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Hello, everyone. Welcome to medical education. Uh Today we're joined by Solomon. He's actually in Pakistan and he's gonna be talking about EC GS uh as always pop your questions in the chat, we want as many questions as you can. So has also asked if you could let him know where you're from. So that would be really good. Apparently, uh I looked on the registrations and there's about 36 different countries joining us today. Um So we would love to know where you're from and then your questions. So please do that. Um And your feedback form will come in an hour's time into your inbox. We want you to fill that out. I will be passing on that feedback to Solomon as well. Um And once you've completed your feedback, your tenants certificate will be on your medal account as well. All right. So like I said, lots and lots and lots and lots of questions in the chat if you wouldn't mind. Ok, I'm gonna pass it over to you Solomon. Thank you so much. Uh Hello everyone. My name is Doctor Sumana. I am from Pakistan, small town of where, where I live and I have been prac practicing medicine for more than five years. Now, cardiology is my passion. I have learned a lot from uh other uh teacher as well, but now I want to teach it to other students as well. First of all, I would like to know where uh where are you from? So we can understand each other better and I can communicate accordingly. Mm Can you hear me? You can pop up your questions in the chart. OK. So my method is a bit different. I won't recommend you to study a lot of books and go blank while seeing an ECG. I think you should go to the hospital and look at the ECG and learn, basically ask your seniors, what is it? What is that when you, when you are able to pick the uh pick any impressions, discuss it with your senior and from then on you can I think uh you can OK, I am seeing a lot of messages. Emma is from Egypt and MS Martinez is from UK. My far is from Islamabad, is Christian Debra. He's from Ghana. Oh, lovely country. And, and Noria Thomas is from UK Abdullah from Sudan. And so he has, we are from Pakistan and he is from Pakistan. So let's move to our presentation. Thank you for all texting me. As I was saying, my method of teaching ECG is a bit different. I won't recommend you to read any books. I will say that go to the hospital and take out the ECG and see it. You won't, you will be blind first of all. But slowly, while discussing with your seniors, you will be able to pick up the pace. Every ECG is, is interpreted to a particular sequence. We will go through that. But uh you are seeing our first slide. This is a very staggering number 17.9 million according to wh O in 2019, uh such 17.9 million people died from cardiovascular disease. So for me, it is a global pandemic. OK. And uh and currently 200 million people are suffering from cardiovascular disease. One in every three deaths are from due to ischemic heart diseases. And therefore, a lead detection and interpretation is very important for doctors paramedics and even message. So a lead detection is very important and I can't see what mine doesn't know if you don't know about ECG you cannot interpret it. So we will go through a sequence and I hope I will make you understand some of it. And lastly, I will touch upon the treatment how we can treat the myocardial infarction. Sorry. So this is our presentation, ecg interpretation and management of myocardial infarction. My name is Doctor Sumana mccarrick. I graduated from uh Punjab and then I am currently uh II have passed my plan one. I will be moving to UK for but uh that will take some time because of my family commitments. So that's my introduction. So what we will discuss ECG basics sequence of ECG sequence of ECG is very important how you interpret this ECG. If a patient comes to you with an M I, you don't look up for ST elevation, you will uh look at the rhythm axis and with the sequence, you will see the ECG every ECG no matter what. So you will not miss, you will not miss anything. And third point is ECG in M II will show you some ECGS that. Sorry, I will show you some ECGS that how you can interpret them. I and uh 4th, 4th part would be of the investigation. I will just touch upon that because that is not the topic of today and treatment plan. Uh What are the treatments that are currently available? Most of the people are from Sudan. Thank you. Thank you for coming today. So let's move to the next slide. Doctor Roman Khan is from Pakistan. So time is the muscle earlier you diagnose an M I, you can so you can save the muscle, you can save the cardiac muscle for that. Your first step should be the clinical presentation. There are various presentations. I would like to tell you that I have seen cardi patient that was having diarrhea. My senior brought me a case of N I. He was a tuberculosis patient. He walked into me. So there are various presentation but the typical exam bookish presentation is typical chest pain radiating to the left arm or the upper and what the patient will tell you that they are so much crushing chest pain. I was to say it is like that uh foot of an elephant is placed on your chest. Chest pain is that much severe and the patient might be tired, freezing. He he he would be he or she would be having cold sweating. So that would be the clinical presentation or? And I would like to focus on that. You must ask five risk factors. For every patient, you ask five questions from every patient. Are you a diabetic? Are you hypertensive? Do you have a family history of chronic disease? Are you a smoker or do you have asthma? If you have asked all these questions, then