Hey, it's London, this is part two of our discussion about Ketamine with Dr Gary Handel Fado. So if it seems like we're starting in the middle, we are so go back and listen to part one first.
Speaker 2:So should we be talking about intubation? Yeah, because I. Do you use it for intubation? Certain types. Why? Absolutely. So, so you can think of procedural sedation intubation and I'll throw in know rapid control of agitation, right? It's really all just procedural sedation. Okay. It's all the same, right? You're achieving rapid complete control is just perform a procedure. Exactly right. I never thought of it that way. Intubation is a procedure. Yeah, it totally is. So, so you want to. If the goal is to achieve complete control, the key is to use the high dose. You once again, you want to avoid that middle ground and this is where ketamine is again, really peculiar because not only does it have a different effect depending on the dose you pick, but it also has a ceiling effect. So describe what that is. Yeah, they call it the dissociative threshold. So we know that as you start at a low dose, you get analgesia. As you start raising the dose, you get past point three, point four, point five per kilo. People start to become disconnected. That's called partially dissociation. Parcel dissociation. As you get to one, and especially after one point five milligrams per kilogram ivy, this is where people have become fully dissociated. Your brain is now completely disconnected from your body. The reason that's important is because if I give one point five, let's say two milligrams per kilogram of ketamine to someone, they will be completely dissociated. Now, let me give you 10 times the dose. I'm going to give you 20 milligrams per kilogram of ketamine. The effect I get will be identical because you're completely dissociate already. You can't get more than you cannot become more completed associated. There's no other drug that I know of that behaves like that. Like if I, if I did that with propofol or if I did that with an opiate, you get more and more, more and more apnea, more and more hypotension, more and more, something more and more in effect. Kevin's not like that, so, so that's why I tell people if you want complete control, go big. The Times where I've seen people run into trouble with ketamine is that we have this natural human tendency like I want to be, you know, quote unquote careful, so I want to give them a little less because in my mind I'm being more careful. Whereas the exact, which probably comes from the Midaz Alam ops, because every other drug fall where it's like we can always give more, but we can't take it back. Every, every other drug we know behaves that way. It ketamine doesn't. So by trying to be careful, that's where you're going to end up in the middle. The scary zone. I was going to say in the weeds,
Speaker 3:there was a four letter word, a better word,
Speaker 2:so, so if I want complete control because I'm going to intubate the sick person, then I'm going to milligrams per kilogram and above because I want it to be realized. Sure, yeah. If a person comes in wildland swinging, there's four security guards in five police officers that are getting the snot beat. None of them by this agitated drunk, intoxicated psych patient. You're going big. You're not holding back, right? Because if you end up in that middle zone, that's actually counterproductive. So great. So you want to go big? Two milligrams per kilogram ivy, five milligrams per kilogram. I am, right? Yes. I said that correctly. Five milligrams per kilogram. And so, so my experience with that was at a small hospital where I get 500 milligrams I am and actually the phone are, are a transport advisor and just verify that again because it was sort of over some text messaging and stuff and I'm like really? 500. I've never heard of this that I've used. When it comes in 500 milligram files, you're not having to give 10 mills. I am. Comes in very high concentrations for that purpose. So where'd you get that?
Speaker 3:I it, I know everyone wants. Yeah, we're
Speaker 2:actually limited by our, the concentration we can have in the hospital. Yeah. This is where other countries like the ozzies have it better than us. This way they can get more concentrated forms of ketamine and veterinarians have an advantage too. So. But we're living into the 50 milligram per milliliter. You're talking about giving sure you are talking about a pretty high volume. We just split it up into syringes and you know, taking down an agitated person or doing a procedural sedation. It's always a team sport. Right? So you split it up into, you know, a couple of syringes you can give. How much can you give into a barker or a thigh for? Well that's number two. Three, three, three. Three is easy. And you can probably do three and a half and make it three syringes. We have enough people and we. Oh yeah, we always have enough people. I actually, I like to split it into four syringes and I say to someone your right arm, your left arm, your left leg, and I'm writing. Then everybody ready, ready, set, go. And you walk in the room and you plunge it into each limb. Regular clothing. Because this person's wild in swinging. You just totally and yeah. And then you walk into the room and in five minutes you, they've gone from gorilla to Pussycat, right? Yeah. And then you can go and then you can actually take care of the patient. And this is the big advantage of the rapid control. I veered into agitation control here because it's a natural thing to talk about, but when people come in severely agitated, they are physiologically deranged, right? They're in a dangerous situation and by doing nothing, doing nothing is very, very dangerous because they're hyperthermic, they're agitated, they're wild, wildland swinging, people trying to hold it down. People get injured that needlesticks and bites and spits and body fluids and all sorts of things. Plus the longer this goes on and more struggle, there is the more chance of having that event that we all hear about in the newspapers. Right? You know when people get taken down and, and then the patient has a cardiac arrest and dies like there's almost always a violent struggle immediately proceeding, immediately proceeding the cardiac arrest right off the choke hold. Is it. And people have looked at, is that because you're the choke hold that cause it is a brief hypoxia that's not so clear, but there's always some type of violent struggle. There's always a long period of metabolic agitation and physiologic demand and who knows what the precipitating event is at the moment, but there is that and so if we can control them quickly. Yeah.
