Further reading

Matt has kindly provided a list of references from his Trauma Care talk which this podcast is based on:

Peri-operative and critical care management of the brain – current evidence. Anaesthesia: Vol 77, No S1.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

Vasopressors in Trauma: A Never Event? : Anesthesia & Analgesia

Blood pressure in trauma resuscitation: ‘pop the clot’ vs. ‘drain the brain’? – Wiles – 2017 – Anaesthesia

Blood pressure management in trauma: from feast to famine? – Wiles – 2013 – Anaesthesia

Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials

Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Early vasopressor use following traumatic injury: a systematic review

Vasopressors in traumatic brain injury: Quantifying their effect on mortality

Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis

Read more about the Cochrane injuries group: https://injuries.cochrane.org/about-us-0

Have a listen to the earlier TXA podcast here: https://phemcast.co.uk/2018/01/18/episode-26-tranexamic-acid/

Do you want to revise your clotting pathways and the mechanism of action of TXA?!

Here are some links to the excellent Life in the Fast Lane:

https://partone.litfl.com/clotting.html

https://partone.litfl.com/unclotting.html

Acute Coagulopathy of Trauma Tranexamic Acid

The Resus Room podcast which discusses Tim and colleagues paper on gender differences in TXA administration is available here: https://www.theresusroom.co.uk/courses/papers-of-june-2022/

Want to read more about Crash 4? https://crash4.lshtm.ac.uk

References

Crash 2: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60835-5/fulltext

Crash 3: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32233-0/fulltext

WOMAN: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext

Use of tranexamic acid in major trauma: a sex-disaggragated analysis of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2 and CRASH-3) trials and UK trauma registry (Trauma and Audit Research Network) data. Tim Nutbeam. Br J Anaesth. 2022

OKAMOTO, SHOSUKE, and UTAKO OKAMOTO. “Amino-methyl-cyclohexane-carboxylic acid: AMCHA a new potent inhibitor of the fibrinolysis.” The Keio Journal of Medicine 11.3 (1962): 105-115. https://www.jstage.jst.go.jp/article/kjm1952/11/3/11_3_105/_article/-char/ja/

Grassin-Delyle S et al. Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial. British Journal of Anaesthesia, Volume 126, Issue 1,2021 https://www.sciencedirect.com/science/article/pii/S0007091220306826

Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, Fergusson DA, Ker K. Anti‐fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001886. DOI: 10.1002/14651858.CD001886.pub4. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001886.pub4/full

Ageron, FX., Coats, T.J., Darioli, V. et al. Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: usefulness for tranexamic acid treatment criteria. Scand J Trauma Resusc Emerg Med 29, 6 (2021).

Guyette FX et al. Tranexamic acid during prehospital transport in patients at risk for hemorrhage after injury: A double-blind, placebo-controlled, randomized clinical trial. JAMA Surg 2020. PMID: 33016996

Marcucci M et al. Rationale and design of the PeriOperative ISchemic Evaluation-3 (POISE-3): a randomized controlled trial evaluating tranexamic acid and a strategy to minimize hypotension in noncardiac surgery. Trials. 2022 Jan 31;23(1):101. doi: 10.1186/s13063-021-05992-1. PMID: 35101083; PMCID: PMC8805242.

Road traffic collisions are a leading cause of death and injury. Following a road traffic collision many patients will remain trapped in their vehicle. Extrication is the process by which injured or potentially injured people are removed from their vehicle by the rescue services.

Rescue service training focuses on the absolute movement minimisation of potentially injured patients’ spine and has developed extrication techniques with the focus of movement minimisation. Unfortunately these techniques take significant amounts of time (30 minutes plus); this delays access to potentially lifesaving treatments for injuries.

 In this Road Safety Trust funded project, the EXIT team across nine published academic studies reconsider extrication, provide evidence of harm, demonstrate that current techniques do not minimise movement as intended and provide a framework of principles for evidence-based extrication: 

