 Hi sir, one of the EI doctors just wanted to come see how you're doing so could I ask you what made you want to come to the emergency department five days ago on Monday. It got to the point where my chest, heart and ribs all felt like it was in a vise and I just I couldn't wait any longer. Okay so what had been going on before you came in what had been going on with you? Nothing really just I guess slowly got worse and worse and got to the point where I haven't been able to get out of bed for like a month. Okay and what do you mean what was getting worse? The breathing, the coughing, the pain. Okay so you had been having chest pain. What side was your chest pain? This side. The left side? Okay gotcha. So you were having left side chest pain, you were having some difficulty breathing and some coughing, right? It was a non-stop cough and I would cough up almost like a fluid, like a runny egg flavored fluid. Okay but that's and it was constant, that's right it's kind of new something. Yeah and for how long had been going on? Since about a month and a half. Okay. Alright so I am going to stop sharing my screen right now. Okay so based on this patient's first initial symptoms. So you see he came into the ER with chest pain, worsening cough, shortness of breath, lethargy. What do you think could be going on with this patient right now? So I'm gonna pull I'm gonna put up our first pull and you should be seeing that pull and go ahead and answer what you think could be going on with this patient. I see lots of people answering and give you some more time. We're at 75% of our participants have answered. It looks like pneumothorax is winning the race here. We're about 90% answered almost all the way there. I'll just give a few more seconds for anybody who hasn't answered yet. So I am not going to end the poll but I am not going to reveal the answer just yet. I just I'm going to finish playing the video so we can collect some more information about this patient's and then I'll give you the results. How's that been going on? Since about a month and a half. Okay any trigger anything that started it for you? I had a tree branch hit me in the ribs and I think that might have. That's unfortunate. How long ago was that? That was at the middle of August when all the storms started happening. Oh gotcha. I was cutting trees down for my parents. Oh okay. And a limb fell and turned around and swung and hit me and knocked me off the ladder. Okay. So stop sharing my screen. So we now know that this patient had some chest trauma. So I'm going to pull up a PowerPoint and I will share my screen about a little bit about chest trauma so we can learn some more about this. Okay so chest trauma. As we can see here chest trauma can be penetrating or can be blunt. Let me move this box right here hopefully so we can see. Okay so if the injury pierces through the skin such that would happen with a stabbing or a gunshot wound it would be considered a penetrating chest trauma. If the injury does not pierce the skin and muscle then it isn't the main cause of tissue damage you would consider the injury to be blunt force chest trauma. So car accidents and falls cause the most frequent blunt force chest traumas and gunshot wounds and strenuous cause the most type of penetrating chest traumas. Alright so I'm going to stop sharing my screen and before I do that I'm just going to reveal the results from our first pull that this patient did indeed have some chest trauma. So if you picked chest trauma in our first pull then you were correct but the rest of you aren't all the way far off so let's finish the video. Hey Leah, Janny jumping in here. I think we shared the second question of the pull so folks might be seeing slightly different answers than what Leah shared but just wanted to share that with you. Okay oh okay thank you so much. Well let's finish the video and we can always go back. Did you did you get medical help at that point? No, I just took a couple of ibuprofins all the day figuring out you know get better tomorrow. Gotcha. And then tomorrow turned into a week and we turned into a month. Yeah. A month and a half turned into me coming in here. Okay so that was almost one and a half month ago right? Yes. Okay so just a little bit more about like when you came into the ED on Monday your main complaint seems like was chest pain and coughing? Yeah. The difficulty breathing. Yeah the breathing, coughing, chest pain, yes. Yeah what was the pain like? Well pain was probably like around in seven in your eye system. Once they got the tube in and everything it was like a one. Gotcha. But I think it was just because it was hitting the infection and all that stuff. Yeah. Yeah. And anything that was making it worse for you the pain? Moving, moving. Okay. Breathing, coughing. Yeah. Anything was making it better for you? I'm sorry. What were the things that were making the pain better for you? Nothing. I mean they gave me like pain meds it made it tolerable. Gotcha. I think I just been so uncomfortable for so long. Yeah. That everything is extra tender, extra sore. Gotcha. I basically waited too long to come in. Yeah. But you know the pain medication made it bearable and somewhat comfortable. Gotcha. Any associated symptoms like were you having any nausea, vomiting? No, not since I've been in here. Okay. No when you came to the ED on Monday? Yeah