Speaker 4:Yeah. So it's a safety thing really isn't safe for the patient and it's safe for us and sure enough
Speaker 2:can use haldol and Midaz alum, um, and my dad's is actually pretty quick too, but the amount of Midazolam might have to use to get them completely stated. Now I'm dealing with a lot more other adverse effects. I don't want to deal with hypotension and apnea
Speaker 4:and if you don't know why they're agitated, I mean you're making an assumption that strides, we don't know. It could be hypoxia, it could be all sorts of different things. So it could be septic, flood as you name it. Yeah. So by giving them Midaz and having all those adverse effects, we might actually be making the situation a lot worse.
Speaker 2:Don't get me wrong, ketamine is not a perfect drug. There's no such thing as a perfect drug. Right? Can, you mean does have effects? Um, you know, people can have adverse effects when you use it in high doses. Learning those spasm does happen, it's just not as bad or as common as people think. People can become apneic but, but I'm trying but nothing is gives you as much control as quickly and preserves their physiology as well as academy. So I think ketamine is the safest option and because because they also make the point that, you know, doing, doing nothing or using a slow lacking drug, I think it's more risk. So the bottle and I used is that ketamine does have problems associated with it. Like there are adverse effects, you need to be ready for that, but Kim is much more likely to get you out of trouble than it is to get you into trouble.
Speaker 4:So can I ask you a question about the procedure of intubating and so we're talking about one milligram per kilogram beyond, right? Yup. If you have a sicker patient, like somebody who's hemodynamically unstable and you're intubating them, does that change your dosage at all?
Speaker 2:It does, yeah. So in the sick, people often like to talk about the DSI approach in a delayed sequence intubation, this is being a Scott Weiland carbine pocket really popularize right? But you get into an interesting discussion discussion of ketamine's effect on your physiology. So we've been talking about how ketamine supports the blood pressure. It does that by causing catecholamine release a little bit of cal Columbian base and also it prevents the agreement, the from it prevents the rehabilitative catecholomines. So the catecholamines that are out there stay up there longer and you release a little more as well. So that's why you get a positive blood pressure response. If you look at their studies out there where they look at the actual direct effect of ketamine on the heart, it's actually a negative inotrope. Interestingly, we don't see that in the people we use it on for say procedural sedation. Blood pressures go up because these people have intact physiology loops, right? So if I get the ketamine, you get those feedback mechanisms, you get the catecholamine release, blood pressure always goes up. This changes when you have someone who's really at the end of the road, there are catecholamine depleted, so someone who was septic, hypotensive, step person, they're like, they've been sick for three days and they're coming in and I looked at them, they're going to arrest any second. That's a different situation because when I give that ketamine, there's no catecholomines left to give from those adrenal glands, and so that's where the direct myocardial depressant effect of ketamine is, takes or, um, and so that balance has tipped towards hypotension. And so this is where we do see hypertension with ketamine. So in the sickest of the sick, I think it is wise to cut down the ketamine toast to see how they respond, see where your blood pressure is at before you give them more. That's exactly the same as we do with the DSI approach. Although delayed sequence intubation is really more about the oxygenation piece where someone comes in hypoxic, I don't want to sedate them right this second. I wouldn't have preoxygenate them first, but I can't get them auctioneer because they're so agitated. And that's where it gave me a low dose of ketamine. You take the edge off things, you can preoxygenate them. Um, and this was shown to be pretty effective. And so you get them in a better state where, okay, now their saturations are up there are completely preoxygenated. Now I can give them the rest of the ketamine dose to do my, my procedural sedation called intubation. Yes. And the other time you see ketamine, ketamine know rapid sequence intubation and the blood pressure will go down, is in the exsanguinating patient. No big surprise. You know, you can stimulate that heart all he wants, but if it's empty, you're blood pressure is still going down, squirt the blood out faster. And this is where I tell people, you