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Yeah. Okay. Good evening. Welcome back to our pediatric series from Minor BLEEP. My name is Dr James Macintosh. I am an S H O. Currently working at a district general hospital. Uh, which for those of you not working in the UK Uh, that means it's a much smaller hospital with less specialties. Uh, but the good news is that means I get to see both adults and Children, Um, and a variety of minors, majors and all the weird stuff in between. Uh, so this evening, what we're doing. So we're gonna be doing an introduction to newborn resuscitation. Um, and what to expect tonight? So all I will be doing is recapping a really good teaching session that I actually received that my new job, which was delivered by one of the pediatric consultants. Now, what this is not, uh is a formal qualification in neonatal or newborn life support. It is not a practical session, obviously, because we're here online, and it is not something that you know you can be taking away and start, you know, running resource calls. But the reason I wanted to give it is because the session that I attended it just really highlighted to me is someone that had done this training in about two years is just how different. Uh, basic life support and resuscitation is in the newborn compared to adults. Um, so I thought it would just be good to see an overview of all the different steps. Um, just to kind of get your thinking. And if you are lucky enough, uh, work or your medical school to get some more training on this, you'll just be that much more prepared. Okay. So, normally in adults, we kind of do our 80. So, airway breathing and circulation, which you can see to make up Some of the steps will be looking at this evening. And we also have to dry them, warm them, do an initial assessment, which are going to slightly different. Uh, and then we also have to think about which drugs we want to give. But we'll come to that shortly. Okay. So dry, warm stimulate. So this is not something we normally do with adults. Um, but if we are approaching a newborn, uh, particularly term in near term infants so above 32 weeks gestation, um, we want to do is drive them off because they will lose heat unbelievably quickly. Um, and there's a lot of good evidence to show that if the temperature is not managed, there are significantly worse outcomes or a way that I had to explain to me, which helped me think about it is the foetus. When it's inside, it's Mother is kept at 37 degrees. And while our hospitals can feel rather warm during the summer months, uh, coming out in the fresh air when you're all wet, you're not gonna be maintaining that body temperature. So we're gonna get some towels, were going to give them a good dry. We're going to try and vigorously stimulate them just to get them kind of awake, clearing their own airway, getting rid of some of the fluid in their lungs. Um, once you driving with a towel, you get rid of that damp towel. Because if you leave a damp towel on them, they're just gonna We're gonna stay wet, aren't they? So we wrap up that new born with a new towel. We keep their head walk with a hat. Um, and yet I know what you're thinking. Where on earth do I find a baby sized hat when I'm in the emergency department. So in recess, at least in our hospital and most other recess departments I've been to they will have a specific pediatric resuscitation trolley. And in one of those drawers, there should be newborns and neonatal kit Now are one has a big draw. You pull it out. It has these two boxes. One is for, um, the near term infants. So it's really clearly labeled on the top, and the other is for preterm infants because you're gonna need slightly different kit for these two different subsets. Um, it's like I said, we're gonna put a hat on their head, just like when you go out in the winter. You lose a lot of your body heat as you know through your head so we can pop that on, and we can put them on a thermal mattress, whereas pre term infants, so before 32 weeks gestation, we don't drive them with the towel. We don't worry about all this stuff up here. What we do is we have the special politician wrap so kind of like a plastic bag, and we put them in fully wet in a plastic bag that comes up to the neck and that helps maintain their body temperature. And we can then put them on a firm mattress and proceed to the next steps. Okay, so initial assessment. So if we think about when we when, uh, if any of you have seen a normal birth or a C section without any resuscitation, uh, you will know that we do something called an Apgar score and listed here several several elements of that Apgar scores the tone, the color, how their breathing and their heart rate. Um, and this will form our initial assessment. That's exactly the same, uh, in a situation where you think you might be needing to resuscitate this newborn. So if they've got good tone, were less worried. If they're floppy, there's a good chance. Uh, they're not going to be, you know, using the muscle cramps, and we're going to be needing to give them some respiratory support. So we're gonna need to ventilate them color. Uh, we like pink babies. Babies come out. They should be kind of pink if they're looking a bit blue a bit pale. Uh, you know, we're thinking kind of Cyanosis Palace. So cyanosis if they're blue meaning they're not getting enough oxygen. Uh, palate meaning maybe they don't have enough blood circulating. Maybe they've lost some blood