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Hey, hello. OK, Bill. Everything's working, I think. Fantastic. You might have to be the one to upload the slides. Yeah. Yes. Um ok. Uh Is that working? Yes, it is excellent. OK. Come on. All right. Well, let everyone join cause the I did see it was about 55 registered so there should be quite a few people. OK. No pressure. Oh good. OK. Um I'll give it one minute and then I'll get started I think. Well, well, you can give me a second. I'll introduce everyone, tell the doctor that's doing it, introduce you and you can, you can take it away. Thank you. Right. OK. I think to not hold anyone else back too much longer. We're gonna have a head start on this. So welcome to another session of Code Blues. ECG um Sorry. Code Blue teaching this week is uh ECG interpretation. And um Isabel is gonna be the one guiding you guys through the teaching today as per usual about 45 minutes of teaching and then we'll have about 45 minutes of sy practice at the end. So please stay behind for that. We've got a doctor present who will be in the sy practices as well. Doctor Lay, she will be joining us later on. Um And yeah, I will send the feedbacks at the end of the session too so that you guys can get access to Isabel's um powerpoint slides and please make sure to feed uh fill out the feedback forms uh in general for our benefit. So I hope you guys enjoy and yeah, uh Thank you. So, I'm Izzy. Um I'm 1/4 year and I'm gonna be talking you through how to approach ECG interpretation today. Um So the aim of today's session is to have a kind of meth er approach to how you would do it. So you do it in a systematic way when you have a look at an ECG. Um and then we're gonna go through symp pathology as well. I don't think you will have done so far. You'll have necessarily learnt about all of the pathologies, but hopefully, um this will give you an introduction to them because I think it's next week. So don't ask me too many questions about the pathologies themselves and kind of um that side of things. This is an introduction into how to spot it in an ECG instead. So this uh first line system partners that, yeah. Um I've, most of the EC GS in this are from Gee Medics and Life in the First Lane, which both have really, really great E CG um resources if you're looking for some more information. Um So we're gonna do three sections. Oh OK. Uh First we're gonna look at the shape of the ECG itself and what, which hopefully won't be new and then we're gonna approach a whole trace and the steps to do that. And then the last section we're gonna be swatting signs that something is wrong, the more you guys talk to me, the faster we get this through and the more of the pathologies we will do. Um If you fill in the feedback form at the end, you will get a copy of the slides. So even if I don't imagine, we're gonna finish all of the pathologies that it would be useful for you to know. So if you fill in the feedback form, you'll get the slides. But the more you talk to me, the faster we get through it, the more pathologies we'll discuss today. First thing um um If you could all do this, then I have a rough idea of where we're all at now. That would be great. So whether you know nothing about Ec GS yet or whether you know loads, if you could answer that for me in the thingy, that would be wonderful so that I can kind of tailor it cool. OK. That's fine. Um So section one understanding the normal wiggles, hopefully this isn't new and we can get through it really fast. So this is the normal choice what cardiac event is happening during each of these sections. So if in the chat, could you please tell me what does the P wave me? Oh, no, slides are not moving? Oh dear. Can you not see the first? What slide I'm on at all? Can you just see the first slide? Is that everyone, the slides are moving for me? I don't know if it's the same for others. So anybody apart from could give us an indication of whether? OK. Yeah. So is the uh this happened to us last time? What you might have to do is you might have to cancel the presentation pretty much every single time. OK. Right. Is that gonna be OK? OK. Yeah. The No. OK. Can you see that? So it should be that one. So it should be a normal ecg trace P wave, you've got it. OK. And does it change if I do that? Does it say pr interval now or does it still say P wave it, it changes? OK. Say, let me know if it happens again. So P wave, I have shown you the answer already. I think. So P wave is atrial depolarization pr interval. Anyone know what that, where, where that is or what it means, what's happening there? OK. Mhm Here it is the, so this is from the start of the P wave to the beginning of the P wave and is the time for the electrical activity to get between the ventricles. So, in on a ECG trace, this is less than one big square normally QR S complex. So what's happening in the QR S complex? Someone said atrial depolarization. I'm not sure if you've sent that just now or you sent that a minute ago. Ventricular contraction, ventricular depolarization. Yeah. So, depolarization of the ventricles is um QR S complex. So there's three separate waves that are all together. So the Q wave, the R wave and the S wave ST segment, what's happening there? It's kind of a trick question. So this is between depolarization and repolarization and then T wave is repolarization. Does that make sense? Everyone happy with that. I'm going