 Good morning everyone. This is Ariana Longway from the Patient Safety Movement. It's one minute until the top of the hour, so we'll just give it one more minute and then we'll get started. Everyone is on mute just to be respectful. We had some issues last time with some noise in the background, so I believe you have the opportunity to, like, hit your hand if you have a question, but there will be plenty of time at the end for questions, so we'll get started here in a moment. Great. Well, good morning everyone. Again, this is Ariana Longway from the Patient Safety Movement Foundation, and you are tuning in to our second quarterly webinar. This month we are presenting an Airway Safety webinar, and we have a special guest, Dr. Art Kanowitz, and so we're really pleased to have him here. He's here with us in person in Irvine, so we really look forward to sharing some information about Airway Safety with you. Just to look over the agenda for this webinar, I'll start with a very brief 10-minute introduction about the Patient Safety Movement Foundation and our actionable patient safety solutions, which we call APPS, and then we'll have 35 minutes for Dr. Kanowitz to spend time on his presentation about Airway Safety, and then we hope to have plenty of time left over to have 15 minutes of questions and answers. If you have any technical difficulties, just a brief briefing, please don't hesitate to email info at PatientSafetyMovement.org, or if you have Jordan Gamart's information, she will be available to help you. As you probably know, our mission as the Patient Safety Movement Foundation is zero preventable patient deaths by the year 2020, so we say zero by 2020. We know it's a very obvious mission, but we believe it's the only acceptable goal to have because one preventable patient death is one too many. The way that we operate as the foundation is we strive to foster new efforts and build on existing patient safety programs through commitments. So we are a commitment-based organization, not membership-based. We really want to take a fresh approach to an old problem. We don't want to reinvent the wheel. We just want to amplify the work going forward there. I'm going to talk about five groups who can take action. These are the groups that we work with day to day. The first group is hospitals and healthcare organizations, and those organizations can make a commitment to improve patient safety and reducing preventable deaths and harm in their hospitals. We publicly post their commitments on our website, so I encourage you, if you haven't checked that out, to look at what organizations are participating. We have over 3,500 today. Committed partners are organizations like nonprofits, associations, and societies who sign a letter basically committing to action so that they can help spread our mission across their membership, across groups that they're working with in the same area. We definitely want to be complementary to other groups that are out there working on patient safety and not prohibit any work from occurring, only amplify it. The third group that we work with are healthcare technology companies, and we ask them to sign an open data pledge. What that means is those companies agree to share data in order to improve patient safety, basically giving clinicians a picture of their patients earlier on. Hopefully we can use that to develop predictive algorithms, and hopefully one day use it in kind of big data analytics. The fourth group that we work with are patients and family members, so we believe it's important to carry Hernandez-Gissel. I'm very sorry, but thank you so much, accidentally switched over to him. We believe that it's extremely important to keep the patient at the center. We ask family members to share stories, individuals to share stories about their experiences in the hospital. We also share resources on our website that they can utilize. Last but not least, the fifth group that we work with are also policymakers. In addition to the 501c3 non-profit that we run, we also run a 501c4, which helps us promote patient safety legislation. So these are the 13 actionable patient safety solutions. These are the challenges that we've identified since 2013 to focus on as primary issues that hospitals are facing that have solutions that can be implemented today. So today we're going to be focusing on airway safety. If anyone's interested in looking at any of the other actionable patient safety solutions, they're available for download at patientsafetymovement.org. We also have the capability to download the executive summaries in Spanish and in German to help reach additional people across the world. And in order for us to reach our goal of zero, you might wonder how we plan on doing that and how we track it. We ask for hospitals that are making commitments to share how many lives they have saved by implementing processes and initiatives in patient safety. This is our historical live-saved reports. So we announce those every year at our annual summit. This last year in 2017, we announced that 69,519 lives have been saved through the work of the hospitals and healthcare organizations that are involved. And that was just in 2016. So this year we have a goal of achieving 150,000 total lives saved. And because we're doing work now both in the U.S. and internationally across 44 countries, we split that. So we hope to achieve 75,000 lives saved in the U.S. and 75,000 internationally. So that was just a brief background about the patient safety movement. I wanted to ensure that everyone had a good background about us first. And I would now love to introduce Dr. Art Kanowitz. He's an emergency physician with special interests in emergency medical services and airway safety. During his clinical years as an emergency department physician and later serving as the EMS medical director for numerous emergency service agencies, he became aware of unplanned