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Right. Um Well, hello everyone and good afternoon. Um Welcome to our first episode of our series of Talks here today called Keep It Light. Um And our first episode for today is Upper Gi T my name is John Dejesus and I am an A&E sho in Queen Alexandra Portsmouth. And I'm joined here today by my friend and colleague, Kevin. Um Allow you to introduce yourself. All right, I'm uh I'm Kevin Beatson. I'm a general surgery registrar cases, Deanery currently on a program doing research at UC. Uh and that's me. Welcome. Um How are you feeling? I'm feeling good. Thank you. Good. So, um Kevin is with us here today because we are going to talk about referrals and particularly for in context with this episode. We're going to talk about upper gi T referrals. Now, just to give you an overview, we're not gonna talk about all of the several million types of referrals that we would like to speak with Kevin about. Uh but we're going to go through some cases and we're gonna dive deep specifically with the referral process. You know, we're gonna go through the ins and outs of an upper GI T referral. Um We're gonna talk about the nuances, the things that we, you know, based on our experience or an insight and things that we saw that is helpful with the referrals and things that we thought that could have been improved. So the objective here is we're potentially going to learn, develop and potentially improve the strategies that we have for effective and efficient referrals. And hopefully at the end of this, you know, hopefully we'll be able to apply this in real life um examples or real life patients. And ultimately, the goal is to improve patient outcomes because, you know, we're all doing this because we're communicating with each other and we want, you know, the best form of treatment or diagnostic that we can offer our patients. Um because that's what specialist referrals are all about and potentially improve the general experience because I know for a fact that, you know, you know, when you start your day KV and you just had a really bad, well, I would say quote unquote difficult referral and then the day just seems to just go down from there. So, yeah, no, it, well, um I mean making phone calls is a little bit, is a little bit um unnatural in a sense like your interaction with somebody face to face versus on the phone is very different. Hm And all of us are working in a stressful environment and all of us are kind of watching our caseload as well. Um Sometimes that just bleeds into uh interactions that aren't um as uh as good as they could be. Mm, I agree. And it can be a bit daunting. But yeah, you know, hopefully, um you know, gaining some insight and, you know, gaining some, you know, something to learn from here. Hopefully it improves the experience and, you know, hopefully we can learn some coping mechanisms and to eventually just look at at a more objective lens in terms of how we can improve. All right. So just this is just one slide I've just prepared about the referral process. You know, you can see the sbar here. Um It's a pretty good um way of communicating. Um you know, it's organized, it keeps it structured, but, you know, looking at the bottom left of the screen, I'm sure you're familiar with that lock and key and induced the theory. It's um it's actually enzyme theory and I've just kind of find the sbar analogous to a lock and key where if you say the right thing and you speak to the right person, then potentially you open that, that lock and you unravel, you know, his specialist input and all of that for your patient. Um But if you don't say the right thing and you know, you're not speaking to the right person, then you're not gonna have an effective enzyme reaction, potentially a a referral. Um But I think it's a bit more complicated than that. I feel like for more induced fitness because, you know, we're talking with two different people, two different backgrounds and I feel like it's always an adjusting process depending on who you're speaking with. And, um, yeah, but anyways, let's get to it. We're gonna talk, start with our first case. Um, we're not talking about enzymes, we're gonna talk about referrals. And so, are you ready, Kev? We can dive in with our first case. Yeah. Go for it. Cool. So we have um first case here, I have a 45 year old lady who's coming into the A&E with right upper quadrant pain and tenderness. Um She was noted to be febrile at 38.4 was tachycardic at 100 and 15. But otherwise for the other observations, she wasn't requiring oxygen, she wasn't tachypneic and she was also normotensive, which is always a good sign. Um Just generally from the examination, she wasn't jaundice, nothing we could see from, you know, jaundice or icterus from the eyes. She was definitely tender from the right upper quadrant with guarding. There was definitely a positive Murphy sign that we could see and just from the investigations, you know, or the bloods that we've done, she definitely has some raised infection markers with an elevated white cell and a CRP AP and A LT is also raised and also the bilirubin. However, we did not, as I mentioned, did not see any form of jaundice with this patient. Um actually, with just the history and you know, the