no everything, everything was good. Were you having any fevers? Yeah oh yeah I broke into fevers I had pneumonia. Yeah. I was in and out of fevers. Yeah. For how long had you been having fever before you came in? In pretty much the whole month. For the whole month? Yeah I'd been in and out of it but then like two days I'd wake up and pull a sweat. Gotcha. Gotcha. You know but then it'd come back in like the next day. Okay. All right. Do you have any medical conditions? Just PTSD from work and stuff like that. Okay. Have you had any surgery done on you before? Yeah I just gave my left shoulder when I was in high school. Okay. That's about it. Nothing other than that? Nothing other than that. No. Were you on any medications? Well I used to be like on antidepressant and punch that stuff but I got off that. Okay. You got off of that. That's what I thought. That's what actually brought me in to the Guilford one was I thought that had something to do with my life. I thought that had something to do with it coming off of like the Lexapro or in all that stuff but then I started realizing this is more physical than mental. Gotcha. Yeah. Were you having any weakness fatigue? Yeah. I haven't been able to get out of bed in a month. Oh okay in a month? Literally a month in bed. Gotcha. What was your trigger that you decided that okay now you have to come to the ED? I just couldn't deal with it anymore it was just too much. Okay. Which one was the pain coughing or? The pain and the coughing. Both? Okay. Gotcha. Gotcha. And I haven't slept in my three weeks at that time so. Okay. Do some personal questions? Do you smoke tobacco? Like cigarettes? Occasionally. Occasionally. Obviously not since this all went down. Alright. Yeah. So it seems like four days ago you were in the emergency department you had this diagnosis of kind of like a pyrothorax or it's all like blood, some air and some purulent collection of bacteria and you got a chest tube in the ED. It seemed like it was not draining so you got admitted and then you went and underwent a video assisted procedure and you got three chest tubes put in. How do you feel today? Honestly it probably doesn't make sense but it feels better with the three tubes than it did with the one. Okay. Gotcha. I feel so much better. Yeah. I don't know if it's because they drain the stuff. I don't know but it's way less painful with the three than it is with one. Do you think you can see the site where the chest tubes are? Okay. So it's all covered with the dressing so we won't remove the dressing. Alright. That's good. You can put your gown back on. Just going to report the CT scan. Alright. So this guy seems like he's had quite a traumatic injury here. I'm going to let's look at these vitals and demographics. So we have a 40-year-old male. He comes into the ER. We know he has some type of chest trauma. And his temperature is 98. His blood pressure is 123 over 75. Heart rate is 95. Respiratory rate is 22. So the blood pressure is pretty normal. Heart rate is on the higher end of normal. Respiratory rate is definitely abnormal. And we can see here that he had trauma to the left chest, falling tree branch, left-sided chest pain, difficulty breathing, increased productive cloth. Now he has worsening fatigue, some nighttime chills, and pain. So I just want to take a look at, take a kind of a deeper look at chest trauma before we talk about what we would do for this patient. So I am going to pull up my PowerPoint here. So we know that he had trauma. He had blunt chest trauma. And it wasn't penetrating. This is blunt. And this is a sudden forceful injury to your chest and can be caused by a car motorcycle accident, blast injury, or fall. It may also be caused by a sports injury, such as a hit from a baseball. It may be painful to take deep breaths. It may cough and sleep. And so blunt force trauma can cause a pneumothorax, a hemothorax, and a hemo pneumothorax. So just keep that in mind. I am going to go back to our video for just a second and I'm not going to play it. I just want you guys to see something here. So now you know what happened to this patient. You see all the vital signs. Now, I want you all to pretend that you are the clinician, you're the nurse practitioner, you're the physician's assistant, you're the doctor. What kind of tasks are we going to order for him? What's the work I'm going to look like? What are we going to do to fully diagnose this patient? Go ahead and just throw your answers into the chat. I just want to see where you all are going, like how you're thinking and what your thought process is. The chat is disabled. Okay, I see. Janne, can you please enable the chat for us? Yep, it should be enabled now. Try again. Thank you. Thank you so much. So again, I would love to know what your thoughts are. What do you think is going on with this? I want to know what is your work? So you're the PA, you're the nurse practitioner, you are the doctor, and you have this patient. So what kind of tasks are we going to do in the ER? Yes, I see ABGs. I love that. X-ray, CT, MRI, EKG, yes. All of those are correct. I love it. Keep it coming. You guys are definitely on the right track. Chest X-ray, white blood cell count, yep. Yeah, definitely blood work. Definitely for sure. Yes. So you guys are on the right track. I love it. And yep, absolutely EKG, CT scan, blood work, absolutely. Blood