extubation, the common and costly safety event that occurs during airway management. Determined to find a better solution for prevention, Dr. Kanowitz spent several years researching the problem before founding Secure Assigned Medical in 2011 to develop and commercialize his patented airway stabilization system. He served as chief executive officer and chief medical officer for Secure Assigned Medical until recently when he transitioned leadership of the company to a new CEO and adopted the role of founder chairman in CML. Dr. Kanowitz also recently retired from his gubernatorial appointed physician as a state emergency medical and trauma services medical director for Colorado's department of public health and environment where he served from April 2008 until March 2017. Dr. Kanowitz has been actively involved in leading emergency services in Colorado for over 35 years. He was the president of the Colorado chapter of the American College of Emergency Physicians, served on numerous regional, state, and national committees and councils, and is diversely published in the medical literature. So with that, I'd love to pass it over to Dr. Kanowitz. Ariana, thank you very much. It's my honor and privilege to be able to present about airway safety, certainly a topic that I have become very passionate about over the last 15 years. Author Simon Sinek emphasizes the importance of starting with why. And so I adopted that philosophy a number of years ago, and so we will start now with why is airway safety so important? Why do we do what we do? This is Drew Hughes. Drew was a 13-year-old, very happy teenage boy living in North Carolina in Emerald Isle. And one summer, he was skateboarding with a bunch of friends, which they did frequently, and he fell and hit his head. Drew was transported to the local hospital where he was evaluated. At the time in the hospital, he was doing very well, actually. He was looking with the nurses and they did an evaluation to see how he was doing. They did a CAT scan and found that he had a basilar skull fracture. Because of that, they felt that they should be safe and felt like it was important to transfer him to the level one trauma center, which was in Gainesville about two and a half hours away. So because the weather was poor, they could not fly him. They made the decision to go ahead and transport him by ground ambulance. And again, to be safe, they decided that they would intubate him so that during this long transport through rural areas, he wouldn't run into any problems. So they started the transport and in route to the level one trauma center, Drew underwent an unplanned extubation. His life-sustaining breathing tube was accidentally pulled. The crew, which involved a EMT, a paramedic, a respiratory therapist, and a nurse, all tried to re-intubate him. Unfortunately, they intubated his esophagus and then on top of that, they failed to recognize that the tube was not in his trachea, that it was in his esophagus. Drew died not from his head injury. Drew died from the perfect storm of airway safety events. And Drew is why Drew died a preventable death. Drew, like the 12,000 other patients every year who die a preventable death from unplanned extubation, is why we do what we do. Airway management is a medical procedure that is supposed to be life-sustaining. Yet it's associated with lots of safety events. And those safety events are associated with lots of complications. Some of them very severe, leading to things like severe brain injury and even death. And the safety events include a whole spectrum of events, everything from failure to get the tube in, delay in getting the tube in. Once the tube is in, the tube moving to a mild-positioned place, causing all sorts of problems, pressure injuries, and then the tube coming out is not supposed to. Today we're going to, during this webinar, we're going to really concentrate on what I believe is the mother of safety events of airway management, and that is unplanned extubation. So unplanned extubation is the unintentional removal of one's life-sustaining breathing tube. It is both a very common and a very costly safety event. Unplanned extubation occurs over 70,000 times a year in the United States ICU alone, leading to 12,000 preventable deaths and more than $4 billion in unnecessary health care costs. So let me give you some background to where we come up with these numbers. This is a study that was published in 2012 in anesthesia and analgesia by the Society of Critical Care Anesthesiologists. It's a review of the worldwide literature. It involves more than 50 studies and more than 50,000 patients. And the average unplanned extubation rate across all 50 studies is 7.3%. Now this review article looks at studies that go back almost as much as 50 years. So you might say, well, that's really old data. Although if you look at just the last five years of the study, the unplanned extubation rate was still 6.4%. So despite all the technology and processes that have been put into effect, we're still at a very poor rate of 6.4%, with the range being anywhere from 2 to almost 20%. Although I'm aware of a study that actually was not included in this review. It was actually a neonatal study done in the neonatal intensive care, and their rate of unplanned extubation was 46%. So if you take that 7.3% unplanned extubation rate and apply it across the more than 1 million mechanically ventilated ICU patients in the United States each year, that's how we come up with the 73,000 incidences of unplanned extubation yearly. Now more recent data would suggest that the number of mechanically ventilated patients is actually closer to one and a half million, and that would put the incidence of unplanned extubation over 100,000. So besides being common, unplanned extubation is very costly. It's costly in patient complications. The complications from unplanned extubation, again being a wide spectrum