to take the answer is yes. So QT interval is the last thing. This is from the start of the Q wave, the start of the QR S complex to the end of the T wave. And this is the whole of depolarization and repolarization of ventricles and is important in pathology we will talk about later. So that's all well and good. But what do we do when it looks like that? Cos that looks a lot more intimidating. So how do we approach a whole trace? Do any of you have a kind of system so far for approaching a whole trace? I? OK. OK. Any ideas? No, the more you talk during this, the faster we will get it through, the more pathology we'll talk about. And the more interesting it will be OK. Page de patient details, rate and rhythm. Yeah. Yeah. Patient details date, calibration, speed and heart rate. Yeah, cool. Um So the rate rhythm access. Yeah. So these are all things that we check and they are most of these. So the the first few things that we check are those. Yes. Um Yeah, so we're gonna use the rule of fours. So we're gonna have four initial features, four waves and then four intervals. Yeah, cool. Um So we're gonna go through them and then I will put them in the categories at the end of this section. So E CG paper just to make sure everybody understands. One small square is naught point naught. Four seconds, one large square is naught 0.2 seconds. Five large squares in one second or 300 and 300 small squares in a minute. All right. Yeah, a minute. Sorry. And ok, so we're gonna start, we're gonna confirm the details. What details are we gonna confirm? So one of them has already been said. So we're gonna check the name and date of birth of the patient. We're also gonna check the date and the time of the E CG because if you've been given an E CG, is this the patient's E CG from three years ago when they were fine and they're now having a heart attack, that would be bad. So then we're gonna check the heart rate as some of you have also said, how do we check what's the normal heart rate and how do we find out what the heart rate is on? An E TG either of those questions? Anybody? Oh, no, the screen is frozen. What's, which one is it frozen on? I take this again in the back. Mhm. Ok, cool. So normal is 60 to 100. Um, and so somebody said 300 over the number of large squares and between the RR waves. that is definitely a good way of doing it. Yeah. Um Cool. So normal 60 to 100 there are two ways of working it out. Um So either 300 which is the number of small squares in a minute over the number of big squares between the R and R waves or you can do the number of complexes on the rhythm strip. So the bit at the bottom times six because the rhythm strip is 10 seconds long. So times it by six. Which one of those are you gonna do if it's irregular? Yes. Yes. So OK. The second one. Yeah. Yeah. So if they're, if it's irregular, counting the distance between the R waves, the distance between the R waves changes between each beat. So that doesn't work. Um So you have to count the number of complexes in a time period. Cool rhythm. So what rhythms could there be? So they could be regular and there are two other, there are two options for irregular. What are they? OK. That may not be a very well worded question. If you don't know what that means, that's fine. I'll just tell you, um, regularly, irregular and irregularly irregular. Exactly. Cool. There are examples of both of those later. So irregularly irregular, no pattern to it at all. Regularly irregular. There is a pattern to it. There just isn't the pattern. There's supposed to be a good way to check if it's irregular or if it's regular is if you mark the first couple of R waves along the edge of a piece of paper and then move it along. If it's regular, they will continue to line up cos sometimes you can see from just looking at it that it's irregular but sometimes it's not so obvious cardiac access. So this is a bit that everybody hates. So I'm gonna talk to you today about the most simple way to identify if there is d um deviation in cardiac access, if you are interested in it and want to learn more. I would highly recommend life in the fast lane for this. They have a really good, they have a few different methods of um working it out and some of them are quite complex, but they're quite interesting. So if you're interested in it, have a look there, but for now, this will be enough. So cardiac access is the overall direction of electrical activity. So it can either be normal, right, axis, deviation, left axis, deviation or kind of extreme, but that we won't talk about extreme today. So the overall direction that the electrical activity is going in points. Uh So when the overall direction is towards the lead, then you get a positive deflection and vice versa. So the overall direction will be most more positive when it's going towards the lead. Normally, this is between 90 minus 30 which you can see how that fits on the picture. Say right axis deviation. Yes. What's that gonna be between on the graph sort of thing? If normal is between 90 minus th um Yeah, 90 minus 30. What will right axis deviation be between 21 9? OK. 9100 and 80. Yes. So right ex deviation is between 9100 and 80. So this direction overall cool, how do we identify right axis deviation? So the most simple way to do this is by the letter R is for both, right and reaching. What do I mean by reaching? So can we see if you look in lead one and VF in this one, this would