have to expect the blood pressure to Kodak. When you see, when you're intimating someone who's at the end of the road, you know on the, on the right, on that slippery slope, we're expecting the blood pressure down because what happens when you intubate someone down anyways, so you've taken blood pressure, return to the heart, happens primarily with that negative intrathoracic pressure when you breathe in. So negative pressure sucks blood exactly up into the heart. That's the, that's the main way it happens. Now let me stick a tube in your throat and I'm going to push air into your lungs. You've reversed that physiology. Exactly. And so of course blood pressure goes down. Physics always waits, Mr. physics nerve over there. Yeah. So in the sickest of the sick, I use half the dose of Ketamine. See how they respond? Because there is a way to approach this. Someone, whether it a Miller did a study using what they call the shock index. Oh yes, yep. Systolic blood pressure over the heart rate called the shock index. So if you're shocking, Dick's is more than zero point nine. That's called a high shock index. They're more in shock and that makes sense. So what did I say? That right? Heart rate, the blood pressure show me the higher your heart rate and to lower your blood pressure it makes intuitive sense. And point nine is that magic number. And he looked at giving ketamine to high shock index versus low shocking next patients. And so when you're trying to decide ahead of time, is that blood pressure going to go down in this patient? Right now, the best knowledge we have is look at the Shawnda chucky next. If they're more than point nine, you can expect the higher chance of blood pressure going down. That's the patient you want to do that, you know, the same as the DSI approach. Give them a half dose, the Ketamine, see how they respond, and then you can either keep giving them half doses until you get them exactly where you want them to be.
Speaker 4:I think the only other issue about that really is when you're talking about some of those effects to when you've got somebody who's really sick, is that you're doing other things as a pretreatment to support their disease process, whatever that can be. So if you were talking about the exact marinating plate patient, hopefully we're also replacing blood loss and things like that as a pretreatment prior to, you know, doing the intubation itself so that we're actually trying very hard to kind of do all those other things. And I think sometimes people forget that piece of it that you know, if somebody is unwell, we're also doing all sorts of other types of interventions on top of the intubation. The intubation is just allowing us to have better gas exchange, but we're also doing all those other things as well.
Speaker 2:Excellent point. And this is something that has come into more of the forefront in all our integrations, like its own, both the preoxygenation, right? We get into high flow nasal canyon, you getting the facebook. If you can wait a couple of minutes to get them nicely preoxygenated, why wouldn't you wear exactly? Same as same as true with someone who's physiologically dreams is the more you can train them up to better. Don't always have that luxury, but it should be. It should be on our minds. Intubation barely fixes
Speaker 1:it makes things work. A lot of my patients lately, I've been starting in our epinephrin infusion, a lower dose to start bringing their blood pressure and not obviously the bleeding person, but the septic person so that if there is that drop to bait them, all you do is turn the dose up or you don't then start frantically running around trying to mix up nor epinephrin and all that. Just part of being ahead of.
Speaker 2:Yeah, so there's various ways people do that. We often have, you know, a push dose epinephrin exactly orphan enough because post intubation, hypotension is so embarrassing,
Speaker 4:but it's common enough that
Speaker 1:it shouldn't be that, oh, this happens once every 10 years. This happens often enough that we should be prepared for it and not trying to mix low dose or a push dose, Epinephrin or federal from the nursing standpoint when their pressure's 40 is not the time to figure out how to make push dose Epi or something.
Speaker 4:That should be part of your preparing. Absolutely. You should have it all drawn up. Do you think you could comment or maybe debunk that myth that you shouldn't use ketamine in, uh, in intubation with patients who have increased ICP? Because that was always kind of the debate out there from us
Speaker 2:whole school
Speaker 4:nurses that used to be. I never heard that. Yeah, whatever.
Speaker 2:Actually I do remember the days.
Speaker 4:Oh yes. When you were a young boy, shorts or whatever it is. Yeah. I've heard about those days.
