# Epi 1 - Vivas - MH, Failed Extubation and Pancreatitis

[MUSIC] Welcome to ICU Fellowship PrepCast. >> Hi, I'm Maddie. >> Hi, I'm Swapnil. I'm very excited to introduce this new podcast series which is mainly aimed at candidates who are preparing for College of Intensive Care Medicine Fellowship Exams. And, Maddie, we have been working together for a while now on another podcast series which has become quite a lot of popular. I must say, and you have received a lot of compliments for your extremely wonderful write-ups or podcasts, but also your dad jokes. So, first of all, tell viewers who you are, what you do currently, and where are you heading in terms of your career. >> So, I'm an ICU trainee. I recently passed my fellowship exam miraculously. I'm currently working at North Shore as an advanced trainee, but a very good education. So, we've been doing the primary prep class to you for what is at the two years now? >> Yeah. >> Yeah, decided that I guess this is a next step and hopefully we help fall to people preparing for their fellowship. Absolutely, and Maddie's voice is quite familiar to most of the trainees who have passed their primary in last two, three years. And ICU primary prep class has recently completed 120,000 downloads. So, that has been a quite unique success in our podcasting careers. So, Maddie has contributed quite significantly. In this podcast series, we are going to discuss some of the Y-Wars that has been asked before in college exams. And we are going to model the approach that is commonly seen during this exam. So, I'm going to play the role of examiner because that's an easy role to play. And Maddie is going to answer all the tough questions which she has been doing for last three years with us. >> I know. >> Let's start. >> How did you manage to swing that? >> [LAUGH] >> I always use your seniority card, you know. As you grow older, you get more power. >> I also want to give the caveat that these are just from my notes and my approach to the answers. They're not, I'm not saying that this is the correct way, or a way to definitely pass. But it's just been my approach for the drivers. >> Yeah, I think that's very important. My detains are clarifying that. You're right. So, what we are trying to discuss here is an approach. And there is no right or wrong approach as such. People might have a different style of answering the same YWA questions and that's okay. But we are going to demonstrate an approach. So, feel free to take good things out of it and continue to modify your approach if you feel that this particular approach works for you as well. [MUSIC] So, let's begin with our first YWA. So, 75-year-old male admitted post a rapid response call for Tachycardia. He is admitted to hospital one week ago for Wipel's procedure. He's post-operative course. He was complicated by surgical site infection requiring IV antibiotics. He's currently receiving more feed and tramadol for analgesia. And also, he's on the regular Hello-Peredol for bilirium management. In terms of background history, he is known diabetic. He has the history of graves disease and rheumatol arthritis for which he takes regular prednisolone. On ICU admission, he's confused, restless, diuretic, with a temperature of 42 degrees Celsius. So, what's the differential diagnosis for his fever here? And what will be your management plan? There are numerous potential infections and non-infectious causes for this man's fever. In terms of infectious causes, these could be complications from his original surgery, such as a worsening of his previous wound infection or an anastomotic leak with intrebdominal collections. It could be other hospital-quired infections given his week-stain hospital, including things like an ammonia, UTI, or a line infection or a costume difficile from antibiotics. Less likely, it could be another new pathologies, such as things like a meningitis or a septic arthritis. There are also numerous non-infectious causes for his fever. These could include drug-related causes, such as serotonin syndrome or neuropsych malignant syndrome. Could be a drug fever as antibiotics are often implicated. It could be drug withdrawal, although a week after admission hospital, this is less likely. Or it could be an anti-colonurgic syndrome and we'd have to look at his medication chart to review. There are multiple endocrine causes as well, such as a thyroid storm given his grave disease or adrenal insufficiency given that he takes regular prednisolone. And there are infometry or autoimmune pathologies that could result such as pancreatitis and aspiration humanitis, post-transvision fever or less likely a seizure. The other potential non-infectious causes of vascular causes, such as a DVT or PE, given his stain hospital and new pathology like a stroke, ischemic bowel or a splenic or portal vein thrombosis. So management in this case would involve simultaneous resuscitation, including cooling, a thorough evaluation and investigation of the cause of his deterioration and specific and supportive management, depending on the results of this investigation. So in terms of resuscitation, this would require an A to E approach assessing his airway, given his confusion and his respiratory status, which would include stats and full monitoring provision of supplemental oxygen in a chest X-ray. So, clitry support, including rapid, large-bow IV access, evaluation of his hemodynamics, checking whether he has any lines inside in situ and providing intravenous rehydration and assessment of his fluid status. He's most likely to require an outline in the central line and potentially a base of presses, depending on his hemodynamics and a septic