 I just want to welcome everybody to Advanced E-Clinical Training's clinical shadowing webinar series. I appreciate you spending your evening here with us. If you don't already know me, my name is Leah, Leah Medwig and I am the lead course instructor here at Advanced E-Clinical Training. I've been a nurse for over 13 years. I started in cardiothoracic surgery and then went on to a level one trauma and burned ER in a large metropolitan city then went on to become a complex and catastrophic nurse case manager for a large health insurance company where I earned my master's degree and teaching has always been in my heart. I love teaching new nurses and new employees and pre-safting. So kind of education was kind of the natural path there for me. So that's how I ended up here at Advanced E-Clinical Training. And I'm so happy to be here. As I'm happy that you're all here as well. If you're not familiar with Advanced E-Clinical Training, we are a fully online program and we provide certifications for our pre-health students and our post-baccalaureate students. So people that are wanting to go on to medical school or nursing school or a PA school or a B&Rs practitioner or a pharmacy school. So we offer certified medical and certified medical assisting, certified patient care tech. Some of our other programs are certified pharmacy tech, certified physical therapy tech as well. And we also offer a certificate in Advanced Medical Terminology. So the beauty of it is all of these programs can be completed in as little as eight weeks and it is also asynchronous. So you complete the program at your own pace. So we are very flexible there. And something that I am very proud of as well is our Lifetime Career Services. So we help all of our graduates and our students with employment services even long after you have graduated. So that's one of the added benefits there. So if you get a chance, you can head over to our website at ADV-C-L-I-N-I-C-A-L.org and I am going to go ahead and put that in the chat here. So just here with me at Adams Clinical. I want to make sure I can smell that right. Okay, all right. Can everybody see that? There we go. Okay, awesome. Yeah, so here we go. And no, so not everybody can see it. So let me try this again. All right, I'm just putting that in the chat just here within your one second. Can everybody see it? We're just looking for the website for Advanced Clinical Training. It should be in the chat. So no, we can't see it. Okay, so let me try this again. All right, all right. Shab or Shea, if you are out there, if you could just place it in the chat for me one more time. I think that it'll work then. Okay, so we see it now. Perfect, awesome, yay. All right, so please go over to our website and take a look at us. If you're not a current student now, we're offering you a discount code for $300 off. Any one of our programs for students that are not currently enrolled, but that discount code is only good for 48 hours. And I will provide that code to you at the end of this webinar. So also you will get your one hour, your one hour of clinical shadowing. You'll get a certificate to the email that you used to enroll in this webinar. So you'll get that within 24 hours. So just keep that in mind. Keep a lookout for that as well. Oh, good, okay. So our discount code is already there in the chat. Awesome, webinar 300 for $300 off for any one of our programs for any students that are currently enrolled. All right, so now that we have all of that out of the way, let's go ahead and get started with our case today. So as far as the webinar goes this evening, I like to try to make it a very interactive experience. So I had a couple of polls I'm gonna have you guys answer. Also, when directed, I'm gonna have you place some of your answers in the chat. But I'm going to ask you to please hold all of your questions and answers to the end of the presentation. We will have a question and answer session at the end. Okay, let me just check here. We have one. Okay, so the case. So the case I'm gonna present to you today comes from a company called Real DX. So this company basically they will film and videotape, of course with the patient's authorization and their consent, their course, their hospital stay or their experience in the emergency room. So you're gonna be seeing a real life case with a real life patient in real time. So we're gonna go ahead and go through that. This is case 959 and this patient presented to the emergency room with inspiratory chest pain, which means when he takes a deep breath in, he was having pain on the left side and he had left lower leg pain and swelling as well. All right, so I'm gonna go ahead and get started. I'm going to share my screen with you. So just here with me here a moment. All right. So hopefully you all can see my screen now. And I am going to go ahead and start the video. And please make sure, please let me know that you can hear it as well. Great, hi there. We are at Yale New Haven Hospital in the emergency department. My name is Dr. Labs and we have a patient here. Thank you so much for joining us. Can you tell us again why you came into the hospital today? My leg was swollen and