you can move on to move on to the history. If one of these risk factor is positive, I think you must suspect a cardiac disease. So diabetes, smoking, family history in family history, your first degree relative, relatives are important. Your second degree relatives are not important. You can ask your patient that either your brother, sister or your from your parents ha has had an M I in the past uh second degree relative doesn't matter. So first thing you ask for the patient, do you have diabetes? Do you have, uh secondly, you ask family history, smoking, asthma and all these things. But this is not the topic of discussion today. So second step would be the interpretation of it. CG you do after clinical presentation. If you suspect the patient has an M I, you go for the ECG. If ECG is positive, this can be supplemented with the biomarkers. There are different biomarkers available depending upon the condition, mostly sorry, the drops. And after you, you confirm that the patient has M I or something like this, you go for the treatment plan, but that depends upon the ECG treatment plans varies according to the ECG interpretation. So I would like to ask you that, what to look in the ECG, what do you look? First thing in the ECG I would like to see in the comments. Thank you. Is a Aisha from uh joining. Thank you for joining us and I apologize if I misspelled the form names Judy. Thank you for coming. Uh So my question to you all is, what do you look for? The ECG? First thing you look in the ECG, the last said R to check uh that uh I have connected before that you look something in the ECG paper and that is a very good question answer. But before that, you look something in the ECG imagine yourself working in the primary care unit and there are eight patients lying everywhere and you have. So uh you have uh an ECG in your hand. So it is not a medical question. Patient demographic. That is an important answer has a patient name written on the ECG. Sometimes E CG might fall somewhere and someone put it on the table again, you must ask the nurse or the uh someone that is doing an ECG, write the name, write the name of the patient. And after that, that is a good answer. Uh name and your yes, identification is very important. First, ask, uh you are seeing in a patient XYZ ask has the name been written on the ECG if it is written well and good otherwise, confirm that this is ECG of that patient. And after that, you go further speed and uh speed and if we are thick. So that is the technical point, you must say that the name is written on that. He says let's move to the next slide. So in an ECG you look out for eight things, you will every ECG that you see, you will, you have to see the eight things that are very important and these are followed. Yeah. So uh before moving to the eight things, I think we will revise that uh what is an E interval? QR S MTP interval is uh P wave is uh the first wave that represents atrial depolarization. And after that QRS complex and then comes the P wave and there are certain segment, the uh the one of the most important segment is PR interval that is very important that it starts from the start of the P wave to the out of the cubic. So you must know all these, I suppose you doctor and this is very basic, I will move to that. So this is a another presentation of the same thing that you have P wave then you have, you are here is something is very important that is J point J point starts from the end of the S wave to the start of the T PA. So if this is elevated, then we will say that if it is an ST elevation and uh please note that first downward deflection is QR s complex. First, downward deflexion is and C complex, this will help you a lot in the future. So uh now I will uh move on to the ECG sequence, uh ECG sequence. Uh You will see a ECG in this sequence. First, you will note down the heart rate, you will note down the rhythm, you will note down the X and you will note on the P wave or pr interval. Heart rate can be slow or faster. And when it is slower, it is called bradycardia. When it is faster, it is called tachycardia rhythm can be irregular or regular. That depends upon the uh certain cardiac condition. X-ray is very important. And I will share you a very uh uh uh pneumonic or you can say a practical principle that you will learn it very easily. What, how a is, you know, in theory, it is very difficult to calculate the X on the books. But practically, when you see the patient, it is very easier. I will share that with you in the next slide. So the fifth point is it can be narrow, it can be broader. Uh one heart, one very uh uh ski tool that I can say you can apply. If QR complex is larger than three smallpox, it is called broad complex. I will not go into the detail of the complex because it is a very basic thing you can apply. If a Qus complex is larger than three big, three small boxes, it is uh if it is a smaller than three small boxes, it is narrow and then comes the c first downward deflection is if it is larger than one big box, it is pathology. Pathological implies that the patient has a cardic has had cardiac event in the past and seven point is T wave T wave can be larger. If it is larger than one big box, there are certain conditions like hyperkalemia uh in which it can go larger. And uh if it is I am so sorry and if it is flat, then you can see and there are certain condition, one of which is hypokalemia if it is flat and last. But the mostly most important point is ST elevation and depre depression uh through which you will diagnose if the patient has had an M I, he is currently having an M or uh it has happened in the past and there is uh one