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Welcome everybody to another of our learn with nurses in conversation session. And I am delighted about this session this morning. And before we dig in too much about it, I just want to remind you how we run things here at, learn with nurses for you guys. So this is an in conversation session which means we've got no slides today. We want you to just sit there and listen and then develop some questions yourself that we can pose to our experts here with us. Remember we've got the chat function that's sitting there. So please do use that chat function even if and I can see quite a lot of people here have already started to say hello, but let us know in their chat function as well. Why you thought this session was something you wanted to get involved in and which country you're in? What role you're in? Just use that chat function because we really like to see who is there. So this session is all around carbon monoxide and it's about how patients and health care workers are at risk of this. And I um as you know, I I'm a nurse and with, alone with nurses. But I also work well, I volunteer with the RCN Public Health Forum when the call came out for carbon monoxide and someone to get involved with carbon monoxide. I was, um, skipped forwards quite fast to put my name there apart for two main reason. One, well, three reasons. Actually one, I'm married to a central heating engineer who does heat pumps now and stuff, which is very different. But over the years, the amount of flus I've been told to look at and how bad they are or he's come home and this fire was awful and all of these things that really, you know, wanted me to get involved. Secondly, my, one of my daughter's partners suffered from long term, both him and his mother, long term carbon monoxide poisoning and they were really, really struggling with that. And thirdly the symptoms that are part and I'm not going to say much about the symptoms because I think we'll hear about it. But I'm a trustee of another charity that has very similar symptoms and those symptoms get missed a lot. So I was really delighted to support the RCM Public Health Board on the carbon monoxide work. And, um, and I'm delighted for us to have this session today. So we're joined by Hillary Waring and Isabella Izzy Myers. And I, I'm going to hand over to these guys now who are going to tell us a bit about them and themselves and then we're gonna start our, our questions that I'm gonna be asking them. So, Hillary over to you. Thanks Mia um Hillary Waring. I'm um my background, a nurse, a midwife and a health visitor. And um I work at creating evidence and getting evidence into practice nationally and internationally around some of the challenges we have in public health. And one is particularly tobacco and that's how my journey started towards working around environmental co. Um We have an intervention called Baby Clear. And that's in the long term plan around how we support women to have smoke free pregnancies. But over the years, we realized that we were seeing a lot of high co levels amongst our pregnant population with no explanation around smoking. And we started to explore what was happening in those women's homes and then became ever more involved in CEO and now um work with that wider group um which is actually not just about co but it is around, you know, the areas where we're interested in around health inequalities and um have worked with Izzy now for several years, she was my mentor when I entered this area. I'm taking that as a handover Hillary, which is um and uh thank you, thank you Michaela for, for organizing this session. It's really great to be here and lovely to be doing it with my colleague, Hillary who um I have drawn into this sector uh having spent uh really probably since about 2001 leading the work on carbon monoxide. Uh within, at the time, the Department of Health, I'm now an independent consultant but have spent uh you know, these past 20 or so years, uh really trying to raise awareness. I'm a researcher by background uh in toxicology, but I do a lot of research and develop research teams so that we can provide the evidence that will underpin policy and improve that uh that the changes that we need uh using those sort of evidence based results. So that's my background and uh Michaela, thank you. I think we need to crack on because there's a lot, there is. There is and I'm going to open it out. I'm just going to say we've already got people putting down what their roles are and what they, why they're here. I told us. So we've got Lee who's a paramedic in London studying a toxicology module because he's currently studying for a master's and we've got Serena who's a doctor, resident doctor, specializing in occupational medicine in Bucharest, Romania. So, um yeah, the whole way. So it's great. So keep that coming in everybody. So I think my first question, I'm going to pose and I'm just going to pose it to both of you and then you can fight over who's going to answer first. But so what, so, so for the untrained