003 Mark Klimek

The transcription discusses calcium channel blockers as being like Valium for the heart, calming it down. They are negative inotropic, chronotropic, and dromotropic. These drugs treat conditions like hypertension, angina, and atrial arrhythmias. Side effects include headache and hypotension. Names ending in "dipine," verapamil, and cardizem are examples. Monitoring blood pressure is crucial before administering. For continuous IV drips like cardizem, systolic BP should be kept above 100. Cardiac arrhythmias and interpreting rhythm strips are also covered, emphasizing normal sinus rhythm and ventricular fibrillation as examples. Hey, it's 11 calcium saddle blockers, another top 10 group of joints, but the good news about this one, there isn't a whole lot you need to know, you just have to know some basics about these hard joints. Somewhere in the margin of this lecture, I want you to write the following. Calcium saddle blockers are like Valium for your heart. Calcium saddle blockers are like Valium for your heart. So why would I say that? I think that makes it easy for you to remember what they do, because what does Valium do for your body and for you in general? What's it do? It calms you down. So what do you think calcium saddle blockers do to the heart? They calm it down. So if you get a question about a calcium saddle blocker, you think, oh, that's going to calm my heart down. That would be just like giving my heart some Valium. Now, did I say it was Valium? No, it's not Valium. It has nothing to do with Valium, but it's like Valium for your heart. So if your heart is hecatartic, could it stand a little relaxation? So what class of drug could you give? Calcium saddle blockers. If you're in shock, does your heart need to relax when you're in shock? No, it needs to get cooking here, so would you give a calcium saddle blocker? No. If your heart was in heart block, would you give a calcium saddle blocker? No. If your heart was having tachyarrhythmia, would you give a calcium saddle blocker? So if you had a heart attack and you wanted to rest your heart, what would you give? Calcium saddle blocker. So calcium saddle blocker is given when you want to rest your heart. When your heart needs stimulated, please don't give a calcium saddle blocker. That's not a good idea. So this is like Valium for your heart. Now, how do we say that really fancy? The way we say that fancy is the following. You see here where it says letter A? Calcium saddle blockers are negative, inotropic, chronotropic, and dromotropic. When you see the fancy words negative inotropic, negative chronotropic, negative dromotropic, don't freak out. All that's saying is what? It's like Valium for your heart. So negative inotropic, negative chronotropic, negative dromotropic relax your heart. They calm it down. Now, the chart below shows you the difference between the positive inotropic, chronotropic, dromotropic, and the negative inotropic, chronotropic, dromotropic. What do positive chronodromos do? Look down here. What do they do? They strengthen, speed up, stimulate. So they are called what? Cardiac? Depressants or stimulants. And negatives are cardiac? Depressants. So a positive inopronodromotrope is a cardiac stimulant. A negative inopronodromo is a cardiac depressant. You see the difference? In that chart, which column should you highlight in this lecture because it applies to the calcium saddle blockers? The last column. Circle and highlight the last column because that's where calcium saddle blockers fit into the picture. They are negative inopronodromotropes. They weaken, slow down, and depress the heart. Letter B. When would we want to do that? What do they treat? Well, they treat A, AA, and AAA. The letter A is your friend here. A, AA, and AAA. Well, what does A stand for? Number one, they are antihypertensive. They are antihypertensive. How does that work? They relax your heart and blood vessels. If you relax your heart and relax your blood vessels, what does your blood pressure do? It goes down. Does that make sense? If your blood pressure was high, would you take a value for your heart or a stimulant for your heart? If your blood pressure is high, would you want a value for your heart or a stimulant for your heart? Value. Value. And that would mean you'd use a calcium channel blocker. You see what I'm talking about? Okay, the second AA stands for antianginal. They are anti-angina drugs. Well, how does that work? It's going to relax your heart, so it uses less oxygen, so they're scared to go the angina way. It works by decreasing oxygen demand. It treats angina by decreasing oxygen demand, because it relaxes the heart. What's the worst thing in the world for a person with angina? What's the worst thing that can happen to a person with angina? With their heart. What's the worst thing that can happen to their heart in a person with angina? Speed up. Speed up. And then it has problems, so you want to do what to the heart? Slow it down. AAA. Anti-atrial arrhythmia. Anti-atrial arrhythmia. So what does it treat? Will it treat ventricular tachycardia? No. No. Why? Because that's ventricular, and it's only treating atrial. Will it treat atrial flutter? Yes. Yes. Atrial fibrillation. Yes. Premature ventricular contraction. No. Premature atrial contraction. No. Paroxysmal atrial tachycardia. Yes. Atrial vigeminy. Yes. Ventricular vigeminy. No. Oh, there you go. I like that. I love medical transcriptions that don't know what they're writing. We always have fun reading those charts on night shift. I remember one time I was working nights. I just started writing. We were reading this guy's history in physical, and the doctor dictated, and the transcriptions wrote out the history because we know they make mistakes. She said that this guy has... This guy has ventricular vigeminy. Take a look. So all you have to know to know what the reason is this treat is to know if it starts with what letter? A. If it's an A, it's yes, and if it's a B, it's no. Well, there's a trick. What about this one? Supraventricular tachycardia. Tachycardia. S-V-T. Would calcium channel blockers treat S-V-T? Yes or no? I would say yes. You're correct. Yes. Why? What does supra mean? And what's above the ventricles? Atria. Boom. So supraventricular is the only ventricular which is actually saying atrial. Does everybody get that? Otherwise, we're good to go. We're going to treat A-A-A and A-A-A. Well, what are the side effects? H-N-H. The letter H is your friend here. Headache and hypotension. Headache and hypotension. Why hypotension? Because it relaxes the heart and the blood vessels. Why the headache? Because you get vasodilation in the brain and that gives you like a migraine. By the way, headache is a great thing to check on a select all and apply. Because what do you have with low sodium? Headache. What