of complications, things like pneumonia, vocal cord paralysis, severe brain injury, and death. This study that was done by Dela Sence shows that when you compare mechanically ventilated patients with an uncomplicated course compared to those who have undergone an unplanned extubation, those patients who undergo an unplanned extubation spend more than double the amount of time, almost triple the amount of time on the ventilator, and spend about 2.5 times the amount of time in the ICU. So that is a significant increased length of stay. The incidence of pneumonia is actually double as well. It's also costly as far as the cost of each hospital stay. So if you look at the cost of an average ICU stay of a ventilated patient who does not undergo an unplanned extubation, the cost is $59,000. For the average cost for an ICU stay in a ventilated patient who undergoes an unplanned extubation, $116,000. So an unplanned extubation essentially doubles the cost of a hospital stay. If you translate that across all of the unplanned extubations that occur in the United States each year, that's how we get the over $4 billion in health care costs. And actually if we use the $100,000 incidence, that would put this at over $5 billion. Now another way of looking at this is for the average hospital, if you have a 1% change in your unplanned extubation rate, your cost will change by $2.5 million. So if you can improve it by 1%, you can save $2.5 million. If your rate increases by 1%, it will cost the hospital $2.5 million. The cost is also very much applicable to mortality. There are over 12,000 deaths every year in the United States. So if you look at unplanned extubations, there are categories that occur. Approximately 50% of unplanned extubations are almost ready to be extubated anyway. And those patients do not, if they undergo an unplanned extubation, they do not need to be re-intubated. The mortality rate in that group is 3%. However, the other 50% of unplanned extubations, those that do require re-intubation, the mortality rate in that group is 35%. And that's how we get to the total unplanned extubation rate. So any all-comers of unplanned extubation, their overall mortality rate is 19%. That's the 12,000 deaths a year. So unplanned extubation is clearly common and it's clearly very costly. So what is the cause of unplanned extubation? Well, this is not crazy physics. This is not about nanoparticles. This is a very simple thing to understand. This is simple physics. So an unplanned extubation occurs when the force that is applied to remove the device exceeds the force that you are applying to restrain the device. Vice versa, if you can apply more force to hold the device in place, you're less likely to have the device removed. So what is the current management? Well, there is the old standby adhesive tape. Adhesive tape has been the gold standard of airway management for as long as I've been in practice, which is over 45 years. And currently today, it still is about 80% of the methods used to restrain a tube. The other 20% are essentially broken up between a whole slew of commercial devices. The Hollister AnchorFast is the most commonly used device in hospitals today, and the Lairdoll Thomas Tube Holder is the most common device used in pre-hospital. Despite a number of commercial devices being out there, the rate of unplanned extubation remains unacceptable. So how do we get to zero preventable deaths from unplanned extubation? I think of four tax that can be used to helping us get to zero preventable deaths. Number one is universal tracking. We have to better track unplanned extubation. Number two is application of actionable patient safety solutions. Number three is identifying and sharing best practices. And number four is developing disruptive technology, technology that can prevent the tube from moving once it's in place. It's commonly said that if you can't measure it, you can't improve it. So the unplanned extubation rate that we talk about, 7.3%, I believe, is likely just the tip of the iceberg. And why is that? Well, most hospitals don't track unplanned extubation, and those that do track it and that publish it are probably the better institutions at improving it. So I think the 7.3% is probably the tip of the iceberg. So why do hospitals not track unplanned extubation? And I can tell you traveling around the United States a lot, I always ask the question, what's the unplanned extubation rate in your hospital? And I always get the blank stare in the headlights look and I don't know what it is. Well, the reason many hospitals do not track it is because it's not easily trackable unless you have a specific data set to track it. And most EMRs today do not have specific data sets for tracking unplanned extubation. The Centers for Medicare and Medicaid Services is certainly doing significant strides at helping improve patient safety, and they're doing that through their quality metrics and then driving procedures to improve the quality of care. And they certainly now have added unplanned extubation as one of their priorities at looking at making that a quality metric and helping to improve patient safety surrounding airway management. Obviously, the Patient Safety Movement Foundation is also doing lots of things to help improve airway safety. Number one, through their Airway Safety Task Force, and the Airway Safety Task Force has developed this data brochure and the data brochure can be downloaded through the Patient Safety Movement website and the instructions are included on this slide. This is the data set that is included in the brochure and it helps you understand what data points do you need to appropriately track unplanned extubation. So first you need when was the patient intubated, both the date and time, and when they were extubated both the date and time. That gives you the amount of time that the patient was intubated and the reason for that is