during the birth again. These are the sorts of things that make us think we're going to need to do some sort of intervention breathing. You assess, you know, very similarly to how you would assess an adult. So we look at the rate we look at how hard they're working. Is there chest moving symmetrically is they're just moving at all. Uh, these are all things that we look at. Um, and we do so and we try and, you know, we assess that over 10 seconds, like with an adult. Um, and then we go on from there. So, heart rate, uh, this is again one of the big changes between adults and newborns. So heart rate is actually the best determinant of how well the newborn baby, uh, is breathing. And I know that sounds strange. Know when we just looked at how their breathing, But if their heart rate is above 100 BPM, excellent likelihood is their breathing Well, don't need any help. Um, and we can kind of relax if it's in that 60 to 100 BPM range, we do start to worry. We definitely start to think about intervention and below 60 BPM. Uh, we at this point would be really, really worried. Um, so any of these factors that we just talked about President, we definitely need to be putting out a cardiac arrest call and specifically a pediatric cardiac arrest call. So, in UK hospitals, you would ask someone to put a pediatric cardiac arrest call, which you do by dialing for two. So 2222, and you would say I'm a pediatric cardiac arrest call. Give your location. Um, and then the switchboard operators would send that out to everyone holding a pediatric crash bleed. And I'm emphasizing the fact that you see a pediatric because if you just put a cardiac arrest or you will get the normal cardiac arrest team, which is good, you normally get some anesthetists, maybe some medics, the same doctors. But importantly, you don't get a pediatrician, so you do not get the experts in Children and babies. So we called for some help. Um, and The other thing we can think about is whether to delay cord clamping. Um, because there is really good evidence if we delay cord cramping after birth for at least 60 seconds that promotes better outcomes than if we immediately clamp the cord. However, if we have all these worrying features ongoing, we would we would choose not to delay cord clamping. We immediately, uh, clamp the cord so we can get this baby into recess and we can start to work on them Airway. Uh, once again, it is different. Uh, so we're trying to say is the airway patents and then I don't You know, Are they talking or their added sounds? You know, if they're kind of snoring gurgling, that would make us think there is something obstructing that airway. Now, if you look at the image over on the left hand side of the screen, you can see in a baby the airway position is actually slightly different. So you want to be doing your chin lift or your jaw thrust. You want to get it so that their head is horizontal. So the airway is perpendicular, so at a right angle, uh, going up here I'm not sure if you can see my cursor. Uh, that is the correct position. If we lift their head all the way up like we would with an adult, we actually end up over extending and closing off part of the airway. Similarly, if we don't help them, uh, they can end up, you know, with their chin down and again that's going to block off their airway. But it's a similar sort of assessment to adults. So if we're hearing those going sounds of snoring sounds, chest isn't moving. That is going to be making us think we've, you know, we might need to adjust our position. And if you are in the unfortunately going to be managing that angry and you're not feeling very confident, asked for some help. Um, but the other thing is, just think. Well, okay, I think I've open the airway, but they're still making some noise is to make me think that there's an airway obstruction. Let me check my position. Let me adjust my position. So does that improve something or does it not really have an effect? So, like I said, we're aiming for a neutral position with the airway if the baby does not have very good tones, You have a floppy baby. You might be needing to do that. Jaw lift, which is again, exactly the same technique with an adult. Obviously, it's in a much smaller person, actually. Just need to slightly adjust your hand position. Um, if you're not really sure what I'm talking about. You think that kind of doesn't make much sense to me? Um, if you get the opportunity to try and get out of your clinical skills department, go down to your recess department, ask if they have, uh, some of the kids and a mannequin that you can practice on. Uh, and I've always found they're incredibly helpful. And they like, they like to teach us what they do. Um, so typically, we will be starting with a mask if we think that they need, uh, some ventilation support. Uh, this is just a standard face mask. You put it sort of covers the nose, the mouth, because over the chin, importantly, does not press down on that track here. Um, and it is again. It is a specific size for newborns, which you would find in the pediatric trolley. There are other options, like the laryngeal mask or pharyngeal nasopharyngeal airways and intubation. Um, so those are kind of things that you can use to escalate. Uh, suction, just like in adults, needs to be done with direct visualization. So you only suction what you can see what we never, ever, ever do is stick our younger. So I could just down into an airway that we can't see because you will