bloods that have come back, you know, this patient is definitely presenting with a biliary type sepsis. Um, you have two of the triad, you know, right upper quadrant pain and fever. So, um in the A and I would normally start this patient on the fluids just to help with the tachycardia and some paracetamol for pain and fever might give a little bit more depending on how she's responding with the pain and, you know, with infections, we normally would start them on antibiotics. And, um, you know, the next part here is I check my phone for the bleep for Kevin Peen who is apparently working in my trust. I dial the bleep and I give him a ring and hopefully he answers in the next 35 minutes and so he answers the phone and I give him a referral. So, um, hello. Um, hi. My name is John. I'm one of the A&E sh Os. Is this the surgery registrar I'm speaking with? Uh, yeah, cool. Um, you doing ok today? Doing all right. You know, typical Friday, Saturday. The usual stuff. Um, is this an ok time for me to refer a patient? Uh, yeah, cool. So, um, I have a 45 year old lady, um, generally fit in, well, in terms of background, she's coming in with the A, in the A&E because of, um, right upper quadrant pain. It's positive on a Murphy sinus, 10 definitely tender, um, on the right upper quadrant, she's febrile, she's tachycardic, but she's not hypotensive infection markers are definitely up with a raised alp and bilirubin. Um, and, you know, I'm thinking this lady is probably having some sort of ascending cholangitis. Um, we don't know for sure about history of bilary stone because she's never had an ultrasound before. Uh, nor did she mention any history of that. Um, but just based on the story and, you know, two of the three in the triad, we're just thinking she might definitely be having this. And so we've only started her on some antibiotics for biliary coverage. We've given her some paracetamol, which seems to have helped with her, um, temperatures and the fluids seem to help, help with her tachycardia a bit as well. But I'm just wondering if you come down to see her and review her and potentially, um, manage her for this case. How was your experience when you did the referral, uh such as that John? Um, well, it's varied. Um, some of it's pretty straightforward, you know, they'll, they'll be like, yeah, take him to s au you know, or bring him up, um, call bed manager, bring him up. Um, I've also had an experience where like, well, if it's ascending cholangitis, I don't think I have anything to do with it at the minute. It's a bit varied. Um, but, you know, the policy in terms of our hospital is concerned, you know, if it's something of bilary concern and it's a surgical concern, then potentially we speak with them first and then we pick their brains on what they want to do. Yeah. Sometimes there are gray areas like, say, um, uh, your pancreatic or people who had complications post will come to the complications, post elective CP through the gastrologist route. Sometimes, um, one thinks about whether they come back to you or not. Um But out outside that some, uh what I would say for the sbar is, is good, it's a good, uh, it's a good structure to follow, but sometimes, particularly if you are calling someone at two in the morning or, you know, somebody up, um, the, uh, you know, the general surgery registrar is usually on site in most places because the tape keeps going. But like, say for me, if I have to call my boss in the middle of the night, sometimes I chase and almost like, um, anything we talked about this before about signposting, like, um I, I'd like, uh II need to refer someone who's, uh, like, say for this uh case who appears to be uh se uh to potentially have septic shock and uh secondary cholangitis and that will tend to get people's attention. Um, in so many words, um And what I would say about making referrals is that there's no one way to, to do it it's sort of like their own styles and it's like adopting it in a way, adapting it in a way that makes, you know, your own style the best it can be kind of thing. But at part, certainly a, a good place to start in a good framework to, to put things in and as you say, you have different personalities that you'll, that will talk and, you know, someone might say, you know, um, me, I tend to be a pragma a bit pragmatic if I, if you told me what you told me, mm, obviously it's, uh, you've, you've got evidence of, uh, a suspicion of bi sepsis. So I probably will need to see the patient. You'll have other people who go into the nitty gritty a little bit of. Ok. Well, what's the, uh, what's this, what's that, what's the coag doing? Um, and, you know, uh, that, that's, that's not necessarily wrong but it's probably, um, it's, it's probably that they're also just trying to make sure that there aren't anything else because maybe they will have been bitten in the past by right one who's got the range all of these and turns out to be secondary to e to etoh. And uh. Right. You know, so you, you, you never know what, what, what, uh, what, sometimes, what colors someone's, um, questions questioning of you, I wouldn't say. Right. Right. Like, depending on what their experience is and sometimes that, yeah, becomes a bit of, um, a challenge because obviously it always comes