you're a surgical ward in the in the hospital. But even if not so, any kind of medical board that has trained doctor strain nurses and can recognize any deterioration. The second case is now a 32 year old who was involved in the traffic accident. The drowsy the GI says his 12. They're not open and riots they are not making any sense on did not really being old, that all all your commands. And now they have confusions on the CT scan. Now, this patient about sicker, they are more likely to become a well more quickly because they're more drowsy. So they may lose their ability to to protect their own airways, for example. As of this patient is more like it, you need to go to a critical care kind of environment. So, for example, a hates to you left also high dependency unit. And so the people that need to be in both now on many more. So you need to involve your critical kind of stuff. Um, potentially only the anesthetist Eames. If you're worried about this patient's, I believe two went in. There was, um, breed on. So these are questions that are really, really helpful to try and determine how sick somebody is and where they need to go for management. There's a couple of differences that we talked about to be I and there's a spectrum of it, too, so people can have what we call is a mild to be. I know they are usually Daniela, so they might be completely normal completely. Just says 15 like everyone else. Or they might a bit confused or maybe a little bit sleepy. But they can obey. You command your instructions, and usually the stations need monitoring. So we would normally admit them the hospital, and watch him for 24 to 48 hours. And make sure that the neurology don't get worse because it still can get worse. If they're fine after a couple of days, usually they're safe enough to go home with someone looking after them. Um, but even though we call this TBI and mild, there are still things that can happen, eh? So, for example, lots of the station can have what we call post traumatic attorneys. Yes, or memory loss, um, around the time of injury that can persist for time and that can really be affecting that ability to get on with her life. And so this is something that we involved additional therapies and your oh, psychology is, and all that and ET team in Managing on bit can be continued to be a manager at home as well. And even the mouth to be I can have long term, so consequences. So, for example, they can have some cognitive impairment going forward. Some mild weakness is going forward. And so it's not just about the very acute phase, but actually people may need a longer term management, even though the injury was mild for the people that have what we call moderate to severe TBI. So the ones that are sicker they tend to be more drowsy. They don't have a lower GIs. Yes, um, often they require admission teo critical care unit, either a heat high dependency or an intensive care unit on Go. Often these people need help with protecting the road airways, and there are things we can do to monitor the brain because if you put the patient to sleep, we sedate them. It's very difficult to assess how alert they are because we're keeping them asleep on, so to monitor how their brain injuries going, we can insert monitors such as intracranial pressure monitors, which have depicted here in the picture on the right, there's different types of them, and often what we use is a small catheter that goes within the brain and and help incest monitor how high the intracranial pressure is, which is a A said before an indication of how severe injury is. The other thing we can do. People have big in my tumors or sort of clot. We can evacuate this lesion so we can do it. What we call a craniotomy, take out the clot some time for the bone back. Sometimes leave it out, which is called a decompression connected me. So leaving the bone out of the brain is getting really swollen on. Weaken diversity. A set away fruit drains that can remove CS after the outside to make some more room for the rest of the tissues if they're swollen. And then last important thing to remember is that we don't We can't forget the rest of the body. As I said early on TV, I often according trauma. And so if you think about more traffic accidents for from significant height and injuries are high impact, their head maybe injured, but the rest of the body could also be injured to on This is not something that we should forget. And so that's when we did with a patient that we call is a polytrauma so patient that have trauma in multiple region off their body on ball of them are important because somebody that may have some, for example, a chest injury. That could be the thing that's most life threatening to them really on. Or somebody that's bleeding from an open leg fracture again. That could be something that needs treatment, and this all sounds really complex. But the important thing to remember is just not to forget the rest of the body, because when you treat this polyp from our patients, you treat them as part of a big team. Usually it's part of what's called the trauma team, where there's members off very specialties that have expertise in each of the organs of the body. And they all each take charge of the era that they normally deal with it, um, and important principle. They're still the same to treat what's life threatening best. That could be hemorrhage that could be the brain injury that could be any abdominal injury or the chest injury or any kind of pelvic injuries as to start from what's most life threatening and then we'll forward. So that's a very quick run through off management, all at what traumatic brain injury is ongoing. Important things to remember that kind of take. The message is that TBI is a spectrum, as I've tried to highlight today, people can be fairly well on, be functioning pretty fine or can be really acutely sick and need all sorts of acute and invasive interventions. But they really important thing is to detect things early on. Eso to do the basics, reading well, do a good way to the assessment, correct physiology with starting from basic principles, and then the rest follows. So that's what I have you today on. What we have no moving forward is that we'll discuss some kids that you can apply some of these principles on. Please participate s so that you can all join in on day chair your thoughts. So I think I'll just briefly go back to show