Transcript

0:11

This presentation is on, we're looking at critical checks, looking at the vital side of assessment. And this is an area that you have to you're like, we go through the process and think about what that when you're when it's appropriate to do certain vital signs, That always becomes a question mark or question during an assessment process. It has been also not doing essential checks that may be overlooked and then doing a reassessment. So this is what we'll we'll cover and say. This is gonna be a rapid overview Just know when you go back, if you were rewatching this video, you can stop, look at the video, look at the vital signs.

0:52

There's a lot of information that will come in a very short time period. And really just hitting on the hot points here. So, hopefully, this is a good review, and we're going when we look at the the these these areas. So, again, my disclosures. And, again, pretty simple.

1:09

We're gonna look at review this patient assessment process you know, timing of we can talk about the vital sound assessment when you do this, but also identifying typical and atypical ranges. We're gonna try to cover that best with Ken. We'll have some areas. We drop in here again. Again, if you have any questions, as we move through, go ahead and just post them in the in the chat.

1:30

And we will get to those at the very end if you answer or ask a question 2 minutes, you know, into the presentation or 2 minutes before the end. So, again, this is a framework we're looking at. Again, this focus here is on this component of the bot this this presentation is on specifically on core vitals and additional diagnostics in the secondary assessment. You've ruled out the initial threats You're now moving into we need to validate this information as to what we what we're looking for. So in this, we've done that seam size up, and this is a different way of looking at this.

2:10

We've gone through the primary assessment We're looking to determine those life threats, and we are addressing the life threats first, as you see on the left left. So circulation, airway, breathing, If those are problematic, we have to address those. Otherwise, the no matter what we do is is intervention, but we still have to look at we all we do have to get vitals. And then we get into secondary issues. So we were just gonna jump into vitals on assessment, and then we're going back into, you know, again, where this comes back in, and it's a cycle where you're moving back through, you're getting your history, you're moving back through a part of your physical exam, You come back and do a recheck on vitals.

2:49

And again, if it is an emergent situation, then medical or trauma, you're doing 5 peak intervals. If it's not emergent, then you can do a 10 extended out to 10 minutes after the first time you've done that. It means they're stable for the most part. So they're stable. They're not regressing in symptoms, etcetera.

3:12

So with that, so let's talk about so, again, we're gonna hit on these this morning. The ones you see here in the middle. Heart rate respiration, SVO, or pulse oximetry, blood pressure, CVG, or blood glucose levels, lung sounds, pupils, and skin. And so we're gonna tackle these in a pretty rapid fire mode for the next 20, 25 minutes. So heart rate.

3:38

Again, multiple locations, infant, is it the brachial others? Other populations or at the radial pulse, that's where you typically check. If the the you know, some people say, oh, go check a carotid pulse. Well, In the case of CPR, you're going to check you're doing a quick assessment there if you're BLS. From a provider standpoint as a CPR process.

4:06

What and, again, this is an indicator if they if you do assessment with someone and you have a rapid based on the type of pulse they're having, you're easily and rapidly determined is this person presenting in a introductory the the pre shock or the early onset of shock or they're having a significant issue right now and we know if they're going into shock. They are they're decompensating. They have a lack of blood flow. We need to identify what that is. This is just a good chart to see just to know across the lifespan how we and, you know, if you have children, or a neonatal on up to adult.

4:47

This is what this looks for. So, again, early on, basically, a 100, a 120, but we've talked CPR moving up to, you know, 60 to a 100 typical for adults. Anything over a 100 becomes in a in a resting state is tachycardic. So that becomes problematic in itself. So when we think about that, when we think about what the context of the heart rate is, Think about where if it's strong, if it's weak, ready, where rapid shallow, regular, regular, regular, we need to note that what that where that is.

5:22

Respiration rate is we're thinking about the quality. And, again, 12 to 20 and you get as younger, you know, the as we get younger, you have a higher rate. And this is important from a resting standpoint if you have a someone who is hyperventilating or they are hyperventilating. So just as a quick note here, And this is a whole another take on we could do respiratory emergencies. We've got, you know, presentation on that separately because you needed more in in respiration versus ventilations.

5:56

Is that when we're at rest, like you and I are we're sitting here, you watch this presentation. Your breathing is controlled by your c 02, the chemical receptors in the in the brain and within the in the brainstem. So you're looking at carbonic drive. So when you breathe, it is simply it's helping control to control the CO2 versus if you're having hyper ventilation or hyperventilation. You're trying to you're controlling that in in hyperventilation.