the longer you're intubated, the higher your risk of an unplanned extubation. Next you want to look at was the intubation planned or unplanned. Unplanned being there was not an order and an intention written to pull the tube out. That either occurred because the patient pulled it out or due to an accident that pulled the tube out. And then you want, once you determine it's an unplanned extubation you want to know was the patient re-intubated, was a re-intubation required. And obviously as I previously discussed, that significantly changes your risk of mortality. And then you want to track what are the complications that were found in that patient associated with the unplanned extubation. So the metric that is used to look at unplanned extubation is the rate of unplanned extubation in patients undergoing mechanical ventilation via endotracheal intubation. So there's two ways that we look at these metrics. One is the standard percentage. What is the number of unplanned extubation per 100 patients? That gives you a percentage number. And for instance 6.4% is the average based on the last five years of the literature with the, you'll normally see that there's a rate. So if you're in the 2 to 20% you're within the published studies rate, and obviously 6.4 being the average. However, the other way of looking at the metric of unplanned extubation is a risk adjusted measurement. And that risk adjustment is for the amount of time the patient is intubated. So to do that you take the number of intubations per 100 ventilation days. So it takes into consideration the amount of time each patient was intubated that undergoes an unplanned extubation. And then that gives you your total ventilation days. That number, based on the published literature, averages .6 with a range of .1 to 3.6. So that gives you a risk adjusted metric for unplanned extubation. So let's talk about the actionable patient safety solutions. How are we going to attack improving unplanned extubation? So on, if you download app number 8 you will get the app for airway safety. And it's broken up into a couple sections. The first section is the executive summary checklist. And I will break down this slide to a little bit more of a summary. So the executive checklist really looks at six different points. It looks at number one, assembling a core multidisciplinary team. It's important to have a lot of disciplines involved in organizing this and making sure it's done and done correctly. So you need clinicians. You need risk management personnel. And you really need C-level execs to help say that this is important and it will be done and we will work at improving it. So once you have the team then you need to establish what is the need for improvement. If you have zero unplanned extubations and zero deaths from unplanned extubation then there's probably no need to do anything. I've not seen that to be the case anywhere. I think we all have room for improvement. So to do that we need to track what is your individual hospitals, right? This is our overall system of unplanned extubation. So that requires tracking the data and then looking at the data to improve care. Next you want to make sure to implement policies and procedures and standardize best practices. You want to develop a comprehensive airway toolkit which I'll talk a little bit more about here shortly. And then use your quality management cycle to make sure that you are improving care. So collect the data, review the data, identify the root causes, find solutions, educate, implement those solutions and then verify that what you're doing is in fact making a difference. The next part of the app goes through a series of very much specific things on these five items. So the first thing is the performance gap and that really looks at threats and vulnerabilities. And I look at the threats and vulnerabilities or actually the patient safety task force looked at the performance gap, the threats and vulnerabilities as really in three main areas. Delayed intubations, failed intubations and lost intubations which are the unplanned extubations. Then the app goes through very specific recommendations for a leadership plan, a practice plan, a technology plan and then metrics. And you can look at those and get very specific details on how to implement those plans in your hospital. And then lastly there's a excellent appendix at the end of the app which really looks at airway essential components. And these airway essential components are in a table that looks at what are the solutions, what are the level of recommendations, are these mandatory things, are they recommended and then there are things that support why we came up with those decisions. And so we look at a failed airway protocol, a series of airway equipment, critical practices in clinical care and then team training. So the Actionable Patient Safety solution number eight airway safety is an excellent method for helping you implement processes and procedures to help you improve unplanned extubation. So what will it take to get to zero preventable deaths? Again I said there are four items that I look at. Tracking, application of the apps, sharing best practices and new disruptive technology. So the technologies that we've seen that are out there were looked at in this study that was done at the University of Colorado Division of Biomedical Engineering and they compared adhesive tape which again is 80% of stabilization of devices in the United States today. They looked at the twill tie and they looked at the two most common commercial devices, the Thomas Tube Holder and the Hollister Anchor Fast. They also compared those to a device that's undergoing research and development that is not currently on the market. And essentially they looked at pulling forces with these, with the twos being held by these devices, pulling forces in 13 different directions. If you're a patient and you are starting to