screen. Further evaluation will involve looking at his GCS and looking for any signs of vocal neurological deficits and quick bedside tests, including his BSL to start cooling. Initially, just with fluids and ice packs initially and an insertion of an IDC with a temperature sensor, further evaluation would involve evaluation of the history examination and investigations. A history would involve looking at particular infectious and non-infectious causes, so infectious causes such as localising symptoms, whether he's had recent antibiotics, recent culture results and his most recent imaging. And a look at non-infectious causes looking through a medication review, his allergies, any recent drugs or transfusions, his recent steroids and any drug or alcohol use. An examination would involve top to toe exam, looking particularly for signs of infection and looking at particular signs of these non-infectious pathologies that we've already talked about. And investigations would be bedside, such as a UA, ECG and chest x-ray, full set of bloods, including looking at his organ function, a septic screen, looking at his thyroid function test, a cortisol and potentially a troponin, and imaging, depending on the coscience on examination, which would involve a CT abdomen potentially and potentially a CT brain, depending on the previous findings. Specific management would then depend on the cause. Infectious would obviously involve broads, butch, antibiotics and source control and non-infectious causes would be directed towards the cause identified. Obviously, there'd be supportive management as with any ISU patient, which would involve adequate nutrition, notifying his family, the direction of David T. Prokfaxus, and adequate analgesia. Thanks, my niece. That's a very comprehensive answer. And that is what is expected in first two minutes. Now, what Maddie did there was, she went through her template of causes for fever, but then she wrote it back to the context of this patient. And that's very important, because what examiner are expecting there, just not the least of causes of fever here, but also how those causes are relevant in this particular patient. So that was really well done. Now, how would you monitor the temperature in this patient? So I would do this by an indwelling catheter with a temperature sensor. This allows for the patient's temperature to be continuously monitored and measured. Furthermore, he's likely to require a catheter regardless, as most ISU patients who are quite sick do. And this IDC monitoring obvious bladder temperature is considered to be reflective of core temperature, and is also recommended by our current guidelines for temperature monitoring and management in the critical yield. That's correct. So briefly outline the potential methods of cooling in this patient. So there are multiple non-invasive and invasive methods of cooling this patient. So non-invasive methods include passive cooling, such as cooling the room and exposing the patient, but this is often ineffective, very slow to achieve results, and it's difficult to titrate the temperature. There's active external cooling, which includes use of ice packs or evaporative cooling with fans and wet skin, which is often easy to implement and cheat, but also slow and difficult to titrate the temperature, and may cause issues with uneven cooling and electrical safety if you're providing moisture to the skin. Cooling vests or blankets can often be used. They can have feedback systems that can be coupled with temperature monitoring. They're often more effective at cooling, but are also and more expensive. and may not be available widely. Invasive methods include infusion of cold fluids, which is effective, easily available and cheap, but can require significant installation of large volumes of fluids, which can cause electrolyte disturbances, arrhythmias, and fluid overload. Intravascular cooling catheters can be used, which are also effective and can be used as central lines, but are not widely available and are expensive. Body cavity lavards with cold fluids can provide a effective cooling, but is invasive as well and can cause electrolyte abnormalities and isn't commonly used. And then there's extra core poryl cooling, which can be achieved by ECMO or CRRT circuits, which provide very rapid cooling, but is invasive and subject to the patients, to the risk of faster access and the circuits themselves. And it's important to note that many of these methods might not be tolerated by this particular patient in his current state due to his confusion, and it can also cause scissorering. So, intubation may be required to facilitate temperature control and to reduce the metabolic demand. That's great. And again, this template of answering how to cool a patient is very useful, because this can be used in some of the other answers, especially when you're talking about targeted temperature management in the setting of out of hospital cardiac arrest. So, having this template ready to answer question around cooling is very handy and very useful. So, let's say in this patient's case, one of your differential diagnoses that you talked about is malignant hyperthermia. So, what are the key features of malignant hyperthermia? Malignant hyperthermia is a genetic disorder of skeletal muscle, which allows for excessive myoplasmic calcium to accumulate after exposure to certain agent, which results in sustained muscle contraction and breakdown. So, common clinical features can be divided by system and include neurological features such as general muscle rigidity, master muscle rigidity and hypotonia. Cardiovascular signs such as tachycardia and