Episode 191 - EMS Protocols 101

[Music] Hello everybody, welcome again to another edition of the MCHD Paramedic Podcast. This is Dr. Casey Patrick. Today we have a special guest on the episode to talk about a subject that I don't know that we've really broached here on the podcast after nearly 200 episodes and honestly it's the core of how we practice medicine in EMS, both from the paramedic side and from the medical director side. And so today we're going to talk about how we use medical directors and how the system writes any MS protocol. And we have one of our in charge paramedics here at MCHD, David Zonos joining us in this really my favorite kind of podcast episode, this stem from a question and an email that David sent us. But before we get to the discussion, David, tell the listeners about yourself a little bit, your role here at MCHD and really how you became interested in this subject. I know the answers to all those questions but it starts to explain itself when you tell your story. Alright well, Heidi, like Dr. Patrick said, my name is David Luzano, I'm an in charge here at MCHD. I got into EMS, my senior year of high school, way back in 2013 and I actually kind of changed my entire career for the trajectory. I initially started with, I wasn't sure what I wanted to do, wanted to go into business, but my dad was a volunteer firefighter, went on to take this EMT class in high school and I fell in love with medicine. I applied to university and I attended a university where I worked as an EMT at our university's agency, became a paramedic. I think my junior year of college and I applied to MCHD. That was December of 2017, so about nine years have been here. I'm really interested in the subject just because I still work at the university agency in an admin role and I was going through our protocols and trying to get everything streamlined and I was like, man, how the heck do people write these? This is really confusing. I found out that there were a copy and face it from Montgomery County a long time ago. So let me ask Dr. Patrick, who writes these and where does it come from? Before we go into the first question, I will tell you as the non-EMS person on the podcast, Dr. Tipasqually and David, we're both paramedics, intro, into medicine, EMTs and medics. I learned medicine from the physician education side. I had no EMS background before I started here at MCHD and so some of y'all that remember 2015, 2016, that explains a lot. But I was really baptized by fire when it came to what the words mean in black and white in an EMS protocol. That is the core. We'll say it again and again. It's the backbone of what you do out there each day and how you pick your protocol and how you decide the medication, the dose, the route, the patient, the peds, adults. It's really a big deal and sometimes writing a sentence or two sentences within that protocol can take days, weeks, even months. And so I didn't know what a big deal this was. So this is probably a podcast subject that I feel like, man, we maybe should have gotten to this one before now. But with us just revamping our protocols, we've talked about that on the podcast in the last few episodes and then David's going through this on the other end and realizing, man, those three or four sentences can be really hard when you consider what guidance that really gives folks. Hopefully this is a good discussion. So far away, David. So you alluded to it, but we've spent the past year going through full protocol revision here at MCHD and I think just to kind of start us off, wanted to ask, what's the protocol and why do we have them? Well, anyone who's any EMS knows the protocol is, like you said, the heart of the service. And I feel like a lot of people are proud of and show off or compare protocols against one another to see what they can do versus what others can do. If you're completely unfamiliar, the scope and the practice authority for EMS for paramedics and EMTs comes from the medical director and that can change based on the state that you're in or but ultimately it comes from some physician somewhere. And so the protocol is a set of standing orders. It's basically a very large set of standing orders that tries to encompass all patient encounters and outlines what the EMTs and medics can do by standing order, meaning that they can do it when they deem fit, when that criteria is met and they don't have to call for orders or talk to an online physician to get those orders. We have them because although there's a lot of education and training behind EMS and you can become a state certified or licensed, it's still not a licensed to practice medicine and so the delegation to make those medical decisions to decide to do either medical procedures or give medications still needs to come down from written orders from a physician and so this is the way we formalize that structure. And I will say the revision process over this past year was a very necessary undertaking that every EMS service out there, every clinical department medical director. This is something that we have to do to make sure that we're up to date and that we don't have old medicine, stagnant medicine, typos, incorrect doses. We found all kinds of those things in our own closet so to speak. Would you think about really what a protocol set is? It's like cleaning out your house, it's like spring cleaning. Sometimes you find things you want to throw away, some things you want to dust off and put out on the counter and re-educate on and mistakes and errors and junk. You have to get rid of so it definitely was an involved process for us but we're pretty proud with the end results. I'll toss it to you David, where are you adding that process now and how is it going? It's difficult. I've gotten a group together about 12 people to kind of go through and come through it and see if we can find what the errors are. I know one of our