be. There's a good chance you will push things further down. You might damage something, um, and cause a whole lot more problems than you're solving. But the important thing is you do not delay ventilation. A newborn resuscitation. Ventilation is the name of the game. So the most important thing is we start getting that chest moving. Get those lungs working. Clear out the liquid. Um, and get that baby breathing. Okay, Breathing. So look, listen. Fill if the baby is not breathing, if their gasping or you just think you know what, they're not breathing as effectively as I would like them to. Rather than diving straight into CPR like we do in adults. We give five inflation breaths and we do that in a row. typically, uh, we'd be using positive pressure ventilation using a bad valve mask with a three second squeeze for a breath in, and you can again see if you can get your hands on some kittens. Just practice counting, you know. 123123. And as I said before, the heart rate is a really good indicator of whether or not this newborn is receiving effective ventilation. So if the heart rate is less than 100 something is going wrong. Either you're you know, your positioning of the airway is not very good. There's a blockage. There's something wrong with your techniques. You might get a second person in to put their hands around the mask to make sure it's a tight fitting tight seal. Um, as you can see, I have put on the top left hand corner a screenshot from the, uh, newborn resuscitation algorithm from the Resuscitation Council. So if the chest is not moving and we're doing these inflation breaths, we want to check our mass check our head and your position. As I said, you're the second person to come in and make that tight seal so we can focus on just doing the ventilation. Think about. Do I need to put in an airway? I jumped. Sorry. I just skipped ahead. We would repeat the inflation breaths. Uh, like I said, it's really important that we start ventilating them. So if we've done some some inflation breath, but it's not worked. We need to try again. Uh, and we would also think about increasing the pressure of which were inflating, Uh and then, like any kind of 80 or resuscitation, we go back and we reassess to see what's going on. Okay, So if there is a heart rate response to the inflation breaths Excellent, Uh, we still need to continue to ventilate them until they're breathing on their own. But we changed the rate at which, uh, we are ventilating, so they're kind of almost squeeze in the back. It would be, you know, 30 breaths a minute. So 121212. And, um, for 30 breaths per minute. Um, and then when you've done that, 30 seconds, you would reassess the heart rate and the breathing and the whole time, You know, if you're managing that airway, you're looking for that chest rise you're monitoring the heart rate. You want to make sure what you're doing is effective. Okay? Again, we can only get into that kind of, you know, continuous ventilation if we know that our ventilation is working, going into the lungs and inflating them. Okay, Okay. Circulation. So, as I said earlier, we would have called the help We would have, you know, And this is just coming in. A pediatrician coming. Hopefully, you will have some someone else here by now. It will not just be you trying to revive this baby. Um, quite a few of these things, you know, they require several people that might be two of you using that bad valve mask. Someone else doing chest compressions. Someone else running full people getting bits of kit. Um, it is a team game, So circulation. So if the heart rate is not detectable or is below that cut off of 60 BPM after our 30 seconds of ventilation, uh, we need to start doing cpr now. In adults, we do 30 chest compressions to two breaths. In Children, we tend to do 15, uh, compressions to two breaths. But in the newborn, we would be looking to do three, uh, chest compressions for everyone breath. And that's as I've kind of tried to emphasize to you guys. Ventilation is really, really important. So if at this point that's not working, we're going to give some chest compressions. We're going to continue to ventilate them. We're going to start supplying with them some oxygen. And if we haven't already intubated them, uh, we're going to be considering intubation at this stage. Um, so when we measure the stats, we do it on the right arm, normally the right wrist, or you can go on the right leg. But right wrist is the kind of gold standard, and that's so it's a pre ductal measurement. Um, and as you can see over on the left hand side of the screen, we have some acceptable product tool, uh, sats. So at two minutes we're not expecting the baby to be doing a fantastic job of breathing on their own. We're just not. They've gone from having fluid filled loans into a world full of air. Um, it's kind of unreasonable to expect to be breathing perfectly at the start, so 65% and we're happy. Five minutes were kind of hoping that they're getting it together. It should have come up to 85%. And after 10 minutes, we would hope, um, they're saturations are above 90%. And next to that little table, uh, I have just put in a diagram here of someone giving chest compressions to a baby. So for those of you that have not managed to attend some sort of neonatal or newborn resuscitation course, uh, what we do is we put our thumbs on the sippy stone, um, hands wrapped around the back as a seen here, and we push in giving those 3 to 1, um, compressions, two