Operational and clinical team members should work together to develop a bespoke patient centred extrication plan with the primary focus of minimising entrapment timeIndependent of actual or suspected injuries patients should be handled gently. A focus on absolute movement minimisation is not justifiedWhen clinicians are not available, FRSs should where necessary assess patients, deliver clinical care and make and enact extrication plans (including self-extrication)1Self-extrication or minimally assisted extrication should be the standard ‘first line’ extrication for all patients who do not have contraindications, which are:
-An inability to understand or follow instructions,
-Injuries or baseline function that prevents standing on at least one leg, (specific injuries include: unstable pelvic fracture, impalement, bilateral leg fracture)All patients with evidence of injury should be considered time-dependent and their entrapment time should be minimisedIncidents where a patient may require disentanglement are complex and associated with a high morbidity and mortality. A senior FRS and clinical response should attend such instances2Clinical care during entrapment:
-Can be delivered by FRS or clinical services1
-Should be limited to necessary critical interventions to expedite safe extrication3
-Rescuers should be aware that clinical observations may prolong entrapment time and as such should be kept to the minimum
-FRS and clinical personnel should be aware of the physical and observable signs of patient deterioration and if identified should make this known to the responsible clinicianImmobilisation:
-Longboards are an extrication device and should not be used beyond the extrication phase
-Kedrick Extrication Devices prolong extrication time and their use should be minimised
-Pelvic slings should not be applied to patients until they have been extricated
-Cervical collars should only be used following assessment and should be loosened or removed following extricationPatient focused extrication:
-Build a connection with patients, explain actions, and use their name
-Where appropriate, reassure patients as to the safety of their co-occupants and others involved in the incident (including animals)
-Provide an ‘extrication buddy’
-Allow communication with family members or other close contacts
-Rescue teams should not publish extrication related imagery to social media or other outlets
-Minimise the ability of the public to view the accident, take photographs or record videos. Provide education to this effectOn initial call to Emergency Services
-Attempt to clarify entrapment status
-Attempt to identify patients who require disentanglement (and dispatch an appropriate priority senior2 response)
-A standard multi-agency MVC trauma message should be developed to ensure the correct resources are deployedMulti-professional datasets should be developed with patient and public engagement and should include entrapment status, entrapment time, injuries, extrication approach, clinical careAgreed nomenclature for categories of patient
Not injured, Minor injuries (evidence of energy transfer but no evidence of time-dependent injury), Major injury (currently stable but should be assumed to be time-dependent), Time critical injured (Time critical due to injury; use fastest route of extrication) m Time critical hazard (e.g. secondary to fire or other hazard)

These principles have been adopted by national level stakeholders in the UK are being incorporated into national clinical and operational guidance which will reduce entrapment time and may demonstrate morbidity and mortality reductions.

Links to papers:

1. Nutbeam T, Fenwick R, Smith JE, Bouamra O, Wallis L, Stassen W.  A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped. Scand J Trauma Resusc Emerg Medicine 29, 17 (2021).

• Nutbeam T, Kehoe A, Fenwick R, Smith JE, Bouamra O, Wallis L, Stassen W. Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN). Scand J Trauma Resusc Emerg Medicine 30, 14 (2022).

• Nutbeam T, Weekes L, Heidari S, Fenwick R, Bouamra O, Smith JE, Stassen W et al. Sex-disaggregated analysis of the injury patterns, outcome data and trapped status of major trauma patients injured in motor vehicle collisions: a prespecified analysis of the UK trauma registry (TARN). BMJ Open 2022;0:e061076. doi:10.1136/ bmjopen-2022-061076

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Wallis L, Dayson M, Shippen J. The role of cervical collars and verbal instructions in minimising spinal movement during self-extrication following a motor vehicle collision – a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Medicine 29, 108 (2021).

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Shippen J. Maximum movement and cumulative movement (travel) to inform our understanding of secondary spinal cord injury and its application to collar use in self-extrication. Scand J Trauma Resusc Emerg Medicine 30, 4 (2022).

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Bowdler J, Wallis L, Shippen J. Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Medicine 30, 7 (2022).

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Bowdler J, Wallis L, Shippen J. Comparison of ‘chain cabling’ and ‘roof off’ extrication types, a biomechanical study in healthy volunteers. In press; Injury

• Nutbeam T, Brandling J, Wallis L, Stassen W.  Understanding people’s experiences of extrication whilst being trapped in motor vehicles: a qualitative interview study.  In press; BMJ Open

• Nutbeam T, Fenwick R, Smith JE, Dayson M, Carlin B, Wilson M, Wallis L, Stassen W. A Delphi Study of Rescue and Clinical Subject Matter Experts on the Extrication of Patients Following a Motor Vehicle Collision Scand J Trauma Resusc Emerg Med 30, 41 (2022). https://doi.org/10.1186/s13049-022-01029-x

This is the book Jon quotes, “Pain is a symphony…”

The International Association for the Study of Pain’s revised definition of pain is available here.