person, um who don't, you know, doesn't know much about carbon monoxide, what what is carbon monoxide? And just what is its risk to health? That's a really big broad one for you. Um, and you can fight over who goes first? Oh, is a dog? I'll, I'll start that. Um, carbon monoxide is it? It's, it's clever. It's a clever gas. It is colorless. It's odorless. It's tasteless and it's invisible. So, essentially, er, you know, you don't know if you're in an, in an environment with carbon monoxide, you don't know it's there unless, for example, you have a carbon monoxide alarm that's going off and letting you know. And it's, uh, yeah, it, it, it, I, yeah, I, that's it in a nutshell. That is what carbon monoxide is and it will kill you at high levels and at lower levels it will cause you, um, a, a plethora of, um, symp, um, health complications, symptoms just almost dependent on who you are and your personal being or comorbidities, et cetera. Henry. Did you wish to add to that? Um, the, uh, uh, we can talk about who's most impacted with, would that be helpful? I think, I think, well, I'm just thinking, let's, let's take, go down the j because I'm loving the thought of it being a very clever yet de gas that's out there. And if I think about, you know, when you leave the, when you leave the cooker on and the smell of gas happens or a gas leak, we're all used to smelling that gas leak and being aware of it and I suspect that, that not everybody's aware of just how devious that that carbon monoxide is. And so should we look into how it's produced then? So you've mentioned some, you know, stoves and things like that. So maybe the, the, even though we want to dive into the health side, um, actually knowing where it's, this invisible gas is coming from is probably quite important. Um, so it, it's produced from, er, carbon based fuels. Now, a carbon based fuels, anything that contains carbon. So we're looking at wood gas, coal, Coke. Oh, gosh, paraffin, er, kerosene, you know, you, you name it and a petrol, obviously that's the other one that probably people will know and, er, Hillary's favorite, the burning of tobacco. Um, so, um, really, er, yes. So what happens is when, um, uh, any of these sorts of fuels are not burnt properly ie with sufficient oxygen, er, they produce a carbon monoxide. So, carbon monoxide co one less oxygen when it's, er, burnt efficiently with sufficient oxygen, it produces CO2. So the two oxygens. Um, so that's just really that, that sort of background in terms of, of, of burning. And, um, really when, when a fuel doesn't burn efficiently, it's usually because the appliance is malfunctioning, it's not being used properly, it's been installed improperly. Um, it could be because, um, the, oh, something really simple, like somebody has turned a generator exhaust, er, that's actually pointing in the direction of their neighbors open window. So the neighbor is getting uh exposed. So there are just little, you know, little behavioral things that can happen there. Um, or a chimney or a flu is blocked, say by a bird's nest or partially blocked by snow. Um, you know, those sorts of little things that can just reduce this ability for er, the fuel to burn properly or the ventilation of combustion gasses to occur in a way that you would wish it to. Um So this is co can then build up er, within, within, shall we call it the home environment for, for the sake of, of today's conversation. And so can I ask you then Hillary building on that and something that you mentioned before about inequality? So are there more people at risk of these incomplete or, you know, not very well combusted? Sorry for my lack of technical phones of fuel. Um is, are, are there who's more at risk of that before we get into the, the, the signs and symptoms and complications? Who's more at risk? Um There's, there's kind of two different groups at a risk. Some are, are a risk because of the health situation they find themselves in positively or negatively. So for instance, people who've got a respiratory illness or anemia, heart problems because of what co does they are more vulnerable to the effects of it. Um Children are more vulnerable, you know, um they, they can cause much greater neurological harm because maybe they can't express the sys symptoms. They can't tell you how they're feeling. And also they have those higher metabolic and respiratory rates and their systems are still develop, developing. So they're more, more vulnerable. Um And pregnant women, my, my, my big one, you know, it's a better start in life and better start, starts at um conception, not at birth. So, um for a baby, uh in uro, they are exposed to what the pregnant woman's exposed to. But the co concentrations actually take longer to build i in that fetus, but they build to a higher level than from the woman herself and takes longer to clear. And because we've got again, a developing immature system, the impact can be anything from failing to gr to grow properly to neurological damage that might last them the rest of their lives to actually not being born alive