6:29

We've blown out too much CO2. And so now we have to be a deliberate process of controlling that. So it's really important when we look at the context of respiration rate, that we think about what's the what's the activity intensity level? What is the environment? Is it hot or cold?

6:47

Or kind of a regular, you know, an ambient temperature is comfortable. Think about their their physical status and a current illnesses which also gets into age is an is an issue. Do they have any comorbidities? So and then, also, what is this overall situation look like? Why are the what's the context?

7:10

Did they just almost are they becoming, like, the flight of flight of flight response? Are they did they have something? Are they stressed? Or do they have emotional stress or they, you know, went to a a a scary sit you know, intense situation, etcetera. So that's gonna elevate heart rate, but also it trail it it also follows other things along.

7:34

So we're looking simply normal, shallow, and labored breathing, if that's the case. So what is normal? Like and I shared this with you a different take on this than a slide standpoint is we look at the at pediatrics because they do decompensate at a much greater rate than adults. We typically see adults, but Neil becomes a little bit different pros not different same process. But, you know, it's gonna go on patient age and medical history.

8:03

Again, we talked about before. Do they have a patent airway? What's the normal for their age? The age adjusted? Are they having normal chest movement or are they having chest compliance is that they have a chest injury.

8:16

They're not going to move once and they have difficulty breathing. So that's going to affect whether or not they're normal, shallow, labor, also the rate other medical conditions going on? Are they having a metabolic issue or or ultimate multisystem trauma so to refer to that. So, again, if you have a problem with your heart, like a blockage, it may also affect oxygen to the Right? Now you have other chemical issues.

8:44

And if you're not breathing, you may be you're increasing the c 02 in the system. And then also then you start having acidosis and you get this other, you know, other metabolic cascade going on. So, again, mental status is a good indicator from a, like, glass glaucoma scale, think about what they're sitting in an Apu, what that looks like. Based on how much the weight, whether you're breathing normally. And then anything above SPO2 above 95 96 or 96 above is is considered normal.

9:15

From an emergency medicine standpoint in skin in skin temperature. So, like, what's abnormal again We think about how that exchange of oxygen and ventilation, the difference there, and understanding there, we're simply getting air in and out. This is what respiration rate is really referring to. It's not referring to what where what is their respiration? How how efficient are they are?

9:41

They're having problems with cellular respiration or pulmonary respiration route. I don't think it'll be older getting but oxygen and carbon dioxide elements in and out of the system of the body. So here, just a quick review, thinking about what their breathing rate is, and, you know, they're having increased rate, tat mea or brady brady nea is lower below 8. Think about what the conditions are there. It's absence of an apnea or moving the the, you know, the different breathing side as well.

10:15

You're looking at something like somebody who may have diabetic, which is common for a diabetic ketoacidosis. They're having cosmol breathing, and they were doing an array rapid and a very consistent rate Think about these additional players that come into play that are causing this problem, their brainstem involvement, etcetera, potential for spine injury, etcetera. So ventilation versus respiration, again, it is the process of moving air in and out. So we think about respiration This is what we're looking at that rate, what that looks like. It's not telling the full story, but it's definitely giving us some indicators that something is not right.

10:54

It definitely with CO2 and oxygen. At the at the end of the day, whether in the body, it's local, or they're just trying to they've gotten excited otherwise. Here, think about respiratory component. So when that's kinda respiration rate that really is not a you know, it's we use we don't say ventilation rates, but typically, say, what's for aspiration rate? It's really about ventilation.

11:18

But it does have an indicator of what these internal and external the the release of of gases in the body. So we're moving We're ventilating in and goes into the pulmonary, and we're moving right back down onto cellular and coming back into the system as well. What that looks like. So something also important to note is what from a history standpoint is What are easy ways? Not easy ways, but this is how you disrupt ventilation.

11:50

If you have head or brainstem trauma, if you have a pneumothorax, Again, their inability to breathe, their move to chest wall, but also you're having a pressure gradient change. Bronchospasm, asthma, or you have a a nasopharyngeal or pharyngeal collapse due to trauma. Those are easy ways to disrupt the breathing from a normal with the air changes. And, again, the right different ways you look at that. Again, you're looking at airway patency disruption.

