In this episode, WHO/Europe’s Press and Media Relations Officer, Bhanu Bhatnagar, speaks with Professor Johan von Schreeb about his experience dealing with mass casualty incidents during times of war as well as his work with WHO to train health workers and specialists who may face such devastating and overwhelming situations.
Show notes:
In this episode, WHO/Europe’s Press and Media Relations Officer, Bhanu Bhatnagar, speaks with Professor Johan von Schreeb about his experience dealing with mass casualty incidents during times of war as well as his work with WHO to train health workers and specialists who may face such devastating and overwhelming situations.
Show notes:
Hello, and welcome to the health and Europe podcast. I'm Greg Bianchi. We've launched this podcast to bring you the latest on w Chase's work in the European region. Our region is born and diverse from the Mid-Atlantic and stretching. As far as the Chinese border, we work with fascinating and driven individuals and groups. This podcast is about hearing their stories and how they might impact your day, day life. The war in Ukraine has grabbed headlines for over two months, w O has been working tirelessly to get much needed healthcare to people, both in Ukraine and flee to neighboring countries. We sometimes hear reports about mass casualties, people injured or killed during war. These incidents are often reported by news agencies, showing tragic images of injured people being desperately transported to hospitals, by family, friends, even onlookers seeking to get help for people who need it yet. We rarely hear from the health workers who are tasked with managing such an overwhelming situation. Johan VRE is a professor in global disaster management at the department of global public health at the Carlins Institute in Sweden. Most recently, he's been working with w H O in Ukraine helping manage mass casualty instance. In this episode, ban Pataga press media relations officer for w HHA Europe speaks with Johan to find out more about his work.
Speaker 2:Hello you, I good evening. It's evening where you are. Good
Speaker 3:Evening.
Speaker 2:Good evening. How, how are you? You got home. All right. Safe and sound.
Speaker 3:Yes. No problems, no problems. Um, so, but piles of work, um, waiting here. So of course the same, uh, same type of topics, but in a different context.
Speaker 2:Of course, of course. Uh, so I should tell our listeners that, uh, UON was, uh, in Ukraine where I am, uh, right now, uh, and, uh, and leading, uh, our emergency medical team, uh, coordination. Uh, so, uh, you, why don't you tell us a little bit, uh, um, about the work you did here, but also your, your, your professional background.
Speaker 3:So I am a, a general surgeon by training and, uh, I'm currently a professor in global disaster medicine that the car Institute in Stockholm, Sweden, which is a medical university, but I'm been working with, uh, the world health organization for quite some time, trying to, um, you know, improve quality and also coordination of international assistance in times of disasters because, uh, a lot of people, um, see horrible images and they want to jump on the plane and come and assist. But, um, this remains a challenge because, um, um, you are not used to, uh, the context, you have to understand, uh, what are the capacity in country, but also how to work with limited resources. So that's, uh, my research area, but also where I've been supporting, uh, w O in trying to develop, um, this coordination mechanism and previous that I've been working a lot with mid south, south frontier, uh, doctors without borders, uh, in various, uh, uh, conflicts and, and natural disasters worldwide. Um, so I arrived, uh, to, to Ukraine. You could say a few weeks after sort of the conflict started and, or all altered and almost all the time, uh, in the start of, of, of such a crisis. It, it's a bit of a panic. Um, people are running everywhere. Um, it's a sense of urgency, uh, which of course is, is true in one way. But on the other hand, uh, when we, when we have conflicts, we know is going to last for some time, but, uh, the sense of urgency is there in the beginning. And, and, uh, even though you have prepared yourself for this type of situation, and I think Ukraine really had, um, I was actually in Ukraine a few years ago, doing some, some, uh, or teaching a bit on, on mass casualty management and, and also on, um, uh, conflict surgery, but still, uh, this sort of, um, uh, shock of, of this conflict was there in the initial phase. And, and I think the ministry of health and, and as well as w O had to find its role in this new, uh, situation with, with a violent conflict going on in the east. And then also these attacks that we, we saw initially in, in the Western areas. So that's where, where, where, when I came in and, and you know, this job I have, uh, you can say that the job description is, um, if you have to be told what you do, you're not the right person for the job, which means that, you know, based on experience, you need to understand. So what are the critical issues in this particular context? You know, how strong is the ministry of health? Where are the gaps? Do they have enough of, of trauma surgeons? What are the, uh, how many healthcare staff do they have? Do they have enough equipment, uh, um, and, and, and those type of, of, uh, issues and, and, you know, how's the staff, the stuff, uh, the space, the security, um, and, and really going through that and understanding, and, and in Ukraine, uh, you know, due to the situation, it, it's been very difficult to understand what's going on. It's a, it's a huge country. Uh, and then just getting information, understanding, uh, you know, from a day to day basis, but also over time, what is AC actually happening? What are the critical issues has been, uh, a main challenge and continues to be, um, a, a problem. But, um, despite all that, I think based on experience, and also the long history of w H O in Ukraine, I think, uh, it's been possible to, you know, understand, uh, the needs, but also try to adapt, um, the support that w H O is providing to Ukraine.