to a stillbirth. So it's a really serious issue. When we talk about smoking, we think about babies. Uh and the risk to the unborn child around smoking. The biggest risk in that smoking is the co it doesn't matter where the co comes from, that's the danger. But there's another group that may not have those health issues but are really vulnerable. And they're the the poorest in our society who might have least choice about where they live and least choice about how they live in a healthy environment, you know, um, we have amazing good landlords, but we also have poor ones and they're most likely to be actually um, renting the poorest accommodation. And also even if things like issue cooker, you know, if you can't afford to replace it, what do you do? You just keep, you just manage the situation, you accept it when your alarm isn't working, you just accept it cos where do you get that 20 quid from? You know, don't even know I can get one for free or maybe my land. Well, my landlord should put one in at least in some places um, or it goes off and I have no ability to deal with it. So I just disconnect it and carry on accepting that suboptimal kind of living living situation. So there are our main groups. Wow. So I'm feeling this very clever gas has got the potential to really seek out the, seek out the people who we'd want them to seek out least, you know, that that's the bit. So, so if we move that on and let's say so. So this, this gas and I, I'm really now like, um luckily I live with a central heating engineer. So every, all our appliances are fine. Well, I say that, but you know, the cobbler's do the cobbler's Children rarely have shoes, don't they? So, but uh anyway, that's another story about how long we didn't have a bathroom sink for. So, um what would they? So what would it say it's got to people? So what would be the sort of the other acu acute symptoms? What would, what would be the symptoms that people would start to see and what are the complications of that? How do we, how do we, yeah, can you give some advice to, to people on what those elements are? So, another area where carbon monoxide has shown itself to be, you know, devious is because, um, the symptoms mimic those of other, what people, well, healthcare professionals would consider more common illnesses. So, um, for example, the flu nausea, headache, a sort of general malaise, uh, feeling sort of tired and especially sort of in the morning and in the evening perhaps because, um, you know, uh, the appliance that is causing the problem is perhaps only used in the morning or in the evening. Um, you've also, so that those are the sort of the more mild uh symptoms and of course there are clues, er, that can help the healthcare professional if, er, say a number of people in the same household have all got the same symptoms. Then this shoulder raise suspicion of carbon monoxide poisoning even if, and it's very hard, all those symptoms are flu like, um, or, um, or they're all similar to food poisoning. You see, it makes it difficult again. So, uh, yeah. So, yeah, it's, it's not, it's, it's, it's not, it's not easy and, you know, there are many sort of case studies where people who have gone to their GP or been into the emergency department. And they have heard that, you know, you've got, one has been, like, for example, you have an infection, um, which again, another, another symptom that's mimicked, um, and sent home again, unfortunately back to a place where that poisoning was occurring. Um, you have, you know, your, all the GP says, oh, you're stressed or you're tired, of course you're tired. You have, you have four Children and you're trying to hold down a, a full time job and you know, work is pressured, um all those sorts of things. So it's, it's, it's very hard, uh especially with what is known as the half life of carbon monoxide. And what happens here is that when you, uh when you, when you go from an area that is, has I say a lower level of carbon monoxide. So you're having these uh more general symptoms, but you move to an area where you're not being exposed. So, for example, you go to work, you feel better at work and then, uh because you've be breathed in sufficient oxygen to negate that er, effect of carbon monoxide and then you go back home again and you re expose yourself and then the symptoms start to develop. So it's, it's sometimes it's really tricky, it is hard to diagnose, but if you are suspicious as a healthcare professional, it doesn't take long to sort of either rule out or confirm that suspicion. Ok. And Izzy, it might just be worth adding. There's a few groups which, I mean, Izzy's already told you how hard it is. But in pregnancy, particularly in early pregnancy, the symptoms actually mimic the early signs of pregnancy, you know. Um, so, you know, it does, it doesn't necessarily ring an alarm bell with a midwife and because of the half life of co and most pregnancy bookings and, and appointments being done in hospitals quite often, even when they do ac O breath test, that levels really reduce because they've been away