biggest challenges is finding the contradictions because we have a protocol that says to do something but the medication reference has a different dose or a contraindication that's not in the protocol. Having that coming through it and finding the grammatical and the formatting errors is a challenge but then also making sure that we're up to date and the medicine is something that takes a village and I can't imagine just having one medical director sitting down and writing all the protocols. That's why I ask who writes it and who goes into the protocol writing and revision process. I can answer that for us here. I believe there's lots of answers. You pick 12 so I will end with asking you how you picked those. We have an enormous service here at MCHD and I believe in a lot of smaller services, protocol committees and round table discussions and those things happen. I am not opposed to those necessarily to me personally as a medical director. I also believe that time is of the essence and efficiency matters too and sometimes too many back and forth discussions whether you're talking about votes or edits or rewriting of a certain protocol. At some point you have to get it done and so we in our revision in 2025 because it had been too long here at MCHD and I'll own that and there were some things that happened around 20, 2021, 2022 that put a little bit of damper on us being able to get there when we needed to and then there was a transition between Dr. Dixon and I and that obviously took precedent. We rolled out a new airway device. We have lots of other things going on in the service that put us behind and so we really couldn't take the most organic involved grass roots approach. We had to motor through it pretty quickly. So here at MCHD we had a group within the Department of Clinical Services that took this on in a pretty maniacal fashion of mowing through each one of them. There are probably folks out there listening that like, "Hey, why don't we get a say so?" And the reality is is that y'all get a say so every single day because our email inboxes, our office doors, our web ex channels are always open and so many of our protocols are medic-driven and even medic-written. We learn from y'all every single day but in this revision process, in a vacuum, in the vacuum that it was, we had to move pretty quickly. Speak to that I guess and I'll ask David where his 12 folks came from. Yeah, I will say though, I mean, and anyone who's outside of MCHD, take a good look at your protocol book and kind of thumb through it and the more you look at it, I think you can kind of tell a lot of these protocols, one, I'm just getting added on to and added on to and added on to and then you get this behemoth sometimes of different formatting, different style, different way medications are displayed and I think that that's something that can definitely happen over time because, you know, well intention or people come in and out and so the way we were looking at it was just kind of a total overhaul. Let's start from the absolute beginning, look at everything that we have now in totality and then get that all down to bare bones and then build that up from the beginning with the same format, the same structure and make sure we're not doing those contradictions or those contradictions I mean. I think we did a good job at doing that and in terms of representation for medics, I mean we looked at a core group here and certainly there were several of the medics here from DCS that were involved and I but I think you're right, if you have a hundred people giving their opinion and we need to stay at dial as they say, right, make decisions and move forward. The medicine is the medicine, right? And what you really wind up arguing is kind of the nuances of how the medicine gets delivered in EMS. And we'll talk about it here in a minute. I'm sure. But when most of the discussions came down to the medicine we're going to give is X, right? It's ketamine or it's medaslam. But the dose that we're going to give is what is it going to be weight-based? Is it going to be a fixed dose? Is it going to be based on the patient's age? Is it going to be different for kids? That sort of stuff. So that's where I think the discussions are useful. But you're right. I mean, you can't have 400 medics weighing in on their opinion on these things and still expect to move through a process for a protocol revision in less than 10 years. Well, and David's point, David spoke to what was our biggest problem. And we actually did two things at once. We did not just write a protocol. In other words, if you're talking about, let's create a protocol for a new medication for agitation. We're going to do oral respiridone, ODT for agitation. And we're going to plug that into our existing set. That's not terribly difficult. We could knock that out in an afternoon, more than likely. Really get into all the details and all the connected pieces. But when you pull everything apart and you think about the protocol, the medication reference, what already exists from field operating guidelines, standpoint, and how does that interconnect? How are you going to do dose support? There's a lot of just what amounts to, you know, clerical work and trying to not contradict yourself. That's just really the biggest problem that we had to disentangle. And that led to some of the answers that we're going to give later. And I'll just tell a quick, a side story because it happened really last week. And I just want to make sure everybody understands how our protocols work around here and that they're not, it's not a, it's not a dictatorship either. I got an email from one of our captains. I'll give, I'll give Clayton Smith credit. Clayton email me and said, Hey, Doc, what about TXA and Peds? This was just an email in my work week. And I said, you know, first, let's look at our own data. And let's, let's think about it. There's more