12:21

That's very that's different than having something like you may see with asthma where you're having a vasoconstriction and a reduction and also increased mucosal in the airways upper airway. Versus respiration is it's gonna think about how it gets into it's at the cellular level. Altitude sickness. Again, that's 1. It's ambient air control patients who would have COPD or emphysema.

12:49

Is problematic. Carbon dioxide poisoning, cerebral vascular valve cardio infarct, Think about where that's a that's a structural blood flow obstruction. And then maybe for, like, we may so commonly see as abdominal trauma or you have a thermal fracture, you're having hypovolemic shock. And that's where we're changing the blood flow in the body. Now we're causing other problems to occur.

13:15

So here's this little device called the pulse oximeter. You've all seen this. This is probably the the most undervalue, I think, just from undervalue device that we have available because it gives us so much information that when if I if I have a, you know, athlete, I have it in my kit, in my fanny, in my pack, I have a blood pressure cuff, I have stethoscope, I have the pulse oximeter and that in in a glucometer. So I have those things there because I can put in my fanny pack very easily under the pouch with the with the blood pressure cuff. And it just pat it it just packs a wallet.

13:56

It's very you know, we sit we saw this a lot because of everybody talking about for COVID. But, again, we're looking at the hemoglobin saturation of oxygen in the hemoglobin saturation. So normal is 96. So on this chart, we're looking at is there in the presence of other things, it just says, hey, they are below 96 or they're above, and and especially for trauma situations. If I had a fracture of a lower a possible lower leg fracture or a pelvic fracture, then if I put this on, is it 94?

14:27

I know this is this person is trending towards they're decompensating whether they might be showing it or not other than pain. So with that being said, we need to also think about Oxford Administration, or we need that, you know, other how the our person is also presenting with increased respiration rate, etcetera. But the context of that Also medical is at 94%. So it's a little bit harder to see that. But again, on the pulse oximeter, you're looking at the part the the heart rate, you're looking at how much oxygen is at the perfusion level or or that.

15:02

But also, you see that little waveform. The the it's looking at the pulse wave and telling it tells you how if it's what that looks like from a poll from a journal poll standpoint, is it is it threading? Is it lower? It'll give you those that reading there as well. So this is the thing to think about that gives you a couple of different things.

15:20

It help rapidly to identify and streamlines what I need to do to take a pulse, I don't mean to talk about taking a pulse. I just slap this on the person on the finger, and it moves with that. And again, below 90% is an emergent condition. Excuse me. Blood pressure is also another one.

15:40

You know, it's again it's either rest or or diastolic, you can either do a with a stethoscope, or you can do one with a pump doing a blood pressure. If you don't have a stethoscope, You can take the blood pressure cuff and use it palpable blood pressure, and you could just you're getting this that that at one sign, but it also at one value, but it is very valuable nonetheless. We're looking at one you're not getting the full value that you would normally think that, but it is very valuable. Any information you get is valuable. Again, 120 over 80, is normal for an adult, slightly lower, you know, changes there for adolescent we may look at versus a preadolescent, etcetera.

16:27

We're doing within a in a sports setting. It's important to know what those values are. We would get into other things as terms of, hey, what do you have a pediatric treating the pediatric patient is a whole another set in itself just because of how they present from the from a triad of of how their presentation is and what their what they're presenting with. So know that they do confidence decompensate very rapidly. Skin color and temperature.

16:56

Again, pale. They're cyanotic, flushing. They're modeling at a gray blue. You know, from a perfusion standpoint, you may see that with that looks like overall, the temperature is either hot, cool, or cold. If it's cold, you're looking at environmental issues versus they're cool, they're hypo perfusing.

17:15

So you think of gold clammy skin. They're cool. It's wet. They're they're sweating, and they feel kinda hurt clammy, and they they may have a pale color. Pale cool cleaning.

17:27

That looks like from an early shock on. So you see in the context of this picture, it looks like this is a military personnel, they've been doing physical activity, is it normal for them to be sweating? So if I'm sitting here and I'm sweating, Then the first question is, what's the temperature? And temperature is 70 degrees, then I'm thinking about what the why why? That's abnormal.