I felt pain this morning around three o'clock in the morning. I was really sharp and I couldn't breathe. Oh wow, okay. Where was the pain? It was like the side, like lower back, it's your type of area that you're going towards your body. Did anything make the pain worse? Just the deeper I breathed in, the more I felt more sharper pain. More sharp. Okay. When did the leg swelling start? Okay, and you said it's the left leg. Is it tender back here? Where is it hurt? Or does it not hurt anymore down there? Okay, so I'm going to stop the video there just for now because I have my first pull for everybody. So based on these first initial symptoms that this patient is having, he's having the inspiratory chest pain, the left lower leg pain and swelling. So what could be going on with this patient? Like what are your initial thoughts? Like what do you think initially could be happening? So I'm going to use our first pull and I'll launch our pull. And if you could go ahead and answer the question. So based on these initial symptoms, what do you think could be going on with this patient? Well, lots of people are answering. We almost 50% or more have answered the question. We'll try to get to 100% and see. And see. Almost everybody has answered. Awesome. Everybody's participating. I love it. You can't see the pull. Okay. For some reason you can't see the pull here. If you just want to place your answer in the chat. Okay. Everybody saw it. Awesome. Okay. So just about everybody has answered. So I'm going to go ahead and end our pull and you'll be able to see the results. I'm going to share them with you here. So you can see that most people think it's DVT. Second in line is the pulmonary embolism, paracarditis and then heart attack blast. So all right. So you guys are, you know, on the, you guys are moving in the right direction where I like the way you're thinking. I like the way you're putting all this together. I'm going to share my screen again so we can kind of look at what the differential, the official differential diagnosis was here with this patient. Okay. So, so we can see here with this right here, the differential diagnosis DVT or deep vein thrombosis, pulmonary embolism or PE and pneumothorax, paracarditis, pneumonia, ACS that is for acute coronary syndrome. So, yeah. So all of those health conditions, all of these diagnoses can cause these symptoms that this patient is having. So you're all thinking along, doing well, you're moving along on the right track here. So I'm going to go ahead and start the video again. Okay. But it just felt, do you feel like it's been swollen for the past couple of days? Okay. And have you ever had a history of blood clots before? Yeah. Okay, when was that? 2013, I was 14, I had a surgery on my leg and I was taking lovin' knots but it was painful to take that. So, but as soon as I took myself off of it and I had blood clots to develop. Okay. And they traveled to my lungs. Okay, and are you currently on any blood centers or no, like Zarell Tower? Just, okay, okay, but before today you weren't. Okay. And have you had any recent surgeries? My surgery was 2013. Okay. Any long car rides or sittin' for a while? No, okay. History of cancer at all? Or bleeding disorders or clotting disorders that you know of? Okay. All right, so we'll finish our work up and we'll take good care of you, okay? All right, so that is the end of the video. I'm gonna stop sharing my screen. So we learned that this patient has a history of blood clots in the past and that he had blood clots from, it sounds like he had some type of surgical procedure in the past and he has blood clots or PE in the past. So that's not super uncommon but why do you think that the provider asked the patient if he has a history of cancer or other clotting disorders? So go ahead and place your answers to that question in the chat. Again, the question is why do you think the provider asked the patient if he had a history of cancer or a history of blood clots or clotting disorders? Go ahead and place your answers in the chat. Believe, yes. Yes, it has definitely something to do with the swelling of his leg for sure but what does cancer or clotting disorders? Why is that relevant? Go ahead and place your answers in the chat or what your thoughts are. So we can kind of talk about them and see how you all are thinking here. Chemo medication that can thicken blood, that's very valid, yes. Yes, it's definitely valid to know family history, yes blood clots can be a symptom of cancer, yeah or cancer treatment, absolutely. That's, yes, definitely, definitely. And absolutely it can correlate to some of his symptoms that he's having, damaged vessels, 100%, you guys are very smart, yes. Chemotherapy drugs, definitely. Yeah, so we're all, sounds like you know, you guys are all thinking, I can see your answers in the chat, they're all coming in and they're all, your thinking is correct, you're moving in the right direction, yes. Absolutely 100%. Yes, and definitely a history of blood clots, yes Linda, for sure, if you have a history of blood clots, then you are at risk for having blood clots again in the future for sure, definitely yes. Yep, Anna, you're