adult data than there is Peds. And we ran the numbers and they were few, but not zero, which is about what I expected. And I went into Dr. Deepas-Guali's office and said, Hey, what do you want to do with this? And he very wisely said, let's reach out to some experts. And so we sent an email out. I believe it was Wednesday of last week around lunchtime to our pediatric partners. And by the end of the day, the business day on Wednesday, my email on box had a back and forth of about eight replies from various pediatric surgeons from TMC Herman and from Texas childrens with praise, data, offer to help build the protocol, some edits on one of the sample protocols that I sent them. And then the last chime in was from the study director for a current pediatric TXA randomized double-blinded prospective study that's going on downtown at the Med Center. And he said, appreciate all of this input. I'd offer another perspective. Let's allow our study to complete so we don't skew the data. And as a medical director, I walked out like, man, I've got the luckiest best job in the world because that's the kind of partnerships that we have. And to close the circle, close the loop entirely, I sent an email back to Captain Smith and said, Hey, great idea. Everybody loves it. We need to hold off for a bit. So how you write a protocol and who you involve, it all depends on the timing and the day. But my email inbox, my web ex channel, my door is open as is Dr. Tipasqualis when you have those ideas. How did you pick your 12, David? So obviously where I work is a lot smaller than MCHC. We don't have 400 paramedics, but we do have our own dispatch center and we have a lot of first aid EMTs. And so I sent it out to our reserve and we got people from each area of expertise really. So we have the people who were there doing first aid, people who are on ambulance attendance, attend EMTs, AEMTs and paramedics. And the people who have technology prowess that not all of us necessarily have, that can go through and make sure that the formatting looks good. And there's no contra contradictions, but also helping us out with linking protocols to each other and going, being able to click from one page to another one and quickly go back and forth so that we're not. Having to scroll through our PDF document and zoom in and zoom out and figure that out as well. That's, I mean, one key in there that I heard was that you involve the actual folks who are doing the different pieces of whether it's dispatch first aid, ALS medicine, BLS medicine. I know I've made that mistake as a non paramedic and that is routing a protocol that is medically 100% correct as an emergency physician and absolutely 100% not doable. As a medic based on logistic reasons. So I believe you can really shoot yourself from the foot and probably one of the ways that I've done it the most is not considering the environment and the structure and limitations which you have out there in the field. That's a great, that's a great protocol idea doc. How are you going to fit that in the bag? I've done that when many times. So I think you do have to involve folks that have done it or are doing it 100%. We, we streamlined ours. How are you streamlining yours and I want Dr. Pasquale to hit on that a little bit. When we think about what a protocol is and what it isn't, we mentioned medication reference. We've mentioned the protocol itself and the contradictions that occur there. How are you streamlining those David and I'll ask the same question to Dr. Pasquale because we may have the biggest 180 I believe that we pulled with our content was really trying to pull. Some of the what I would call fluff out. But how are you approaching that now? Toss that with each of you individually. I think kind of in the same way that we did it here. The way our protocols were written we had a lot of references because it was copy and pasted from Montgomery County I think in 2011. But there is each. Each protocol was broken up by disease type and then each protocol started with an assessment. Page and in that assessment page there's background information of the disease the findings that you can find on the disease and then the next page is your actual protocol for specific. So if you had your respiratory protocols first page would be your respiratory assessment and then the second page would be COPD and then the next one would be asthma or going on so forth. At the top of each of our protocols we had your assessment your inferentials findings things that could be suggestive of this disease and it almost read like a textbook. And then towards the bottom of the page we had our individual treatments for the providers. So we're working on kind of what we did at Montgomery County. Streamlining it towards not like reading a textbook and it's finding what information we need right then and there in the moment. Instead of having to dig through so that if we're in a case where we need to DSI somebody or give them I am happy you can pull up that protocol and immediately know what to do versus having to search and zoom in zoom out on a PDF. Tag on we've had this discussion of zillion times you can do this when you're asleep. Yeah. When I was a medic I worked at several different services regions agencies. I've seen a bunch of different protocols. I've been curious and looked at different states protocols and if anyone's familiar with any of this they've seen some are stepwise approach some are bullets some are numbers some are flow charts and diagrams and all sorts of different iterations on this. And when I looked at the protocol set that we had at mchd when I first got on board a year ago or so we had a protocol book that was the orders on what to do the instruction on when to do it. But also a lot of the clinical education behind it. You know like you just mentioned the assessment part so the protocol would start with for example short to