thing I want like to, there are protal changes, protocal changes are the mirror images of that. You're back, you're back on. OK. It might have just been an internet blip. OK. I am back on. Yes, you are. OK. OK. So uh can you tell me where I was uh can share where I was um ECG sequence too? Have you heard about, have you listened to all this? II don't know where I disconnected ST segment. Oh, so OK. Thank you of the L for telling me that. So ST se ST segment elevation will tell you either the patient is having an M I or not. But uh one thing very important here is you will see the reciprocal changes. The reciprocal changes are the mirror images. If you are having an ST elevation in uh particular leads, you will have ST depression and some other leads. And this is these are called vocal changes and there is a small formula for it. Pa il. So uh I will share that later on in some other lectures, how you can see where you will have reciprocal changes. So how your rate is uh how your rate is calculated. So uh as you know, uh we count the number of big boxes between R and R between R and R. This is a formula that will come in the next slide if uh the uh number of big boxes are five. So let's start from 300. If the number of big boxes in between R and R wave is one, it is the heart rate is 300. If the number of tick boxes between R and R is 12, then heart rate would be 150. Just remember that you don't remember any. Uh You don't need to remember any calculation 300 divided by two. If there is, if there is one big box between R and R, the heart rate would be 300. If there are two big boxes, then the heart rate would be 150 so on and so forth. Can you uh can anyone tell me how we calculate uh heart rate? If the rhythm is irregular? If the rhythm is irregular, how you can calculate the heart rate? Because if the rhythm is irregular, the RR interval between uh each uh beat would not be the same. OK? No problem. I will share it uh in some other lecture. How you calculate heart rate in irregular rhythm uh into mother's life? So how you calculate the uh OK. Someone has answered this yes, that is one way of calculating it. So how I do it? II calculate the number of uh 30 s complex, 30 us complex. I calculated uh in a 32nd lead and multiply it by six. So yes, you are saying that right? The rule of six. Yes. We calculated the large boxes in 15 hour and multiplying by 20. That is another way of calculating it. Yes, I have a very educated audience. So let's move to the next slide. So each P wave must be preceded by a QR s complex. This is sinus either. So this is a, this is what you already know. So if the inter between R and R wave, if we have equal number of boxes between R and R in each beat, then the rhythm would be regular. If the number of R and R, if the number of big boxes between R and R are not the same as shown in this blue ve then the rhythm would be irregular. So when you have an ECG in your hand, first thing you would do, you will will calculate the rate and then you will check the rhythm and all these things are checked in the second grade. Second grade is called rhythm strip. So you will check the heart rate. And after that, you will calculate, sorry, you will uh check the rhythm. If the number of uh boxes between each successive wave is the same, then we can say the heart rate is regular. Let's move on to the next slide. So this is how you calculate the A I know there is a, a circular diagram where you uh calculate the uh if you can clear the rhythm. Uh But uh in practically this is how we calculate, we see the direction of QR s complex in the direction of QR S complex in lead one. And APF is in the upper direction, which means that the is normal. If the cure is complex in lead one is upwards and in aVF it is downwards like this, then this is my left hand, this would be the left axis deviation. If I repeat that if the U complex direction is predominantly in upward direction in the lead one and in the lead F or two, it is downward in direction, then that it would be left axis deviation. Let's opposite it. If the, if sorry, I'm really sorry for that. If the QR S complexion uh QR s complex direction is in the downward direction in the lead one in the lead, which is in the upward direction, then this is my right hand uh uh not the thumb where thumb would be upward. That would be the side of uh excess deviation. So it would be the right axis deviation. I have explained it in the slide. I will share this slide with you. You can note it down if you want. So can someone tell me what is extreme? Right axis deviation, extreme right deviation is this then uh uh both QR s complex in a one and will be in the downward direction. So that is excellent, that would be the extreme right axis dilation, but that is not important in the case. So there are certain causes of left axis deviation and right axis deviation. Uh you will. But first you know how to calculate how to uh do the axis, how you understand that uh axis deviation, go to the uh cardiac unit, see an A CG and calculate the xray division there and ask your senior, ask your colleague even you can mail me, what, what is the xray have I noted down clearly, I will help you with that. So let's move to the next slide. So that next comes the complex. There are certain conditions in which s complex can be narrow or it can be broader. As I have already told you, if it is less than three small boxes, it is narrow. If it is larger than three big, uh three small boxes, it will be called broad QR complex. Broad QR uh are usually present in arrhythmias and same goes with the narrow that depends upon the condition of the patient. But uh you must know when it