do you have with a high sodium? Headache. What do you have with a high glucose? Headache. What do you have with a low glucose? Headache. What do you have with high blood pressure? Headache. What do you have with low blood pressure? Headache. You know, I think headache is pretty... I'll go with headache. Okay, names of calcium channel blockers. Names. Anything ending in dipine. Anything ending in dipine. Amlodipine. Nifasdipine. The dipping. I always say you're dipping in the calcium channel. Notpine. Why notpine? Why would you... Why do I not want you to memorize everything ending in pine? Because there are loads of drugs that end in pine that are notpine. It has to be a dipine. Dipine. Dipine is your calcium channel blocker ending. And then there are two others you have to know by name. Barat. Bamil. And cardizem. Barapamil and cardizem. So the dipine, barapamil and cardizem. Dipine, barapamil, cardizem. Those are your calcium channel blockers. Which of those is continuous IV drip? Can be given to get your cardizem. So when you give a calcium channel blocker, now think about this. When you give a calcium channel blocker, what vital sign do you need to measure before you give it? Blood pressure. Why? What's the side effect? Hypertension. Hypertension. So you measure the blood pressure. What are your parameters? What are your guidelines? You get a blood pressure. So what? What are your guidelines? How are you going to use it? For non-women, I'm thinking. You're thinking tall. You're thinking tall. Okay. Which one? Yes. Hold the calcium channel blocker if the systolic, that's the top number, is under 100. Take the blood pressure. Or measure it. Don't take it. Measure it. Measure the blood pressure, and if the systolic is under 100, then you hold the calcium channel blocker. So what do you have to monitor continuously or fairly quickly, intermittently, while they're on a cardizem drip? The blood pressure. And there again, if it was 98 over 52, what would you do? What would you do? Get the drip? Slow it down. Measure it again. So you titrate. Do you know what I mean by titrate? Change the IV rate to keep the blood pressure what? Systolic over 100. LPN, they would say somebody's on a cardizem drip. Do you notice all the following? Which one would you report to the RN? Is the systolic falling below 100? Same information, just asked from a different perspective. Okay, cardiac arrhythmias. The ones we're going to do for the rest of the night are short. So that you, you know, if the day goes on, your brain gets more spaghetti-like. And I just want to keep it fast so you don't get no good long ones in the middle of the night. Cardiac arrhythmias. Knowing how to interpret rhythm strips. Now, turn to page 13, the next page down. Do you see at the bottom of the page there are four rhythm strip tracings? These are the four you must know by sight. You have to know these by sight. The first one is normal sinus rhythm. How do you know it is normal sinus rhythm? There's a P wave, a QRS, and a T wave for every single complex. There's a P wave for every QRS, and every QRS is followed by a T wave. But what else tells you it is normal sinus rhythm? Do you see the peaks of the P waves? How equally distant they are from one another? That tells you you're not dealing with something called a sinus arrhythmia. So that is normal sinus rhythm. Because there's a P for every QRS, and the QRS complexes are evenly spaced. When you see that, that's normal sinus rhythm. It doesn't really matter if they go up or down. It's going to mean you could have a P wave going up, QRS going down. That's okay. That's still normal sinus. The second one is VFIB, ventricular fibrillation. It is a chaotic, squiggly line. The third one looks like a 1970s wallpaper border. That's VTAC, ventricular tachycardia. It's got the sharp peaks and jacks. Is there a pattern? Yeah. Is there a pattern with ventricular fibrillation? No, there's no pattern with VFIB. There is a pattern with VTAC. And the last one is called what? Asyphilis. Please don't mix it up. Honestly, don't mix it up. You're going to look down on them now. Crash and burn time. Okay, let's go back to page 12. Now, I just want to hit those right out of the gate. Now, could they show you Wolff-Parkinson-White syndrome? Yeah. But why do I not teach you that? You don't need to know. You don't need to know. But Mark, he said, if they show it to me, don't I need to know it? What's the answer? No. What do you need to know? You need to know the answers to the questions that everybody else knows. And everybody else knows what asyphilis looks like. And everybody else knows what VFIB looks like. And everybody else knows what VTAC looks like. And everybody else knows what Nervositis looks like. Nobody else knows what Wolff-Parkinson-White syndrome looks like. So if you miss that, it doesn't hurt you. You understand? These questions are all given degrees of difficulty. So do you have to get every question right? No. What questions do you have to get right? The ones that everybody knows. The easy questions. You can miss every single hard question on the board and pass with flying colors. You understand what I'm saying? So why do I teach you what I teach you? I want to teach you the stuff that everybody knows. So that you real quickly get correct the answers to the questions that everybody else knows. So that real quickly you get to what kind of questions? Hard ones that no one knows. Now you're going to feel how? Horrible because you don't know any of this stuff. But that's good. You know what I'm saying? My goal is to, as fast as I can, get you to the hard questions. The questions that nobody else knows, including you. So that you feel really stupid. Do you see what I'm saying? I want you to, halfway through this test, I want you to be going, What? What is that drug? What disease is that? What are you talking about? What's this? You know? Because, you know what I'm saying? You don't have to know everything. You just have to know what everybody else knows. What, you know, little less than, average. And so we're not going to... That's what kills me about a lot of these review books. A lot of these review books have all these rhythm strips in it. Which is ridiculous. And these people have to memorize these rhythm strips. Like 50 of them. And only four of them really are going to hurt you if you don't know. So why do these other books put those rhythm strips in their review? Why do they put them in there? Because they what? Heard that they're on there. They heard that they're on there. And so they what? They heard that something's on there, so what do they do immediately in their book? They throw it in. And their books get what? Thicker and thicker and thicker. My books are what? Thin. Less focused on the stuff you need to know. And nothing. It's crazy. If I