be right axis deviation because the VF is reaching up towards lead one and lead one is bigger down towards a VF. Does that make any sense? Can people see what I'm talking about or am I talking rubbish? So this bit is pointing down, the bigger bit is pointing down and this one is pointing up. So they're reaching together. Yeah. We can see excellent cool. Any questions? Let me know. But hopefully that makes sense. So then left axis deviation is between minus 30 minus 90. So like this and we do, we can identify it in a similar way. So L is the left and leaving. So at this time, the bigger one is pointing down in a VF and up in lead one. So they're reaching away from each other. So they're leaving. So they're left. Actually, this deviation. Does that make sense? Can I explain it again? Yes. So we change this slide. OK. Say on an E CG if you look in F. So this one, if it is pointing, if it is overall, the QR S complex is pointing down. So there is a bigger deflection down rather than up and that's combined with the bigger deflection going up in lead one, they're leaving. So there's left axis deviation. And if you swap that, so the bigger deflection in lead one is down towards a VF and the bigger deflection in a VF is up towards lead one, they're reaching. So that's right. Access ST deviation. You can't see my cursor. That's very annoying. Um No. OK. So do you all know where? So all I was pointing at was the one. So in pink, there are, that is how each of the leads are laid out on an ECG trace. So leads 12 and three are the first column a VRA V LVF of the second column and then the chest leads 1 to 6 are columns, three and four. So all I was doing was pointing at lead one which is the one top left and aVF which is the one on the bottom row that has an actual TD trace on it in that picture and explaining whether their main deflection is up or down and whether that means they're reaching together or leaving and therefore whether they are right axis or left, OK. It's really complicated. Lots of people take a minute to get their head around it. So it might be worth having a think about it. So you will get these slides. It might be worth in a couple of days having a look through them or having a look on geeky medics or life in the fast lane and having another think that might be the best and I might move on now. But if you have any questions and we have time at the end, let me know. So last thing on this, why is reaching for right axis deviation, more reliable than leaving for left axis deviation. So if you've got, if, if they are reaching together lead one and a VF are reaching towards each other, the overall deflections are reaching towards each other, you can reliably say that's right axis deviation. But if they're leaving away from each other, you can't reliably say they left axis deviation. It might be, but you can't be sure. Why is that any ideas? There's a clue in the picture. Left ventricular hypertrophy. Not quite but good. Guess it's not quite what I'm getting at all. I'm not getting so much at a pathology I'm getting at in what situation would there be leaving? And it be normal access deviation. So, not the type of heart that would cause that, but the cardiac axis, I'm not explaining this very well. Right. Ok. I'm gonna tell you cos I don't think I've explained it very well. So what I mean is an E CG which shows leaving that the overall electrical charge is between zero and minus 90. So, however, we mentioned before that left axis deviation is only between minus 30 minus 90 whereas right axis deviation is between 90 100 and 80. So right axis deviation and reaching is always gonna be, if it's reaching, it's always gonna be this quadrant, which is always gonna be right axis deviation. Whereas if it's leaving, it's this quadrant which isn't necessarily left axis deviation and there are reasons for that. So I can't remember what they are off the top of my head. Left ventricular hypertrophy may very well be one of them. But yes, is that all right? Hopefully, that makes sense. We're then gonna look at the shapes themselves more individually. So we're gonna look for the P waves first. What are we gonna look for in the P waves? So, is there always ap wave, just kind of look along the rhythm strip. Is there always AP wave? Are they the right size? So they should be three square, small squares high or smaller? And then are they a normal shape? Are they inverted? Are they biphasic? You don't necessarily need to know what could cause all of those things, but you need to be able to identify if they are there. Um So just comment on the shape pr interval. What could go wrong here? So what could go wrong here? We're looking at the duration is the duration normal? And is it the right height? Is it depressed compared to the rest? So we use the term isoelectric line, which is the baseline of the ECG. Is it the same height as it was before the PP wave or is it lower? So is it depressed? And it should be naught? 0.12 sec. Um Yeah, naught 0.12 seconds to naught. 