back to them. Like I remember this one time where, yeah, I know. I know. So I thought it was this. Yeah. Yeah. And, and we all have that n of one experience that, that call it up a little bit. Right. So that's true. That, yeah. But, you know, I perfectly agree with you and there's no one way to actually do these referrals. Each and every person will want to receive information differently. I personally had a referral before when I'm speaking to, you know, radiology. And they're like, so what are you thinking? Like literally mid sentence and we just go straight to the diagnosis, not even a story at all. And then, yeah. So I think in terms of referrals, it's finding out, you know, quickly what, how they actually want to receive and just not taking offense in that and just like, literally, you know, changing your whole way of presenting and then just getting it overwhelm anyone who's carried a bleep here is, I mean, a A&E is, is, is uh I don't envy you guys in juggling so many patients and having so many. But the at least my experience of uh being jump surge on call, say in the middle of the night, I've got inpatients, I'm looking after I've got cpod on my case, I've got uh mm unit and then I got A&E and, and the S AU and sometimes, um, sometimes I call it like a bleep paralysis sometimes. Uh, uh, like you, you get so many bleeps at one time before you know it, or just answering phone calls rather than seeing anyone. So, um, yeah, uh, I, II think, I think with, with the experience you start to, uh, you, you start to appreciate other people's pressures and hopefully that makes you a bit more receptive to, uh, discussions and, uh, and appreciating what the pressures for everyone else. Exactly. Yeah. You on a, they're saying oftentimes in my experience they want it quick and for them to know our immediate impression. Yeah. Yeah. Yeah, it definitely does happen. Um So anyways, um those are all very good insights. Um but going back to our case, um what would you do in this case, would you um bring them up or would you actually see them first before you've actually consider? I might, I might, uh I think, I think, you know, given the patients uh appear septic um with uh the range of fts and White count CRP, et cetera, then they would need, they definitely do need to get seen. My question probably would be uh and I would check is that, let, let's say I know that there are one or two things like if I'm in recess or I'm just finishing up a case, uh I might ask to uh double check their coag as well and make sure that's done in a group and safe. Sure. So prepare them for surgery, not preparing for surgery, uh, but just a, uh, there will be um, between the sepsis uh where you, you know, you have your, uh coagulopathy potentially. But also the, um, the obstructive jaundice uh will probably cause a, um, uh, coagulopathy as well, you think and not, not, not a lot of people, sort of, they, they, people see the range of FTS and they go coagulopathy because of uh liver dysfunction. But what a lot of people don't is that in these patients uh with obstructive jaundice, they also um what it is is they, you need bile to absorb your fat, right? And to absorb fat. So what you end up is uh with uh is that you don't absorb your fat soluble vitamins, which include Vitamin K So people can get coagulopathy because they're not absorbed Vitamin K And so if you need to correct it and I've had it with juniors where I asked them to uh ask them to correct someone's clotting. If I'm not explicit in how to administer it. They don't appreciate the fact that oral Vitamin K will not do anything for um their coagulopathy. You need IV in these patients. Um Yeah. And, and then, you know, depending on how they are as well, I'd potentially be asking you if you had space to move the patient to recess. Um Right or majors if uh, if they're, if they're in minors depending on, on your capacity. And, uh, yeah, but they're certainly jumping up in my priority list that they appear septic and cholangitic cause these guys can get really sick really fast. Right. Right. Fair enough. I actually didn't learn, uh, that's new to me about the coagulopathy bit. And, um, yeah, that's actually good to know. Yeah. Yeah. If you, if you give some, if you give these guys, uh, oral Vitamin K it's like we're not gonna absorb, it's a fat soluble vitamin. Fair enough. Yeah, the b their bowel system is blocked up. Yeah. So um sure. So now that potentially, you know, you've seen this patient and we've done some of the examinations, we'll do an ultrasound on this patient and that shows that she has some dilation of the CBD with a biliary stone. Um I put here policy, medics versus surgery because different trusts will operate differently. Um, particularly in my experience because majority of what's gonna happen now is going to be intervention specific to E RCP or some sort of, you know, MCP, then it kind of falls under medics in a sense because they're not definite, they're not gonna go in a theater room at this moment, I don't think because you, you treat them for the sepsis first, you try to tame that down and because there's a stone in the CBD which obviously you can't nick with a laparoscope. Uh it's going to be an E RCP. So with this case, normally we might need to liaise and