were to give you three levels of nursing knowledge. Stuff you need to know. Stuff that's nice to know. And stuff that's nuts to know. And most of nursing books are made up of nuts to know. Have you ever asked a teacher, just tell me what I need to know? And they say, well read the book in the notes. Well that's helpful. Well part of what you're paying me for is to take all of that that's in those books and narrow it down to this. So that you know this. You know what everybody else knows. And soon you'll get to stuff that no one knows. You won't know everything, but hey, that's cool. So don't think you have to know everything. Because if you try to learn everything, you'll master nothing. Do you hear what I said? If you try to learn everything, you'll master nothing. That's what students do. They just try to learn more, more, more, more, more. No. More isn't the solution. Okay? Focus on what you really need to know and then how to apply it. That's what we're talking about. Okay. Back on page 12A. Terminology. Whenever the question says QRS depolarization, it's talking about ventricular. If it says blankly, blank, blank, blank, blank, QRS depolarization, blank, blank, blank, blank, blank. You can always narrow it down to one of two. Both of those would say one word. Ventricular. You can rule out anything that says what? April. April. If you see QRS, you can rule out anything that says atrial and go with what's ventricular. However, number two, if it says P wave, that will refer to something atrial and you can rule out anything ventricular. Unless they say a lack of a P wave. Well, I mean, that's not really talking about a P wave. All right. Let's use that to answer letter B, the six riddles most tested on implants. Number one, they will use this phrase, a lack of QRSs. There are no QRSs. Zero. None. What do you think that's called? A disability. That's a flat line. That's a disability. Number two has to be a form of what? Atrial. Atrial. Why does it have to be atrial? That's B wave. That's B wave. And when you see sawtooth, you always pick flutter. Flutter is always described as sawtooth. I always think of the movie Jaws. I saw the teeth and my heart did flutter. Sawtooth, flutter. Numbers three and four, do you notice they have the same adjective, the word chaotic? Chaotic is always the word used to describe fibrillation. Fibrillation. So what is number three? How do you know it's atrial? And what's number four? Ventricular fibrillation. How did you know it was ventricular? How did you know it's fibrillation? Chaos. These are the words they use. What is number five? Some form of what? Atrial or ventricular? Ventricular. How do you know it's ventricular? QRS. QRS. And when it says bizarre, bizarre always applies to tachycardia. Bizarre is the word they use for tachycardia. Chaos is the word they use for fibrillation. Don't get that confused. Chaos is for fibrillation. Bizarre is for tachycardia. So you put two and two together, what is number five? Ventricular tachycardia. Do you see how this can be easy if you just know your words? Why did they do that? What's that? Why did they do that? Why did they put chaotic in? They didn't do that. How would we know that? Oh, why didn't they teach you that? I mean, why did they put that in the HESI test? Why did they put those words in there? They did. I mean, yeah, why do they? I mean, they're trying to mess us up? No, actually, what they're doing is they're seeing if you know what those words mean. You see what I'm saying? So we were supposed to be taught. Do you know what chaos means? Somewhere along the line we should have been taught this. Yes. Somewhere along the line we should have been taught that chaos was fifth, flutter was sawtooth, bizarre was tachy, QRS was ventricle, T-wave was atrial. We should have been taught that. Well, what about a periodic wide bizarre QRS? That's a PVC. Why is it ventricular? And why is it wide bizarre? Because it's like one snapshot of a tachycardia. Right? It's just one piece of tachycardia. So, is it possible, could you call a salvo of PVCs? You know, a salvo of them, a group of them in a row, a salvo of them. What else could you call it? A short run of VTAP, couldn't you? Because it's the same idea. Now, let me ask you this. Do we care, do physicians care about people having PVCs, generally speaking? No. How high a priority is a client with a PVC? If you had to prioritize four clients and one of them has PVC, how high would you prioritize that guy? Low, moderate, or high? Low. All right? Now, under three circumstances you could elevate that person to moderate. Not high priority, just moderate priority. And here is the list right here below. If there are more than six PVCs in a minute, or more than six PVCs in a row, or if the PVC falls on the T-wave of the previous beat, that's called R-on-T phenomenon. If one of those is true, you elevate the priority of your PVC client to moderate. So PVCs never reach what level? High. They never reach high. The most a PVC client can reach is moderate, and that's if there's more than six in a row, six in a minute, or falling on the T-wave. Otherwise, how high do you prioritize your PVC patient? Low. Isn't it true that after an MI, after a heart attack, if they're having PVCs, what do you know? Is that good or bad? That's good. So actually, it means they're reperfusing. So that doesn't raise their priority. It even lowers it. They're doing great. So anybody ever work coronary care or telemetry? If you call physicians in the middle of the night to tell them that the patient is having PVCs, what is the most common order you will receive? And how will they say that? Just continue the monitor. They'll tell you to DC the monitor. Why? Because if you don't have the monitor, you can't see the PVCs. If you don't see the PVCs, you won't call them. You learn real quick. Don't call a doctor about PVCs unless you want to lose your monitor. Okay. Alright. Lethal or rip-ins, how high a priority are these? Moderate, low, or high? These are high priority. There are two of them that are super high priority. They're lethal, meaning they will kill you in eight minutes or less. The first one is asystole. Right? If you're asystole, like you had eight minutes, or that brain's gone. V-fib is also the lethal one. What do asystole and V-fib have in common? No cardiac output. And if you've got no cardiac output, you do not have brain perfusion. And if you don't have brain perfusion, you're dead in eight minutes. So, think of your four patients, and one of the patients has asystole or V-fib. How high do you prioritize that patient? They're probably number one. Probably number one. Letter D. One of these arrhythmias is a potentially life-threatening. It is not life-threatening. It is only potentially life-threatening, but that still makes it a fairly high priority. And