get conscious and you grab at your tube, you're likely to pull let's say if you look at the chart at the bottom left here in direction number four. You're going to grab the tube and pull away from your mouth. That will pull in direction four. However, if you're being put from a gurney into the CT gantry and your ventilator tubing catches on the edge of the gantry, it may pull in direction 13 or direction 10. So when they did the study, they felt it was important to look at all the potential directions that potentially could be applied to remove the tube. And the chart there shows that there are lots of different forces and what the restraint forces are. And to just make that chart a little simpler to understand. So looking at each force, there's a minimum force and a maximum force. There's also an average force. The authors felt that really looking at the minimum force was most important because that was your most vulnerable force or position for an unplanned extubation. And you can see at the current devices that are being used today to restrain tubes, the most vulnerable direction and force is about 15 to 20 pounds. And the new device is about two and a half times that amount. And so I think this study suggests that we can get better at restraining against more force, need to continue to do research and development and develop a device that can restrain the tube from coming out regardless of the amount of force that is applied to remove the tube. So that takes us to my ask. And I'm going to request that everybody that is on this webinar today do a few things. Number one, I'm going to ask you to go to your individual hospitals and ask the question, what is our rate of unplanned extubation? If you're given the typical answer, we don't track it, we don't know, then I would ask the question, why and what do we need to do to begin tracking it? I would also ask the question, what is your hospital's electronic medical record and do they have a specific data field for tracking unplanned extubation? If they do not, I would request that you contact your EMR and ask them to begin including the data fields for unplanned extubation so that we can do a better job of tracking unplanned extubation. If you are told your rate is 2% or 7% or 12%, I think you then need to look at implementing the actionable patient safety solutions because if your rate is more than zero and there are any deaths from unplanned extubation, you need to do what you can to get that death rate to zero. Implement the actionable patient safety solution number eight, airway safety, in your institution and help us improve unplanned extubation and help us get to zero preventable deaths. Wonderful. Thank you, Dr. Kanowitz, for a very thorough presentation. I love the focus on all the costs and both financial and having to deal with human lives. So we really appreciate you coming the way to California to share with us and everyone who's on the line. I'm going to unmute everyone. Ah, yes. No. Is that right? Yes, it is. Yes. The question is, what do you do in the countries where we only use five or six months? But what they say is not interactive but that it feels like... Function? That it feels like it's positive and that it feels bad for my daughter. Thank you. As a reminder, we've put everything in mute so that you have the opportunity to get out of the question. I definitely don't want to sign off early if there are any questions out there, so now it's time for me to sign off. Acknowledgement that there are people out there. Here's some background noise so we know that this is a problem at all. Okay, yep. And from someone who is on the chat who says what can patients and families do? Well, I think anybody can certainly do a better job to improve the quality of airway management. Again, there are so many complications and being aware of it, passing the word, talking to your clinician, getting the word out to all of the agencies on improving quality of health care, those who are on the clinician, so they can improve hospitals to understand the patient fate and do what they can to improve it. I know as a patient, we all, for many people, at some time in your life, definitely have to breathe in this, but the last one is for breathing air, come out, die from the tube coming out rather than from your... So, you know, encouraging your hospitals to know what their unplanned extubation rate is and making sure that they can improve it to make sure that curfew management is safe. I'm sure... Okay. Go away. Great. Thank you, Katie. Congratulations. Are there any other questions? Yes. I think we have a question. Is there any other questions? Thank you. Thank you. Is there any other questions? Yes. Is there any other questions? Yes. Is there any other questions? Yes. Is there any other questions? Yes. Okay. So, the device is currently undergoing significant research and development. It's a functional manufacturer, and it's being reviewed by the FDA. We're looking at clearance probably mid-next year. Sorry, I had to mute. Okay. So, great. Great. Did that answer your question? Yes. Thank you. Okay. What's time for more questions if there's any other questions? I think that hospitals are... When you ask them to... No. Are they acceptable to it usually, or are they... Yeah, I think there's a combination. I think... I think if hospitals are really unaware of how big a problem it is, it's kind of... We've got the blindfolds on, and so we don't really... When I talk to hospitals, other than them, well, certainly the House of Medicine has some hesitancy to tracking things that lead to complications and lead to death. However, I think that is changing in healthcare completely. I think we're really getting to the point where we understand we have to track them and we have to improve them. And so I think hospitals would be definitely willing to do that. I think part of the problem is the hospitals don't really have