is narrow and when it is broader, three small boxes, less than three small boxes complex, it would be narrow. And if it is more than that, you can see in the broad slide, it is uh reaching up to the four small boxes. So it would be called the broad complex. So this is the ST segment. Uh If you see that uh yes, uh recording would be made available for sure, I think. OK, so the first would be the downward deflection that is Q, then the upward deflection QR then, and the s the point where uh S is complete is called the G point. If that G point is elevated more than two millimeter, it is called the ST elevation. There is certain criteria according to the American cardiology guidelines that will help us to understand what is it. But for now, I just want to show how an ST segment elevation look like looks like. So that is ST segment elevation and the uh and the picture on the your right hand side is ST segment depression where you see that JJ point has lower to the base nine level and it is lower up to the three small boxes. These two things C segment elevation and ST segment depression are very important in diagnosing the myocardial infarction. So this is another slide where you are seeing the ST depression and ST segment elevation, we calculate the ST segment elevation and depression from the baseline. So uh it will be hard for you to calculate initially. But uh after that, I think uh after some time it would be very important. Uh The as per said that why it is called the G point, uh I will look it up and I will answer that currently, I don't know, I never took and test why it is called the point. I just remembered it, but for sure I will set it up and I will personally uh answer this question for right now. I don't know why it is, I'm so sorry for that. But uh you must know why you must know uh where is the G point rather than why it is called the G point as being the inspiring physician, nursing nurse or a paramedic. You must know the G point is because it is the point that will tell you that uh that the patient is having an M I or not. So uh uh the next slide is about the T wave. This is I am telling you all these crude rules. There are certain bookish knowledge about how milli uh how much millimeter you have to calculate. I will teach you about the number of big boxes, everything about big boxes, smaller than three big bo uh small, three lesser than three small big boxes. It would be narrow risk. If it is more than that, it is broad. Same goes with the T wave. If it is larger than one big box, then it is uh called tall T wave. If it is uh uh has that been changed? Uh Smart has answered excellently that uh complex joins the ST segment. That's why it is called your point. I will look it up when doctor thank you for answering that. Yeah. So I was uh telling you about the TV. If it is larger than one big box, it is gone to TB. If it is uh if it is reaching the baseline or it has inverted, then it is called the inverted TV. Usually in ischemia, both arms of T wave are equal like this, both arms of twa are equal in ischemia. If uh inverted T, if both arms are not equal, then there is, there is a chance that it might be not ischemia. This is a true to that. I will tell you let's move to uh uh our next slide. If Q wave, uh there are normal variations of QQ wave that might be present in every patient. But as a rule, if Q wave is larger than one big box, if Q wave is larger than one big box, it is always pathological patient has had an mi in the past, this is very important. So there are certain ter which you, you should know that uh for localizing the ligand, there are ways in which you can localize ligands by just picking up the ST elevations in different ties. So in the blue, in the blue colors, you are seeing 23 in A, they show the lower side of the heart, the inferior side of the heart, right, uh which is supplied by the right coronary artery. So if an ST elevation is in the 23 or aVF, then there is a high chance that uh right coronary artery of the patient will be blocked. And this right, right Coronary artery supplies to the A V node and S node. And there's a high chance that you might have clots uh might have heart blocks in this patient, first degree, second degree or third degree. We will tea uh we will get that in later lessons. So as I am saying, 23 in, remember that, that shows the inferior side of the heart. And if you see the chest 21, V one, V two V three and V four, you place these chest lead in front of your heart in front of your heart. So they will show you the interior side of the heart which is supplied by left circumflex arty. So if uh if the block, if you see ST elevation or depression, ST sorry, ST elevation in V one V two, V three and V four, there is high chance the left circumflex a left anterior descending artery of the patient is blocked. And if uh the block is in uh V five, V 61 and ADL, then the little circumflex arteries block. So just memorize these coronary. And if that's the elevation in one of the two territories, then you can see it is an M I, if you see just elevation, let's say lead to it might not be an MRI. But if you see ST elevation and two and three, then there is a high chance that patient might have an Mr. And if it is uh you see uh ST elevation in V one that is not important. But if you see ST elevation V one and V two, it is very important. So two leads, uh changes in the two leads must be uh there to diagnose N I. So let's move on to our next slide. Yeah, so I will ask her students ca can you pick up the changes there? You can calculate the heart. You can tell me about the rhythm. But the most important thing I want you to pick where is the ST