that is ventricular tachycardia. V-tach. So, therefore, what is the difference between V-tach and the asystole V-fibbers? V-tachers have a cardiac output. So, that makes all the difference in the world. Are you ever in a code situation, and they're giving drugs or something, and the rhythm changes? On the monitor, the rhythm changes because of something they did? What's the first question the doctor will always ask? What's that? Do you get a pulse with that? Why? What are they asking? Is there a cardiac output with that? You see? And so, even if the rhythm changes to something that looks good, but there's no pulse, there's no cardiac output, it's just as bad as what was there before. Okay? All right. Turn the page. Let's talk about treatment of these problems. Treatment, yes. On that number six where periodic is underlined, does periodic mean PBCs? Yes. Because it's not a continuous phenomenon. It's only a case. Okay, let's talk about the treatment. The first two are PBCs and VTACs. They are both ventricular, correct? See this? See my fingers? What letter do they make? A B. A B. For ventricular, now watch what happens. For ventricular, use, what letter is that? L. Lidocaine. For ventricular, use lidocaine. For ventricular, use lidocaine. So I just want people to remember that. Ventricular, lidocaine. Ventricular, lidocaine. Now, I know that lidocaine is not used in a lot of squads now in the bigger cities, because they're using amiodarone. But Boris is going to talk more about lidocaine. After April 1, it would be amiodarone. A-M-I-O-D-A-R-O-N-E. So I guess after April 1, I'm going to have to say, see the V for ventricular? A-M-I-O-D-A-R-O-N-E. No, I'm going to get something else. Why do squads in rural areas still stock lidocaine instead of amiodarone? Or V-TAC? V-TIC. I mean, V-TAC and C-T-C. Yes, it's like, one test for lidocaine is four times the shelf life. So why would you buy a super expensive drug that's going to expire in three weeks when you won't use it that much? If you work squad in Franklin County, you're going to use it up so fast, you might as well have amiodarone. So if you work Vinton County or something like that, you're good luck. Amiodarone is going to spoil before you ever use it. Okay, supraventricular means, what's that asynonym for? Supraventricular. Atrial. For atrial arrhythmias, use the A-B-C-D. Atrial starts with what letter? A. So remember the A-B-C-D of atrial treatment. So for ventricular, you use what? Ventricular, you use lidocaine. For atrial, use the A-B-C-D. So what are the A-B-C-D's? A-B-C-D stands for adenocard. A-B-E-N-O-C-A-R-D, adenocard. A-B-E-N-O-C-A-R-D, adenocard, which is adenosine. For adenosine, you have to push in less than eight seconds. So is it a fast or slow IV push? Fast. Now, why do I bring that up? Well, here's why I bring it up. The reason why I bring it up is, when you're talking about IV push, when you don't know, you go slow. You've heard that? You don't know, you go slow when you're pushing. Now, I'm worried because you go, oh, I don't know adenocard, so I'm going to what? Slow. No, this is the one you've got to know. It's a super fast, you've got eight seconds. They call it slamming. If you've ever heard that, you've got to slam this drug. You've got to push it in in eight seconds, and then the other nurse pushes 20 milliliters of flush right after it. So you're going wham, and they're going wham. So you've got to use a big vein. You can't use one of these. You have to use what we call the intern vein, something so big an intern can hit it. So you have to use an intern vein, one of those big ones. Now, the problem with this is, when you slam it fast, what could they go into? Asystole. And they could go into asystole for about 30 seconds, but they'll come out of it. You just have to trust. They'll come out of it. They really will. It's kind of scary. You know, 30 seconds of asystole is scary. But what do you do? Sit there, relax. You're going to be okay. So what's the big thing you have to know with identicar? Push it fast and don't worry about asystole. Oh, well, that's longer than 30 seconds. V. V stands for beta blockers. Beta blockers. And what do all beta blockers end in? L-O-L. L-O-L. Yes. They all end in lol. L-O-L. Simolol, Atenolol, Nalol, Carbetolol, Retolol, Copranolol. Those are all beta blockers. This is the best class of drugs, best made class of drugs in the universe. Every drug that is a lol is a beta blocker, and every beta blocker is a lol. It's great. Every drug should be that way. I always used to say, when we were in school, we used to do stupid things. See that right there? That's baby beta. See the little chromium? It's actually a bigger chromium. It looks like this. That's baby beta, and she's what? Blocked in. She can't go either way. Blocked. Lol. Beta blockers. Now, beta blockers are negative N-O, negative C-O, and negative D-O-M-O. Negative N-O, negative C-O, and negative D-O-M-O. So they're like what? And so they're like value for your? So they'll treat A, A-A, and A-A-A. And what are we talking about here? A-A-A. Anti-Atrial Arrhythmia. Correct? So what will beta blockers have as a side effect? Headache. Headache and? Hypotension. Hypotension. Just like the calcium channel blockers. So don't make a big difference between calcium channel blockers and beta blockers. Generally speaking. The only thing is, is that calcium channel blockers are better for people with asthma. Because beta blockers, they don't, I mean, don't go. True. So people that have other diseases like COPD probably should be on a calcium channel. Although a beta does all the same things and does all the same stuff. Oh, so therefore what's the C? Calcium channel blockers. Because beta blockers and calcium channel blockers are like value for your heart. They're a negative N-O, negative D-O-M-O, negative D-O-M-O. Your A-A-A-N-A-A-A-N has the side effect of H-N-H. Both of them. And these stand for digitalis. Digoxin. Lanoxin. You have to know these names. Because they will only give you one name for this drug. They'll say Lanoxin. You're supposed to know that's digitalis. They will not give you both. If you do not know that Lanoxin is digitalis, you don't know what everybody else knows. So know these. So what are the A-B-C-Ds of treating atrial erevium? Adena, beta, calcium, dig. Adena, beta, calcium, dig. Adena, beta, calcium, dig. Adena, beta, calcium, dig. Those are the A-B-C-Ds of atrial erevium. So what do you use for ventriculars? Ionicaine. What do you use for atrial? Adena, beta, calcium, dig. A-B-C-D. Okay, and what do you use, number four, what do you use for V-fib? It rhymes. For V-fib, you D-fib. For V-fib, you D-fib. In other words, what does D-fib mean? Shotgun. And asystole, what do you use for asystole? Epinephrine and atropine. Epinephrine and atropine. In that order. What's the