thinking the same thing too, 100%. All right, well thank you for being brave enough to go ahead and answer that question. I'm gonna share my screen with you guys again. We're gonna just look at a PowerPoint here. So, DVT, impulmonary embolism, risk factors. So age, so age is not one I think that people tend to think about very often, but your age, so being older than 60 increases your risk for DVT. Fortunately, I'm not there yet, but on my way. So lack of movement. So sitting for long periods of time. So often you'll see, ask, you'll hear providers say, have you been on any long car ride? Have you been sitting in an airplane for very long? So that lack of movement in those long car rides or in an airplane, if you're sitting for a long period of time there, can cause blood clots or a pulmonary embolism or a deep vein thrombosis. So injury or surgeries, so injury to the veins, I think one of the students, you are one of our participants said that in the chat. It was absolutely right. Or surgery can increase the risk of blood clots. So if you've ever had surgery in the past, if you've had a broken bone in the past, most of the time your provider will go ahead and put, will go ahead and put you on a blood thinner to help prevent those blood clots. Pregnancy, so pregnancy is put you at risk. Birth control pills or oral contraceptive, so or any type of hormone replacements, all of these things can increase the blood's ability to clot. And we talk about hormone replacement therapy, usually in women that have gone through menopause, they're trying to replace their hormones there. So being overweight or obese is another risk factor. Smoking is a big one. Smoking affects how blood flows and clots, which can increase the risk of a DVT. Cancer, so a lot of our participants and attendees were thinking along the lines of that, yes, some cancers can increase substances in the blood that can cause the blood to clot. And even some types of cancer treatment can also increase the risk of blood clots. And I know one of our participants made that point as well. So heart failure. Heart failure increases the risk of the DVT and pulmonary embolism, inflammatory bowel disease, so Crohn's disease or ulcerative colitis. A personal or family history of DVT or PE, and I know one of our participants made it, pointed out that risk factor as well in our chat. So genetics, so some people have DNA changes that cause the blood to clot more easily. So one example is the factor five, Leiden. And so this type of inherited blood disorder changes one of the clotting factors in the blood. So an inherited disorder on its own might not cause blood clots unless combined with one of these other risk factors that we've talked about as well. And then unfortunately, sometimes a blood clot in a vein can occur with no identifiable risk factor. And usually this is called an unprovoked PE or unprovoked DVT. So I'm gonna go ahead and stop sharing here. So as I thank you all for being so interested in putting all of your questions in our chats, I appreciate your enthusiasm. If you could just please keep your questions till the end, I'll be happy to answer them. We're gonna go through a question and answer session there, but I appreciate all the enthusiasm here for sure. All right, so I'm gonna go back and share our screen here with our patient. I wanna show you guys something here. And let's go down to the demographic store. Here we go. So here you can see the patient's demographic. So he's a male, he's 37. We don't have his BMI or his height or weight. So he's 37, so he's not over 60. He does have some of those risk factors, having a blood clot in the past I think the biggest one that he has. You can see his vital signs here. So his temperature is 98.5 Fahrenheit. That's completely within the normal limits. His blood pressure is 137 over 73. So it's creeping up there, but that's probably normal for him. Not quite high blood pressure or hypertension just yet. His heart rate is 92. We know a normal resting heart rate is between 60 to 100 beats per minute. So he's a little on the higher end of a resting heart rate, but he's within normal. Respiratory rate is 18. I don't know if I believe that when you get in the field, please make sure that you are always counting respirations. This is a big, big, big one because it takes a minute to fully count somebody's respiration rate. So you wanna watch the rise and fall of their chest for a full one minute and you'll get the respiration rate. But here it's documented as 18 and that's normal. And then his pulse oximetry is 96% on room air and that's within normal limits as well. All right, so I'm gonna stop sharing my screen and I just want to know. So based on what we know now, based on how this whole picture is starting to come together and the information that you have based on his assessment, based on his past medical history and his vital signs, have your thoughts changed at all? Have you, have your thoughts changed? So what do you think is going on with this patient? Is it the same? Have you changed your mind? So I'm gonna bring up our second poll and I just wanna see where we are. I know I can't pull it up. Let's see. Okay, here