subrith right and it would say people with COPD can have short to subrith or something similar right and it would go into kind of path of physiology at the top talk about expected physical exam findings. And then towards the bottom start talking about treatment options and they were somewhat vague it would just have some stuff on there it would just say have we give all you're all and we give steroids it wouldn't say when or what order or how it would just say do those things. And then like you mentioned earlier there was a medication reference at a separate part that then had the actual doses you're looking for. And I think that that if I'm being frank I think protocols that look like that are somewhat of a relic from the past when we had a spiral bound book that you could hold and flip around too easily. And much like almost all other services in EMS our current iteration was using an app on your phone that then lets you look at the protocol book on your phone so you were taking that spiral bound book turning it into a PDF which is still a book and then using your fancy phone to look at a book. Which to be honest with you would be easier to just navigate with an actual book itself and trying to like you said a couple times zoom in and in the moment try to figure that out. And so I think fundamentally we sat down and said what is the point of the protocols why do we even have this and if the reason if the protocols exist to do education on how to do patient assessment. I think we've missed the mark a little because patient assessment comes from your initial foundational paramedic skills and EMT classes and then continuing education. I think. the protocol book exists for like we mentioned earlier written standing orders but also just in time reinforcement and reference material for when you are in a critical scenario to go quickly look at and say oh yes this is the correct dose this is the correct route or make adjustments is needed based on a really easy to look at concise flow that you can get to quickly with the patient that's in front of you so I'm going to play devil's advocate for a second and this is you may have heard this in your agency David and no Dr. D. P. Pousquale and I have so if you've asked us this this is a reasonable question there is no malintent but I'm preparing for my in charge I'm preparing for my in charge where do I find out about the pathophysiology of COPD so I'm going to ask a two-parter that's going to kind of push us down our question list here and what adjuncts are coming to our protocol revision here at MCHD and this will be the quick disclaimer we're going to talk product specific no conflicts of interest but we can't really explain this very well unless you know what we're using and there are other options out there and we just can't like just like we talked about our uescope we can't have this discussion without talking about our product so what's coming now that we've paired the protocols down and a lot of that pathophys and that exam finding and that medical knowledge that our medics I'm glad they want that like that's great for sure want to solidify that foundation and we need to be continuously doing that and CE plays a role there but having a reference that describes how we at MCHD expect our medicine to be practiced and what is that based in that's a reasonable question for a medic so answer that and talk a little bit about our platform so the platform is a program called mission critical protocols and it's a totally built from the ground up solution that is made for EMS protocols so it's app based and on the back end for us all of the development and all the writing of the protocol happens right in MCP itself and so it's a it's a complete package that lets us both edit maintain update and push updates live to our apps to our medics using the app all in one system and what that does is it lets us build the protocol with the specific intent of using it on a mobile device this is not a book that we have co-opted to work on a phone this is a set of protocols that are built on an app made to be used with your devices either a tablet or your phone whatever you've got so that it works seamlessly and more importantly quickly when you need it the most and so like I talked about we pair down a lot of that stuff from our protocols to keep it concise and you're right we have had this question a lot about how do I study from the protocol and so what we will be coming out with is the MCHD protocol study guide and basically what that looks like it's not done so don't hold me to this but we are intending this to be is we will basically take the protocols that we have now and all the stuff that we've taken out of each one that's what'll be in the study guide so for example that's short as a breath one right now our short as a breath protocol says if you've got wheezing let's give out butro let's give it patropium let's give steroids etc in the study guide it will say patients who have COPD benefit from beta agonism right and we'll talk about all those steps and why and the path of is and some diagrams and it's going to be robust and it's going to be cool but this is a totally separate thing this thing exists for you to read on downtime when you're interested in what's going on or for people who are getting ready for their in charge exams this is not for in the moment use that's the protocol for I'm at the you know fourth or fifth medication what should I do next okay I am happy for people who are having asthma exacerbations got it you know so that mcha protocol study guide target date q4 2026 so give us 11 months or so and we'll be there we've got project management task board lined out we've got dates now I've got to do my end of the bargain and actually write some of these but we can and we will and we know that you want that but to David's point to dr. G. Presquale's point to things that we've hit on over