Speaker 2:So yeah, that's one of the Classic Contra indications of Ketamine use was increased intracranial pressure. We now know that's really not true. I get, once again, there's an asterisk there. If you have preexisting Hydrocephalus, then it is true. And that that's where that mythology actually came from is so many scientists were using ketamine as a general anesthetic. This is back in the sixties. Oh, right, okay. Remember that? Remember the ketamine was actually invented as an anesthetic for the Vietnam War. Like all these good drugs, we have the, the, almost all of them come out of the war. They almost all start out in the military research, get taken up in the prehospital setting, and then gradually make their way into the hospital. Ketamine was no different, so these needs, this could have been used to be an intubation drug drug in the continental us, and then they noticed, Whoa, we get all these. We've got this population of patients where these got these huge, these neurosurgeons found these huge gigantic increases in interest you that pressure, so these well meaning an east just said, do not use ketamine in people with increased ICP. What they were doing it in patients who had hydrocephalus and that was the original publications. It got expanded to everyone. Everyone was increased intracranial pressure of course, who then writes the textbooks, the anesthesia textbooks, the same guys who had that experience. Now it's become the rule of law is handed down in that zone. Mythology happens, and this has been looked at. There's really no basis for it, so if you don't have preexisting Hydrocephalus, ketamine actually causes your ICP to go when you pursued your profusion pressure to go up and it probably causes your ICP to go down. Once again, that makes sense because ketamine causes your systemic blood pressure to go up and we all know your cerebral perfusion pressure. Is your ICP exactly. Taken off of your blood pressure? Exactly, so that's a good. Yeah, so ketamine is actually good.
Speaker 4:You're a head injury here, don't you drive for head injury because it avoids hypotension, which I love. Complaint reversals like that period of five years. Don't use it to actually this is the one you want to. Yeah, exactly, and I also have heard that because of the Bronco dilator effects of ketamine, it's also a really good drug for patients if you're needing to intubate them, if they have some respiratory like asthmatic, so hopefully we don't need to intubate people with asthma and clpd, but if we do, because ketamine does have a little bit of Bronco dilator effect, it's actually not a bad choice as well.
Speaker 2:Yeah. If you. If you have to have, if you have to go there, if you have to go, there is no better choice. I mean the physiology for those asthma patients and what years it always gets worse just because of the presence of the tube, but ketamine is better than any other choice because you do get that Bronco dilation. Interestingly, one of the side effects of ketamine as hypersalivation, right? Oh yeah. So this is actually a big advantage in those clpd asthma patients because you get that it was bright yellow secretions that help mobilize all the mucus and you can suction it out. You can actually improve the physiology of it that way. Interesting. So I guess you could call it making the best of them
Speaker 4:real bad and I'm not recommending that. Absolutely not. I think maybe the last thing we would like to talk about is perhaps some of the new and different ways that we're using ketamine or we're hearing about, and I'm not sure what the studies are finally saying about them or if there are studies, because I have. I think you even mentioned it to Gary when we were talking about using ketamine for depression, which was interesting to me, especially with all of this talk at the moment about, you know, we've had so many suicides recently and talking about depression and having good ways of treating it, not, you know, just having different things out there and I think you mentioned ketamine being used for depression.
Speaker 2:Yeah. There's a boatload of research coming out with ketamine and depression. Really, really, really interesting stuff. Ketamine given intravenously as well as intranasally in low doses. This is another use of very low dose Kenny. There's dozens and dozens of studies and it has been picked up by research groups funded by the NIH and you see the same six names on know 90 percent of the research that comes out there, but all of the effects, it seems to be pretty consistent that when you use ketamine for depression and they have different scales that you can measure the pressure on and in particular suicidality. The effect is really rapid and this academy is really exciting where people have a positive effect on their suicidality. Not more suicidal, I meant less suicidal within hours as opposed to the classic anti psychotics and antidepressants that take weeks to work. So you, you can make someone feel better within hours. The problem is there's two problems with the research. One is that all the numbers are really small, so it's hard to say this definitive to very, very small studies. And the other problem is that the effects him to be transient. So by that time, several, you know, four or five days up to a week goes by, they're right back where they started. And so that's why ketamine is still not mainstream for that yet. Um, I suspect it may, may, may, may become mainstream, but there's the fact that the effect is transient. So, so it does, it doesn't solve your downstream problems and that's what people are looking at. Maybe we just need to get ketamine and repetitively, but then you get into the side effect issues. And so people are looking at different analogs of ketamine. Ketamine causes effects on it, you know, the MMDA receptors, glutamate is in there and so they're looking for other drugs that act on those same receptors to see if you can get those antidepressant effects without the adverse ketamine effects. So that's all stuff that's coming down the line. So right now ketamine is not first line for that but it's pretty exciting and I, I was actually hoping to get it as an emergency department drug, very selfishly thinking if I can make you not suicidal in a couple of hours, I can get you the hell out of my department onto the cycler and they can fix you. They're had trouble convincing. Trouble convincing my psychiatrist that, that was a good idea. So but that. But things take say 10, 20 years before I was still living before they really start to filter filter through. So. And there's still. So it's still early days but there's definitely something there and definitely something you're going to hear a lot about in the future. So low dose ketamine for suicidality, depression. Absolutely. Is there anything else trendy coming with ketamine, any other patient groups that are sort of. Well, just starting to use it with, well my reasoning, my recent interest for ketamine has said before it's been more in the analgesia realm and I've been looking at taking ketamine more into the prehospital setting cut because in the emergency department, like in the hospital, we have access to so many people and verse three therapists in Ivs we can give just about anything we want, but there's a lot of prehospital providers that are a lot more limited. You're looking at one of them.