Speaker 2:Thank you. Uh, so why do you think you, you've sort of touched on this a little bit, but, but why do you think these kinds of mass casualty trainings are important? I mean, there's obviously the obvious answer that, uh, you know, you need to reach, uh, people who have traumatic injuries. Uh, but, but beyond that, can you tell me why, why these trainings are so important?
Speaker 3:So, uh, training has been a particular, uh, point of intervention or operations for, for, uh, w O uh, in Ukraine. In other context, you might need to send in staff that are, uh, that have, are trained before, or, or just to add up, but in Ukraine, there are 130,000 doctors, uh, in Ukraine. So, so lack of staff is not the issue, but, you know, um, as it is in all conflict, and also in my own, uh, country, Sweden, where I, I conduct a lot of these mass casualty trainings, but here, when I do it is more like a game and, and the students, uh, laugh and play around. While when we started doing this training in Ukraine, it was, uh, serious. This was really, uh, happening. And, um, one of the hospitals where we were doing this mass casualty training had just, you know, a few weeks before actually been in a mass casualty situation, receiving a hundred injured patients. So what are the critical aspects of, of mass casualties? Well, normally at the hospital, you can have, you know, one, two, or maybe five patients arriving there might be a car accident. So you might have five, uh, injured arriving on the same time, but when you have a mass casualty situation, it is, uh, it is a situ situation that per definition sort of overwhelms, uh, the hospital. And then you need to have routines in place of, of how to manage this. What do you do if you have, you know, a hundred patients or injured people arriving just like at this hospital where we did the training, you know, what are the procedures? And, uh, so everybody needs to know how to color code basically based, based on, on, um, the urgency of, uh, the injured, uh, patients condition. So you need to color code them by saying, this is a green patient. And the easiest way to determine whether it's an, a green patient, which means walking wounded is basically to whistle at the site of injury and said, please come here. I will offer you coffee. And then you get rid of everybody who can walk, even though they have a broken arm, they might have a bruise or, or a cut, but they can still walk, which means that they are lightly injured. They are not your top priority. And then usually you get rid of, of 80 to 85% of the injured, uh, because, uh, that is normally the, the rate of, of green patients, uh, among all injured, which makes, and they are not, should not enter into the emergency room because that, uh, that will just create chaos. Uh, so you need to take them to a separate place, but of course you need to manage them. There might be some that has severe injured, and they MI among the green, and they might turn sort of say more severe, um, after time. But, but overall, this is the first type of triage. Then you have your sort of lying, uh, injured, left the red and the yellow, and then you need to determine which, uh, of, uh, of the, the lying wounded, uh, are, uh, sort of read and needs to go quicker into, uh, surgery or, or critical care. Well, then you use vital signs. The so-called a, B, C, D E uh, procedure that is being taught to all, uh, emergency physicians around the world, which means that it's a, is airway. B is breathing C circulation, B is disability, and E is exposure. So you need to deal with it in that order. So airway and, and breathing of course is very important. And then of course, if you have a massive bleeding, you need to sort of put on a tonic, uh, that is sort of the, what is called C a, B, C D E, but, but overall, it's it, it's the B, C D E procedure that you follow. Uh, and then, uh, and then based on, on the, the number of, of breadth per minute, and the, the pulse rate, or if you even have a pulse rate, you can determine using an algorithm, a very simple algorithm, you can determine this is red or yellow, and the red one is really your, your main target. Those are the ones that, that need critical attention that might die within a few minutes. That's where you need to, you know, focus on and spend most of your time with, but also the yellow ones are the ones they can wait, but they shouldn't wait, but, but they compared to the red ones, they, they are less urgent. So by color coding them, you can also allocate resources and in your emergency room. And that's also what we train. You need to have a