arrhythmias, respiratory signs are such as hypercarbure and unexplained increase in the N-tidal CO2, despite increase in the minute ventilation and tachypnea. And metabolic signs such as hyperthermia and sweating. Results of investigations include arrhythmias and ECG changes of hypercalemia, such as peak T waves. Myoglobin, inoclopulin, Nurea and Ray's CK, a mixed metabolic and respiratory acidosis, hypercalemia and then organ dysfunction such as an acute kidney injury or DIC in the case of severe malignant hyperthermia. Okay. And what are the potential drugs used in intensive care unit that can give rise to malignant hyperthermia? So, the main one is succumbentheronium, but volatile anaesthetic agents such as severe flu rena are also a common trigger, although they are rarely used within the IFU and more commonly within the anaesthetic department. That's correct. And what is the drug that is used to treat malignant hyperthermia? So, denturally is the major drug used. That's correct. So, that's the end of our first viwa. Now, we are going to move into our second viwa. And again, in an exam, you will not have much time. So, the next time for you, Madi, is 64-year-old female previously well had right hemicolectomy, which is complicated by an anaestomotic leak with sepsis and multi-organ failure requiring return to theater. After 10 days in ICU, she remains oliguric, receiving intermittent renal replacement therapy, but has otherwise had resolution of her organ failures. She was extubited this morning, but required re-intubation within four hours. So, one of the possible reasons for her failed extubation. For those numerous potential causes in this lady, and it's likely in multifactorial with a combination of complications from a prolonged stay in IFU and potentially a new pathology, potential causes can be divided by systems. And neurological causes include delirium or agitation, weakness such as a potential critical illness polyneuromyopathy given her long stay in ICU and multi-organ failure, significant abdominal pain for her previous abdominal surgery and with difficulty taking deep breaths, decreased elimination of sedatives causing drowsiness or new pathology such as a stroke. Cardiovascular causes could be also a new pathology such as ischemia, myocardial ischemia or Rhythmias causing cardiac failure, any sort of new shock whether septic or cardiogenic or acute pulmonary edema. Gastrointestinal causes for maybe aspiration might be an isleus from these previous surgery causing increased abdominal distension or from a long ICU stay. And renal causes given her new renal impairment could be fluid overload secondary to a renal failure which could be exacerbated by the loss of positive pressure, postextubation or a metabolic acidosis causing tachypnea and increased respiratory workload. Respiratory causes could be a new infection such as pneumonia, significant sputum load with differently clearing her sputums, a postextubation triner which is left likely if she's re-interested after four hours, aid electruses from the loss of positive pressure, other new pathologies such as apognomy embolism or an allergic reaction or bronchospasm if she had a history of syropyriol asthma. That's correct. So again, the template or causes for failed extubation is pretty standard and you might get this pattern of failed extubation either in hot case or in the virus scenario. So have this kind of template ready so that you can answer this question quickly and efficiently. Let's say this patient has now optimized post intubation but in order to get her ready for another trial of extubation, how will you optimize her further? So optimization requires first identification and treatment of the contributors to her first failed extubation. This involves first a thorough evaluation including a targeted history, examined investigations and the history and exam would be particularly focused on these system reviews. So looking at neurological causes like any vocal neurology, weakness including her bowel function and anti-gravity movement signs of a critical illness polyneuropeathy, adequacy of cough and a review of her medications such as especially sedatives or steriles which might contribute. Cardiovascular would look at her hemodynamic status and any signs of new cardiovascular impairment. Respiratory would look at her sputum load, any signs of infection or bronchospasm and the support she is requiring from the ventilator and the trajectory prior to her failed extubation of the sport she needed. A gastro-testal review would look at her abdominal exam, abdominal distension, whether her bow is open and whether she had any aspirational vomiting. A renal review would look at when she'd last dialized and have fluid balance and then an overall look at complications such as sepsis or line infections. Targeted investigations would involve bedside investigations such as an ABG looking at gas exchange and lactate and ECG for signs of ischemia and arrhythmias and consideration of an echo for those thought to be a cardiac pathology contributing to a foud extubation. Blood tests would look at her organ functions such as a renal function, a septic screen and her electrolytes and electrolytes might be particularly important in the consideration of her critical illness polymioneuropathy and imaging would depend on the evaluation but would include a chest x-ray to look at her if there's any signs of infection or fluid overload and consideration of a CT scan depending on the findings. So looking specifically at signs of infection or if there were consideration of a new stroke. In terms of the optimization, I think about in terms of decreasing her respiratory