speak with medics. Um, sometimes it's not an easy one because it's obviously sounding like a straightforward surgery case and sometimes policies might get in the way or sometimes they don't get in the way. Um, but yeah, ba based on my experience, um, some people actually know the policy and that it's so straightforward. Yeah, we'll take a patient but for most people, or at least some of in my experience, they were, they're not really aware and there's a bit of um backward and forward in terms of the conversation and I have to force like, well, let's have a look at the policy together. Yeah, if, if you work somewhere that has one of these sort of written things where say so and so goes here, alcohol kind of goes here, Gulf and Panc goes there. Yeah, kind of helps a little bit but not every, not everywhere has pretty clear cut things and sometimes can be uh can be a uh a back and forth, um which is unhelpful for you guys referring in A&E. Um But uh um one thing I would say with scenarios like this is you mentioned earlier about, you know, referrals to S AU and things like that. Um sometimes uh sometimes uh people will get uh will get uh sent to S AU appropriately. So your career appendix is things like that. But for someone like this, um I wouldn't uh if I had, if I was asked if they come to SA UI wouldn't. And it's not, it's not a, um, it's not a uh uh a capacity thing or thing or, or a AAA blocking thing and I want them to stay in A&E, it's that, that sometimes if, uh, if you have a patient who is unwell like this, like I say, tachycardic and hypotensive, they're going in, uh if they end up going into shock, see is not the best place for them, it's not a safe place. And then the and then the knock on effect of that is that the, the staffing in au is the nurses are look uh tend to be looking after the patients in there for assessment and they're also the ones who are kind of keeping the, the heart clinic and things like that going. So if they get, if they get uh caught up with an unwell patient, um one, it's not staffed for, for that and two, it's um it's uh uh the, the flow of eu just gets thrown as well and you end up with this back. Um I already said about um if, if you told me about this patient, I might be even saying, you know, have you considered taking this patient to recessive there? But then she's in septic, you know, develop in um ultrasound scans will uh will typically show uh dilated CBD. Uh If uh if, if someone's got uh well may may show a dilated CBD, the gallstone is not necessarily always seen. Mm So in terms of uh so in terms of uh um in terms of uh further investigation, they may need an MCP which can be challenging if you have an unwell patient to try and get because mcps are not MRI are not very easy to get, are they on, on, on an urgent basis? Um So then you end up having a discussion. If you don't have a proven stone in the CBD, you do another form of IMA imaging like a CT scan. The CT scan is not very great for picking up gallstones cause gallstone in the west. Certainly. Um Most of the time, 80% of the time are mostly made of cholesterol and so are radiolucent and those show up on x rays ie. Um So, uh if the patient was decidedly unwell, you might just have to go straight to uh uh trying to go for bi drainage and your main options. There are ERCP or interventional radiology, right? And that's where the correction of coagulopathy it comes in. Um that uh you know, if you're doing something like Vitamin K obviously, it takes a few hours to work. So, um getting that in earlier um helps otherwise you might need to use um other ways of correcting it a little bit quicker, but more expensive and get involved and things like that. Um uh So if someone has to do either a PTC or an E RCP and an E RCP can bleed badly if the coagulopathy is not corrected because to access, to access the cystic, uh, the, to access the, um, uh, um, that you need to do a sphincterotomy. So you're cutting muscle and if you have muscle you'll know that it, it does tendons. So, if they're coagulopathic, they can bleed quite badly with that as well. Right. Hm. It's a lot of good insight about these things. I never, you know, it's, it's one of those things, you know, when you're in the A&E you're like, you know, this is the diagnosis, just get into the specialist that needs to see them and then after that you're just like next. So it's actually quite helpful, you know, knowing about all of these things because particularly it helps as well. You know, about the knowledge about how to actually refer these patients. And I think, you know, we're all here to help each other, you know, next time around. I'm actually bleeding a patient with potential sending cholangitis. Now I'll actually add a coach because I never used to add coags for everyone. Yeah, that's really good. Oh, the, the, this patient is, um, making sure the amylase is checked as well to make sure they don't have a concurrent pancreatitis. Um, and it's possible for someone. So, the, the thing with pancreatitis I thought is a stone drops going down the bile ducts causes a um, a block of the pancreatic duct and causes a backup there to cause an inflammation in the pancreas. Uh Right. So it is possible to have a concurrent pancreatitis and uh cholangitis as