separate unit for the yellow and a separate one for the red. And of course the red ones needs more or less just to touch base in the emergency room and then directly go to surgery or to, to, um, to the critical care unit. Uh, but you need to immediately have a plan. And you, you have like, you know, uh, maybe one or two minutes to decide this person needs to go, uh, directly to surgery, or this, this patient needs to have a few, um, infusions of blood. And, and then this person can, can wait, but, but the blood is needed emerge, uh, urgently. Uh, and then you have people working, you know, one nurse and one doctor really making this quick assessment and then sending them on to be ready for the next patient, because there's a mass casualty situation, which means that you will have a lot of patients to deal with. So you need to have a flow, uh, you know, from, uh, arrival away ambulances to leaving the emergency room and, and really have a plan for every patient. Uh, and these decisions, uh, they need to be made very quickly and we call it, we have a no regrets policy, we call it, which means that you need to take decisions very quickly. You don't have time to do x-ray most probably you don't have time to take lab tests, which you normally do. You might have time to do a, take the blood pressure, but it's even better just to feel the radial pulse, whether you have it or not, because that will give you that blood pressure basically. So you need to take decisions only based on vital science and, and, you know, also looking on the type of wound and, and, and what the patient, but these quick decisions, we are not used to that in the health sector, neither in Sweden, UK, uh, or in Ukraine, we are used to having additional, uh, information. And, and so this taking decisions with these very limited information is something you need to practice on. And that's why you also need these algorithms because they help you to take, um, uh, quick decisions. And it's interesting to note that these algorithms, they are much better than the medical doctors, um, to a large extent, unless you're very experienced, but they outperform, uh, the ability to predict who is, um, uh, the red or yellow, uh, much better than actually just, uh, doing the, the clinical checkup and, and, and, uh, asking the doctor. So this is very interesting. And especially when you're in this situation where you have so limited time, you need to act quickly, it's very good to use these algorithms because they, they help you a lot. And, and you can, you know, even though you can't rely on them to afford to, to a large extent, it's the best way to sort the patients. And then of course, you need to do more in depth, uh, uh, and, uh, you know, investigation of the patient, but for that, you need to have experienced surgeons, uh, uh, or anthesis that, that take those type of decisions.
Speaker 2:So I'd like to take you back if I may, because, you know, you're, you are a respected surgeon and now you are an educator. You, you, you help the, the next generation, if you will. Uh, but presumably you have gone through that life experience of, uh, of, of dealing with those mass casualty events yourself, or, or, or traumatic, uh, surgeries or injuries. Uh, so maybe, maybe tell us about a story or two from your own life, not Ukraine, uh, that sort of stayed with you and is still with you.
Speaker 3:Uh, yeah, and I, I remember it so well, because that's why, uh, I would have been helped by knowing this algorithm better when I was working in Afghanistan. This is way back, uh, uh, many years back, but I still remember the sound of the trucks arriving, uh, at this small village hospital, uh, that we had, uh, set up with, with the medicine of frontier at the time MSF, uh, and, uh, just pouring in of patients. Uh, you know, it was really a mass casualty situation and the, and the court Jordan,
Speaker 2:Was it an explosion or
Speaker 3:Was it, they had been injured by the front line? Uh, so they had just, uh, piled up all these injured on a truck basically. And they were driving, uh, you know, through the front line being shot at, by, by and bombed. But I just remember the sound of the breaks, uh, outside our, our, our small hospital, and then the, the sound of, of the excitement of, of, uh, uh, everybody come rushing in to help carrying these wounded into our ARD on, on very, you know, basic stretchers made of, of more or less of bamboo and, and, uh, hammocks. And, and, and I remember seeing this whole, um, uh, core chart filled up of, of 30 injured patients and, you know, some with their intestines outside, uh, that