 OK, I would say let's proceed with Col, Tribeco-Loch to me, and tube shunt care at the VA. All needs improvement. I took that, I took that to heart, Dr. Petty. Talk briefly about traps and tubes at the VA. Before I do so, I just wanted to put a quick plug in for the QI project that I talked about last year, which was prevention of exposure in the ICU. So there's an order set now for any ventilated patient in the ICU. When they get ventilated, they automatically get an order for lubricating ointment four times a day. And we did a study that looked at, you know, rates of exposure or caretapathy and ointment use before and after the intervention. Here's one of our authors, Candid Photo. In brief, what we found, why that one got shifted. Patients now receive more ointment in the ICU when they're ventilated and there are lower rates of exposure. I just wanted to mention this because this was done back in 2020. And we haven't done an update on the study, so it'd be really good to see longevity data of the intervention. So if any junior residents are interested, this would be a well teed up QI project for next year. So talking about traps and tubes, specifically at the VA, incisional glaucoma surgery is not a benign surgery. These are procedures that can lead to permanent vision loss and myriad of other complications if you don't handle them with pretty diligent pre and post-operative care. So this is from the TBT study. And it just showed that you can see at the bottom, early complication rates were as high as 39% in the trap group and then post-operative complications for both were up over 30%. And thinking about doing these procedures at the VA, there's just all sorts of roadblocks that we run into that can prevent a good outcome. I think most glaring is the lack of a consistent provider. Every day in glaucoma clinic, we have a different attending often a different fellow and then they're often going to be seeing a different resident who's of a different training level. And when these patients have really complex disease, it's almost impossible to like meet them for the first time and really synthesize the information to make a good clinical decision. So in the post-operative period for traps and tubes, you know, you have to be seen weekly for the first six weeks or longer. And when our wait times are so long at the VA becomes really burdensome for patients. And kind of tied into that is compliance. So when we don't have time to talk to these folks about the importance of drops and return precautions. It can become, you know, difficult for them to understand what's going on. And finally, we don't have access to compounded drops at the VA. Many of our glaucoma surgeons here prefer conservative free tax after surgery, just because with the frequency of use you see less surface disease and we don't have that at the VA. And so back in the fall, Dr. Stag, Dr. Simpson, a few residents and I kind of put our heads together and said, What can we do to make this better and get better outcomes for traps and tubes? I mean, we schedule all post-ops at the VA with the same attending. And you realize very quickly that that's almost impossible to coordinate based on schedules. Do we just route all of these to the Moran and bypass the VA in general? And I think that's an option, but it kind of removes all of the education for our VA residents. And so what we settled on is maybe having a chief resident who's involved in the surgery and have assumed care for that patient, particularly in the early post-op period, and see them over at the Moran in their own continuity clinic. And it kind of checks off a lot of these boxes. So you're going to have that consistency. You're not going to have as long with clinic wait time. You can get preserved free decks if you want. And then you'll have more time to chat with them. So I have an end of one for this. We had a veteran at the VA who had a very severe glaucoma, a central island in the right eye. You can see he had really asymmetric disease, but he still had preserved central acuity. And he had a really tough time understanding to use his drops, wasn't using them, didn't tolerate them, his surface was poor. And so he was reluctantly signed up for a trabeculectomy, which Dr. Stag and I did at the VA at the end of November. And I saw him post-op day one at Moran and then weekly thereafter. And you can see in the early period, his pressure was not controlled, but after one sutralysis and then subcons 5FU, his IOP has been consistently about five or six. And he doesn't really understand that, but I've been thrilled that his pressure has been there. He's mostly, mostly felt the sutures for a long time. So he finally has felt better. So I think he's getting a little bit happier. And so what the advantages this were, I got to know this veteran on a, you know, first name basis we met weekly. He really trusted me. I think he called me on my cell a lot. He called me one day to tell me he had COVID and like wasn't anything to do with his eyes. He's just like, I have COVID what I need to do about it. Well, just go to your other doctor. But he had like zero wait time here at the Moran, which I thought he really appreciated. He was not very happy when he had to reenter the VA clinic pool. For me, it was really invaluable kind of post-op education for these patients that I hadn't really received yet in residency. I got to participate in the trap. I got to make all these post-op decisions, you know, on my own. Dr. Stagg was certainly very supportive and there for all of them. And then I got to do the laser sutralysis and the 5FU injection. So overall a good educational experience. It was a lot of extra logistical work for me trying to work out time in my clinic over here, often time on different days over lunches, whatever, but it did work out. And then we do split documentation across two EMRs for this. One issue we ran into is that I tried to bill all of his Moran visits as a post-op visit so he wouldn't get charged without a VA community care consult. Unfortunately, because there was no op note at the Moran, then it got billed and it became this big hassle. So that got worked out in the future. I would definitely have the community care consult pre-approved at the VA before doing the surgery. I think there's much room for improvement for these surgeries. Some ideas that were thrown around back in the fall would be, can we dedicate a half day at the VA for just traps and tubes that the PGY4 on glaucoma attends and then maybe build a little bit more flexibility into our glaucoma rotation so that that resident can see these early post-op visits or even reserve a few spots on glaucoma in the continuity clinic. But I'm open to any suggestions from RAS faculty, any other faculty to make this flow work better. It was pretty cool to see a good outcome and it's not as fun to see bad outcomes at the VA. Thank you. Why don't you walk over here? Is it a good time? Yeah. Okay, good. So the advantage of still seeing this patient at the VA, like our experience where you had a complicated case, did a trap and it was a post-op visit. Like I got to see that patient with you and do a sutralysis. And I think maybe if the chiefs are responsible for seeing these patients and some more experience but also still doing teaching the PGY2s and 3s, I thought that was pretty useful, at least for me. There's probably a world in Dr. Simpson's stretching like she has something to say where we could build these post-ops into some sort of VA clinic and then still have a junior resident. Yeah, there you go. I'm just saying that the schedule changed a little bit. So next year that the chief on glaucoma will be at the VA Monday morning every week one through five. So, so that that continuity will be there. And if you want to build in then a subsequent day, we have the schedule flexibility. Now, if you want to do a half day of glaucoma surgery, we can look at the calendar and figure that out so that we can pull the glaucoma chief to do that at the VA as well. Not a problem. Brandon cut a suture at the VA. He saw the pressure go from 25 to five and he's still doing retina. So, he's doing peas, I'm sorry. Thanks, Cole.