well, particularly if you have a stool blockage. Ok. Cool. Um So actually we're a bit short on time, so we'll go forward with what's happening. Um But actually it was, it was a lot of things to talk about this one case. So I think it's a bit rather effective. Um But anyways, you know, the patient actually does get an E RCP. Um But however, they did mention it was quite difficult, uh potentially, it might be some bleeding bits there or maybe just the anatomy was quite different. Uh so much so that they mentioned it was an inadequate drainage. Um So what happens now is they've stopped the procedure and they've um now arranged an urgent PTC or percutaneous transhepatic cholography, which you've mentioned uh is going to be an interventional radiology thing. Um What happens in during the middle is obviously, this patient becomes a bit more septic. Um you know, hyper bouts of hypertension might be having some sort of renal or some organ damage there. Uh And so the urgent PTC was actually arranged quite sooner and they were actually able to get the stone out and get the, you know, the markers to go down after that because once they've removed the stone, um they've continued the antibiotics and the fluids and generally the patient slowly improved and was able to respond well with the antibiotics and all of that. So, yay, thank you. We've, um, got this patient. Well, I guess, no, like my, these guys can get sick really fast. So, if, if there's, mm, you know, I haven't come across too many places where you'd be getting like an E RCP in the middle of the night for a septic patient and things like that. Right. We might work in places where IR is a bit spotty whether you have it available. So, on the weekend, so you do need to get intensive care involved if there's going to be any, any delay in your source control of sepsis there, which is your blocked biliary system, right? Um My next question now is, you know, we've gotten this patient. Um, well, potentially we've um, corrected the issue and now he's actually better. Um, what happens next? Like, do we wait while he's in the wards to schedule him for a surgery or does he go home? Um, and then does he come back for a cholecystectomy for the? So I don't know what everyone's experiences of uh lab col and listing people for lab col in their own trusts. But um uh despite despite uh targets and guidelines, sometimes the patients do end up waiting longer, like, say to prevent pancreatitis. The uh suggestion for golf and pancreatitis is that uh the patient should have, uh, should have their lab to on the index admission or within two weeks and at least experiences that with pressures and, and things like that, that doesn't tend to happen 100%. Um, so for this patient, uh, the main thing is making sure that their bilary systems, uh, drained that. It's because you don't, you would, you don't want to do a lab to, if there's a stone in the CBD cause, uh, can cause a back pressure into the cystic and potentially more at risk of leaks. Um, also, um, uh, it is possible to do, to clear the, uh, bile ducts during an operation. You can do ac, uh, CBD exploration during an operation, right? You can, you can access the cystic duct or even make a cut as you alluded to, right. Uh, uh, call it ay into the, that's, uh, you know, you need someone with that expertise and that experience, right? Equipment. So it's not, it's not, uh, it's not the most straightforward thing to do and you'll have varied experience in, in places I've seen, I've seen, I've seen one trust in the country that tends to deal with their gallbladders as a one stop. So, when, if patients fit for a ga they will do, uh, they will do a CBD exploration as they take the gallbladder out avoiding knee pain, et cetera. There's, um, cholangiogram. Right. Yeah. No, not, uh, yeah. So they'll do sort of an on table cholangiogram or uh sometimes you, there are some places have an, an ultrasound probe that they can do intraoperatively to look for stones in the CBD, um like laparoscopic ultrasound probe. Um But most places they probably will clear. Uh We, we'll try and make sure the CBD is clear before you do lab for this patient. PTC. Um I probably, uh and, and given the fact that they've been septic, you might want to do it. They've, you might want to, um, let, let, uh, let them recover from that. Uh, and, uh, and, uh, um, maybe let the, the, the drain sort of mature around it and then plan to take it out. Um, right. Um, so you don't take it out too early. Um, I suspect I sus, I suspect you'll need to see how this patient goes. Uh, but, uh, you're probably looking more at the, at the sort of, uh, weeks rather than, uh, rather than, uh, uh, days rather than days. Um, again, it depends on a few ifs and buts if they have, if they had a concurrent pancreatitis, you might want to do that sooner if they have a concurrent cholecystitis and it's been a few days later, you might want to let the inflammation around the gallbladder settle. Um, the, if there's a, uh, a drain that's, uh, been placed, um, and some people they talk about sort of an internal, external drain. So, uh, they might need a drain internalized, um, uh, before you take the gallbladder out. So it's, it's difficult to say, um, exactly when, and if you go looking, there will