17:49

So We wanna take that in the context of what that looks like for a person. What's also important, like, for example, you if you work in during sedans, etcetera, or they've been outside for extended amount of time is what the context is for blood pressure and respirations, all those things. So, like, for respiration, like, for heart rate, for example, I'm gonna go back on this. You look at temperature. If they have an elevated heart rate, skin temperature is probably gonna be up there as well.

18:15

It kinda has this drag along effect. But just be aware of what that what those would look like. There's a people assessment. Really simple. We're looking with it, you know, with it without the using a penlight.

18:28

Again, if there if there's dilated, you're gonna be thinking potentially of drug stimulants, like amphetamines, could be cardiac arrest, constricted? Are they having a lack of narcotics or CNS? They're unequal, could be you know, they have it could have anesthesia that's one thing to be aware of. Is this normal or abnormal having an equal pupil size? Or are they having a CBA or head injury eye trauma?

18:53

Or they're nonreactive. They've had a full blown cardiac arrest. They they they they're an asystole. They're overdose. Have a brain injury, etcetera.

19:03

That's we're looking at very significant level there as well. And then you can think about nystagmus as well as an involuntary movement. And then you can also look at what about horizontal movement vertical move, how they're looking. You set see that a lot normal, like, for horizontal. If they're adjusting, like, for example, field sobriety test, they're looking at what they get It was automatic, but they're sitting here that's and the body is just compensating, you're getting rapid movement, and they're also having other things as well, what they're showing up as well.

19:31

Lung sounds. Lung sounds, you know, it's really Lung sounds are very simple. And this try to demystify that. You have to put we already do the auscultations on the on the arm, and you're simply listening for these basic sounds. So This shows a little bit more detail if you've had the ability to, you know, you have time, you can do a full assessment.

19:54

But the most part though, you're looking up above the collabicals. And you're listening for Strider. That's that that really hot pitched noise, like an airway upper airway blockage versus you're using wheezing It's coming more in the within the lungs, and it has, like, for example, asthma. They're dicks. You hear that deeper voice or something?

20:15

You see the difference there like strider versus the wheezing is it deeper as well. You can hear that very easily. On if someone's having that distress, but you have to identify that you've done that, and you can if otherwise, if they're normally breathing, you and they have no you can say they're normal breathing even with the lungs, you know, not recognizing as well, And then crackles, and then, obviously, the last one, you think of grunting or snoring. You may see that someone who is unconscious. Have had a, you know, had a have been knocked unconscious or they are unconscious.

20:52

They maybe are a a grunt or snoring where you're hitting that that jaw is moving backwards. In that case, you may have to do a jaw thrust, which is recommended in anyone for seizure, or they're having potential cardiac arrest, or you recognize that. You hear that. Do a jaw thrust maneuver initially stabilizing the head, and that that may resolve even breathing issues from being moving in from apnea to having normal breathing versus they're not going having to go into cardiac arrest. Early one with there.

21:22

So, again, you'll hear typically do a 4 point from I'm gonna do a 4 point up above I'm looking the upper lobes, and the middle lobes, and just keep in mind that the right lung has 3 lobes. Left lung has 2 lobes. And in the middle is the medial stentum where you have the aorta, you have other, you know, the heart sitting over here at the lower side as well. So just be aware know that you're gonna do those. You can drop down to the lower level as needed to, but you're really thinking about from a trauma standpoint, Are they having difficulty breathing up?

21:56

Can you hear it? Can you have in the middle areas as well? Can you do it in the very systematic? And then you reverse that in the on the posterior side. In the same areas.

22:06

So what is that what is the long you know, they're they're thinking about breathing you know, from respiration and when your sounds, you know, is it they're looking at it. And and again, you know, I apologize. This should have been pushed over. But just to go back again, Think about what those you know, pull this in also. Think about what's the problem of supporting?

22:26

Is it exertional? That they fry these vital signs change, and this gets into rapid pull. So I apologize about this. But they also give us a good I'm a change this presentation a little bit just to really indicate what are these common things that we're looking at, not just for heart rate, but also for respiration rate. What is causing this person to have those what's causing this and where they're interrelated.

22:53

Capillary glucose, blood glucose. We're thinking one of the values of this in a per who has altered mental status. This is where this without knowing they are hypoglycemic or hypoglycemic, if they are hypoglycemic, you're going to you're going to be able to rapidly determine if it is of a blood sugar level. If you can't get a history from them, And from that, it's rapidly treatable. So you can get push them, you know, Google gone or if you had that that level or you just have glucose or you're having, like, something sugar or liquidy, you put it in the cyst, put it in there.