good control over the EMRs. And so I think the hospitals need to encourage the EMR companies to get on board because they're the ones... And this is an easy change. This is five or six data points. Adding that to the EMR is not a difficult process. And so I think that's something that if the EMRs had better tracking and the hospitals understood how much money they were expending unnecessarily because of these complications, that would be an impetus for them to improve. But I think most importantly, we have to keep in mind, foremost, this is about patient deaths. And one patient death is too many. And so I think that really is the impetus for hospitals that we should do what we can to make it better. And this is not rocket science. This is not difficult. It's really a pretty easy procedure if we just put it in front of us and take it on. The literature that I referenced, certainly what you're referring to is a significant problem as well. And it's really the same kind of issue if the force to remove the tracheostomy tube is more than the force you're using it to hold it in place, it's going to come out. So I think that's a good question. I think that's a good question. I think that's a good question. If you're using it to hold it in place, it's going to come out. Replacing an endotracheal tube typically is more difficult than replacing a tracheostomy tube, especially if it's an older tracheostomy tube or tracheostomy hole that's really healed over. The big problem with decannulation of tracheostomy tubes and we've just had a big case of this on the news in the last week or two was a child that the tube came out and the child was sleeping, there was nobody around, they didn't hear the ventilator alarm when it went off and the child ended up dying. So although it's fairly easy to put the tube back in with the tracheostomy tube, whereas endotracheal tubes can be much more difficult to put back in, it's still a significant problem and thank you for bringing that up. Great, we have another question from the web and it's from Katie Mukadis and she's asking, when will CMS add unplanned extubation as a quality measure? Well, I personally have spoken with CMS numerous times and I know they have made unplanned extubation a priority for this round with their hospital engagement network. They're looking very closely at doing this and including it as a quality metric and I think it will be soon. Now, obviously remember this is a federal government agency and the wheels turn a little bit more slowly, they have to be looked at very, things have to be looked at very critically and we have to make sure that they're doing it right and that takes time. So my guess is probably, it could be a year, it could be a couple years, but I think they clearly understand that this needs to be a priority, that there are significant patient safety issues related to unplanned extubation and that CMS can help us improve it. Number one, by mandating data tracking of unplanned extubation and then through their quality metric system encouraging hospitals to get on board to put in place the improvements that are necessary and we all improve it together. Okay, great. I've unmuted everyone again, so if anyone would like to ask if I can just stand up to hear them. Thank you. Now that that's me. I'm just going to go back to the text. In fact, this is a little strange. It's not a text, but... It's not a text. It's not a text. It's not a text. It's not a text. It's not a text. It's not a text. It's not a text. It's not a text. It's not a text. Does the data with that come in your way? Oh, sure. The tube when it is ready when the tube comes out the infection needs to be there and they need to be made in your vision. Will the tube staying in for another half hour or hour or several hours when they're ready to be intubated does any significant problem. Not likely. It's certainly staying in the arena of brain injury, which has of spectrum know that when a tube comes out, although 50% of the time they're ready and about to be re-intubated, 50% of the time they're not ready, and they need to be re-intubated. And when death is the bottom line, I wouldn't want to be in control if my tube is not ready or not. Because you don't care how each of the clinicians approve to try to defend the optimum time of an unplanned extubation. And that's just vigilance of the clinicians. I'm sure that once they see that patient is getting closer to being ready to be extubated, really determining when that optimum time is in. Great. Thank you. Any other questions? What are your comments regarding patient sedation? So, yes, great question. And today, because of the inability of our department to make devices, we have to use other methods, we also have to be careful because those methods have their own significant downsides, both talking about restraint and talking about sedation. And I think the thing would be if we could develop a restraint method that allows us to do that and does not require us to restrain the patient and does not require us to sedate the patient, the patient will get off the ventilator more quickly, they'll be less agitated because of the restraint. Specific recommendations regarding both sedation and patient restraint. So, thank you. Great question. OK, everyone, we're going to mute it again. So if you have a question. What's the source of getting a copy of the slides? Yes, we'll have the slides available on our website and we'll have the slides available on our website. So, I'll be back. So, I'm going to send them all over the screen. I'm going to send them all over the screen. And the other thing is that the authorities and the people who don't come from outside can send them all over the screen. So, we're going to do a lot of this. Thank you very much. Thank you. Thank you. Thank you. All right. Thank you. Thank you. All right. Great. So, do you mute it again at the website address? No. No.