be sort of different papers in terms of timing of, uh, lap col versus, uh, af after, uh, biliary drainage. Um, and then the, the actual, you know, how is your trust at sort of doing, uh, getting through the backlog gallbladders and things like that? It really depends on your back and your expertise, I think. Right. Cool. Um Right. So I guess we're um we're towards the end of our 30 minutes. Um but I think we've covered a lot just with that one case. So I think we have to skip on these next two. Next, I just wanted to su before we summarize. Does anyone have any questions at all or, you know, things that you might have encountered in your own practice or some, you know, queries or maybe just want to add your insights on the things things that you've experienced in your own trust specifically drop them on the chat box below if you have any. Uh Right. So maybe some of you are still typing that on. Um and I will go straight with the summary whilst you uh formulating your questions. I think we've covered a lot here today. Um Kev, you know, a lot just in one case, you know, to be honest, um I think it's giving me a lot of insight and specifically for gallbladders. You know, I never thought there was so many kind of pathways where it could actually get into. Um, I thought it was just pretty straightforward because my kind of background with surgery is, you know, this is a problem. You fix it, you cut it in you. It's all over. Uh, but it's, it's actually quite, um, complicated as well and how it interacts with the other organs. Um, you know, as you said, pancreatitis, you can have coagulopathies and all of the sort. And yeah, I think it just, it's, it's a good insight and it helps me as a doctor prepare for my next referral insight and it's not going to be, you know, a straightforward, just gallbladder, you know, it helps me think about other things as well, which is obviously helpful. Yeah. Um yeah. And so, you know, I would hope this case gets accepted with no problems because it's an obviously an unwell patient that needs sort. Yeah, we, we, we, we'd like to help that as well. Um But yeah, you know, um just, but just going through our summary or things that we've just done today, uh, you know, referrals again, it's a two way process and we're dealing with two or more individuals here and that means the referral itself is multifactorial. Um, you know, we're talking about policies that can get in those, uh uh adds a layer to it. We're talking about the individual himself or herself and, you know, they have their own baseline of knowledge, they have their own baseline of practices and habits and those multiple things can actually take effect in how the referral process becomes. And so I think, you know, different approaches will have varied outcomes. You know, we talk about sbar, we talk about headliners. I'm sure there's other sorts of styles as well that, um, people use. Um, but I think it just comes with experience, you know, selecting what the appropriate one is and, you know, depending on who you're speaking with, I think it just comes with experience on how you kind of adapt based on how based on um how they speak to you or respond to you and it just, you know, likely would improve the effectiveness and the experience of the referral. Um And yeah, so hopefully, uh you guys have learned a thing or two and, uh you know, we're not, you know, we're not going to be idealistic that you, you change just over the last 30 minutes. But um the goal here was obviously to give you some insight on the referral process and, you know, seeing things on what you're actually good at already and seeing things on what you might improve what you might want to try on your own practice and hopefully just generally make the experience of the referral a bit better. Yeah. What I, what I would say for me is that sometimes when I call the bosses to, um, for a patient. I still kind of think to myself. Um, yeah, I could have actually said that in less words or I could have been more direct. Right. Yeah. And there's no, there's no, again, there's no one way to do it. Um, but yeah, uh, but if you do throw a whole bunch of numbers at somebody you might not engage there, engage them at two in the morning the same way. Um Look, I've got a shock patient who, uh, I've got a patient who had more in septic shock with the A and cholangitis, then get the same goes for calling Itu or other specialties. Um, uh, it's, uh, there, it's an art rather than the science. So everyone will develop their own style and adjust as you progress in your careers. I agree. So, yeah, actually that's an additional element. Um, the time. So if it was eight o'clock in the morning and they had their coffee and their breakfast, I think people are a bit more amenable to having a chat. Uh, but as you know, as you said, four o'clock, three o'clock in the morning is a different uh scenario. Uh, so yeah, I think adjusting based on the time as well is pretty good. Um Right. So, um, thank you for that, Kevin and um thank you for those who've given their, you know, precious time for 30 minutes of their weekend to join us. Um, I hope you guys have learned a thing or two today and, you know, just generally, um, find things that you can use for your own practice and hopefully.