from the home Children again, same as before, um mimics childhood illnesses. And also they may not be able to express how they're feeling, but also a vulnerable elderly. So there may be a presumption that for instance, the confusion is because uh of old age or because of the dementia and people aren't thinking co it's just not, it's not in the range of possibilities that the professionals are considering and that and that I think is I've just been obviously sitting here reflecting and I was thinking because I mean, I'm a chair of the chair, I'm a trustee of a charity pots UK. And often the symptoms that people present with, well, not very exciting symptoms. You know, I'm tired, I'm, I, I've got no energy, I'm not sleeping well, I might be being sick a lot. I, you know, and they are as, as clinicians you think? Oh, they're not very exciting symptoms for people to come in with. And there's so many other things it could be. So I it's not necessarily that other healthcare professionals don't care about it. It's just there, there are so many other things I'm just going to if it's alright for you start to dip into some of the questions that are coming through and I'm gonna take them if I don't take your question. Now, what I'll do is I'm trying to fit it in into the order of how the discussions are going. So, Lee wants to know what is the half life, you said the half life of carbon monoxide. So what is the half life? It's, it's between sort of 4 to 6 hours. So, um so when you take that into consideration for somebody who's gone into the emergency department and the wait time is around four hours, your carboxyhemoglobin level will have halved from that to what it was when you were maximally exposed to carbon monoxide. So again, when um I suppose we should have spoken about this in terms of uh testing for carbon monoxide. Hillary mentioned the breath testing in um in the pregnant woman and you can also take a, a venous blood sample and have a blood gas analysis and that will provide the level of carboxyhemoglobin uh in the blood. Uh So this level will have halved. Um once, once you're rough. Roughly speaking, once you get to get to, once you're seen in hospital and that again reduces the suspicion of, er, having been exposed to carbon monoxide. And the same happens with the breath test as well. That level will also decrease because it's related to the carboxyhemoglobin. So, um, so that's, that's, and just, actually, I'm just gonna bring in one little point because it's, it, it, again, it just shows you the cleverness of, of carbon monoxide in that regard, even though it is, um, it, it, it's not a, it's not a, it's not a gas that we, er, are pleased to have, shall we say in that regard? Um, but you have to be careful and if you're using a, a pulse oximeter that will not record the carbon monoxide levels, you have to use a co pulse oximeter because carbon monoxide actually, um, tricks hemoglobin into thinking it's oxygen and that's why it binds to the hemoglobin in the red blood cells, uh becomes carboxyhemoglobin and it's transported around the body and the red blood cell thinks it's transporting all its oxygen and it's not, and any oxygen that red blood cell is carrying. Still, er, the car bizarrely, the, um, the carboxyhemoglobin prevents even that oxygen from being released. So, a, as you're breathing in the carbon monoxide, there is insufficient oxygen being transported to the, um, organs and that's why it can lead to, er, death. Yeah. And, and I was going to ask before I come into some of the other really good questions, the longer term complications because we've just had the short, you know, people going in and we've had the challenges and we'll come back. What are the longer term issues that might? Well, obviously you've just said death. So that's a particularly awful longer term combination along we'll get from a, from an acute exposure, a very high level acute exposure, death can occur very quickly with uh some say almost within three breaths. So, in a very high, yeah, in a very high, highly concentrated car carbon monoxide environment, it will kill you very quickly. Um So really what we look at in terms of that sort of progression to that ultimate end as it were is um is the, you have the sort of the dizziness, the nausea, the headache and then uh no, not in that order at all. Yeah, they have the dizziness, headache, nausea. Um then you get this sort of uh uh a collapse and er through to then coma and, and death. So that's the, the very, very basic um sort of uh line of events that you might see. Um So yes, it at the, at the lower levels over a chronic period of time, um you can get a um that, that sort of that continuing feeling of being out. Well, and as Hillary mentioned, depending on your comorbidity or depending on uh what stage in life you are at, it can have, it can have different impacts and there are people who will uh just carry on and sort of press on as normal thinking that that's just the way it is when in fact, you know, the problem, it could really be resolved fairly easily. Um And I