Speaker 1:Amen. If you're still is, but um, but it is, it's a different, it's a different story when you're on the side of a mountain with one other, you know, search and rescue person or even in the field with your partner and possibly giving, you know, verse that and Morphine and, and the poor monitoring that happens when you're in the back of a stretcher or a ski Toboggan or something and give to them to respiratory depressants, throw them in the sled and lay down and my feet away. Yeah. And now you have a four hour slog out of a mountain. And how often are you really watching them? Right,
Speaker 2:yeah, so this has led to my most recent kind of research emphasis and that is a intranasal ketamine for prehospital crews and especially for basic training crews, not not the advanced care paramedics or the critical care paramedics who have access to all sorts of drugs. In other words, do you have things, but you want something that's easy to give reliable and can cause anything bad to happen. Once again, this idea comes from the U. S military. It was actually, they looked at intranasal ketamine as a battlefield analgesic and it made total sense because these, these medics are running out into the field, was very little on their back, a small backpack to an injured soldier. They want to be able to give something quickly and easily but still allow that sorta to age in their self extrication from the field. So you don't want to go work them out. You don't want them to stop breathing because then that just complicates everything. It makes everything worse and so they looked at intranasal ketamine as a battlefield and analgesic and in the days when we were horribly overcrowded and and I was doing, we were doing most of our medicine in the waiting room hallways. I was reading this paper and I'm thinking to myself that battlefield sounds a lot like my emergency department and so we did. Am I going to. I might have been the first intranasal ketamine for analgesia study in a hospital thinking that if we could ensure that intranasal ketamine works for Analgesia, we can take the ketamine, take the analgesic out to the people in the waiting room because we can't get the people from the waiting room into our department. So my byline on for that one was a, if I can't get the people to the Analgesia, I'll take the allergies you to the people. And that was. And that was highly successful. I know subsequently realized that the more austere your environment is, the more it makes sense to use ketamine and the more it makes sense to use something easy like an intranasal delivery system. Because for endonasal, the only special skill you need is, you know, if you have an opposable thumb,
Speaker 1:push fast. Yeah, that's the only technology
Speaker 2:you need is a simple two cent syringe and a twelve cent atomizer. So the, the technology cost is low. That technique is dead simple. You could, you teach my mother do it, and you take it out into a place. Not Saying your mother isn't overly intelligent.
Speaker 3:She's very intelligent that we can teach her to start an idea as well, but she's going to like it simple. She's kind of depth if you're short the thumb, perfect.
Speaker 2:But um, the thing that makes it work as a prehospital or I broaden that to an austere environment, analgesia because, because we've done studies on local ski mountains, um, I've looked at doing it in places like Nepal and other third world countries where they don't have mantras and they don't even have analgesics. The moral of the environment, the more it makes sense to use intranasal because it's easy and it's reliable. It's simply you can carry it anywhere. The same is true of ketamine. It makes a load of sense to use ketamine in an austere environment because you can never make someone stop breathing. It can't happen and so so the the kill potential is zero and that's to me that was really important. If you're gonna give an analgesic to someone in a setting that you expect and be completely unmonitored and even by people who don't have advanced airway skills, so there better be zero percent chance of actually doing serious harm and for me the intranasal Ketamine, the two together fulfills that. I can never ever make someone stop breathing. I absolutely can give them analgesia and I can do it without the person giving it, needing any special skills and to me that's why it made a whole lot of sense.