cultures, absolutely. Yeah, he has beavers, night chills. Yeah, blood cultures for sure. We need to know if there's an infection. All right, so let me share my screen again. Let me go back here. All right, so let's see what they actually did. Actually, so this is the patient workup. So this is actually what they did in the ER while he was there. This is what they did. So you all were on the right track. CDC, the complete blood count, CMP, we did a coagulation panel. I'll tell you about that a little bit more if you're unfamiliar with it. And the next here, shortly, a type in screen, EKG of course, chest X-ray, chest CT blood cultures. So you guys were definitely on the right track. You were, you know, definitely, definitely on the mark. Let me pull this up. Let's move on. And we can see that. Oh, let me go back. Sorry about that. So the medical diagnostic workup, you can see vital signs. So obviously, that's obviously that is number one. When you first come to the ER, we're doing all these vital signs, right? CBC is the complete blood counts. This measures several components and features of your blood, including your red blood cells, your white blood cells, your hemoglobin, which is the oxygen carrying protein in your red blood cells, your hematocytes, your platelets, which helps with blood clotting. You're also going to do a CMP, which is a complete metabolic panel. And that provides really important information about the body's chemical balance and metabolism. It shows all of these things here, your glucose, your calcium, your sodium, your potassium, your carbon dioxide, your alkaline phosphate, all of your liver enzymes. Also, the BUN, which is the blood urea nitrogen in the creatinine, and those are indicative will show how well your kidney is functioning. These coagulation panels, so that's when we're talking about the PTNINR, and that test measures the blood's ability to clot and how long it takes for the blood to clot. Type in screen, so the type in screen determines both the ABO and RH of the patient and screens for the presence of most common antibodies. So if you're in the ER, if you're working in the ER, these are all things, blood work that's going to happen with most patients. The type in screen has to be done before a patient's, well, I shouldn't say has to be done. Should it be done if it's possible before the patient receives a blood transfusion, but there are times in especially level one trauma ER when you don't have time to get a type in screen and you're just mass transfusing blood, but that wasn't the case here. But if there is time, yes, you definitely want to collect a type in screen. We're going to also do an EKG and that is an electrocardiogram records the electrical signals of your heart, the chest x-ray, of course, and then a chest CT. And that CT scan is obviously it's an imaging test. It's going to give you better pictures than a chest x-ray does. And what's different about the chest CT and it's very kind of hard to explain. So if you would imagine a patient is lying on their back, which is the supine position, the CT takes pictures of sagittal views. So it's like if a patient is lying on their back, the CT if you would just take a slice of a patient, a slice of a person. And then you're viewing it like this. This is that's how a CT scan reads. And I'll show you a little bit more about that. And I'm not a doctor. So I am not allowed to actually interpret those CT scans. But you know, being a nurse for so long, you just learn to look at them and know what how that is, how the pictures are taken. Okay, so moving on here. I did. I definitely wanted to move on to our blunt force trauma. So again, we know about this blunt force trauma can cause the pneumo, chemo, and hemi pneumo thorax. So what I know, what do you think the real diagnosis is for this patient. So I will stop sharing my screen and go back here. And let's see if we can pull up. So this was the first question. And we'll see if we can get to the second question. I don't know why it won't. So this was really the first question and we went backwards, but if for the first question, yes, chest trauma, rib fracture. And we went backwards, but yes, this absolutely this is chest trauma. For sure. And pneumonia is not wrong. He did also have pneumonia so if you pick pneumonia you are definitely not wrong. 76% of you answered I am going to end the poll here very shortly in a couple of seconds but yes chest trauma we know that. If you pick that you are not wrong either because yes he definitely did have a pneumonia. So we're all thinking you guys are all in the right track. For sure. So I am going to go ahead and end the poll. So chest trauma is great. I'm going to move on here. I'm going to share my screen. Close that door so the actual diagnosis for this patient after the whole workup that we did and you guys for all did so well with trying to figure out what kind of test we would give to this patient if you were the clinician in the day that night, or that day. So this actual patient's diagnosis was left-sided, loculated, infected, hemo, pneumothorax. So those are really big words right there. Loculated, we didn't talk about that yet, and hemo, pneumothorax. I want to pull up my PowerPoint here and I can see it. I kind of just put this here as left-sided, loculated, infected, hemo, pneumothorax, and this is a