think, I think it's worth saying is that group again, is quite often those who are more accepting of suboptimal health. Yeah, because that's how things are and we're going back to our most vulnerable in society and also our elderly who have an expectation that they are not going to feel as well. So quite often just put down to that's life. I can see it all spiraling, it's all spiraling, isn't it? With? No. So there's been a really good, I want to go back to the testing bit and I know I'm weaving my way around. Let's stay on the testing bit. So um so you said about by the time people get into a hospital or by the time they go somewhere, the half life, all of that. So Z said, if so let's think about so community workers, people going in and out of people's homes. Um Could they carry something maybe similar to a blood glucose machine? Can they do it? Is that possible to do a, a near patient or could they carry that exhaled breath monitors? Is there something that, you know, clinicians can take into the home that they could use. Yeah, I mean, all midwives that go into the community should be carrying their own co Breathalyzer because they should be using it at every appointment and at every opportunity with pregnant women, one around smoking. But two now around that, um, environmental co, so that's possible. We're trying to encourage that in health visit and it's starting, um, and we're doing some research, we just actually closed the study of looking at CEO it is in pregnant women's homes. But I think the results from that may also impact what we do more generally about health and social care workers who go into people's homes to protect and help identify people who need protecting in their homes. But also, you know, to protect us as workers as well. You know, I had a midwife call me the other day who said I've just come out of a home and, and done ac O cos I didn't feel well and it was 17 parts per million. Do you think they've got a problem? Yeah, I think they've got a problem. Um But it was impacting her as well. Yeah, and that was, and that was going to bring to my next question. So our people who are going into the home could be at risk as well. So we're putting our health care workers, our healthcare professional, Amanda's just said she thinks that district nursing that they should definitely have some form of monitor. And I think there is a, there should be a call, I'm going to put it out there. A call for anyone that goes into homes, whatever, whether you're a care worker, a midwife, a health visitor, a community nurse, because it's the ideal opportunity to test for it and to keep themselves safe. Absolutely. I mean, in the meantime, one of the things that we've started to find really useful is some of the alarms that are fitted, have associated apps with them and, and we've got health workers downloading that app and then if they go into a home with that monitor, they just offer their phone up and it will give you a picture of what's happened in that room over the last four weeks. And that can be, that can be useful. It shouldn't be, it's not a diagnostic, it's not a definite, but it's another indicator that you can use if you have suspicions in that home and all those. Oh, and we've got as well. First line ambulance workers who are on the scene also potentially at risk. So, are these bits a bit expensive then are we thinking what, what is prohibiting? Is it the, the energy, the knowledge, the expense or what's stopping this from happening? I think it's a combination to you. I think II, I'm, I'm with you on that Hillary. I talk going to, to, to Matthew's mention of ambulance workers, the heart teams in the UK, all have um the pulse co oximeters uh on, on their, on their um trucks, lorries vans calls. Now you do depends, but they uh um so, so that, that, that's great. But obviously kit can also get damaged and it is expensive and therefore, uh you know, that's why at the moment it's probably only in with the heart teams if we can get that wider, that would be great. I also think just having the knowledge is really important so that, that people can be aware when they go into homes and this is kind of hot off the press news, but we've just been commissioned with e-learning for health, which every healthcare worker has access to across the UK to um develop four modules around co and these are the first to go up. So there's gonna be a generic module about learning about co how to recognize it and what, what actions to take. One particularly for pregnant women in early years, one for vulnerable elderly specifically. And is he say about the one you've got as well, which I think is really important. Well, thank you, Hillary. Um um I'm going to be undertaking one for the medical examiner because obviously, as I mentioned, carbon monoxide does kill and it er is what we're, what we're looking at is situations where carbon monoxide has been associated with er somebody's demise. And so that could be uh somebody who's say um Michaela, you were saying you, you, you work very much in the sort of cardiovascular side