we go. I'm gonna launch our second poll. Sorry about that, everybody. Okay, so have your thoughts changed? What do you think is happening now? Have you changed your mind? Let's see where you think we are now. Hold open over half has answered the question. So based on what we know now and how the whole picture is coming together, what do you think is happening to this patient? Almost everybody has answered around 85% I'm just going to wait just a few more seconds. Hopefully we get everybody to answer what they think is happening. All right, so just about everybody has participated and answered, I'm going to end our poll and I'm gonna share the results and here you can see DDT, Pulmonary Ambulance and again, number one and number two. So some people are thinking along paracarditis. Thank you for placing your answers in the chat as well. If you can't see the poll and I apologize for that if you can't see it, but thank you for still participating. I appreciate that. All right, so we're, yes, thinking, yes. DDT, Pulmonary Ambulance, yes. Definitely thinking along the right track here. So I'm gonna start sharing our poll. All right, so you guys are thinking awesome. You're putting it together and it's starting to make sense. So all right, so I'm gonna show, I'm gonna share my PowerPoint here. So I just wanna show you guys what a DDT and a pulmonary embolism. So what is the difference here? So hopefully you can see, let me see if I can move my, there we go. So hopefully you all can see this image well enough. What is a DDT? So DDT is a blood clot that forms in a deep vein of the leg or pelvis, either partially or totally blocking the flow of blood. So you can see that there's a deep vein clot here and then what is a pulmonary embolism? So what is the difference between the two? So a pulmonary embolism is caused when one of those DDTs in the leg, in the deep vein of the leg where the pelvis breaks off from the vein and then travels in the bloodstream to the heart and then migrates to the lung where it lodges. So the clot then blocks a vessel in the lung interrupting blood supply, which could cause shortness of breath, which could cause a cause. Sometimes it'll cause people to have homoptysis, which is coughing up blood. So that's the difference between a DDT and a PE. All right, so I'll stop sharing my screen here. All right, so we're gonna continue to put this all together because it's like when you're working in medicine and you're working in healthcare, it's like you're putting the puzzle pieces together. So you get one bit of information from over here and then you get some more information. You get some more information and more information then you put it all together like a puzzle. So we're putting the puzzle together. And so what we know now is this patient comes into the ER. He has a history of a PE and a DDT in the past. We assess that he has left lower leg pain and swelling for four to five days and he has that sharp inspiratory chest pain. So we're definitely thinking, yes, he probably has another DDT or another pulmonary embolism. So now you're the provider here. So what kind of workup or what kind of testing is going to be important for this patient? So we can help to diagnose and to actually diagnose them because right now we don't really have a definitive diagnosis. We have all these suspicions but we need something to, we need to diagnose them. So what kind of workup would you do? What kind of test would you order for this patient? So go ahead and put your answers in the chat and we'll discuss them. So, yes, CT scan, MRI, chest x-ray, yes, love all of that. CT chest PE study, yes, blood work, definitely blood work, MRI, yes, EKG, absolutely sonogram, absolutely. Or ultrasound, ultrasound, definitely. Yep, you guys are so smart. I love it, I love it, I love it. Yes, you guys are saying all of the right things, CT, everyone's saying the right things and the same things. So we're putting it all together. Awesome, yes, EKG, x-ray, ultrasound, yes, definitely 100%. So I'm gonna share my screen because I wanna show you a back to our patient so we could see actually what did for him. So I'm gonna put this away, different. Okay, so here we go. So we see this, we've already talked about the differential diagnosis, so patient workup. So this is what they actually did. This was the actual workup that the providers put together for this patient to diagnose and to confirm their suspicions of a DVT and a PE. So they did basic lab, so basic blood work, including a D dimer, which we'll talk about, a troponin and a PT-INR. We'll talk about those a little bit more in depth here. Very shortly in EKG, a lot of our participants were suggesting the EKG and that was 100% right. Left lower extremity DVT ultrasound, a couple of our participants suggested that as well and a CTA, which is a PE chest with and without contrast to look for the pulmonary embolism in his blood. So as you can see, like I said, you guys were thinking along the right line. So all of our assessment and our instincts and our vitals, everything that we know, we're driving us in the right direction to this diagnosis. So you guys are doing awesome. So I just