first one you give? Epinephrine. Epinephrine, and if that doesn't work, you give? Atropine. Atropine. Now, the way I remember this is, look at the word asystole, all right? What's the first letter? A, which stands for? Atropine. What's the last letter? C, which stands for? Epinephrine, but give it reverse. So, A for atropine, C for epinephrine. What I do is, I would do this. Asystole, atropine, epinephrine. And I have that, you see this visual? I sort of have this visual of it coming down, and then I just give it off. So, what do you do for BPAC? BPAC. What do you do for BPAC and PBC? PBC. What do you do for atrial flutter and atrial fibrillation? Atrial fibrillation. What do you do for asystole? Epinephrine. Epinephrine and? Atropine. Atropine, okay, very good. If you know that, you know more than what most people know about those emergency things. Okay, let's talk about chest tubes. The purpose of a chest tube is to reestablish negative pressure in the pleural space. Reestablish negative pressure in the pleural space. So, the pleural space is a place where negative is good. Because don't pretend to think of negative as bad, but negative is good in your pleural space. Negative makes things stick together. Got me? Okay, what's your name? My name is Sean. Okay, Sean and I are going to demonstrate something. Sean is the Teflon. I am the love. She is the Teflon. I am the love. Now, we're actually three-dimensional, although we're only showing you a one-dimensional picture. It's actually, you know, we're, you know what I'm saying? Everybody get to cross-section here where we can actually see. Okay, so she's the love. I'm the love. Okay, what's out here? Atmospheric air, right. So, this is skin and bones and muscles, right? And then I'm the what? Love. And what's in here? There. The what? The alveolar. I can't say it was one because I know you're going to show a picture with three, but I can't do that. Okay, that's the alveolar. Are you getting the picture? Now, on the inside of me is a lining called the parietal flora. So, this is the what? Parietal flora. It lines the inside of the Teflon. Teflon. Okay, now on the outside of me there's another lining. What's this called? Visceral flora. Visceral flora, and it lines the outside of the, between the parietal flora and the flora in the floral space. So, we have this space here called the what? Floral space. Now, what kind of pressure should be in there? Negative. Now, what does negative pressure do to things? Pull them together or push them apart? Pull them together like a vacuum. Positive pressure pushes things away. So, what are we going to do here? If there's negative pressure in here, what's going to happen? We're stuck together because there's a lot of negative pressure in the floral space. Now, how is this going to work? Okay, we're going to breathe in. Now, when we breathe in, it's just what we're expecting. Oh, okay. Now, we're going to breathe in, and you watch the air. Air going into the what? The alveoli. Okay, here's the air. Now, ready? Let's breathe in. Now, what happens to the air? Excuse me. Now, let's breathe out. You see? Now, let's breathe in again. Let's breathe out again. All right. Now, there's good luck. Negative pressure there. Okay, now, take your gun and shoot us. Sorry. Let me throw it. Now, what does that have to do with the floral space? Air and creating what? Positive pressure, because we're much hotter. Okay, now, I want you to work along the what? Together. She has muscles. What don't I have? Muscles. She does the work of breathing. I just hang along for the ride. Now, what we're going to do is, now that there's positive pressure in here, I want Shana to breathe in and then breathe out. I want you to watch what happens to the air. Okay, breathe in. Breathe out. Breathe in. Breathe out. What happens? She's doing a lot of what? Work. But there's no air escape because there's positive pressure in the... Okay, now, take that chest piece you have there in your hand. Pretend you're sticking it in here. Okay? Now, give me some suction. Now, what did we just do? Re-establish negative pressure in the world. Okay, so now she can breathe in. Breathe out. Breathe in. Now, we feel. And what does she do? Pulls out the tube and we're good to go. Thank you. Amen. So, she'll never see this with the back of her mouth. So, what's the purpose of the chest piece? Re-establish negative pressure in the closed space so that the lung expands when the chest wall moves. Does that make any sense why you need that tube in there? Okay. Now, when you get a chest tube question, look at the reason for which it was placed. Letter A there, number one, says, you know, in a pneumo-thorax, the chest tube removes what? Air. Pneumo means air. So, in a pneumo-thorax, what created the positive pressure? Air. So, I've got to put a chest tube in to remove air so I can re-establish the negative pressure. But in a pneumo-thorax, the chest tube removes blood because what's causing the positive pressure? Blood. Blood, and I've got to remove it to re-establish the negative pressure. And in a pneumo-thorax, what's in the plural space? Air. Air and blood, and I must remove both air and blood to re-establish the negative pressure in the plural space. So, if Warren gives you a question and says that you have a patient with pneumo, with chest tube in for a pneumo-thorax, what would you report to Nurse LPN or Dr. RN? What would you report to the nurse or the doctor? Number one, the chest tube is not bubbling. Two, the chest tube drained 800 ml in first 10 hours. The chest tube is not draining. The chest tube is intermittently bubbling. Well, you have to say to yourself, what do I expect from a pneumo? What does a pneumo chest tube put in for a pneumo-thorax? What's it supposed to do? Drain what? Blood. So, which one of these says it is not doing what it is supposed to do? Number three. Number three. So, which one would you report to the nurse or the physician? Number three, because it is not doing what it is supposed to do. Do you see what I'm saying? Well, what if I said this? Pneumo. A pneumo-thorax. What would you report to the physician? Well, you could have two of them. What would they be? One or two, right? What's wrong with one? It needs to bubble. It's not doing what it's supposed to do. What's wrong with two? It's doing something it's not supposed to do. And in that case, it would be a hard one to do. But the point is that you see how that... It definitely wasn't number three. You see, when I changed from a pneumo to a pneumo, what was the right answer is no longer even an option for the right answer. So, if you're going to get chest tube questions correct, what must you pay particularly attention to? The disease for which it was placed. And that will tell you what you should expect. Does that make sense that you're going