of nursing, um, in people with heart failure, um, you would expect them to die at home quite peacefully perhaps. Um, or, uh, well, the, the, or, or not, they, but you'd expect you wouldn't expect you wouldn't expect, wouldn't be unexpected, unexpected. Exactly. That's what I was trying to say. Thank you. Yeah. And, um, but if that death had occurred, um, at home in, sitting in front of a say a gas fire, um maybe that death had occurred a little earlier than you'd expected. But um perhaps that death, that's what can happen in heart failure. That's what you think. Well, that's heart failure for you. You know, you just, you do a bit of this and you're Yeah. And, but that the, but the carbon monoxide coming off of that uh appliance could have brought that death forward. Yeah. And so we'll be looking at it in terms of association uh with, with carbon monoxide and which could easily be missed. And we see this in um the, the coroner certificates where carbon monoxide and that quite rightly can't be registered as a cause of death um in, in, in any of the sort of the top top three tiers, but we see it in the narrative. Ah and so it's not recorded as AC Os. So that does skew our if you like the figures and that, but that was gonna be my next question to you is do we know the scale of the problem in the UK and I and II think I almost know the answer to this question. But, but do we have any idea? Not really? Um, there, of course, the, you know, the Office of National Statistics has, um, a record of deaths and the cross government group on C and Gas Safety, they produce a report every year which looks at the mortality statistics and of course, we're looking at, er, non fire related nonsuicide related, er, deaths and, er, the figure is currently sort of around that 2021 mark and everyone says sort of around because it's, er, averaged over a five year period and this number has come down over the, over the years and, you know, which is good, which is good news. But, um, as we said, there, there are elements of the figures that, er, those within the co fraternity as it were, er, know, probably are not particularly realistic. I mean, one of the problems is, is we only know when somebody seeks help and even then that relies on good coding which, yeah, separate issue. But, um, one of the things because all pregnant women now must have co tests throughout their pregnancy. Um, we've got the first opportunity to actually, and, and it has to be recorded on their systems, on the, on, on the systems. So we've got that first opportunity of actually watching that though some of them will have a high co when they're not a smoker, but some might have a high co when they are a smoker, but they could have that co from two different sources. So that, but that will start to give us a little bit more information. And also literally, we're, we've been um monitoring over periods of time, two weeks, uh um a cohort of pregnant women's homes. So that data is just being analyzed now. So that's gonna be an interesting picture and you see there's other research going on in things like A&E departments. Yes, a lot happening. There is a lot happening and in particular, um because I'm also very aware of time and we could go on for about an hour. You're welcome to come back and do another one for sure. Oh, co mark two. Excellent. So um the not is that um uh some of you will know that uh the coding for, er, for, for diseases are the ICD codes is changing to from ICD 10 to ICD 11. And this will mean that um carbon monoxide will be uh C can be coded for not just in terms of mortality, but also morbidity. And so this is an area that we're really, really trying to unpick um really, and as as Hillary mentioned, really through the research and the er, and the, the work that's going on with the pregnant women. And uh there is enormous scope for improved granularity and understanding where the carbon monoxide incident took place, what sort of house, which room it was, uh what sort of an appliance, what sort of er, fuel? Um and this will really, really help in terms of surveillance and understanding the prevalence of carbon monoxide associated with er environmental exposure. So this is really great news and this is part of what uh Hillary and I are trying to do with this e-learning for health is to raise that awareness and uh facilitate that. Um that coding right up to the um ICD 11 stage when that's implemented, you know, with a, with a, with a, with a public health coding is key because unless you can really count and monitor, then it's really, I'm gonna switch it on cos and I'm, and I know we've got lots of questions coming in that we will get to. So I'm gonna think about what can we do now to help ourselves and help our patients. And I wanna go back to, before I get you into that. I'm gonna go back to a question that was earlier on that said, um, should the boiler, should the cupboard where your gas boiler is be kept clear and free from clutter? Yes. It's all about that allowing the oxygen, the fresh air to come in and help with that, that burning? Yes. So