ventilations again. The best way to get confident doing this. Make sure you're doing the right thing. Go down to clinical skills, go down to a resource, um, or book yourself into a course, um, and get some hands on experience because you don't want the first time you're doing this to be on a real child. Uh huh. Now we've been through our ABC. Uh, the next letter is obviously the we stand for drugs. Before we can give the newborn babies and drugs, we need to get vascular access. So imagine we've got a 27 week old pre me that is just being born. Uh, their risk is about this thick. Um, do you reckon you can easily put a cannula? And as we've pictured here, absolutely not particularly their shutdown requiring resuscitation. Likelihood of you putting a cannula in in a pressurized situations is really, really, really unlikely. So that's not at all what we do in the emergency setting. What we would do is we would get umbilical venous access. Okay, So if we were doing this on a neonatal I to you or the neonatal ward, um, we would use a sterile technique when we do this. Um, however, this is an emergency. Um, So what we'll do is we'll just use clean technique, so we'll clean hands. Um, we use a sterile Pak. It's, um but it's not vital that, you know, we do every single thing with an a septic non touch technique. We just want to get access as soon as possible so we can start to administer those drugs. Now, what I've put here is a diagram of an umbilical cord. So hopefully you can see that there are the two umbilical arteries. And the one for a large, um, umbilical vein below the umbilical vein is the part that we would want to I would want to put a catheter or cannula into, but the way we would do that is we identify the vessels. We know which vessel we're aiming for. Uh, we've got our scalpel. Uh, we cut about 1.5 centimeters away from skin so away from the belly button. A nice straight slice across exposing those vessels once. We're confident that we know which vessel is the umbilical vein with insert are capita, Uh, and it's important. We just keep pushing it into it. A little bit of resistance. Then you need to aspirate some blood before using it. So you pull back with a syringe, get some blood and run it through a blood gas machine. Uh, the reason that we have to do that is because, as you can see from my diagram, uh, maybe with the labels and you'd be confident saying, which is the umbilical vein or the umbilical arteries? Um, in real life in an emergency and that pressurized environment mistakes do happen. Uh, and we really do not want to be trying to clean drugs into the arterial system. Um, first of all, it's under pressure. Uh, second of all, it also means it's not necessarily going to get to where we want it to go. Now, if we can't get umbilical venous access, um, intraosseous access is also a useful second option. Um, I do not know how to get I Oh, access. I understand the gist of, you know, we crack out the I Okay, get a drill and drill into one of the long bones and put a catheter in there because the bones have a nice vascular supply, but I don't know how to do it. I won't be explained that this evening again, if that's something you're interested in, um, find someone that is trained in it and get them to hopefully explain it to you. Maybe show you if you're in resource. Um, there's a call out that requires I Oh, access, but try and just, you know, seek out that practical experience. So we have vascular access. Success. Uh, we need to be thinking about what sort of drugs we want to give you. Um, I know you're thinking there are loads and loads of different types of drugs, but in resuscitation of the newborn, Um, we are only really looking at four different types of drugs or maybe five if you want to be pedantic. Um, but we would give adrenaline so heart if the heart rate is below 60. Despite us having been through all the stuff we've talked about this evening, um, we would give intravenous or intraosseous adrenaline. So not intramuscular. Um, and then we would repeat that every 3 to 5 minutes while the heart rate is below 60. If when we run our blood glucose, we picked up some hypoglycemia, um, we would want to do some, uh, glucose. So normally some dextrose again intravenously. And it's definitely something you want to think about if they've been down for a long time, because that is more like to cause hypoglycemia the next one or two. Like I said, depending on if you want to be pedantic, is blood or fluids. So if you suspect that they have some sort of volume loss or if they're in shock, if you think that they're bleeding a bit like adults, we replace blood with blood. But if it's just they are dehydrated. Don't have enough volume. We will talk with some crystalloid fluids. Uh, could you please repeat the fifth drug? Of course. And then the last one is sodium bicarbonate. So this is if we have intracardiac acidosis. Um, sodium bicarbonate is just a base which neutralizes that acid. So the five drugs on screen five. So we have adrenalin, glucose, blood, crystal of fluids, sodium bicarbonate. Um, but you can kind of consider blood and fluids. Um, it's kind of the same thing. Okay, so let's just do a quick recap. Um, here, I've put on the European recess councils top five messages about newborn resuscitation. Um, so these are all well evidence things and just things to bear in mind. So dull ache or camping. We spoke about this at the start that can optimize the condition, especially in preterm