combination of two medical conditions which is a pneumothorax and a hemothorax. So a pneumothorax, which is also known as a collapse lung happens when there is air outside the lung, in the space between the lung and the chest cavity, and a hemothorax occurs when there is blood in the same space. You could imagine that now the lung is totally compressed and the lung cannot expand. So this man really could not even breathe on that side. So it makes sense that he had chest pain, that he had shortness of breath, that he had fatigue, because there was not enough, his lungs weren't making enough oxygen to refuse to the rest of his body. So now loculated, what does that mean? So loculated means having forming or divided into loculite or loculated pockets of fluid or pus, which is usually infectious in the lung. So if you said pneumonia, you aren't wrong with that because he did have pneumonia because there was an infectious component to this hemo pneumothorax. So I'm going to move on and show you some pictures of that as well. So here this will give you a good idea. So here all the way on the left hand side. An image of healthy lungs. The normal lung, the visceral pleura, the chest wall, where the diaphragm is, these are healthy lungs. Here's a pneumothorax. So again, this is when outside air enters, it enters into the lung space due to a disruption in the chest wall and the parietal pleura. Yes, you can see your image. I'm sorry, thank you so much. Let me go back. Thank you for that, Gianni. Can we see now? Yep, I can see it. Perfect. Okay. So let's go through this again. Okay, so here is an image of healthy lungs. So here you can see your normal lung, the parietal pleura, the visceral, the chest wall. The next image is of the pneumothorax. So you can see there's air that enters into the chest wall and the parietal pleura because of some type of disruption. And that's when the lung collapse. You see how it kind of shrinks and shrivels up. The next is the hemothorax. And this is just when blood enters the pleural space and that can happen for the same reasons. It could be for chest trauma, blunt force, or penetrating. But this, this poor patient here, he got the double whammy. He got the hemo-nebothorax. And that's when both air and blood enters into the pleural space. So that is why this man was having such a hard time breathing. So how do we treat this patient? So now we know what his diagnosis is. We know what's going on with him. How do we treat him? So I will stop sharing my screen here. And I will go back to our video. So our standards of care. So we already talked about the workup. And again, you guys were all on the right page thinking about that. So the suggested treatment. So immediate chest tube insertion by thoracic specialists in the ER, it's mostly the trauma surgeon or the ER doc in this case that he's a trauma doctor. But in the setting of the loculated collection of VACs and antibiotics were indicated. So if you remember in the video, in the video it said that he initially had one chest tube placed in the ER and that can be done at the bedside. It's not an easy procedure. And the patient is usually awake when this happens. But you're doing that emergently to help reinflate the lung and to drain the blood off of the lung. But we now know that he ended up with three chest tubes and how and why did that happen. So before we go on to that, I just wanted to show you a little bit more about chest tube placement. So we see here that he had the chest tube placement to the left side and it's treatment for the hemothorax and that's obviously aimed at draining the air and the blood in the chest with the hopes to returning the lung to a normal functional capacity. And then the procedure involves placing that a hollow plastic tube between the ribs into the area around the lungs in order to drain the air and the blood. The tube may be connected to a machine to help with drainage. I just want to make sure that you all are being my screen. Okay. So he needed then to go on to have a vass procedure because he had the chest tube placed in the ER and apparently that wasn't draining enough. It wasn't helping enough. So he needed to have a vass. It's a video assisted thoracoscopic surgery. So this is when the patient actually goes to the OR. They, you know, give them a probably like a general anesthetic. Enduring a vass procedure, a tiny camera and surgical instruments are inserted into the chest through one or more small incisions in the chest wall. And the thoroscope transmits images of inside of the chest onto a video monitor, then where the surgeon or the thoracic surgeon can see performing the procedure so they get a really good idea of really what's going on with that patient. Just move on. And this is kind of what you can see a chest tube look like this patient. This is not our patient that we were just seeing on the video. This is another patient, but this is a patient with a chest tube. He has one. Our patient ended up with three. But this tube is then connected to this device here. It's called a porovac. It doesn't all look like this, but they mostly all do. This is just the most one of the most common. And then this instrument is connected into the wall in the patient's room where there is suction and it's kind of pulling the air and the blood out into this container and then you're measuring the drainage