that's a nice, that's a nice simple one. And somebody else has said, um, they've only got electrical appliances, are they therefore not at risk. Depends, depends where you live. Um, so, um, are you, are you in a flat above a restaurant or a cafe? Who has co, are you, um, in a terraced house where either side they've got combustible fuels? So you might feel safe, but that doesn't necessarily mean you are, are safe and moves. Oh, it's, it's devious. As you said, it's devious and very clever. Um, schools. What about schools? Do they regularly tested? Do we do? We know? And I will tell you the very shortest story is schools don't and neither do other, including some health venues. I'll be very careful not to mention where um um you would hope that they were the best at getting things checked, but we have only recently had a community center where health care staff were working actually have a situation which was caused by nonmaintenance. So, um you know, we always say, you know, we, we, you know, we look at other people's environments, we should must say, look at our own first. Exactly. Exactly. And I think that leads us on to our, one of our last, what can we do? So what else can we do our own? What, what can, what can anyone who's listening and all healthcare workers do to help themselves and, and patients should I, should I start off and you join cos iz he will not manage it but, or, or one of us. So um there's an acronym called coma? Oh, I was going to say that. So, C OM ac is for cavities. If somebody is not feeling right in the house, is that just them or is it the other people in the house? Oh, it's for outdoors? Do you feel better when you go out? It's a real telltale or is it only when you're in the car? For instance, cos let's not forget cars can be a seriously, uh, dangerous place if not well maintained around co so, but when you're out in the fresh air, when you're somewhat in somebody else's house, do you feel better maintenance? Is the boiler maintained? And is the cooker maintained and is all other appliances that is combustible? Feel like your, you know, log burner are um well maintained and do you have an alarm? Is there a w and is that alarm working? But I would say alarms actually are there when you, it, it, when that goes off, you should be out that house, turning things off, getting out that space and ringing the emergency number. So it's a life, they're lifesavers. It doesn't mean that you're not being impacted. I bet most people on this um webinar would not know at what level ac O alarm goes off and it has to actually be at around 50 parts per million for a period of time, something like 30 or 40 minutes before that alarm will sound. And so it has to be continuous as well. So if you're opening and closing doors, it goes back, the, the, the level goes back down. So it does, it does stop people dying, but it doesn't necessarily stop you. The continuous one, if there's one telephone number to write down, if you, if you think you or the family or, or whoever you're visiting are in danger. It's the emergency number. The gas emergency number. 0, 800. I put it, hang on, I'm putting it into the chat. 0, 800 101 11999. And my view always is err on the side of caution. Yeah, I just can't spell emergency first. So there we go. You know, it's err on the side of caution, it's better to be wrong in that direction than to be wrong in the other direction. And they take out, they will, they will also attend calls for non gas appliances as well in an emergency situation. They will take your call, they will give you advice. So don't just think it's for gas. Brilliant, brilliant. And, oh, so somebody said thank you so much for your time. We're not quite finished, but we've got a few more minutes left but for the phone number and they're going to check at the boys school as well. So I think there's a, there's a bit. So I think if I want to sum up or actually I'm going to get you guys to and I'll do my own little bit of summing up. But is there are there, are there, let's do a tiny, little bit of myth busting and what misconceptions are there. And I, and I've learned one because I thought the ta monitor would be like a smoke monitor that if you just waft a tea towel, you know, when you've, you know, when you've burnt some toast, you're not wafting a tea towel for it then. No. So what are your, what are your myths? Any myths, any misconceptions out there? I can tell you one. Sorry, we do. We have, and it started last year and we have this, we have the big co quiz and we started it last year as part of the co awareness and one of them was about which is not, which of the following is not a sign of a co leak. And the thing that was most commonly thought to be would be a sign of a co leak was excessive condensation. Almost half of the people thought that excessive condensation is, er, er, is, is a, is, is a, is a sign of AC O leak. Also that things have to look different. Your stove has to look broken or burnt or yellow that you would expect to see something different. So my lights, I'm not apologizing for the