elevation of ST depression? I think doctor's man would be answering that and saying this interior wall ST and two little wall semi he has had back. That is a good question. Anyone else who wants to participate in that? Uh I want to tell my student that interior uh M has high mortality rate around 40%. If a person has uh anterior wall blockage, you must, you must actively and if there is no uh facility available, you must thromb the patient with stato or whatever is available and with the mortality rate is 5%. But that comes with o other problem like heart or infant. So Christian Debra has said that and two little tell me. So can you tell me uh I want specifically where are you seeing the changes? Where are you seeing the ST elevation in which leaves? So there are many other changes. So ST elevation is in we two V two V six and one in. So, the answer was right as of 12 and there were changes in the uh lead three and 80. Sometimes you find a reciprocal changes. Sometimes you, there might be done that you missed that. But most important thing, you must pick where are the ST patients? So this is an other interesting E CG uh I think you will come in in the last portion of the ECG, you are seeing a long. Secondly, that is called the rhythm. Whenever you want to calculate the heart rate or rhythm, you check the uh I will say that but first, uh I think you must answer this ecg inferior time. And if there is a suspicion of where we place the chest leads, can anyone tell me about the rhythm? Can anyone comment on the R boil? Uh whenever you want to calculate the part, you place the leads in the opposite side, on the right side, you will place the leads, these leads V one, V two, V three and V four in the V four. If there is an ST elevation, you might suspect that there is in fact, but this ACG point is not that sensitive uh echo must be done to rule out the in. And if the uh interestingly inferior wall M I is the only an M I in which you can give fluid, ample amount of fluid I II. Yeah, we wouldn't even up to 2 L of load in A one M I. So it is the only M I in which you can get the fluid. So the answer was mark ST elevation in 23 and with early QA formation. So how we treat these M I patients? We either opt for fibrinolytic therapy uh or primary PCI. Primary PCI is the goal method. And it is ideal if the patient uh reaches the hospital from the first point of contact in 90 minutes, if the patient can reach the uh the hospital, then uh you can say it is primary PC. And if there is uh if the patient cannot reach the hospital in uh 90 minutes, you can opt for fibrinolytic therapy. As in Pakistan, we uh use streptokinase injection in the uh developed twenties, they have replaced it with a or neck replace. But in our country, I think uh uh it might be due to the late presentation of the patient, patient might have come late. So wave formation. Yeah. Uh that's why there is gonna leak over formation. It might be due to the late presentation of the patient. If the patient might have come earlier, there were no uh that's what right. That's up to the best of my notice. And uh for treatment, uh I would like to tell you that you can opt for primary PCI, which is uh you place a stent in the heart. And there are three different ways in which you can place a stent through your radial artery, brachial, arterial femoral artery. Uh the most uh usual do is through the radial artery. You place the stent in the coronary artery depending upon the block. But if uh if uh the primary care facility is not available, you opt for fibrinolytic therapy in which you can give streptokinase injection or a place that depends upon the condition of the patient. And but if the time is more than 12 hours, then you manage the patient uh conservatively with the heparinization. And I would like to comment on that, that these uh fibrinolytics, they thromb the clot. And when a clot is thrombo, there's a high chance of arrhythmias. So 1st 24 hours are very important for the patient. Uh after thrombosis, there are high chance that patient will develop arrhythmias. And there's certain criteria that uh either you can give efficient for immuno therapy or not. That is not the, that is not the subject of today. So if the patient after uh fibrinolytic therapy, if the patient pain is not relieved, then we send the patient to care facility. If it is already in the care, uh then we open the Cath lab, we do rescue PCI primary PCI is the first thing. But after fibrinolytic therapy, if the patient pain has not relieved and ST elevation has not settled, you go for the rescue PCI that is that will save the patient from the cardiogenic shock or the ultimate other complication. But if the PCI has failed or due to some uh complication of PCI. There are high chance for that. Uh You can uh you have to go for the reason why that the chronic units are not set up in lower cities or in peripheral areas that they don't have a cardiology, cardiac surgery back up. So this is the criteria that if uh angiography or angioplasty has to go in a hospital unit, they must have a cardiology, cardiac surgery backup. So yes, I can show you accurate changes. There is slight two wave changes uh slide. Uh If you see in the lead three, there are more visit but in low lead to it is uh very slightly visible. Uh If I zoom in the ECG, then it would be more permanent. I will share this slide with you or I will share this slide with you. You can, we can have a discussion on that either Q waves are present or not. And most so there are uh today's lecture. Uh If you have any question, you can pin it down. And one thing I want to tell you that while working in cardiology, I from uh from