the, the cavity, uh, that, uh, and, and, and just, you know, I was come to think about it. This is happening here, and I am the responsible, and I, I happened to have done some, some basic, uh, uh, military training at, at the time we had the, uh, comp, uh, compulsory medical training for, for medical doctors. We don't do, uh, don't have that anymore in Sweden, but we did at the time, and I had done some basic courses, but I still didn't remember this algorithm, but I, I, I tried to remember, so what, how could I sort it, I remember this color coded things, but it was a very challenging situation for, for, for a young doctor to be in. But I, I understood that, okay, now I need to, to set an order. So basically I, I just had a piece of paper and, and, you know, first of all, you need to see everybody and you, you can spend 10 seconds at each patient. So, you know, in two, three minutes, you should have a good overview. If you have 20, uh, or, or 30 injured that you, that you, you check, uh, just for very quickly for, for these vital signs. And then you have to decide, okay, which goes first. And then, uh, you need to also to understand, you know, if I take this one first, uh, okay, maybe I need to spend, let's say three hours in the, in the operation theater, uh, which you shouldn't at the time. I mean, you try to go very, very quickly with this sort of damage controlled surgery at that time. That wasn't the concept, but if then you need to reflect. So if I spend a few hours with this patient, what will happen with number two and three, maybe it's better to leave number one, and then just go over 2, 3, 4, 5, because that will be much better. So you, you get in this very utilitarian thinking where, where you need to think, so how can we use our resource in the best possible way? Yeah. Horrible decisions that you need to take. Uh, but back to this, no regrets, you have to take them and you have to think in the overall, um, you know, how can we save as many lives as possible? How can we reduce the number of, of amputations, how we can save limbs? So that type of calculations that you need to do is just unhuman, but inhuman, but you still need to do them somehow. Uh, because if you only take them in order of severity, uh, more, most likely you will, you will spend too much time on somebody that has very limited chance of survival. And maybe, you know, that's also the option. Maybe you should, uh, there's a, a blue category that is sometimes used that this patient, sorry, we, we simply don't have enough resource to save this person's life. And maybe you need to ask, uh, a nurse or somebody else to give morphine and, and, and just sort of, uh, let that person, uh, die because you simply don't have enough resources. So it, it's very, uh, difficult, uh, decisions to take. And, and people shouldn't be left with it. Nevertheless, um, these type of decisions need to be taken and, and, and you need to take them in a, in as good PO in as good way as possible, meaning that you need to discuss with colleagues. You need to have partners at the time. I was all by myself. So, uh, there were no other doctors around, so it was a very critical and, and difficult situation. So that's why I, I think it's so important to, to teach this to the next generation, because I've been in, you know, since then several similar situations and, you know, over the time, um, more research I've been made available and, and have not been in as a bad situation as in Afghanistan at the time, but in Haiti, after the earthquake, it was a bit similar, but cause we were a bit overwhelmed, but we, I think we managed very, very well, but nevertheless, you had to take decisions of whether to, to make an amputation or try to save the limb based on, on, uh, how many patients you had. And, and those are sort of decisions that are very difficult to take, but, but you need to, to take them somehow to, to optimize, um, uh, the care that you are providing in these mass casualty situations.
Speaker 2:It, it struck me actually that you were taught as you were recounting this story from Afghanistan that, um, you know, here, here was a group of people that had suffered, um, trauma, essentially really massive trauma, but here was you also suffering trauma, uh, in a, in a, in a very different kind of way. And, and the, and I, I, it was struck by your use of the word utilitarian. Yeah. Um, so if, if, if I may just like explore that a little bit, because you know, how much of your emotions must you leave at the door. Right. And, and, and how do you do that? And then how do you train the next generation to do that?