Speaker 4:That's great. From a triage perspective, frankly, when you have so many patients waiting in the waiting room who are uncomfortable, I think it is difficult for us, again, from a humane perspective, this is such a great option because if it's safe, we run it past a physician and said, do you think that this would be an inappropriate thing for us to do? They could be in the waiting room, they don't need to be monitored and we can actually provide them some care analgesic while they're waiting, and to me, it's far kinder than what we have that exists right now. Even allows you to go home at the end of your shift and not think all I did today was prolonged people's misery. That's the moral distress. Have a treasure. She revolves around. I just looked at people in pain all day and had no. It's so it's tough out there
Speaker 2:and, and, and the other reason it makes so much more sense is that intranasal are better given while see seated
Speaker 4:in a chair don't have a stretcher, no problem. Yeah, exactly.
Speaker 2:It makes, it makes so much sense from a practical point of view and from a physiologic point of view and that's the way I really. I really pushed it. So
Speaker 4:yeah. So that's great. Now, do you think you can summarize that into some key points there? Atlanta,
Speaker 3:that was probably one of the most exciting podcasts I've ever done that are sitting here just like staring at me like, oh my God. I think if I were to summarize it, I think
Speaker 4:that we would talk about dosage, that if it's a point point five and below that the analgesic dose and you should start to that. You want to avoid the middle zone and complete dissociation is one milligram per kilogram and above and you have a ceiling which means that you can't get more dissociative than complete, so regardless of how much you give your own, you're only have a ceiling, so I think I would say that is definitely one of the big major points. The other one is that when you're doing a procedural sedation so you can teach an old nurse new tricks, a procedural sedation that it is probably more beneficial to use both propafol and ketamine in lower doses. If you are intubating a sicker patient that you might choose to use a lower dose of ketamine and that there is a very rapid effect of you're using it for complete agitation. That we can give it Ian through clothes and big doses, so big doses, so go big. If you've got somebody who's agitated and you want to take them down fast, it'll work within five minutes and then look out for some of the future exciting new ways of looking at ketamine, whether that's in the prehospital, in your treatment, waiting room for analgesic, and then this new thing with depression. That might be kind of exciting down the road type things. Anything else you guys wanted to add or did? I do not
Speaker 2:too bad. Not too bad. That's pretty awesome. Can I bring you with me to my talks? No problem. Anytime, anytime. Show up places. The only thing they'll ask you now is, Oh, where's monique? I've been living in this dream for a few years now, but we want to thank you,
Speaker 4:Gary. It's very nice of you to. You should see this spread he's put out in front of us and he made us pretty darn good coffee and beautiful mix, so we thank him very much for sharing his knowledge. It's very exciting. There's so much to talk about. We can do the skin. I know we totally could. He could be a recurring guest on our podcast when. That'd be fun. That would be. Yeah, I know. Alright. Alright. Thank you very much. Thanks listening.
Speaker 2:Any final thoughts from you? Thanks so much guys. I love talking ketamine, so we can tell. Oh, you're going to tell them about the link. Gary, don't forget to put a plug in that. I'm shameless. Shameless plug plug. I don't get money for it, so I'm happy to. I'm happy to talk ketamine with anyone anytime. As you guys probably know, put a plug in for the UBC Department of Emergency Medicine Network, which is a recently put together online resource. I'm not just sedation and Analgesia, but all things to with emergency medicine, prehospital and otherwise it's meant to be a multidisciplinary resource where you can ask questions, get resources. Right now the only problem with the set as they put me in the other.
Speaker 3:Oh dear. I wanted my own category. They can. They put me under other. Oh dear. Oh my. Well we'll talk about. We'll talk about that, but now you're on that podcast a little bit more,
Speaker 2:but anyway, but, but seriously it's a, it's a continuing is continuing to be developed because I think it will become a very, very rich source of source of information and also kind of semi real time resource where people can ask questions and banter back and forth and paranoia his concerns and, and I love a good argument if you think I'm full of
Speaker 3:yes, you can say it. Okay. You can say it. Okay. If you think I'm full of Shit and you want to call me out, I love it. Bring it on. I love. I love a good argument. Yeah. Excellent. Okay. Then, and we'll put that. We'll put the website link on your website. Oh, thank you. This is monique and I'll see you next month I guess. Oh, I don't know why I have to say that. Of course. I'm the only woman here. Of course. I'm just going to say goodbye. All right, goodbye. Thanks.
Speaker 5:Past episodes and to comment on this episode, please visit our website at[inaudible] dot org dot. You can follow us on twitter at nursing past and also find us on facebook at some podcast. We look forward to your comments and suggestions for future episodes. Remember the incorporating anything new into your work to ensure you were supported by your own scope of practice, work place, policies, and your own knowledge and awesome podcast is brought to you by prn education, www.prneducation.ca.