to have to watch that? Otherwise, you wouldn't get it right. Okay, the other thing you have to pay attention to is letter B, the location of the tubes. The location of the tubes. And the two locations are apical, A-P-I-C-A-L, and basilar, B-A-S-I-L-A-R. Apical, number one is apical, A-P-I-C-A-L. And number two is basilar, B-A-S-I-L-A-R. Apical and basilar. Now, apical means the chest tube is way up high. And if you put a chest tube way up high, what are you going to remove? Air, because air rises. So apicals remove air. Basilars are at the bottom of the lungs, so they will remove what? Blood, because blood is subject to gravity. So apicals remove air. Basilars remove blood. A for A, B for B. What do I mean by that? Apical starts with A, and that removes air, which starts with A. And basilar starts with B, and it should remove blood. So if they say your apical chest tube is draining 300 milliliters per hour, your apical is draining 300 per hour, what do you think? Good or bad? Bad. Your basilar is draining 200 mils per hour. Fine. It needs to come out, you know. Your apical tube is not bubbling. Your apical tube is bubbling. Your basilar tube is not bubbling. Fine. Your basilar tube is bubbling. Why? Do you understand? So do you see where location depends? So what will they put in for a hemo? What will they put in for a pneumo? And what will they put in for a pneumo hemo? One of each, which brings up the next three questions. Example, how many chest tubes and where would you place them for unilateral pneumo hemo thorax? Unilateral pneumo hemo. Two. You'd use an apical for the pneumo and a basilar for the hemo. B, how many chest tubes and where for a bilateral pneumo? Two. Again, how many? Two. But what would they both be? Apical. Apical. So you'd use an apical on the right and an apical on the left. Then letter C, how many chest tubes and where would you place them for post-op chest surgery? Here again, two. An apical and a basilar on the side of the surgery. Because you are to assume, you are to assume that chest surgery or trauma is unilateral unless otherwise specified. So if they just said he had chest trauma, would you assume it's unilateral or bilateral? Unilateral. Chest surgery, unilateral or bilateral? Unilateral. You always assume unilaterality. Never assume that it's bilateral. So the only time you're taking care of bilaterals is when they say bilateral. All right? Oh, there's a trick question, though, about chest tubes. How many chest tubes would you need and where would you place them for a post-op right pneumonectomy? None. None. Why? Pneumonectomy means removal of the what? Hold on. There's no lung. There's no pleural space. There's nothing. So if there's no pleural space, why do you want to reestablish pressure in something that does not exist? Correct? So you do not use chest tubes for pneumonectomies. You use them for lobectomies, wedge resections, those kinds of things. All right. Turn the page. Let's talk about troubleshooting. Do you guys remember seeing closed chest drainage devices like a Thoravax, Pneumothax, Emerson? And they're those plastic containers that the tube is connected to? Well, what are you going to do if you knock that over? I mean, you didn't break it. You just knocked it over. What do you do? Does that feel bad? I'm taking a deep breath. Is it a medical emergency? Does the physician need call? Does the RN need notify? Do you need to do anything other than have him take a couple deep breaths? No. It is no big deal. Do you understand that? So do not get all uptight when you knock over that device. But number two, what do you do if the water still breaks? The actual device, that device breaks. Now, is that the same thing we were just talking about, or is this something totally different? It's totally different, because now positive pressure can get in the closed chest. So what do we do? The thing is breaking. What do you do? Clamp it. Clamp it. That's the first thing you do is clamp it. Why? So nothing gets in. Then what do you do next? Well, there's a couple of steps they're going to put in between there. Clamp it. There's a step before that. That's the third step. Clamp it. Too obvious. Cut it away from the broken device. Make your decision to cut that tube away from that broken device, because it's no good anymore, right? So cut it all away. Then what do you do to the end of that tube that's been cut away? You said it's in the back here. Stick that end of that tube under? Sterilized. Sterilized, okay. Now what are you going to do next? Unclamp it. Why unclamp it? Because now you've reestablished the water tube. Just that it doesn't need clamped as long as it's under water. And it's better to be under water than to be clamped. Why is it better to be under water, the end of the tube under water, than for the tube to be clamped? Why is it better? Sterilized. No, not sterilized necessarily. Why is it better to be under water than to be clamped? Air can't go in, but stuff can come out. If it's clamped, what's the problem? Nothing can go in or out. And you want stuff to come out. You don't want stuff to go in. So clamping is only a stop-gap measure. It doesn't solve the problem. What solves the problem? Sticking the tube under water. So what is the order? If they gave you a click and drag when the water seal breaks, what would be the first thing you'd click and drag? Clamp, then what? Cut, then submerge, then unclamp. It's alphabetical. Clamp, cut, submerge, unclamp. Clamp, cut, submerge, unclamp. That is your order. So if they said to you, what is the first thing you're going to do when the water seal breaks? The first thing, what would you say? Submerge the end of the tube under water or clamp the tube? Clamp. Because when they say first, they're asking about what? Order, right? But what if they say this? They ask you the exact same question with the exact same answers, and they change one word in the question. The word they change is from first to best. And they say, what is the best thing to do when the water seal breaks? What is now the answer? Submerge it under the tube under water. Why is it the best? Is it actually solved the problem by reestablishing the water seal? The clamping was only what? A temporary fix. A temporary fix. It's not the best. It's the first, but it's not the best. So do you understand that a best question is different than a first question? Very different. A first question is asking you all about order. A best question is asking you what's the one thing you would do if you could only do one of these. So if you could only do one, clamp it and nothing else, or put it under the end of the tube under water and nothing else, which one would you do if you could only do one? Submerge. So it's what? Best. Because what's the best answer? The one that you would do if you could only do one. What's the