wanna show you my, go back to this PowerPoint here. So we can talk a little bit about some of that workup. Some of these things you may not know, some of them you may. So the blood work, a D dimer. So what is a D dimer? So a D dimer is a blood test that measures a substance in the blood that is released when a clot breaks up. So if there's a suspected PE or suspected DVT, 100% all the time, I'm sure the provider is going to order a D dimer. So if the D dimer is negative, it means that the patient probably does not have a blood clot. If it's positive, then it's most likely that he does, he or she does. What is a PT? So a PT is pro-thombrine time. PT pro-thombrine time. So it is a pro-thombrine is a protein made in the liver that helps blood to clot. So when you talk about a pro-thromb... I'm sorry, I'm having a hard time saying that. Pro-thrombine time, a PT is one way of measuring how long it takes blood to form a clot. So, and it's measured in seconds, so such as 13.2 seconds. So that's how that number would come back or that value would come back to you and after you've drawn the blood work and it went to the lab, that's how it would come back to you, a value of seconds. So a CTPA scan is a commuted tomography pulmonary angiography and it is a special type of x-ray test that includes injection of contrast material or dye into the vein. And this test can provide images of the blood vessels in the lungs and it is a standard imaging test to diagnose pulmonary embolism. We have the electrocardiogram abbreviated as EKG or ECG, which measures the electrical activity of the heartbeat. It's used to quickly to attack heart problems and monitor the heart's health. So a lot of times the EKG is ordered, because if there is a suspected PE then that PE has traveled through the blood to the heart and then to the lungs. So it went through the heart. So they wanna make sure there's no, that that blood clot didn't cause any damage to the heart while it was passing through there, which they can. Then we have the echocardiogram and an echocardiogram is an ultrasound of the heart and this test will provide images, detailed images of structures of the heart and structures of the heart valves. And again, this type of test would be ordered if there was a suspected PE or even a diagnosed PE. We just wanna make sure that there are no, there's no damage done to the heart, to the structures of the heart either. And then the duplex ultrasound. So the duplex on ultrasonography is an imaging test that uses sound waves to look at the flow of blood in the veins and it can detect blockages or blood clots in the deep veins. All right, so let me stop sharing my screen and I'm gonna go back to our patient. All right, so let's look at the actual outcomes. So what were the actual outcomes for this patient? So we see here, so this was actually his blood work. So you can see they did a troponin as well. Again, a troponin would tell you or indicate if there's any type of cardiac or heart cell death and they're looking for that. If A, you have a suspected MI or heart attack, but again, if there's damage done to the heart by a clot passing through it. But his was negative or zero. A BNP is another blood test they do to look for any type of heart failure. Again, if you remember back that heart failure was another risk factor for blood clots, but he doesn't, his BNP is normal. But what we can see here is that his D dimer is positive. So you see the reference range here, but here you can see that it was elevated. So he has a positive D dimer. So I mean, that goes right along with the suspected PE or DVT. Here is an ultrasound image of the ultrasound that they had of his leg. And what you can see here are normal veins, normal, this is normal, but what you can see here and this is the clot is where they're showing. So there is a positive clot there. Again, this is just another view of the ultrasound. I'm just going through that slowly. They also did an EKG, of course, we talked about that to make sure there was no damage done to the electrical circuits of his heart because of the blood clot, clot passing through it. And this is normal sinus rhythm. This EKG, normal sinus rhythm, nice PRQ waves. This is totally normal. Now when we get down to his CT results, I don't know if you all can see, but I'm gonna have to squint to read it because it's pretty small. But there was a CT done and the impression, which is the impression is always when you look at the radiology report is going to be what the radiologist diagnosed by looking at those images. And you can see that the radiologist said that he is bilateral, lower and sub-mental pulmonary emboli, new since his prior examination. So this means that he has pulmonary emboli, not just the pulmonary embolism, he has more than one in both of his right and his left lung. And then this is just the echocardiogram results. Again, those are the ultrasound of the images of the heart and it looks pretty normal here. All right, so let me go back up here and we will look at the diagnosis. So I'm sure there's no surprise to anybody here. He was diagnosed with a venous thromboembolism by lateral, lower and segmental pulmonary emboli. So