23:34

Or if they're having some decremental status or a slurred, then you can actually put it on your finger and, again, rub it on the on the gums without pushing it into them. Again, we're just it's gonna rapidly take care of it. And typically, it's gonna in 3 to 5 minutes, you're gonna see a response. That that I I know that I've seen that on numerous occasions, it comes around, and it just likely it jumps back really fast. So Again, turning thing about what that looks like.

24:02

Typical accepted values for Mercy Medicine nationwide. This is national nationally accepted value is typically 70 to 120 is a normal range. If they're in that lower they get below 80, you're gonna start seeing those you're gonna start seeing altered mental status versus okay. I need to move it. You may see some protocol there in 60, but you get down into sixties.

24:26

They are definitely having altered mental status They are other symptoms. They're cool, clammy, skin. Their heart rate is up. Their respirations. I mean, it's just gonna move They're moving in a very they're they are decompensating rapidly, so you have to do some early intervention.

24:43

So but also, if you do this, then you say, okay. This is what it is. You can eliminate that as a major cause of other problems that are that are occurring with the person. Something easily changes by not overlooking. And again, not overlooking this and thinking more than what it is, Without otherwise, you would do this anyway.

25:04

So with that being said, we're kinda come up with business up. So, again, you know, the the other side of this is take your you you're looking at vital signs as a trended data. You do your first set, and you're gonna come back in this if you do one set or like an assessment, just like this the the head to toe assessment, You've done this one time. You're gonna come back and do it again because you wanna make sure you're not missing anything. And the same luck with vinyl signage, you do it once.

25:31

Assume the value is, and then if you're doing any type of intervention, though, for example, if you put a blanket on someone, in their cold, what should what should happen in a couple of minutes? They should get warm, and they should tell you warm. Well, if you put that blanket on, it's an intervention. Then it doesn't get better. Or if you put a spline on some water, so the same thing with vital signs, you're just measuring how they are in their stability for that.

25:59

And with that, patient situation matters. Think about the age, the activity, the context, how are they been from doing activity? I do a lot of endurance or we I said, we do a lot of endurance events. Where you see where you're seeing someone who's dehydrated. So, for example, if they come in, they're presenting, they're lethargic, and we do a vital sign set.

26:22

And we look at okay. When did you finish your race? I'll finish it 20 minutes ago. If their heart rate is still and it's and it's like in the sixties, mean, the temperature isn't the sixties. So it's not overly it's not hot, but they are lethargic and take a vital sign.

26:37

If you see that their heart rate is still 85 and they're used to running a marathon, that's not a normal heart rate response. So it should be dropping rapidly. So it means they're dehydrated. So if we give them fluids, it should it's it's gonna affect their they're resistant for for their blood flow. They're getting decreased oxygen.

26:58

They're decompensating. And if you don't do something, they're still going to go in that negative trend. So may maybe indicated they may go with an assessment doing IV fluids, etcetera, as an example. Again, look listen and feel. This all that through this process, we we do this.

27:15

We're looking at vital signs. We're listening to the person what they're telling you, but also what we are what we are. Obtaining through auscultations or and then also feeling, you know, that part of that as well, seconds count. We focus a lot on a pit crew approach. You give if someone can do some of their vital sound assessment, do part of that rapid assessment, It just makes that shorter.

27:38

You know? Even even if you're doing all those final signs, probably, you're gonna get it's gonna take them. If you're going back to back, even with two people, probably get it done about 2 minutes, you know, to and then you're restarting the process again. And then leaves. Think about where I go with that is is a drag along is that if you know that, like I mentioned in a while ago, if you have if you look at one vital sign, if they're dehydrated for example, and they have a higher respiration rate, it's gonna equate to increased or or your your you look at pulse rate or or you're gonna that's gonna be high.

28:15

That's gonna if it changes so it's blood pressure over time, those are gonna change as well. So that's that pretty much knocks it out. So, again, wanna share that with you again. It's practicing these skills is that approach is moving through a vital sunset, doing it very rapidly by yourself, and with someone kinda helps even doing it every, you know, twice a year or once a year with a certain scenario helps you move to that when you have to do something whether it's not related, it automatically kicks in that you do that net process. Us.