first one? The one you do first. And that may be the same, and it may be different. But a lot of people screw up questions because they're answering first instead of best, or best instead of first. And they're not paying attention to what the question is asking. For example, and this is really important to get, because people have trouble with this. You notice a person has ventricular fibrillation on the monitor. V-fib, good or bad? Bad. Bad. No cardiac output. You run to the room, they're not responsive, and they don't have a pulse. What's the first thing you're going to do? A, place a backboard. B, begin chest compressions. Now, first is about what? Order. So you're between those two, right? So if you pick place backboard, what do you say? I'm going to place the backboard first, and I'm going to start chest compressions. If you pick chest compressions, what do you say? I'm going to start chest compressions, then I'm going to place the backboard. Well, what would be better to do first? Place the backboard. And remember, it's a perfect world, so where's the backboard? Right there. Right there. It's there. Don't say, well, it's going to take ten minutes for somebody else to bring the code. No, it's a perfect world. It's there. Okay? So, what's the first thing you do? Place the backboard or begin chest compressions? Place the backboard. But what if I say this? Person has V-fib, they're unresponsive, no calls. What's the best thing to do? Place the backboard or begin chest compressions? Well, if you do one of those, you don't get to do the other one. You understand? In a best question, how many things do you get to do? One. And if you do one, you don't get to do the other one. So if you pick backboard as the best, what are you saying you're going to do? I'm going to roll them over, put them on the backboard, and go, oh, okay, now. Hmm. They're still not getting a call. Hmm. Hopefully somebody will come along before eight minutes. Right? But if you pick chest compressions, what do you think? I'll do chest compressions while they're on the floor. They get no backboard. Right. Well, would you rather do chest compressions without a backboard or a backboard without chest compressions? Which one's best? Chest compressions. The chest compressions. The chest compressions. Which one's first? Backboard. The backboard. Are you getting this? First versus best? We're going to talk a lot about this in the next three days, but you're getting good at this. Most people don't even catch the difference. Okay? Right over there. No, not you. Number two, what do you do if the chest tube gets pulled out? Have you ever seen that? I've done it. Yeah, I did it. I worked Southwest Nine when St. Eve's was open in Dayton, Ohio. I worked in the intensive care unit for the open heart. And Andrew's chest is, you know, well, this guy's huge. So he's like ten times my size. That's not hard to beat, but he was really big. And I knew that I had to get him in bed, and I had one chance. How do I work them both at once out? And I do it all in one motion. So I got there like this, you know, wide stance. The bed's here. He's here. I got the belt. I'm like, okay, now. And I'm like, oh, your stance isn't wide enough. So I went. And when I went like that, I stepped on his chest tube. Oh, no. I did not know it. And I went, okay. One. Two. I'm sorry. You know, I lifted him up and out came this, because our stance pocket got pulled out. But I didn't know it. And so he's there, and he's talking and whatnot. And I'm going, there's a blood on my pants. There's blood all over my pants. What's this? Here's the chest tube lying on the floor. So I don't know. But he says, oh, I feel pretty good. I feel a lot better now. And so did the other one. But what's the first thing you do? What do you think the first thing you do is? Take a glove hand and cover the hole. What's the best thing to do? Cover it with Vaseline gauze. So what's the first thing you do? Cover it with your glove hand. What's the best thing to do? Vaseline gauze. Because if you get, they say, you accidentally pulled out the chest tube. What's the best thing to do? Best thing. And you're between cover it with your glove hand versus Vaseline gauze. If you pick cover it with your glove hand, what are you saying? I'm going to cover it with my glove hand, and that's all I'm going to do. You're going to follow him around all day long with your glove hand. No, you're going to put a Vaseline in it. That actually solves the problem. Do you see the difference? If they ask first, you're going to put a glove hand, then Vaseline gauze. But that's the Vaseline gauze. Forget about the glove hand. Are you seeing the difference? It's real important. It's real critical that you see this. Bubbling. They love to ask about bubbling stuff. Did you see these questions around? Okay, ask yourself two questions. Where is it bubbling and when is it bubbling? If you do not ask yourself those two questions, you're going to get it wrong. You can get this question right if you ask where and when. Because then it's going to depend on where and when. Because sometimes bubbling is good and sometimes it's bad. It depends on where and when. So, let's talk about it. If I say bubbling, bubbling, bubbling, what do you say? Where? I say water seal. Do you see where I'm at? Then what do you ask me? And I say intermittent. Is everybody where I'm at? So, intermittent bubbling in the water seal is good. Document it. It's never bad. It's always good. Document it. Okay, I say bubbling, bubbling. You say what? I say water seal. You say? I say continuous. This is bad. There is a niche. You do not want continuous bubbling in the water seal. That means there's a leak in the system. You've got to find it and tape it. Put tape over it until it stops leaking. LPS is perfectly within the scope of your practice. Just put tape on this thing to stop the continuous bubbling. I say bubbling, bubbling, bubbling. You say what? Where? I say suction control chamber. You say? And I say intermittent. That's bad. The suction is not high enough in that case. If you're only getting intermittent bubbling in the suction control, your suction is too low. You've got to go to the wall. You know what I mean by the wall? You know that dial at the wall? And you've got to turn it up until what happens? Bubbles out. Continuous. Because if I say bubbling, bubbling, you say? Where? I say suction control. You say? And I say continuous. That is good. You document that. So, two scenarios are good and two scenarios are bad. Did you notice that? And what did you notice about the two chambers? They're opposite. What's good in one is bad in the other. Now, I do not memorize all four of those. I don't. I memorize one and then I deduce all the other three. The one that makes the most intuitive sense to me is this. Think about