Speaker 3:Hmm. Uh, no, of course you need to somehow, uh, leave your, uh, emotions. You need to be a bit, uh, cold, uh, minded, maybe not cold hearted, but cold minded in the sense that, you know, if you, you need to look upon, um, which is a problem that you start seeing people and the probability of survival, rather than, and, and, and as, as, as, uh, uh, fathers or, or, or mothers or, or children, uh, um, and of course, according to these algorithms, you shouldn't, um, prioritize children over anybody else, or, or if you're utilitarian, it, it, that perspective, it means that any life is, is, uh, uh, that can be saved, uh, uh, is, has the same value. So to say, but I think it's almost impossible, at least on the emotional level to not engage more in children, uh, and, and give up earlier, uh, in, but while if you have somebody that's old and, and has had a long life, and so maybe it's, it's, um, you know, you, it always strikes you, like, it's not, um, dignity become gets there. And, and of course, is it, uh, and you, we can see this in normal healthcare, is it really, should you start, uh, uh, cardiopulmonary re resuscitation of somebody that's 90 years old and, and, and, or should you just leave that person be? And, and, um, I think in these situations, uh, it's more the resources that than, than, uh, dignity that, that plays out. But I think, uh, it, it is there all the time. And, and I guess even though it's not part of, of your algorithms, it it's, it's it's plays in, um, because we are not machines. We are, we are, we are humans. And, and I think this type of algorithm thinking is, is one way of, of helping you take very critical decisions. But I think it's, it's, you know, it's, you cannot vaccinate yourself against emotions, uh, and, and reactions, uh, you, it's overwhelming, but you need to, to, to stay, uh, focused. And, and, and then you just tell yourself, uh, that the feelings that will take them afterwards. And, uh, that, which is very interesting, because once you've been on this type of, of, um, emissions, when you've had to take these very difficult decisions and, and you sort of return to some sort of reality, uh, uh, where things are more normal. Um, I remember I was after having worked in, in the genocide, in, in, in, uh, uh, Rwanda, uh, I, you know, I was, you know, you could, we were, we were allowed to see, uh, or we were asked to go and see talk with a psychologist, but I found that very difficult because the, the psychologists knew nothing about, um, the being confronted by these choices. Um, so it, it's my, my experience and, and that's what we, uh, are doing very much when we've been on this type of missions is to go to discuss with colleagues who can, you know, understand the context that you've been working in. And, and I remember one incident after we'd been to Haiti working with, with, uh, you know, really difficult, uh, uh, situations. So we went to, to a bar here in Stockholms that we were like five or six of us. Who'd done, you know, surgery and, and, and really, you know, been in diff very difficult situations. And suddenly we realized that we were the only ones left in the bar. Everybody else had sort of moved away from us because the stories we were discussing, we, you know, for horrifying people, it was just horror stories. But for us, this was what we had to deal with. So that's why it was so easy to discuss with them because they understand you very well. And I think that's, that's a peer, peer support networks, uh, are very important for this, uh, moral stress that you might be confronted with. And we see this also with COVID, um, the challenges that, that the health system has been dealing with to take these very critical decisions that the best, um, um, people to discuss with, to debrief and, and, and to decompress with is, is to talk with your, your, your fellow, uh, colleagues who can understand you much better than, than somebody who's more sort of linked to, to psych psychologists, because this is not so much about psychology. It's about moral challenges, where, where you need, because you don't have enough resources, you need to take choices that, that, um, just needs to be taken because there's no other way out of the problem.
Speaker 2:So I wanted to, uh, move on to sort of the w H O's role now briefly, because I know that, uh, w H O has been sort of working with emergency medical teams like this, or, or building them, supporting them for about 10 years or more. So, so explain to me the value of an organization or an agency, like w H O uh, doing this type of work. What, what is the value, what value does it add?
Speaker 3:So, um, I think it really has significant, uh, value in, uh, you know, in this emergency medical teams, um, uh, uh, system that we have developed, and we started this, and I was actually part of starting this after the Haiti earthquake, where we saw over 450, 50 different medical actors arrive to Haiti to help everybody with a pounding, warm heart and, and, you know, blossom cheeks, ready to save lives. Uh, like, you know, they ran outta the,
Speaker 2:Like saviors.