28:46

Very good. Excellent job, Ray. Paul asked a question, Ray, about do you have any recommendations own blood glucose monitor.

28:57

You know, you can go there they all do basis. You can go to a drugstore, you know, like CVS or local drugstore Walmart. They have a number of variety that does though. There's none with that. I think the the the the the thing to keep in mind is that you've gotta do something that's easy to use and that anyone could you you know, that's the ones we have in in like, if you're equipping a medical kit, you wanna have the same one.

29:26

So that's really for multiple cross because if you do that for 1, you gotta rethink how to use that. I'm For me, I'm personally I don't like using the you know, they have the pins on me. You have to put the needle, the the cartridge in. I like using a single. It's almost like a rectangle and a cap on it, and you just press so one press.

29:47

So that would change a lot if you're dealing with an elderly population or if they're dehydrated based on their skin tone or skin I mean, their skin texture and the thickness is where you apply the, you know, do the pin the the the needle stick. I mean, for the to make blood accessible. So just keeping it simple. That's the main thing. That's what I would tell you.

30:14

Really, like, the idea of you mentioned a pit crew and, you know, both of us are EMTs and and it really when you take a look at the way that an EMT and an EMT work together because they're partners, they predetermined their roles very nice in the I'm not sure athletic trainers preplanned that as well. Of course, they don't work in the same repetitive nature of emergency medicine. I can't teach too, but still talk about the importance of working together and signing roles, specifically with vital signs, how important that is.

30:53

Well, I I will say that, you know, this has come to you know, we're both dual credential, and we do this already. I think the the the it's more, I think you alluded to this. So for example, we talk about spine boarding and those type of things. We do that a lot already. It's the it's knowing how you're going to you've done that walk through regards to the pit crew is if you have one person, we do this very simply.

31:17

Hey. This person's gonna call in your venue specific EAP. Okay. When I do this, the person's gonna go call here. It's just a simple step of moving I've gotta re I've gotta practice with someone doing a rapid vital sign assessment, and that I think that's the but but the bigger item we think about practicing is that in this standpoint of this this, the need to do rapid assessments it is in from a from a typical athletic trial.

31:49

I worked in you know, I worked high school, those as well. I just don't see that very often versus I go into an ambulance if I work I've I've ridden the NPR and work on an ambulance. I may see eight cases in a shift of the need to use I have to do it. These are medical, these are life threatening issues, back to back to back, So you're that repetition, you get there. So I think the if you are or you're if you're practicing if you know that you're not seeing this as often, That's even more reason to practice more frequently.

32:20

You're billing those reps in. I think that's an excellent question that we think about the context versus but it's also the same thing for other providers. They may not do some things that athletic trainers do on a regular, like, for some of the splitting or, like, the helmet removal or equipment removal. So they have to practice that and they have to practice that in a different country. But it's still practice.

32:41

It's still about collaboration It's about working with the resources you have to make the most efficient evaluation and the treatment that you can. Yeah. But, yeah, you know, practice. It's that's a common question that you and I both get is how often do you practice. It would be, like, these vital signs, sips.

32:59

Had a question asked not long ago, well, how often do you need to practice blood pressure? I'm like, well, it's not so much practicing. Blood pressure is easy. We know to do this. It is, are you doing blood pressure effectively during an emergent situation or you forget to do it?

33:17

That's the that's the that's the bigger item. It's like, in the middle of all this stuff, oh, I wish I would've done a done the fur done the the vital side. One missed one small vital, but it's very critical. So I know when we do, you know, the training stuff that we go through, Ronnie, we and we we teach this, it's going you know, you've seen this We're working on those first couple of minutes. So it's like we call mini mocks, and it's really important to tackle those in, get that first part in, because the 1st 2 or 3 minutes.

33:50

The what you do and moving through the prime the same size of primary assessment, it's gonna it dovetails right into this. It's the vinyl sign. And really what we hit on, you know, each of the the different presentations, they hit on in this this is a core one is not to assume that The other side is just you gotta have it there, and you gotta practice it, have it as your kit. So, like, if I do blood pressure, I know that I have a pulse oximeter or glucometer in. So when I open it, I've opened that blue if I open the blood pressure kit, I I need to be thinking about doing both of those as well or putting a pen light in, for example.

34:23

Having all one nice compact area that you pull 1, you know you're gonna roll through that process. Yep. We're, I think,

34:33

we're out of time here. And