sunshine but uh but it's there any misconceptions apart beyond the ones I've just mentioned, maybe II I'm trying to think is they, can you think of any. I'm almost thinking it could be so many other things, you know, so many other things I think, I think, I think the biggest one for me is from now training a lot of healthcare professionals around this is if you've got an alarm and it doesn't go off, you're safe. Yeah. Not true. It absolutely saves you from catastrophic, you know, constant and wheel down the end. But also that your, you know, if you've got a zero alarm, it will protect you throughout your house. You know, your landlord should have one where your boiler is, but they don't have to put one where your cooker is. Oh, now that it's just not in the law good landlord would do that and us as a, you know, homeowners and also, you know, be aware, you know, in other environments so you may protect yourself at home. Yeah, but you may be going to other environments, um, like relatives homes or, um, staying away where you really are not safe. I now am one of the paranoid people who carries ac o along with them. So that if I'm somewhere else and I don't feel safe. Oh, now I, that's where I'm definitely thinking part two is gonna come in because I've just seen Izzy's written that sorry, everyone, something's gone wrong at her end. Izzy, we can see and hear you just, well, we can see you. So just in case you think that, you know, you're not there, we can see you. But um and I think that writes us up, actually, I'm going to wrap this up now because we're almost there, but I'm feeling a part two would definitely be good. And in fact, you're welcome to come back and do as many as you want to, whenever you want to on any topic you want to. That's part of how we do it here. So, um and we've had quite a few people, Zoe saying yes, please support to Amanda said she would definitely come back uh to come and to listen if there was more of these. So II think we've got a call for that one. So um I'm just gonna wrap up everyone to say a huge thank you to these guys. I've learned loads and I thought I knew a lot about co given, you know, I'm gonna tell my husband stuff now. Um And he'll be saying that Matthew is saying at excellent informative session um for those of you who are watching on demand. Um Oh yeah, part two or I might maybe we'll get a, well, I won't get him there yet to a boiler. So yeah, somebody's asking about um is it law to get your boiler serviced? That's part two. I will, I'm not going to go down on boiler servicing just yet. It's just, but um I'm going to leave it to do you remember to do your evaluations before I give Hillary, the last word. Remember to do your evaluations. It's really important to us to get feedback on this. And of course, we've been back to the, the RCN um uh Public Health Forum and we go back to and let the uh the uh the A PPG know about what we're doing and go and who's on the call here to know what we're doing. But um I'm gonna, I'm gonna give it to you Hillary to say any last minute. Um anything before we let everyone go, I think, remember the coma acronym? Remember the number and also just the offer of I'm seeing some really good questions in the chat. But Michaela, if you want to let us have those and you've got a mechanism where I'm, I'm gonna speak for Izzy as well. Now given she can't um I'm back, I'm back. Oh, you're back, you're back. Lovely. I'm sure we're both happy. I'm calling you in on this one Izzy to, to look at those and give some short answers back now rather than waiting for another se session. So is there a way that we can um I'm just trying to think of how we can do that is that should we just, I'll tell you what if everybody puts your questions in your evaluation, then we can collect them much easier because I've not a clue how to download the chat function from this. Sorry, I'm not that technical. So if anyone's got outstanding questions that either you'd like directed individually or you think that would make part of a really good part two session and we don't have to wait that long to put part two on. Um You know, we can make this happen quite quickly then. Um Yeah, so Izzy last bit from you now, you're back. Welcome back. Sorry. Yeah, sorry. I don't have no idea what happened. Um Well, apart from thank you and thank you all for coming because just coming to this will have raised your awareness. And I think that that is so important because it's unless you have that awareness and unless there's something that just makes you a little bit suspicious, you are not necessarily going to think about co and as we have said, you know, it is, it's, it's easy to have it fixed if you have, if you see somebody in your health care setting and you think co get it checked because otherwise you could be sending them home to an environment that is unsafe and an environment where actually that minimally unsafe could very quickly raise itself into a fundamentally dangerous situation. So keep your patient protected, keep yourselves protected and think car carbon monoxide. I