Speaker 3:They ran outta the airplanes with their operation, their scrubs on, and, and, you know, chasing patients to operate. And, and I mean, really compassionate and, and with a, but they were not at all fit for work, uh, for sure. And, and, uh, they were, they had, no, they were no quality standards around. And we, you know, uh, we did several, uh, um, scientific studies, uh, that we published. And, and basically it, it was difficult to say, what was the, the result of these interventions, except for, for that, it was very chaotic. And, and, and, uh, we, we, we cannot say, uh, and I also had done, uh, previous work on, on international field hospital. So then we started this foreign field hospital initiative, which is now the emergency medical teams initiative, where we said that we need to set standard first. We need to have a classification system rather than to talk about field hospitals. We need to talk about, you know, different levels of services that can be provided. And basically we have three different levels. So an emergency medical team, one is like a, a health center. A two is like a basic, uh, hospital that can provide surgery and a type three, it's like a referral hospital with intensive care units and burns, and that can manage. So these also, and then you have what's called specialized care cells. If you have very specific surgical skills like aplastic sales or, or rehabilitation, then that can be also, uh, um, like a team. And then for each of these teams, you need to have, uh, logistics. You need to have, we, we have set standards, meaning that, okay, you need to have, uh, you need to, uh, uh, be self-sufficient. You need to have an insurance for malpractice. You need to make sure that everybody that works with you are licensed to practice are specialist, surgeons, et cetera. And then, um, teams global teams that are interested to join this roster is a w O roster you can say of, um, they, they can be qualified or, or verified by w O. So what we do also is, is that that teams apply to say, okay, I would like to become, uh, an emergency medical team type one. And then, um, you, you set up, uh, you, you apply to w O and then you can, if you, based on that, you, you live up to these standards, we'll check and, and will make sure that you do that. And then once that, uh, uh, has been achieved, you become a w H O classified EMT one. And this is very useful for an affected country, because if an earthquake or a conflict happens, uh, the affected country can call is one, one, two number say, Hey, I need five EMT ones. I need three EMT twos, and one EMT three, and then w O can call to this roster. And these teams can, um, uh, arrive. And they, we know that they have good quality. We know they report, and we know that they are ready to be coordinated by w H O because that's part of the standards. And then you can sort of support the existing health system and fit in where are the gaps, and then you can task these teams. You need to go to this region and, and you need to report, and you can refer your patients to this hospital here. So they might be, the hospital is destroyed. It might be that they're displaced people. You have more need for, for an, uh, EMT one, uh, that needs to be, uh, uh, sent there. And, uh, but currently in Ukraine, um, there are, uh, of course it's a conflict, which means that less of these EMTs, uh, have been, uh, deployed, but also that there are lot of, of, um, uh, international teams that are not aware of this classification, uh, system that want to play their own ball game a bit like in Haiti, they don't register with neither the ministry of health, nor with w O so they just run around on their own and, and, uh, do what they like. And there's no way to ensure accountability. Uh, they don't report with the ministry. And it's very difficult for also for, um, uh, the ministry of health to understand what resources are available. Um, and, uh, their accountability, I think is really a critical aspect. If, if there's malpractice, you know, who can you hold accountable? And how do you follow up this and this idea of just rushing in, and, and, and as a doctor, I'm trying to explain it here in Sweden, that, you know, you tell, okay, just let's just imagine that suddenly there's Ukrainian doctors arriving here, start setting up a small health center here and, and providing medication that's written in Ukraine and, uh, uh, and then starts doing surgery. And, and don't even explain to you, uh, without knowing the language. And they don't even give you a, a paper afterwards. We saw from HAI that were amputations done without the, the patients knowing why, uh, so, you know, a lot of, uh, you know, with a good intentions, you can create a lot of problems. So we say that good intentions are not enough. Uh, you know, um, the road to hell is paid with good intentions. Uh, it's, it's one of the sayings. So here we really need to be critical and, and assess our own need for helping others. Uh, I think there, there's this sort of power imbalance we see with, with helpers and those being helped, that is always those that are the helpers that set the agenda and decide what the, the one, the ones in need of help, uh, needs. But I think it's important here that we should base, uh, the assistant based on needs of the population, but also based on the health system, and then respond to that rather than just coming up with our own, uh, ideas of what is needed
Speaker 2:Well, um, on that note, uh, Yuan, that was, um, a fascinating chat. And, and it's, it's interesting because, you know, you're doing such, um, amazing work, uh, and ultimately trying to save lives, but it's, it's also quite dark. Uh, and, uh, and, and it's, you know, it, I guess we strive for a world where we don't need to, to do, uh, traumatic limb amputations and, and what have you. Um, but, uh, but yeah, we, we thank you for your work. Um, and I hope I, we get to meet you again, maybe in Ukraine or, or somewhere else. Uh, but thank you for your time.
Speaker 3:Thank you very much.
Speaker 1:That's all we have time for special, thanks to Johan and Banu for joining us. If you'd like to find out more about mass casualty management and w Ho's work and the war in Ukraine, you can do so on our website, that's Euro dot w O do I NT or check out the links in the show notes, make sure to leave us a rating. And if you like, what you've heard, recommend us to a friend or a colleague. Thanks for listening until next time, stay safe, stay healthy.