0.2 seconds. So that's three small squares to five small squares. What could cause pr depression? Any ideas if you don't know now, that is fine, you will in a bit anyone right now. No, we will talk about it later. So QR S complex things that we comment on here are the width of it, the height of it and the general shape. So a normal QR S complex afib and heart blocks, pericarditis. Yes, pericarditis. Well done. Um We will talk about that a bit more later. So with height and shape to your RS complex. So normally they are what we call narrow, which is less than three small squares. If they're bigger than that, that's not normal. And we say broad, you can comment again on the shapes, are they overly tall and then are there delta waves which is a slurred up stroke? Um And the J point is where the end of the S wave meets the isoelectric line again, is that the normal height or is it slightly high? So, if it's slightly high, this can be called something called high uptake, take off that one high take off, um which can mimic er stemi but can be very normal in healthy people. Um Yes. So ST segment is what we're gonna do next. So is it elevated? Is it depressed? And it can't just be a tiny bit? So it needs to, to be considered significant. That's more than one millimeter, 11 small square in two or more limb leads or two millimeters or 22 millimeters or more for chest leads. Um If it's less than that, there may be elevation there, but it's not significant or if it's only in one lead, it's not necessarily significant. Also check for depression. Um and more than half a millimeter in two plus leads, um is significant T waves. What can we look for in, at wave? So we're looking at a tall, so more than five millimeters in Limnes and 10 millimeters in chest leads what can cause a tall T wave one A cos this is something that I think it is particularly important that, you know, cos it's a common thing that can come up in exams. Hypokalemia, nearly hyperkalemia, hyperkalemia. Yes. So, hyperkalemia causes tall tented t waves. We say the reason I'm mentioning this now is because it's the one thing that I think is really important that, you know, for exams that I forgot to put in the pathologies later. So if you make a note of it, make sure that you know what that is for exams, other things that you can comment on on the shape of AP wave are, are they inverted? Are they biphasic? So they kind of um go down and up and are they flattened? Are they present? But not, but they're quite flat. So they're only little, that kind of thing. Um Yeah, next, we're gonna look at the QT interval. So what's normal for a QT interval? So this is this changes for men and women. So we look at whether it's prolonged, it also changes depending on what source you look at. So here I think this is from life in the fast lane. It's more than 440 milliseconds in men and more than 460 milliseconds in women. But different sources say slightly different things. So if you're gonna remember anything, just remember more than 500 milliseconds or 2.5 big squares check for that because that's when you have, if it's more than that, there is a increased risk of ARDS, which we will talk about what that is later can be quite problematic. Um So if you just do the 500 milliseconds, is it more than 2.5 big squares? That's, that's plenty. Um cool. OK. Last wave is U waves. Is there? What, what, what's AU wave anyone know, cos we didn't mention them before? Are they always there? Are they common anything like that? Do we know anything about you? A S I? Mhm I'm gonna take that as? No. So they aren't a common finding. Um They can be due to various things, various electrolyte abnormalities and they are more obvious in a bradycardia and it's this extra wave after at wave. Um And it's just something to comment on if it's present safe. That is all the things we're gonna do. So you can either do the four initial features and then work along the complex and do AP wave and the PR interval, Q RSST T QT and then U waves or you can do it like this. So you do four initial features, four waves. So that's the shape of the four waves. So the shape of the P wave, the QR S waves, T waves and U wave if present and then for segments and intervals. So the pr interval the QR S interval, the ST segment and the QT interval, you can think of it in either way, whichever works best for you. Um, yeah, I've kind of, whichever one works better to just making sure that you've done all of the things and you've done them in a systematic way and in an exam, er, particularly CCA, if you talk through what that is, then that, yeah. Yeah, you need to talk through a system. So, whichever system it is, that's fine. But you need to pick a system um or another system if you can find one online that works better for you. Um Yeah, pick a system and then do it in a systematic way in an exam. So how do we tell when something is wrong? So this is the interesting bit I think. Um So is this normal? Does this look normal to you guys? I'll give you a minute to look at it. You don't need to go through every single detail. Just have a look. Is this normal? There's one thing that's not normal about it and it's not really niche as a no tachycardia. Yes. So this is a sinus, tachycardia. What do we mean by the term sinus? I didn't mention this before. So sinus means that there is ap wave before every QR S. That's all it means. Um So have a look at this. What is the obvious abnormality with this? And what could that be irregularly irregular? Exactly. And somebody has said there's no P waves. So, is this AFIB af yep. So atrial fibrillation so irregularly with you and irregularly irregular and no P waves, what could this be? This is atrial fibrillation. So this is disordered contraction, the atria. And if you don't know what that is at the moment, that is fine, you are doing it, I believe