time to time, I look up to the uh uh Medical Institute of Cardiology, I keep revising and there is uh no rule that uh I have worked, I have seen 1000 of P gi might not, I might miss anything. So from the time to time I visit there is an excellent website that is called the Life in the Fast Lane. Life is in, is in the Fast Lane is an excellent website where you can live in the hospital if you see any, any change, it might be there or it might not be there. Look it up in the, uh, website that is called in the first. And it is an excellent website that is made by the emergency physicians of, I guess. And you might, must visit that from time to time and the time would come where you will be um, very will where you will be able to understand it more than ever better than your Yes. Life in the Fast Lane. It is an excellent website. Ok, and deep breath. Perfect. Um Someone would you be happy to click on that little button that says present now and then your slide will come off the screen. Ok. Stroke presenting. Yes, that's right. That'll do us. Perfect. So any questions, anyone that was way above my head? I'm not gonna lie. I think our delegates know that I am not at all medical. Um but it was way above my head. No problem. So, does anyone have any questions, please put them in the chart even after the after this presentation? If uh does anyone has any questions, uh please, uh you can send me that on my email even if you see an A CG, take the picture and email it to me. I will try it once with my students. As far as Abdullah has uh asked any recommended book, go to the hospital, look, look out the AC but the for bigness there is a book card ECG by made by Dale Dubin Dale Doin. He was an interesting author, so I would like to read that book, Dale Doin. Uh and he had written it in a funny way that you will not get bored. But most importantly, passive learning is very important. In the case of ECGS, you must go to the hospital, you must look it up. If you read five books, five advanced books while sitting at home, it would be of no good ECG interpretation along with the clinical history and the presentation of the patient is very important. So you must go to the hospital and see the ECG. But uh if you want to learn from the start, I would recommend uh by Dale Doin ECG. Made Easy. It is an interesting book. And for advanced learners, there is a book called ECG Made Easy. I don't remember the author. And there's another book called 100 Cases of ECG that are very good books. These are very good books and thank you for that. Thank you for coming today. Any other questions? Anyone? Yes, John R. Hampton E CG. Very easy. So as students are already connecting, it is not a great, a great place for teachers to give lectures, but also for students to connect with each other and teach. No good, wonderful. Any other questions, please pop it in. Like I said, your feedback will be coming to you in about 15 minutes in your inbox. It will arrive um after you've filled that out, what I would love for you, uh your attendance certificate will be on your med account. I will be uh forwarding the feedback on. So please pop in if you like, even if you have a question or anything like that or if you have further teaching, if you want anything, like we really want feedback to pass on to our speakers because it's just a way of us being able to thank them for their time by giving them good feedback so that they can improve wherever they need to improve. It's good feedback is good. We may not like it sometimes but it is good. So you fill out your feedback form and get your, the one thing I want to add here that uh uh uh as soon as I believe that we in the current world, we have attention span of the jellyfish. You must uh take it slowly, uh just uh 15 minute or uh 20 minute, 25 minute lectures uh would be enough for you people. And, but most importantly, you must go to the hospital and look out the ecgs. That is the most important lesson and take home message for today. And I wanted to include more slides or involve you with uh myself. I wanted to solve ecgs with you. Uh like tell me or tell me. So uh what is the heart rate of this? I might be noting it down but for that, I uh I need a tablet or some more advanced setting of this and medical will improve that in, in the future. And I want to thank you. What we might be able to do is just smaller sessions with examples and make it more interactive. So like I'm on the screen with you right now to be on the screen. So you can, I think in the future, a tablet would be that would be more important that writing pad involvement would be more important. So I can make to understand where, where exactly is the P Yeah. Yeah. So what we'll do next year because we're not much in this year left. Now, what we can do is actually create a couple of events where we have small participation, but actually, it's more interactive so that people can come and you and you can all interact on the screen together. So maybe we'll create some of those in the new year. And obviously we can advertise on middle education. And then anyone that's here today can sign up for those. If you have the time, we can do it. So OK. OK. So I think we're gonna say goodbye now. So we are gonna log off now. Uh Everyone have a um lovely rest of your week. We have a few more medical education events happening over the next few days and next week. So please sign up for them and then we're gonna take a little bit of a break. We're gonna take a couple of weeks off and then in the New Year, we'll have some new events coming up. Ok? Um So thank you very much for joining us today and we will say goodbye for now. Thank you all.