every eight hours. So, but as we saw in the video, our patient had three. He started off with one in the ED and then apparently that wasn't working and maybe it was like the next day they took him back to the ER. I'm sorry, back to, they took him to the OR to do the VATS procedure and just a little bit more about his treatments. So let me stop sharing here. I wanted to go back to the video first. So, what were his actual outcomes? So the left chest tube placement followed by the VATS, which we know, but then he needed frequent installation of TPA through the chest tube to help break down those locked relations. So, why did that need to happen? So this patient was pretty complicated. One, as we know, one chest tube was not helping to reinflate his lung and drain the blood out of the space. That's why he needed the VATS. And with that VATS procedure, the surgeon was able to have a better view with that camera to see actually what was going on in the lung and probably saw these loculations. And let me show you a little bit about that. So again, these loculated, having forming or divided into pockets of fluids. So these loculations can complicate a hemonomer thorax by preventing adequate chest tube drainage. So that makes sense that he had the chest tube place in the ED. Maybe the next day it was, they could see it really, he wasn't responding to that as he should. So he had the VATS procedure done and they could see that he had these loculations. And so how do they get rid of these loculations to help adequately drain the air and the fluids so we can return the lung to its functional capacity. So they instilled a TPA through the chest tube to help break up the loculation. So the loculations are very hard. The TPA is a very powerful naturally occurring protein found in endothelial cells and it activates the conversion of Plasminogen to Plasmin, which is an enzyme responsible for the breakdown of the plot. The TPA was then injected or instilled through the chest tube into the lung to break down these loculations, allowing the blood and the air to drain and return the lung to its best functional capacity. So let me go back to a video and we can see here that that is exactly what happened. The patient spent 20 days inpatient and that is a long time, especially this day and age. Nobody spends 20 days in the hospital unless you are really sick or you have a lot. There's a lot going on. So he spent 20 days in the hospital, but apparently he made a full recovery. So that ends our presentation here. I hope you all really, really loved it. I know there's probably a lot of questions, so I will open up the question portion of our session. I won't be able to answer all of them, but if you have questions, you can put them into the chat and I will try to grab on to as many as I can. Please, before that, don't forget at the end that we will provide you with that discount enrollment code for $300 off of enrollment into any one of our courses if you're not already a student with advanced clinical training. And also we have a post session survey. We would love for you to fill out. We'd like to collect, you know, just feedback from our audience about our webinar, how we can make it better and also if you want to suggest any topics that you would love to see us present in the future, we would love to hear from you. So what are some of your questions? So, I see was the pneumonia secondary to the trauma, I guess. So the pneumonia was secondary to the trauma. Anytime you have fluid collecting into the lungs, there is fluid or matter, I should say, there is potential for pneumonia. So, yes, the pneumonia was secondary to the trauma for sure. Any other questions? Let's see. I am trying to get to them. I can't, I see like there's more questions coming in. I can't see them all. I do appreciate you all spending your time here with us on a Friday evening and attending our webinar series. Again, if you're not already a student here with advanced clinical training, we'd be thrilled to have you webinar 300 is our discount enrollment code, Jenny, if you could please place that into the chat for everybody. That would be helpful webinar 300. So that is our discount enrollment code. You will also receive a certificate to the email that you use to sign up for the webinar for one hour of clinical shadowing because you joined us and we're so happy that you were here. Any other questions? Does anybody have any other questions? I do have a question. What types of symptoms should folks look out for when you're looking at possibilities for things like pneumonia or any sort of chest issues? And at what point should you go to the ER? We always tell people if you're having chest pain or shortness of breath, you should always just go right to the ER. There's no, you know, if you're at home, you're, you know, you're, you're a lay person. You know, you have chest pain, you have shortness of breath, you go right to the ER because that could be anything. But, you know, worsening lethargy, if you have a fever, definitely fever, fatigue, shortness of breath, all things pneumonia related. If you have a productive cough, if you're coughing up, you know, blood, obviously, even if it's just a small amount, people don't generally just cough up mass of the balance of blood. It's usually like, you know, the sputum is usually pink tinge and, you know, people