next week. Correct me on that if it's this week and I've got it wrong. I think next week in your TCD, this is one of the things you will be learning. What about this one? Yeah. Any ideas on what this is? Someone's asked what, what leads should these should we be looking at? So for this one and for the last one, if you look at the rhythm strip along the bottom, um and I'll tell you if there's things that can only be seen in specific le so Sawtooth appearance. Yes, that is right. And atrial flutter. Yes. Someone said ventricular tachycardia. This one isn't ventricular tachycardia that will come up later. We will, it's, we may not get to it, but it is in the powerpoint so you can look through it yourself later. Um So do the parents for anyone that doesn't know is this jagged appearance between the R waves. So they're P waves that are making a jagged sore tooth like appearance. Hopefully, that makes sense. So irregularly irregular and saw too flat away. This isn't blatantly obvious that it's irregularly irregular, but it is, if you look at this one, it's much smaller than some of the later ones. Um So this is atrial flutter, which is an S VT caused by reentry of electrical activity in the atria causing rapid contraction with irregular ventricular contraction. And again, it's in T CDI believe next week, we can be extra specific with a few different things. One of which is flutter cos we can give a ratio of the amount of flutter waves compared to the QR S complexes. So this is one QR S complex every four flutter waves. This looks like three, this little notch at the start counts as a flutter wave. So this is 1 to 4 atrial flutter. What about this? One? Is this regular and is that abnormal? Could we practice axis reading on this too? Yes. So if you would like to have a look, all of the axis so far have been normal. Um So if you look at this one's not very good example because it doesn't aVF doesn't really um A VF doesn't really go up or down much. What would be better for a practicing access reading is if you stay. So I'm gonna finish in 10 minutes and then, then we're gonna have 45 minutes after that. In small groups, you can go through. I don't remember how many there are 10 ish EC GS in small groups. So you can each have a go it would be better to practice access reading then. Um Oh no. Is it still on the h or flatter slide? Um Is it still on the atrial left side? Hopefully not. Yes. No. OK. Good. So this isn't regular. Is that normal? I'm going to give you a clue. No, it's not. Uh it is normal. So it's, it is irregularly irregular but it's sinus rhythm. Someone said, say, I see why you said that we will talk about stemmy later. I'll tell you this isn't a stemmy. What this is sharing is sinus arrhythmia, which is a normal phenomenon where reflex changes in vagal tone during different stages of the respiratory cycle affect the heart rate. So we have, can you see in parts of it there is a much longer RR RR interval and then it gets shorter again and then gets longer and gets shorter. That's as they breathe in and out. And it's very common and normal. It is not pathological. Can any bee spot an abnormality in this one? It's frozen again. Oh, no. Oh, sorry. Oh my goodness. There we go. Hopefully it will be back. What is the abnormality in this one? You can look, it's in all the leads. No sinus ready. Uh I think you're right. I think this is bradycardia. There is another abnormality I haven't actually worked out but I'm gonna guess go with you are right. And it is sinus B cos it looks like it probably is but yeah, there is something else and you want to spot that. Ok. OK. Yes. II think you probably are all right that this is a bad, I haven't worked out exactly what it is but it looks like it. Um, what the other abnormality is in this is that there is pr prolongation. So if you look at that is much bigger from the start of the P wave to the start of the Q wave than one big square. So what could that be? It is sinus body as well. You are right there. It's not atrial fibrillation because it's regular and we have P wave present but pr interval is really long. So what first degree heart block? Exactly. So this is first degree heart block. So where there is delayed electrical conduction, it's not interrupted, it's just slow between the atria and the ventricles. This doesn't need treating. Um It can be very common. I believe athletes don't quote me on that. I believe you're common athletes. I don't know. Um But yes, this is first degree heart book. It can also look like this. So where the P wave and the T wave are so close together, they kind of merge and you get a notch, which is the P wave um that can also be first to be out. This one is a good example of irregularly, no, regularly, irregular. So as you can see, this is not regular, but there is a pattern to it. What is the pattern and why? Any ideas four times, I think I'm going to move on. So this is progressive prolongation of the Pr interval until a QR S drops. So before the Pr prolongation was the same every time and the QR S was always present this time, it gets progressively longer until it drops. What is this Mobitz type one? Exactly. So this is secondary heart, second degree heart block which we call Mobitz one. and it's reversible conduction block at the atrioventricular node. So at the atrioventricular node, cells progressively fatigue until they fail to produce a QR S, they fail to conduct an impulse