and over and over if you are in the back of the truck with a respiratory failure patient and you're looking up the pathophysiology of COPD that is not efficient and not great for patient care so there's two separate things both very important but but not a protocol David you're in the middle of this so you've you've got the the closest proximity and we'll go around the table with this one what's the hardest part that you found about riding a protocol um I think one is writing it in a way that someone in the moment can read it and understand what they're looking for to without making it overly complicated but also not making it so broad that you're just kind of giving free will or free free right reign um but yeah I think that's probably been the hardest part is kind of wording it to where it's it makes sense but it's not a channel or not a trying to think of what word would be but like not I think of the quote from the Pirates of the Caribbean movies the Pirates Code is a we think of it more with the guideline um and getting to that point where it's clear what the expectation is without making it does this I'm going to hold your hand and tell you this is what you're doing. You're balancing complexity with clarification it's really really hard because many of these subjects are exceedingly complex and so complex medical pathways complex pathophysiology generally doesn't lend itself to simple statements but you want to make it as clear and concise as you can that balance is really really hard I think that's a skill that I struggle with to this day and trying to write these things for the last 10 years it's not easy what about yours Dr. D. W. Scuelly. Just a touch on that point for a second I in the process of doing hours I kind of came up with a rule for myself when I was writing the indications for medications as these are little one-liner headings that appear right before the indication right before the actual medication is listed and I didn't want those to be lengthy because you'd lose it on mobile so they have to be less than one line and it has to be very brief and I use a lot of verbiage like you said to not be super strict is the verbiage says if such and such is suspected or if you think this is the working diagnosis or nothing rigid to say this is what's happening but if this is what you think is happening or you suspect this or you think this then go with it because we get it this is the MS we're not and we get 10 minutes to try to figure out years worth of problems right so to try to give the latitude to the medic that's working in the field the ability to operate the way that they need to without everyone feeling like well I don't want to be a cookbook medic this is just a list of things to do well at some point it has to be a list of things that you're allowed to do but written in the way that lets you make the decision as to when those occur but what to answer your question I think the hardest part is recognizing the overreaching impact that these little decisions make not only to the service but to the patients and to all the stakeholders so our hospital partners are our O partners like these decisions that we make have big impact you know we decide we want to treat pathology a certain way and like you mentioned about the TXA right we think all this sounds like a good idea let's look at it is there any data let's ask the experts and they'll say yeah let's do it and we would have no idea that we would be potentially gumming up someone's study on this locally before they get it to finish it without reaching out to a stakeholders and partners first in saying hey what do you guys think this is okay yeah I believe my answer is very short and sweet and hopefully it y'all can understand this this is not a negative statement but the hardest part for me is being sure that we've considered the ultimate downside to the patient and where does that lie and how can we shore up the safety net within the protocol just like we put the moves safety net bundle in place when we have a period of rest patient I have an own and just like Dr. Deepas Gully said he developed patterns I have patterns when I look at a protocol now and I think about where are the edges and where do there need to be guardrails where do we need to let paramedics have clinical judgment because we absolutely have to do that and how do you balance all those things but always always when I reach for the ink pen or the virtual signer think where could this go the most wrong for our patients and how can I how can we prevent that that's always the part that you can never really know till it rolls out into play so last one I want to close up with with a good one because I got I know mine but I'll let David go first we'll go around and wrap this thing up and it can be your other service it can be here at MCHD let's talk about unique protocols what's your favorite unique protocol that maybe we have heard MCHD or you've worked other places with maybe you want to bring here you got you got free reign answer the question I know what mine is though I just the one that I saw that really made me think about rewriting our protocols was the B less delegation of care I think it's super cool it's something that really shows a delegated practice that Texas offers medical directors where medical director can write essentially whatever you want and double double edge sword but I think it's really cool that we have the ability to not downgrade care but triage down to an EMT something where other services may if you put on a total lead it's an ALS call apparently I have to write it in we have the ability to do a total lead interpret it and then go triage it down to an EMT level, while still maintaining that responsibility and having the paramedic there with it. I know some services do that without having a written protocol for it, and I think having that protocol is definitely, hey, let's have