our suspicions have been confirmed. He has a DVT and he has a bilateral, bilateral P. So now what, now that we have the confirmed diagnosis, now that we have the confirmed diagnosis, how do we treat it? How do we fix on? How are we going to make them better? What are we going to do now? So let me pull my last poll for everybody. So how do you think we treat a confirmed diagnosis of a DVT and a P. Go ahead and place your answers there in our third poll question. Thank you all for participating and for your enthusiasm. You make this very easy. Most everybody has participated. We're almost at 90%. I'll wait a few more seconds so all our participants can answer almost there. All right, so just about everybody has answered, I'm going to go ahead and end our poll for the sake of time. I'm going to share the results and you can see that all of the above, anti-coagulants, thrombolytics, thromboectomy or embolectomy, insertion of a venequil filter. I'm going to stop sharing here. So actually all of those answers are right. So if you answer all of the above, you're correct. But if you also answered any one of those, you're also correct because all of those, all of those treatments are used to treat a DVT and a P. And I just want to elaborate on that a little bit more. So let me pull up my PowerPoint here. All right, so DVT and pulmonary embolism treatment. So anti-coagulant. So that's usually the first line. So we have unfractured heparin. Unfractured heparin is actually injected into the vein, usually by way of a heparin drip. That heparin drip is titrated by usually the nurse, titrated by MLs based on serial PT and INRs, whether it's every two hours, every four hours or six hours until that number or that PT and INR becomes therapeutic. Then we also have low molecular weight heparin. So that's heparin that's actually injected under the skin. And actually most patients in the hospital to prevent blood clots or DVT while you're in the hospital because most people that are in the hospital, they're not moving very much because they're sick or they're in pain or they've had surgery. So most patients actually do get in low molecular weight heparin injections that cue into their belly or their leg or wherever they want it, but it has to be sub-queue every 12 hours. And we have thrombolytics. So commonly referred to as clot busters work by dissolving the clots. We also have the thrombectomy or embolectomy. So in rare cases, there will have to be a surgical procedure to remove the clot that may be necessary. And that involves obviously removal of the clot or the DVT and from the lungs or from the leg, depending on where it is. We also have the inferior vena cama and this one isn't as popular, but so when anticoagulants cannot be used or don't work well enough, a filter can be inserted inside the inferior vena cava. And that's the large vein that brings blood back to the heart to capture or trap an embolus. And that's what we know now as an embolus is a clot that is moving through the vein from a lower part of the body. So that filter is in place to catch that clot before it reaches the heart or the lungs to cause damage. All right, so let me stop sharing the screen. I wanna actually go back to our patients and let's look at his actual outcomes. Oh, I'm sorry, I wanted to look at his, I'm sorry, I wanted to look at his standards of care. So because of what happened, so in this case, this is what happened to the patient actually during this case in the hospital. So the patient had a normal troponin, as I said, a normal BMP as I said, he had a normal echo. So treatment with simple anticoagulation was appropriate. And it looks like they gave him that unfractured heparin, which was given and that was given as a heparin drip and we'll see that here in the actual outcomes. So you can see here, that's what they gave him was that heparin drip to treat him. So I will stop sharing my screen. So that is the end of our presentation. I appreciate your enthusiasm and your participation and you guys are also smart and it was really fun. I think it is, I guess that's why like medicine and healthcare, someone should like, is putting all of those pieces and those puzzle pieces together. It's like being a detective almost. So now I'm gonna open up the question and answer portion of this webinar. So I will try to answer as many questions as I can. I can put them in a chat. I'll try to grab onto one here and there. If you have any questions, just go ahead and place them in the chat and I will try to answer them. Again, don't forget to go to advanced ADVC shade or chat if you could put that in the chat. Again, one more time for everybody so they could go over to our website and check us out. So don't forget that. Thank you. So there is our website. Again, don't forget webinar 300 is the discount code that we're giving to all new students that aren't currently enrolled for $300 off of our program. You can check out our full course catalog over there at advanced clinical training, learn.adclin.org. And also don't forget that you will receive that one hour of clinical shadowing time. You'll get a certificate to the email that you used to enroll in our webinar