key here, progressively fatigue. So that's why they get progressively longer as they progressively fatigue. What about this one? So this one is similar in that there is, it's irreg it's regularly irregular, there's a pattern to it, but it's different. Why is it different to the last one? I will tell you the answer. So this is there's a sudden drop of QR S without the Pr interval. So it's almost a combination of the previous two. So what could this pathology be? No, it's two. Exactly. So when their failure is at the bundle of his rather than at the A V node, they fail suddenly. When they fail, they fail suddenly. So you get this sudden drop in um QR S complex without the prolongation, the Pr interval will be normal. Similarly to atrial flutter for secondary de second degree heart block. So Mobitz one and Mobitz two, we can do the ratio again. So in this one, which was the Mobitz one, E CG, we can say that for every five, there is four. So QR S complexes, two P waves, every, every five P waves there are four QR S complexes. What is the abnormality in this one? So the it is bradycardic or it looks at initially when you're looking at it, but it's not regular. Why is it not regular? What? Well, it's not regular. Yeah. What is the pathology here? Third degree heart block. Exactly. So, in this one, um there is no association between the P waves and the QR S complexes at all. So it's not immediately obvious. But if you look, there are lots of P waves um randomly throughout and the QR S complexes don't necessarily come immediately after ap wave. So this is third degree heart block cool. Um This one is really hard to spot. So I'm just gonna tell you this is a delta wave which is the slurred start of the QR S complex. And this is typical for something called Wolf Parkinson White syndrome, which is a congenital accessory pathway between the atria and the ventricles. And it dispose predisposes v reentry tachycardia which doesn't slow conduction. So it can quickly become ventricular fibrillation. Yeah. So it's, yeah. Um it's a bit subtle but it's, it's this slurring of the OK, slowing of the start of the QR S complex. That is, I can't think of the word, you know what I mean? That bit. So this is the last one I think we're gonna do. So what this is, er, this is regular and I don't think it's tachycardic or bradycardic. The P waves are normal. There is something, ooh, someone said, well, fuckin some white, well done. And yes. So there is something wrong with the QR S complex. What is wrong? And what could the pathology be? And then we'll, we'll finish that. Oh, it's frozen again. Oh my goodness. Can you see it now? So what is wrong with that QR S complex and why? What's the pathology? I'm going to tell you so broad complexes throughout. Um This is left bundle branch block where the impulse runs down the right bundle to the right ventricle and then across the septum to the left, left ventricle, bypassing the left bundle cos there's a blockage there. We know you can tell the difference between left bundle branch block and right bundle branch block for using William marrow. So if the first down, if the, if it goes down first in V one and up first in V six, that makes a W and an M don't take that too literally, just look if it goes down first. That is a W even if it doesn't look like one, if it goes up first, it's an M and then W in one M in six is left bundle branch book M in one W in six. And you've got right bundle branch book, William Murray. Hopefully, that makes sense. We're gonna pause there. If you fill in the feedback form, you will get the rest of the slides. So there are a variety of things. So um stemi pericarditis, pericardial effusion, VTV, F torsades are all in this. And I would recommend also knowing hyperkalemia um 10 to T waves like we mentioned before and then there is three sides at the end that just talk through um a couple of other things that's useful to know about. But if you stay behind, then you can practice looking at um different Ec GS and looking through and practice going through them systematically and finding the anomaly, you don't necessarily need to know the pathology. But if you can find what's wrong with the shape, then that's enough. Um So I would highly recommend staying behind. And if you can fill in the feedback form, any particular feedback for me would be much appreciated. And if I get to the end of this, there is a that if that is easier, but it's also in the check in the chat. Um Thank you very much for listening to me. Thank you very much, Izzy. That was unreal. Um If everyone who wants to stay behind for the osteopro uh could can you please display on the screen? So we can scan Izzy. Do you mind stopping your presentation again and re uploading it on the feedback page so that people can um can see the QR code easily. Yeah, if everybody can go join a breakout room now, the um the session host. Oh, sorry. The OSC facilitators will be there waiting for you guys. So if you see way too many people in your the breakout room, just choose another one and just try to keep it as even as possible. Because last time I tried to allocate people to rooms, it just doesn't work. So if you see like upwards of five people in a room jump to a different room, et cetera, et cetera, uh Thank you very much, Izzy and hope everyone enjoys practice. Yes. Fill out the feedback forms. What was it that you wanted me to do with? My? Sorry, I brain blanked.