infants. So if we are able to delay the cord camping, um allows them to continue to get those nutrients from the mother as it kind of progresses transitions from one environment into the next. The second top message is that effective thermal care. So those would be hats those thermal mattress is drying them off with towels and put them in a plastic bag is really, really important for a good outcome. As we've spoken before, fast heart rates will indicate adequate oxygenation. And it is probably the best sign in the newborn that they are receiving appropriate ventilation. We've said several times this evening ventilation is the name of the game. So simple steps that we can do to support the airway and breathing. We'll manage most issues. Um, so once we're getting that kind of the appropriate ventilation, we should be okay. And as a result of this chest compressions only effective once ventilation is established, um, And if the heart rate, um, is remaining very slow, that's what we'd be thinking about doing our, uh, our chest compressions. So this was the scenario that we discussed during my training, and apparently this does happen. Uh, and several of the more experienced doctor said they have known it to happen in department that they worked in. So you've been working in the emergency department? You've seen kind of a young lady in their twenties with some abdominal pain. Um, maybe some PV bleeding. Uh, and they don't really know whether or not they could be pregnant. So you go off your request. Your investigations? Um, you, of course. Some of the abdominal pain. Like I've written here, you'd be requesting a pregnancy test in any women of childbearing age. But all of a sudden, the emergency buzzer goes off for that room. So you So you and various nurses, doctors in the area, although rushing in, um, but the nurse tell you that the patient has just given birth, no idea that she was pregnant, but the baby is now here, but it's not breathing. So you, of course, you immediately shout for help. Make sure that some of your colleagues are looking after the mother who has just gone through childbirth, and we would go back to the start of our algorithm. So I think I put the, um, the official algorithm on here, which is very small. Um, and there's just a Q u A link there to a really good website on a really good Web page on the resuscitation council guidelines where they go and explain each step. Um, but back to our scenario. So it's not breathing, So let's go all the way back. And the first thing we're going to do is make sure we're gonna warm that baby. So we're going to say, Please, please, let me have some towels. It's dry. This baby, Um, let's stimulate them, see if we can get them breathing. Let's get rid of the damp towel. Let's wrap them up, put them on a firm mattress and let's get them into the into the very suspect. Um, you start to assess the baby. It's floppy. Looks a bit pale. Um, the breathing is kind of shallow, and it's working really hard. The baby, the heart rate is 65. Um, and you think this this baby is in July, so we position our area. Um, we also need to go and put out a pediatric cardiac arrest call. You get one of you asked one of your colleagues Sorry to bring over the pediatric. On the in. It'll crash trolley. Um, we do our chin lift. Or obviously it was a floppy baby, didn't we? So we probably will be doing the jaw thrust or jaw lift. I suppose it's slightly gentler in a baby, so we get that airway in the correct position. We can't hear any added sounds um So we're quite happy that we have managed to, you know, reposition our airway in the correct way we put on our face mask and we start our inflation breaths. So as I'm sure you remember, we do our 123123 We do that five times watching really, really carefully the chest to make sure that it is rising. And you know what? We've done a good job. We've got the chest rising. The heart rate is starting to come up. It's about 85 now. Um, so given that it's still below 100 that might mean that our ventilation has not been as effective as we would like. Um, So what we're gonna do? We're gonna repeat those five inflation breaths once again. Three seconds. 123123 on the bad valve mask. Um, and now we've got some extra colleagues. So we asked one of them to come and, you know, provide a really good seal around that around the mask. And now the heart rate, the heart rate has gone up. We can see the chest chest moving. Um, so we're happy that our ventilation is doing some good. So we're going to now do Are we going to continue to ventilate? We're gonna be doing 30 breaths a minute with one second inflation. So 1212. And after 30 seconds of this, we're going to reassess. So at this point, the heart rate has dipped again. So what? It did come up? Um, it's now dipped again, and it's sitting at about 70. Um, we look at the SATs. It's been, you know, it's been probably four or five minutes. Um, and the SATs probe is showing that the baby is only saturated 60%. So we're gonna have to start some chest compressions. Um, so we asked one of our colleagues who come in and they've done the neonatal life support course they know exactly what they're doing. Um, you know, we're going to be communicating between the two of us on the bag valve mask and then doing the chest compressions. So we get three chest compressions to everyone ventilation. Um, and the anesthetist says, Well, right. I think we should intervene this baby. Um, so they start getting the kit