tonight and you'll get that within 24 hours. Any questions about the presentation itself? Does anybody have questions about, you need any clarification or any questions? I'll thank you guys so much. I love doing these webinars. I hope you all will join us again. So is pregnancy a risk factor for DVT because of reduced movement lack of exercises or is it due to blood vessels being pushed because of the changes to the body? Like the baby pushing up against the pelvic region. That comes from Ellie. Yes, all of those actually. So pregnancy is a risk factor for DVT because of, yes, reduced movement lack of exercise for some, but also you're gaining weight. And that weight is putting pressure on the pelvis and the lower half of your body. So you're gaining weight. There's reduced movements. And then there's actually just more volume overall in your body because you're growing a human. And so your blood, the volume of your blood sometimes almost doubles. So all of those reasons. Ellie, yes, this makes that a reason that pregnancy is a risk factor for DVT. So was the lower leg edema a symptom because of the DVT? Yes. Yes. So the lower leg edema from this patient he had a blood clot in his leg. So the swelling in the pain because that clot was reducing, wasn't allowing the blood to flow where it needed to. So his leg was swelling because of that. And then that causes pain now because that leg is expanding and it's pushing on the nerves and causing pain. So I hope that made sense. And I answered your question there. So can a PE be mistaken for a heart attack? So some of the symptoms can be similar. So you're talking about chest pain or talking about shortness of breath. So yeah, so if you go to the ER and I'm like, I'm having chest pain, I'm having shortness of breath. First, the first thing they're gonna do is do an EKG. They're gonna draw those troponins to see if there's any cardiac cell damage. The EKG is going to tell you if there is an MI or a heart attack or some type of cardiac issue. So the symptoms can mimic each other but usually when you get to the hospital, they quickly can differentiate the two. But I have seen that some people will have a DVT and then that causes a PE and then that PE that travels through the heart to the lungs has now caused damage to the heart and now the person has a heart attack or they have an MI. So a PE can cause an MI. Yes, so there will definitely be other open opportunities for clinical shadowing, absolutely. Just keep, try to, we're planning more and more and more, just keep an eye out for the invite and our advertisement. But yes, we're doing these more often for sure. So why was the chest x-ray ordered with and without contrast? I've read that studies have shown contrast with those issues for patients in the future breakdown of this contrast. So contrast can cause people to have difficulty breaking it down. A lot of times they won't, a lot of times providers won't even do, won't have a patient receive contrast or IV dye, especially if they have chronic kidney disease or if they have kidney problems because your kidneys, everything is filtered. The contrast is filtered through the kidneys. And so if you have kidney problems, usually you're not going to get contrast, but the contrast is going to give you, they're going to give you better pictures. They're going to kind of light up where that PE is. It's just going to give you better pictures overall, every time with contrast. Esther, okay, is there any way I can get this video sent to my email, my phone die? So we do record all of our webinars. We do post them on our YouTube channel, I believe. I know there will be recordings available there as well. So although his vital signs seem to be normal, there have been something to keep an eye out for as in vital signs, 100%. So yes, it's that. So at this point, this patient was younger. He was what we call compensating. So although he had a PE and he had a DDT, his body was compensating for it at this point, but you want to watch out for tachycardia. So if his heart rate gets above 100, shortens the breath. And then definitely if his pulse oximetry was lower than the normal of 92, 93 to 100% for sure, definitely want to look out for that. So those are the two big things. So a low pulse oximetry and that tachycardic, a high heart rate, and then a lot of times it's low blood pressure to watch out for. But that's usually one of the very last things that you will see. So since healthcare workers are on their feet for hours at a time, is this why they suggest them to wear compression socks? Yes. But also so you don't get varicose stains. Yes, for sure. So yes, just so everybody knows, we will post this webinar in the recording to our YouTube channel and to YouTube, so you can all see it. But we're getting here towards the end. I just want to thank everybody for spending your evening with us and participating. It was awesome. I appreciate your enthusiasm and I hope you all enjoyed it. And I hope we see you again with our next presentation or I hope we get to see you over in one of our programs if you're not already a current student. All right, good night, everybody. Take care. Bye. Thank you.