don't think, well, maybe this is okay. I mean, it's not that bad. Definitely you want to go to the ER, but fevers, chills, lethargy, feeling fatigue, all of those things. Definitely you want to seek medical attention for right away. Thank you. Thank you for the chat as well. I don't see any additional questions. I know I see a comment about a question related to our training program. So if you can put that in the chat, we will do our best to answer it. If we don't have an answer today, we will follow up via email. But please feel free to post any questions related to either today's session, or if you have any questions about any of our certification programs. Yes, please do. So what happened? What would happen if there was no electricity? Anyone have been able to use the plurivac to drain the blood and air? So this patient was in the ER. That's a good question. This patient was in the ER. Probably a level one trauma center. If they weren't, they're being transferred to a level one trauma center. A level one trauma centers have backup generators. So if the electricity ever does go out, there's backup generators. So there is always electricity. There's always electricity. So it was maybe not draining the blood and the oxygen because of the loculations. And so that is what ended up having this patient go to the OR to have a VATS procedure. So this is another question. Is there any labs on the phlegm the patient was coughing? That's a good question. So there are things called, there's something called a sputum culture. And so usually the patient, if they can, they spit their sputum into a cup and they send it to the lab and any type of culture, whether it's a blood culture or a sputum culture, any culture, a wound culture. It takes at least three days for anything to grow. So we generally, if we think a patient has some type of infection like that, we generally treat them with a broad spructum antibiotic until the culture grows the specific bacteria. And then we know what specific antibiotic we use to target that bacteria. But yes, there's a sputum culture. Yes, we do use sputum culture. He said that it took him a month ago. Is that correct? It did take him a month to go to the ER. And we see this often. I mean, you see people come in and say they've been having these symptoms for two weeks and then you do work up on them and you find out they have these major things going on and you wonder how they survived like that. It sounds like he was a young guy, 40 years old. He didn't have many comorbidities. He didn't have other health complications. So his body was compensating for a period of time and to the point where he just couldn't take it anymore. He went to the ER. He probably should have gone right when he had those symptoms that generally men in their 40s aren't running to the ER. I mean, I don't want to, you know, you don't want to categorize people but, you know, they want to, they're tough. They don't think there's something wrong. They can handle it. And then this is what happens if you wait that long. What happens in volume after how much blood loss would blood transfusion be warranted? Well, that's a good question as well. It just depends on that what we call your H&H, a hemoglobin and hematocrit. If we have time to get that then usually if the hemoglobin is below 7.0 is when there's indication to replace the blood with a blood transfusion. But in this instance, but in the instance of a trauma where you know there's already been massive blood loss, you're not doing that blood work. You're just mass transfusing because you already know. A lot of good questions. I'm glad you guys are pointing things in the chat. I'm so glad to hear that you were so engaged. What preventative advice would you have provided to him? Well, I don't know if we could really prevent this type of injury. I mean, this was an accident, right? He was cutting down trees for his family or his parents because there was a storm. And so you can't really prevent these things from happening. Like you can't really fully prevent a car accident. You know, you can't really fully prevent an assault. I mean, you can try to keep yourself out of these situations, but sometimes they just happen. They're accidents, you know. Of course, there's preventative advice you want to give to everybody like you don't smoke. Well, if you, you know, likely if you weren't a smoker and you had this type of injury, you're going to have a much better recovery. If you are healthy, if you eat healthy, if you work out and you don't have comorbidities that are preventable, then your outcome when you have one of these accidents are going to be much better. So will the slides be posted in the email for certificates? So no, we're not going to post these slides. We do record these and we post them. I believe we post them on our YouTube channel. But you will again receive a certificate for one hour of clinical shadowing and that will be sent to your email that you use to sign up for this webinar. Leah, I just want to quickly acknowledge a question about full scholarships. Affordability continues to be at the center of what we do for pre-health and pre-med students. So we do offer discounts and payment plan options for people who are students who are looking for those opportunities. Unfortunately, we don't have full scholarship for those who are looking to enroll in