resistance improving the respiratory compliance, decreasing the work of breathing, increasing the oxygen supply, optimizing the ventilatory drive and optimizing muscle function. So in terms of decreasing the respiratory resistance, so ensuring that the anterochial tube is an adequate size, considering a tracheostomy if it thought that there'll be a difficult weed. The usual things we do such as humidification, chest physio and a consideration of bronchoscopy if there's significant sputum plugging with collapse and bronchidylators if there's bronchus bazaum present. For improving respiratory compliance, this involves treating the underlying lung disease such as infection, ensuring that we have set appropriate ventilator settings and decompressing the abdomen if this is a contributing factor. To decrease respiratory work, it can be sitting the patient up, decreasing oxygen demand by treating federal agitation, avoiding overfeeding and adequate analgesia and correcting acidosis. Increasing oxygen supply involves treating any myocardial dysfunction and treating severe anemia and optimizing fluid balance. So in this case, what involve aggressive fluid removal with dialysis as tolerated, maybe needing low dose bazaum pressure support to help tolerate this. I'm optimizing the ventilatory drive would be by minimizing sedation, screening for and managing delirium and avoiding any significant alkylosis. And finally, optimizing muscle function, which would be by adequate nutrition, intensive physiotherapy, trying to avoid contributors or polymineuropathy and the critically ill, such as steroid and neuromuscular blockers and optimizing electrolytes. That's correct. So you mentioned about tracheostomy in your answer. So what are the indications and complications of tracheostomy? For the major indications that facilitate weaning for mechanical ventilation to aid in sputum management, if you there's any upper airway obstruction to bypass this airway protection from aspiration and often used as an adjunct in significant head and neck surgery or trauma. Complications can be divided into procedural acute and chronic procedural include airway fire which mainly in the case of surgical trackostomies bleeding injury to surrounding structures such as bolstract, nubian metastine or pneumothorax, atracia, osteophejil fistula injury to the posterior trackula wall, recurrent laryngeal nerve injury, thyroid injury, trachea or ring fracture or cryoid fracture. There can be guideway issues in the case of percutaneous trackostomies which include loss, ink or fractured guidewires. It can be a loss of airway pressure which could involve hypoxia, de-recruitment, pulmeredemia, bradycardia or hemodynamic instabilities. Complications are foreign material in the airway which can result in bronchospasm or aspiration humanitis or amelpa positioned or incorrect size trachea. Acute complications include tube displacement, infection, dyspagia, post-abstructiver dima, mucus plugging and bleeding and chronic complications include tracheal stenosis, tracheasophageal or tracheocutaneous fistula, trachea emolation, tracheitis, bleeding and tracheoenominate fistula, voice changes and chronic cough, pneumonia, swallowing difficulties, sternocovicula osteoamilitis and scarring and cosmetic issues. That's correct and you are on the ward round and you are a junior registrar ask you what will be the optimal timing of tracheostomy in this patient and what is the evidence for the same? So there is no consensus on the optimal time to perform a tracheostomy so this is very dependent on the individual patient and the environment you're working in. An early tracheostomy is generally thought over those performed within 10 days of intubation. Proponents of an early tracheostomy hypothesise that this may allow for less sedation, improve patient comfort, fewer complications from an oral endotracheal tube, a shorter ICU stay and therefore reduce morbidity and mortality. However, proponents against it state that it subjects more patients to the risk of tracheostomy which are not negligible and some of the patients who may not actually go on to require tracheostomy if they're intubated for a prolonged period. The major trial quoted regarding timing is the track man study from 2013. This studied 909 intubated patients who were thought to require at least seven more days of ventilatory support. They were randomized to undergo a tracheostomy within four days of ICU admission or after day 10 and the major findings was no mortality difference between the two and no statistically significant difference in duration and mechanical ventilation or ICU length of stay. However, this trial did not include patients who may have required a tracheostomy for non-respiratory reasons and less than half the patients in the late group and ended up actually requiring a tracheostomy. There's also a COPCRAIN review in 2015 of almost 2000 patients but the majority of this do come from the track man study which did find a statistically significant mortality benefit from early tracheostomy with a number needed to treat of 11 and that the early group had a decreased duration of sedation but no significant decrease in duration of mechanical ventilation. However, they advised that these findings were only suggestive of those minimal high quality evidence available. So the optimal timing of tracheostomy is ambiguous and it's not well established. Some patients such as those with significant neurological dysfunction or severe facial burns may benefit from early tracheostomy but decisions regarding the timing relies on clinical experience and consideration of the individual patient factors. That's correct and again that highlights the complexity of intensive care environment where decision about a tracheostomy is usually case by case basis but in exam settings please don't be afraid to state what is your approach and what decision you will make as a consultant if you are looking after this patient. So if your practice is to perform tracheostomy only after two weeks, feel free to say that because again there is no wrong or right answer but also it's important to rationalize or justify your decision and support that decision by providing the findings which are made available to you during the history exam and investigations. Let's move on to our third and last y-wav this episode. 