ready. Uh, and we continue to resuscitate the child as well as the anesthetist. We also have a pediatrician who for their sins, you know, we have had excuse me, a lot of experience covering the neonatal unit, the NICU. So they know how to get umbilical venous access, and you see that they take out their scalp or they cut across. They have a look at the vessels. They thread that catheter into the umbilical cord. A spirit, a blood sample, which someone kind of runs to the, uh, the blood gas machine while And this this is obtaining access through innovation. Um, and some of them back and says, Yeah, it's all good to use to being a sample. Um, and then we start again. We we reassess our babies. So heart rate is, you know, it's staying about 60. So we're going to give some adrenaline. We would, of course, look up the dose. Although in the boxes, we needed resuscitation. They do come pre drawn up. So we give our first dose of this. Um, we've had a look at our blood gas. They're not hypoglycemic. They're not acidotic. Um, we don't think they've lost any blood or fluids. Um, so we continue, so I'm just checking the messages. We continue with our, uh, CPR and ventilation of the baby for another 30 seconds, and then we do another assessment. And now the heart rate has come up to, you know, 90 the saturations are coming up to 95%. Um, and everything seems to be going in the right sort of direction. So, as I said before, this here is a really good resource. Um, explains a lot of the science is far better than I can go through every single step of our algorithm. Um, and I've just seen that there is a question. So it's So this is from Jorgen. I hope I'm pronouncing your name correctly so I can imagine that premature babies The next position isn't so easy to find out, uh, as to whether they're hyper extended. Uh, So, for example, below 30 weeks, Um, so I must say I have not stabilized the airway in practice of a premature baby, but absolutely, they're going to have less tone. They're going to be much smaller. So that is why we're reassessing things like the heart rate. We're looking to see if when we do our ventilation breaths or inflation breaths the chest moves, and if that we can use as feedback. So even if we think we're in the right position, we give those five breaths the heart rate, it stays really low. The chest doesn't move. That tells us, actually, probably we're going to need to reassess, you know, the seal of the mask. And actually, that airway positioning is going to be one of the things that we re assess. So hopefully that answered your position. So I agree. Yes, it's difficult. But that's that's why we use those kind of proxy measures to give us some feedback. Okay, Uh, is there any other questions? So what I've done here is I put a QR code that links to our feedback for those of you that have attended our webinars before. You know that you'll be sent an email linked to this, um, as well. Um, basically, just take a couple of minutes, right? Some feedback, Um, as well. As you know, for our presenters, it could be going on portfolios, but it also allows us to go and improve. Are teaching. Um allows us to think about exactly what you guys need and want. Um, so be honest. Be direct. Say, is that you know, Tell us the things that you like, and we'll carry on doing that. But if there's something we can do to get better, we're always looking to improve our webinars. Um, any other questions coming in? I can see that you've said thanks. Good. Glad I can answer your question. Just going to send the feedback out. Okay. And as you can see, a link has just popped up in the chat. So thank you very much for joining us. I know it's been quite some time since the pediatric series been putting on webinars. Um, but now that I'm working in an area where we see far more Children and I have access to the GI doctors, um, pediatric ent doctors or the GI doctors, I'm hoping we'll be putting on more regular webinars. Oh, so Mars is asking, Do I know of any pediatric emergency course is offered in the UK, like pediatric trauma courses or pediatric emergency courses like impact? Um, so I know that that the research council put on very basic so basic life support and advanced life support. Um, and they have a a neonatal version and a pediatric version. Um, if you look into kind of pre hospital medicine, um, there are other kind of society driven courses. There are lots of different ones out there. Uh, best thing to do, Have a quick google. Um, but also, um, ask your colleagues, um, I find, particularly when you start to branch out from kind of the main official courses. There are some fantastic things out there. Um, unfortunately, there's also some stuff that it's just there to make money, so find out what other people have done. Um, But what I will do is I'll have a quick look, and if I can find anything that looks really interesting, I will post it on Facebook page later. Okay, Hopefully that answered your question. Mars. Any other questions before we go? Okay. Thank you very much. Enjoy your evening, everyone. I have not got to go to a night shift. Um, but hopefully in the next few weeks, like I said, we'll have some maybe some minors cases. We might have some talks from pediatrician's or emergency department. Uh, doctors that focus on pediatrics. Um, so keep your eyes peeled. Please do fill out our feedback form. And if there's anything specific that you want teaching on again, make sure you write it down there. Thank you very much.