any of our programs, but that's something that we are working towards in the future. Yes, yes, definitely. At this time, we don't offer any federal financial aid or our full scholarships, but our programs are priced to be very affordable and we do offer payment plans. And we do offer another assistance through another loan program that's kind of like a private loan, but that is, you know, we can certainly provide information, detailed information for that if you would like. Leah, I see another question in the Q&A box. What is the typical amount of time someone is in the hospital for and why do you think this patient stayed for a longer amount of time? Well, it's hard to say what the typical amount of time is for this type of injury because every patient is different. And with this patient, he had a complication, right? He didn't have just a pneumothorax or a haemothorax or a hemonymothorax. And the fact that he waited so long to come in, then he also had pneumonia on top of that. So he really, that was the complication and that's what kept him in the hospital as long as it did. You know, all of the loculations, having the three chest tubes, draining the blood and reinflating the lung. All of those things is what kept him in the hospital for 20 days and had he come in sooner when he started having symptoms. He, you know, would have been in the hospital for a lot less amount of time for sure. I'm going to give you something in the chat about what kind of discharge instructions would you give to the patient. So I'm sure this patient was probably sent home. He completed, I'm sure, at a course of IV antibiotics in the hospital. He's probably sent home with oral antibiotics. You always tell those patients, make sure you finish all of your antibiotics. Even if you start to feel better, you want to finish them until the end. You definitely want to complete your follow up appointments with all of your doctors, which is probably a pulmonologist, which is a long specialist. He probably his primary care physician and obviously the cardiothoracic surgeons that provided care with the chest tubes and the best procedures. Definitely not smoking. He might have had to do some cardiopulmonary rehab just to get that long working again. So just to follow up with all of, make sure he's following up with all of his appointments, refrain from smoking and being exposed to secondhand smoke, definitely immune support with through eating healthy foods and probably taking some type of vitamin supplement as well. And then also, of course, if he had any type of, you know, reoccurring symptoms, which would be the same like chest pain, shortness of breath, fatigue, fevers, seek medical attention right away. How do I feel about antibiotics being used in everyday medicine, although there have been reports of antibiotics killing gut flora. So that is a very, very good question. And there has been a very big shift. When I first started nursing, it was like everybody, you know, they had the fever, they had this like, you just put them on antibiotics. Now there's been a big shift that unless we know for sure that the patient has some type of infection through whether it's we've confirmed that through blood cultures or a urine culture or sputum culture or a wound culture, we're not just prescribing antibiotics because there is the concern of antibiotic resistance. And so that is why we are confirming with these types of cultures to make sure we're not over prescribing antibiotics for sure. And antibiotics can kill your gut flora. So it's killing the bad bacteria, but it's also killing the good bacteria in your gut and not some antibiotics are worse than others. And please don't anybody ask me exactly what the names on of those are, but I generally tell people if you can take some type of probiotic while you're taking your antibiotic that's always a really good idea to add some of that good bacteria back into your gut. While you are killing the bad bacteria that's causing your problems. Right. Yeah, I think we have time for one more question. And it is, what complications would we need to be aware of specific to the lung re inflammation surgically and medically. Um, so those same. Nothing new just worsening chest pain. Shortness of breath, a high respiratory rate and fevers chills. Low oxygen saturation. Those are all things you would look out for a high a fast heart rate because your heart's trying to compensate for your, your breathing so attack a cardiac would be one as well. fatigue so all of those things would be something you would want to look for in a patient that is not responding to initial treatment. So it is 559. I really just want to, again, thank everybody for joining us here with advanced clinical trainings web webinar series. I hope that you come back and see us again real soon. And our 300 is your discount enrollment code. If you're not already a student with advanced clinical training, please go over to our website and take a look at us. We would be thrilled to have you here. And again, you will receive that certificate for one hour of clinical shadowing and please don't forget to please don't forget to fill out your post session survey. So we can collect feedback from you and also please provide to us any topics that you would like for us to discuss in the future by everybody. I hope you have a wonderful weekend. Stay safe.