a safety net and not run into really some sketchy positions because paramedic doesn't want to write a report. And so I think that's probably my favorite, and I think the coolest protocol we have. I'll speak to that one specifically, that was months of work. We got lots of amazing, fantastic, really good edits from our district's group on that one. So just a shout out to those guys and gals. They are unbelievably valuable. That's our clinical and operational leaders here at MCHD, and most of all of our protocols really route through them in their monthly meeting, and they really helped to guide that one. So that was a cool one for us because it is a risk-filled process to your point that happens out there every day, David, without any guidance, because it just sort of happens in a natural flow. Well, what makes you more sure of yourself as a paramedic out there allowing the EMT to ride the call is having a set of general guidelines, guardrails, up into place that gives you a little bit of comfort that you're doing the right thing, per medical direction, per the service. I'm here, your host, Dr. Deepas Kulley. Well, I'm from New York and where it's cold, so I didn't even think this was going to be a thing, but I like our cold water immersion protocol. I first learned that. I was like, "Well, that's pretty cool." And if you don't know, it's when you're really, really hot and overheated from when it gets really, really hot and overheated here in Texas. And you wind up having a heat stroke, we put you in a bag of ice water and cool you down. And we've brought people's temperatures up from 107 down to 99 on arrival of the emergency department. I think that's really cool for us to do in the ambulance. We've got a case series in prep that should be published here in the next few months talking about our first nine or ten of these. And that clinical outcomes are amazing. I know the people that work in heat stroke and work in cold water immersion are zealots. And I know why now, because it is an absolute time sensitive situation. And immediate cold water immersion on scene is a lifesaver. So I'm not a zealot, but I'm definitely on board. Because we've got the data, we're going to publish it. And these patient outcomes are absolutely amazing in these folks that are critically ill. I'm going to take last and y'all, I believe, know which one I'm going to go with. I couldn't be prouder of our end of life protocol that we rolled out in 2025. If you think about what goes into those last moments in our lives and how important that moment is to our patients and their families to allow folks to have a say so and some latitude in that moment to their wishes and their comfort is beyond impactful. And I've said this in front of CE and I believe it 100% is sacred. And we have seen just some amazing cases where we've navigated hospice situations, pain situations, short subrath and anxiety, and absolutely made those final moments that folks and their families are going through more comfortable and closer to what we all want and that's dignity. So to the medics out there that are using the end of life protocol, huge props, huge kudos, it's maybe not a resuscitative effort in the same sense as a finger thoracostomy or delayed sequence intubation or defibrillation or a cardioversion. But in many ways, I believe it's as impactful or more. So that's my pick. I think that's a good one to wrap it up on. David, I love the podcast episodes that come from paramedic questions. Thank you for putting the effort into this one and for sending the thoughts and ideas because this one came from came from the field. And so hopefully the medics out there that are listening to this that haven't thought about it quite as much as David got something out of this. Anything y'all like to close with before we wrap up. We, um, in case anybody wants to know, we put a lot of effort and time and many, many meetings to making this new protocol set. And we're not infallible. We get it. So that protocol's email is still there. Protocols at mchd-tx.org. So if you've got questions about the protocols, or you want to know more how it works or why we did a certain thing, shoot us an email. I'm happy to answer. And that goes to anyone who's listening because our protocols are publicly available online. Is that right? They are publicly available online. We have a web link that we're happy to share with y'all. It is not the same way that you've accessed them in the past through the triple P or the acid remap website. They actually live now on the mchd website. If you would like that link, please email podcast at mchd-tx.org. But if you email protocols or podcast at mchd-tx.org, you'll get your answer. Thanks again, David, for coming on and talking with us today. We did find a fairly massive protocol error today. So we're still working through these. And protocols I will leave y'all with. Fairly massive. Yeah, they're not carved into stone and they never should be. They're a living, breathing document that should have say so from our stakeholders, from our medics, from our clinical leadership, from our operational leadership. It's always going to be an ongoing revision. When you think you've dotted the period at the end of your protocol sentence, you're just wrong. It's a constant comma and there's always an eraser and there's always rewriting. So as always, thanks for listening. Like, follow, subscribe. All those things out there where you listen to podcast. We'll be back with a new episode soon. Thanks for listening. This podcast was brought to you by the Montgomery County Hospital of District, Texas, a production and editing by Andrew Adams. Questions or comments, which are always welcome to be sent to [email protected]. Make sure to subscribe and love to keep updated to all our future castes. Music, copyright, heaven-cloud, and compotec.com. License in the creative commons with ad dreaming 3.0.