If you’d like to read more about ‘nocebo’ i.e. the non-pharmacological adverse effects of an intervention, have a look at this article.

Penthrox

For more information on Penthrox, you can read about it in the BNF, The Emergency Medicines Compendium and on the manufacturers own website.

Jon is the author of the Pain and analgesia chapter in the 2nd edition of the ABC of Prehospital Medicine, to be published soon!

Before you listen to this new podcast, we encourage you to go back and have a listen to Episode 16: Blood which we released in 2017 outlining the available evidence about prehospital blood, and the background to the RePHILL trial.

The RePHILL (Resuscitation with Pre-Hospital Blood Products) original paper is available here, and you can read more about the trial at the University Of Birmingham Clinical Trials site.

On the day of publication, Critical Care Reviews hosted a Livestream which is available to watch back including the investigators, an editorial by Simon Carley (of St Emlyns fame) and discussion panel. This is a really detailed and informative presentation which includes a summary of the results from the statistician.

This podcast is dedicated to the memory of Emmanuel Cauchy.

George’s adventures!

Grading frostbite

Stages of frostbite. From Cauchy et al, 2016. Grade 1 Grade 2 Grade 3 Grade 4 Stages of frostbite. From Cauchy et al. 2001

The GELOX study

The Hyperbaric oxygen study described by Carron is now in print and available here.

Guidelines

The guidelines mentioned by Chris can be found on the Wilderness Medical Society website.

References

Cauchy et al. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. The Journal of Hand Surgery. 2000; 25(5): 969-978.

Cauchy et al. A Controlled Trial of a Prostacyclin and rt-PA in the Treatment of Severe Frostbite. NEJM. 2011; 364: 189-190.

Cauchy et al. A New Proposal for Management of Severe Frostbite in the Austere Environment. Wilderness & Environmental Medicine. 2016; 27(1): 92-99.

Cauchy et al. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness & Environmental Medicine. 2001; 12(4): 248-255.

Handford C, Buxton P, Russell K, Imray CEA, McIntosh SE, Freer L, Cochran A, Imray CHE. Frostbite: a practical approach to hospital management. Extreme Physiology & Medicine. 2014; 3, 7.

Magnan et al. Hyperbaric Oxygen Therapy with Iloprost Improves Digit Salvage in Severe Frostbite Compared to Iloprost Alone. Medicina. 2021; 57(11): 1284.

Some useful videos:

Hopefully you found the podcast interesting, but since this is quite a visual topic we have put together some videos to demonstrate some of the pathologies discussed and what they look like on ultrasound:

How does ultrasound work?

Want to know how to use ultrasound? This is a whole 45 minute introductory lecture. Although a face-to-face course is really required before you start on patients!

The radiopaedia website is an amazing resource for all things imaging. Their section on POCUS is here.

The Sonosite website has some excellent resources, which you can filter according to specialty, including prehospital using ‘EMS/Air Med/Ambulance’.

Airway

Intubation

More detail on intubation from 5 minute sono

Front of neck access

Breathing

Pneumothorax

Lung pathologies including PE and pulmonary contusion

Pulmonary oedema

Pleural effusion

Circulation

FAST scan in trauma

Free fluid/haemoperitoneum in the RUQ

Pericardial effusion with engorged IVC

Disability

Ocular ultrasound

EMCRIT post on use of ultrasound to diagnose raised ICP with ocular sonography

Extremity

Rib & sternal fractures

Ultrasound guided hip nerve blocks (including femoral and FIB)

Cardiac arrest

Use of ultrasound in cardiac arrest (US)

POCUS in cardiac arrest (UK)

Further Resources

FAST ultrasound examination as a predictor of outcomes after resuscitative thoracotomy: a prospective evaluation. Kenji Inaba. Ann Surg. 2015

Marik PE, Cavallazzi R. Does central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41: 1774-81.

Cavallaro F, Sandroni C, Marano C, et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med 2010; 36: 1475-83.

https://theresusroom.co.uk/ultrasound-in-cardiac-arrest/

ResusMe bibliography of PH ultrasound papers

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism

Definitions

UK definition (RCEM): It describes the sudden onset of aggressive and violent behaviour and autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness.

Australian definition (NSW Health): Behaviour that puts the patient or others at immediate risk of serious harm and may include threatening or aggressive behaviour, extreme distress, and serious self-harm which could cause major injury or death.