56 year old male with a two day history of severe epigastric pain and vomiting presented to emergency department is conscious distress with a blood pressure of 75 or 45 millimeters of mercury. His heart rate is 120 beats per minute. Respiratory rate is 38 per minute. Temperature is 38.6 degrees Celsius and his stats are 91% on rumour. On clinical examination he's abdomen is distended and diffused tender without any guarding. He's oligury so what will be your differential diagnosis and how would you investigate this patient? So I'm concerned that this patient has severe pancreatitis but other possible differentials include other cause of shock which include hypervalemic shock and in this case potentially aortic dissection or a leaking triple A. Cardiogenic shock with you in fact in the schemia. Distributive shock such as sepsis from intrebdominal pathology, is it really sepsis or colitis or a non intrebdominal pathology such as the severe pneumonia with septic shock. A vascular cause such as mesenteric eschemia or eschemic bowel potentially a non infectious cause of distributive shock such as adrenal crisis or trauma from the vomiting such as a boi-hav syndrome or perforated viscous. In order to investigate this patient would involve focused history and exam and investigations. History would revolve around the presenting complaint including patterns of the pain, exacerbation and relieving factors if he's had any similar episodes and any associated symptoms such as infected symptoms or neuro symptoms for things like dissection. Any comorbidities including atrial fibrillation which would made more stress than mesenteric eschemia, previous eschemia, heart disease, any peptic ulcer disease, recent trauma or steroid use and any risk factors for pancreatitis such as alcohol use, higher triglycerides, HIV, previous gallstones or certain drugs or recent ERCP. Examination would involve looking at their via tools, any neurological signs or radial radial delay for considering dissection. Any osculation of the chest including looking for bronchial breath sounds for a pneumonia or any new murmurs and osculation of the bowel such as tinkling bowel sounds in small bowel obstruction or and a palpation of the abdomen for signs of rigidity or a powerful triple A. Investigations of bedside blood tests and imaging, bedside tests would involve an ECG to look for signs of a scheme or AF and ABG to look at lactate, the BSL electrolytes and acid-based balance. The chest X-ray would be important to look for free air under the diaphragm and pneumonia, a wide and medium-styne and enumerum medium-styne and for ball-hars, UA looking for signs of a UTR or pilot of brightest and urine culture. Blood tests would include a lipase for pancreatitis, a septic screen with blood cultures, a full blood count looking for anemia or leukocyteosis, UEC to look at renal function, LFTs for hepatitis and for part of the rants in school. Collapse to look at DIC and a consideration of further blood tests such as a cortisol of concerns regarding an adrenal crisis, group and hold if thoughts of potential for surgery and considering deproton or triglycerides depending on previous evaluation. And imaging would likely in this case be a CT abdomen to look for abdominal pathology and consideration of an ultrasound of an abdomen if it is pancreatitis to look for gallstones. Thanks, buddy. And very important to note in my read is answer, when you present any investigations in fellowship exam, make sure that you don't just give a shopping list of investigations, but be prepared to mention what you're looking for when you're ordering this particular investigation. So as Madi mentioned, she wants ECG to look for signs of ischemia or AF, ABG to look for lactate sugar electrode. So that is very important rather than giving I want to do one, two, three, four investigations. Always make sure that you state the investigation and say what you're looking for while you're ordering the investigation. That's really important. Now let's say on investigation, his lipids comes back 2000 and his CT abdomen confirms a diagnosis of pancreatitis. So how will you manage him? The management consists of resuscitation, logistics, specific and supportive management. So resuscitation is again the A to E approach with supplemental oxygen given his low, that's on room air, full monitoring, large bore IV access and fluid resuscitation initially and likely an arterial line and central line for vasin pressure support if ongoing hypertension, provision of analgesia and antipyritics given his fever and an insertion of IDC to monitor his food balance and urine output. Logistic aspects would involve admission to ICU and surgical involvement and specific management would revolve around evaluating the local complications. So looking at a CT scan for finds of local complications such as the crisis, abscess or collections it repeats CT during his stay as a progress scan or early if patient's condition deteriorates. If there is