Toxidromes

There are some superb resources on the Life in the Fast Lane site on this topic. Really recommend having a look!

De-escalation

There is a useful summary on some de-escalation strategies & techniques, from HSI here.

This handbook from a UK NHS Trust outlines some key principles from their conflict resolution training.

Further reading

JRCALC Clinical Guideline: Acute Behavioural Disturbance. 

NICE. NG10. 2015. Violence and aggression: short term management in mental health, health and community settings.

RCEM. Best Practice Guideline. 2016. Guidelines for the Management of Excited Delirium/Acute Behavioural Disturbance.

Faculty of Forensic and Legal Medicine. 2019. Acute behavioural disturbance (ABD): guidelines on management in police custody.

College of Paramedics. Acute Behavioural Disturbance Position Statement

The CQC brief guide to restraint

This was a joint podcast with our friends & colleagues at WEMCast – to hear more from them, have a look at their podcast back catalogue, and there’s more information on the World Extreme Medicine website.

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Mosquito born disease

Malaria risk areas. From: https://www.iamat.org/risks/malaria

Malaria is transmitted through the bite of an infected female Anopheles mosquito. It is widely distributed throughout tropical regions of the world, within the majority of cases reported in Africa. If you would like to read more about malaria; its signs & symptoms, variants, at-risk countries and treatment, have a look at the Travel Health Pro website.

Dengue risk areas. From https://travelhealthpro.org.uk/factsheet/13/dengue

Dengue is a viral disease transmitted by mosquitos. Symptoms include high fever, muscle and joint pains, headache, nausea, vomiting and rash. It is generally a self limiting illness with improvement in symptoms and recovery occurring three to four days after the onset of the rash, although rarely can lead to dengue haemorrhagic fever. Again, the Travel Health pro website has some excellent information on this.

Zica virus is spread by day-biting mosquitos. In addition a few cases of transmission by sexual contact have been reported.  It is found in parts of Africa, Asia, the Pacific Islands, Central and South America and the Caribbean. The majority of people infected with Zika virus have no symptoms. For those with symptoms, it is usually a mild and short-lived viral type illness, with conjunctivitis and muscle/join pains. However, Zika virus is a cause of Congenital Zika Syndrome (microcephaly and other congenital anomalies) and neurological complications such as Guillain-Barré syndrome. Read more here.

Exertional heat illness

From https://moveitnq.com.au/exercising-in-the-heat/

The UK Faculty of Sport and Exercise Medicine has produced a position statement on exertional heat illness, available here, and the Royal College of Emergency Medicine’s elearning platform also has a module on the spectrum of heat related illness.

From https://tactical-medicine.com/products/caervest-core-body-cooling

To find out more about the CAER vest mentioned in the podcast, have a look at this YouTube video. Or read this article.

Pitted keratolitis

Further reading

Smith M, Withnall R & Boulter MK. An exertional heat illness triage tool for a jungle training environment. J Royal Army Medical Corps, 2018. 164, 287-289. DOI: 10.1136/jramc-2017-000801

Alele FO, Malau-Aduil BS, Malau-Aduli AEO, Crowe MJ. Epidemiology of exertional heat illness in the military: A systematic review of observational studies. Int. J. Environ. Res. Public Health 2020, 17(19), 7037. https://doi.org/10.3390/ijerph17197037

Guidance documents

College of Paramedics Statement on Intubation, available here.

AAGBI Safer Prehospital Anaesthesia 2017, available here.

Positioning

From: http://anaesthesiatoday.blogspot.com/2013/03/10-common-procedural-basics_29.html

Recommended Rich Levitan resources

EMCrit 70 – Airway Management with Rich Levitan

Airway axes

From: McGuire B, Hodge K. Tracheal intubation. Anaesthesia & Intensive Care Medicine. 2019. 20(12);681-686. From: https://veteriankey.com/tracheal-intubation/

Epiglottoscopy

Bimanual Laryngoscopy

It should be noted that this is not entirely consistent with current standard UK practice, as it discusses cricoid pressure and a stylet being used in the ETT, rather than a bougie

Further resources

Direct Laryngoscopy Bimanual laryngoscopy

Apnoeic Oxygenation in Resuscitation: Is it time?

https://anaesthetists.org/Home/Resources-publications/Guidelines/Safer-pre-hospital-anaesthesia

Article available here.

Click here to hear what our friends over at the Resus Room think about Airways 2

References (kindly shared by Rich)

Davis DP et al. The Effect of Paramedic Rapid Sequence Intubation on Outcome in Patients with Severe Traumatic Brain Injury. J Trauma 2003; 54:444-453

Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscope attempts. Anesth Analg. 2004 Aug;99(2):607-13, 

Hasegawa K et al. Association Between Repeated Intubation Attempts and Adverse Events in Emergency Departments: An Analysis of a Multicenter Prospective Observational Study. Annals of Emergency Medicine 2012; Volume 60, Issue 6, Pages 749–754.e2

Delson NJ et. al., Anesthesia and Analgesia, 2002; 94; S-123.

Levitan RM et al. Laryngeal View During Laryngoscopy: A Randomized Trial Comparing Cricoid Pressure, Backward-Upward-Rightward Pressure, and Bimanual Laryngoscopy. Annals of Emergency Medicine 2006; 47(6):548-555

Lewis  SR, Butler  AR, Parker  J, Cook  TM, Smith  AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD011136. DOI:10.1002/14651858.CD011136.pub2. 

Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann HC, Arntz HR. Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS. Resuscitation. 2011 Dec;82(12):1519-24. doi: 10.1016/j.resuscitation.2011.06.028. Epub 2011 Jul 2. PMID: 21749908.

Bossers SM, Schwarte LA, Loer SA, Twisk JW, Boer C, Schober P. Experience in Prehospital Endotracheal Intubation Significantly Influences Mortality of Patients with Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. PLoS One. 2015 Oct 23;10(10):e0141034. doi: 10.1371/journal.pone.0141034. PMID: 26496440; PMCID: PMC4619807.

Sunde, G.A., Heltne, J., Lockey, D. et al. Airway management by physician-staffed Helicopter Emergency Medical Services – a prospective, multicentre, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med 23, 57 (2015). https://doi.org/10.1186/s13049-015-0136-9

Crewdson, K., Lockey, D.J., Røislien, J. et al. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care 21, 31 (2017). https://doi.org/10.1186/s13054-017-1603-7

Gellefors M et al. Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. British Journal of Anaesthesia, 120 (5): 1103e1109 (2018)

Konrad, Christoph MD; Schupfer, Guido MD, MBA HSG; Wietlisbach, Markus MD; Gerber, Helmut MD, PhD Learning Manual Skills in Anesthesiology: Is There a Recommended Number of Cases for Anesthetic Procedures?, Anesthesia & Analgesia: March 1998 – Volume 86 – Issue 3 – p 635-639. doi: 10.1213/00000539-199803000-00037

de Oliveira Filho, Getúlio Rodrigues, MD The Construction of Learning Curves for Basic Skills in Anesthetic Procedures: An Application for the Cumulative Sum Method, Anesthesia & Analgesia: August 2002 – Volume 95 – Issue 2 – p 411-416 doi: 10.1213/00000539-200208000-00033

Je S, Cho Y, Choi HJ, et al An application of the learning curve–cumulative summation test to evaluate training for endotracheal intubation in emergency medicine Emergency Medicine Journal 2015;32:291-294.

Toda, J., Toda, A.A. & Arakawa, J. Learning curve for paramedic endotracheal intubation and complications. Int J Emerg Med 6, 38 (2013). https://doi.org/10.1186/1865-1380-6-38

Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann H-C, Arntz H-R. Difficult prehospital endotracheal intubation – predisposing factors in a physician based EMS. Resuscitation. 2011;82:1519–24

From: https://www.bbc.co.uk/news/uk-wales-46441129

From: https://www.ultimatekilimanjaro.com/blog/should-i-use-supplemental-oxygen-on-kilimanjaro/

A portable hyperbaric chamber (Gamow bag) From: https://litfl.com/hypothermia/ Classic stretcher technique Improvised rucksack stretcher technique

Want to know more?

This is one of the organisations Lucy mentions: British Exploring

And this is the Global Health MSc

The Wilderness Society Guidelines are available here.

This is the link to the Wilderness Medical Society.

Consensus statement from the UIAA on People with Pre-Existing Conditions Going to the Mountains, and their website for more useful resources.

Li Y, Zhang Y, Zhang Y. Research advances in pathogenesis and prophylactic measures of acute high altitude illness. Respiratory Medicine. 2018; 145: 145-152. https://doi.org/10.1016/j.rmed.2018.11.004

The Faculty of Prehospital Care have also published guidance on the Medical Provision for Wilderness Medicine. Thanks to Dave Hillebrandt for sharing this with us.