a collection they may need percutaneous or endoscopic drainage and consideration of abdominal compartments. The drama is part of the complications that can result from pancreatitis. Other specific, mentally optimization of organ support and minimising any systemic complications from the pancreatitis. So this would involve judicial fluid management with Bay's appressives support, generally aiming a map of 65 or more and respiratory optimization with adequate analgesia, decompression of the abdomen with an NG tube and chest, bizio and supplemental oxygen. Treatment of a cause if it's identified, so if there is hypercytriclyceridemia, this is generally treated with an insulin infusion initially. And consideration of ERCP if there's biliripancryotitis with concurrent cholangitis. And then the supportive management would involve things like DVT prophylaxis, stutritional support and BSL control, generally aiming for issue goes between 6 and 10. Thanks, Maddie. And again, very important finding to note in this answer from Maddie is that she covered and a holistic approach towards the management. So you're not just expected to talk about the resuscitation, but also talk about the logistics, how we are going to get this patient. Where is what's the destination for this patient? And then moving into specific management is crucial, but at the same time talking about the supportive management is equally important. And usually I call it as a housekeeping stuff in ICU, which kind of involves your fast health. But when you admit the patient to ICU, we just don't manage the disease itself, but we also look after other important aspects. Normally one thing I often add to this particular answer is family update. And how am I going to or what information am I going to tell the family? So upgrading family, which is also part of our day to day here is important. And I guess if you add that answer that shows the examiner that you are not just managing the pancreatitis, but you are managing the patient as a whole. Now this patient continues to be fibrile and your registrar asks about commencing antibiotics. What will you tell her? So there's no role for routine prophylactic antibiotics in pancreatitis and no evidence that it improves patient-centered outcomes. I would say that I'd consider commencing antibiotics if the patient remains severely shocked despite fluid resuscitation, was requiring high dose phase of pressure support. If you develop necrotizing pancreatitis or with a positive cultures or a pancreatic abscess, or there was a high suspicion of an extra pancreatic infection such as pneumonia or something else that developed during his stay. That's correct. No right or wrong answer and a lot of people you will find that there's a lot of subjective variability in commencing antibiotics. And it's a controversial topic and that's why examiners are asking you to see what will be your approach. So again feel free to state your opinions without any hesitation. Now another controversial topic with pancreatitis is around nutrition. So what will be your approach towards managing his nutrition? So in broad terms, entral nutrition is preferable to parental nutrition. Assuming this particular patient has severe pancreatitis, I would start entral nutrition within 48 hours by an NG tube generally first off or consideration of an NJ tube, but they're generally depending on the logistic issues. I would start at a low rate and slowly increase as tolerated aiming for 25 to 35 kcal per kilogram per day. I would only start TPN if entral nutrition is not tolerated after five to seven days, provided that he had a good baseline nutritional status. That's correct. So first of all, you need to state what's your approach, but at the same time you want to support your approach by justifying why you are doing it. So well done, Maddie. That's the very comprehensively answered three why was. So folks, I guess what we're trying to demonstrate here is a particular approach towards why was in fellowship exams. As Maddie mentioned, it's just her approach. And obviously Maddie has another interesting element which she can't give away, which is the integral part of our all podcast episodes when we recorded our primary podcast series. And she wants to continue her legacy in this field. Maddie, do you want to talk about what you like and how you like to torture me? Well, no, this is just my favorite part. I'm really trying to make a ask a question. So I'm going to continue. Okay. So just to just for those listeners who are listening for the first time, before we end our episode, Maddie gets her chance to ask me a question. And usually her questions are very intelligent questions. Go ahead. So why didn't the antibiotic succeed as a YouTuber? That's simple. That's because he's not swapnil. I don't even understand that. No, it's because he could never go viral. It's really very, very intelligent, that joke. So thanks, Maddie, for your valuable contribution as usual. So folks, all these show notes that Maddie writes that are available on the website called Critical Care Education, www.critcare.au.com.au. And this podcast will be available on all your favorite podcasting platforms, including iTunes, Spotify, Google podcasts and Stitcher. So make sure that you subscribe to this podcast so that you will get notification about the next episodes. And hopefully this episode will help you in passing your exams. If you have any constructive feedback, make sure that you email us at critical care education 2018 at gmail.com. So we'll be back in months time with another three YWATs, till then, goodbye and have a nice time. Thanks for listening. See you next time. [Music]