this. If something is sealed, which chamber am I talking about? If something is sealed, should you have a continuous bubble? No. That means it's what? Leaking. So that is bad. Intermittent in the seal is? And the suction control is? The opposite of that. Because this doesn't make sense to me. If this were a two-liter bottle of pop and it was on the grocery store shelf and it was sitting there going bubble, bubble, bubble, bubble, bubble, bubble, bubble, bubble, bubble, bubble, bubble, bubble, bubble, bubbling, how? Continuously. Would you buy it? No. What's your conclusion about it? It's on what? The seal is broken. The seal is broken. Don't you think it's like when things bubble continuously, you think, oh, the seal is broken. Well, in a test tube, if it's bubbling continuously, the water seal is broken. And so that's bad. You see how I don't want you to remember it? Do you guys ever, did you ever notice that when you do test tube questions, that it is so frustrating because sometimes you're saying, it's bubbling back, sometimes you're saying, and they say, no, it's okay, and then the next time you say, oh, it's okay, and then they say, no, it's bad, and then the next time you say, oh, it must be bad, and then they say, no, it's okay, and you're going, just make up your mind, is bubbling good or bad, and what's the answer? Both. It's both. It depends. And that's what you're not picking up. You never have, you have made all test tubes the same, right? Yeah. And they're very different. See, my philosophy is make something simple if it's simple, but don't oversimplify it if it's actually more involved. So, hopefully that will help you with your test tube questions to know when bubbling is okay, when bubbling is not okay, and when draining is okay, and when draining is not okay, and what the hell is bubbling is. Do any of you like analogies? You learn by analogy, dog is to meow, and bark is to cat. You know that you're not good at analogies when I say, meow is to cat, and bark is to, and you say tree. You know, you're not going to hear me with that, you know. But here's an analogy that might help you. A straight catheter, got where I'm at? A straight catheter is to a foley catheter as a fluorescentesis is to a test tube. Did you get the analogy? Because what's a straight catheter? In and out. What's a foley? In, secure, drain in. What's a fluorescentesis? In and out to reestablish negative pressure. What's a test tube? Stick it in, secure it, leave it, and so on. Do you see the point? So, just think of a fluorescentesis as an in and out test tube, and that will help you answer questions there too. So, which one has a higher risk of infection? Fluorescentesis or testing? Because what has a higher risk of infection? A straight catheter or a foley? Right? Same idea. Rules for clamping tubes. Never clamp a tube for longer than 15 seconds without a doctor's order. You're not allowed to clamp test tubes for longer than 15 seconds without a doctor's order. So, when you break the water seal, what is the first thing you do? Break the water seal, first thing. Now, how long do you have to get that thing cut off and underwater? 15 seconds. So, you've got to what? Unclamp. So, I have those sterile water bottles nearby. It drives me crazy. When I work as a nurse and I get people with septic, I go into the room and guess what's all over the walls and all over the bed table and everywhere? Clamps. I can find like six clamps in every room. What can I not find within 100 yards? Sterile water. Which one can I simulate and don't need? Clamps. Because I can keep the tube off with my fingers. What can I not simulate? Sterile water. Which is good, you know. Number two, use rubber-tipped double clamps. Use rubber-tipped double clamps. In other words, if you're going to clamp something, what should they be covered with? The teeth. Rubber. Why should the teeth in the clamp be covered with rubber? No, right? You're going to puncture it. That's good. And why double clamps? Why two? Because we're nurses. Okay? There's no research-based evidence to prove that two clamps is better than one. It's just the way we are. Okay? Okay, congenital heart defect. And then we'll do some real brief ones and be done for the day. Congenital heart defect. Congenital heart defect. Everybody knows what congenital heart defects are? Okay, good. Every congenital heart defect is either trouble or no trouble. What I mean by that is either a congenital heart defect causes a lot of problems or it's no big deal at all. There is no in-between defect. It's kind of bad, but kind of good. It's either what? All bad or all good. It's either all bad, all good, and there's nothing in between. They're either what? They're either what? Trouble or they are no trouble. Now, to memorize congenital heart, I want you to memorize one word and only one word. And that word is trouble. Now, you notice it has seven letters. You notice that shaded box has seven blanks. I want you to write the word trouble in there, but capitalize the consonants. Keep the vowels small and lower case. Capital C, capital R, small o, small u, capital V, capital L, small e. Now, all congenital heart defects are what? Trouble or no. So, what's the big word you have to memorize for congenital heart? Trouble. Okay, now if you memorize that, how many of that already memorized? You memorized it the last ten seconds. Okay, you can repeat that. You now know 95% of all congenital heart defects. How do I know that? You probably know it. If a congenital heart defect is trouble, let's say you guys have trouble defects. Does logic say you need or don't need surgery if there's trouble? When? In order to what? Live. Okay, if you guys have a no trouble defect, do you need surgery? No. Might you have it? Possibly. When? Years later if it causes a trouble, but we don't expect it to cause any trouble because it's not trouble. Right? Okay. Well, what if you guys have a trouble defect? What is your growth and development? Slow, delayed. Why? Because you have a defect which is? What is your growth and development? Why normal? Because your defect is no trouble. What's your life expectancy? Normal because it's no trouble. What's you guys' life expectancy? Short because it's trouble. What are your parents experiencing a lot of? Stress, grief, financial, all kinds of caregiver issues. What about your parents? No more problems than the average person on the street. Do you go home on an apnea monitor? No. Why? Because it's not trouble. Do you go home on an apnea monitor? Yeah. Because you have what? Trouble. How long do you stay in the hospital after you're born? Long time. Weeks? How long do you stay? 24 hours, 36 hours and you're gone. Why? Because it's no trouble. Who follows your care? What medical professional follows your care? Which doctor? What kind of doctor? Pediatrician. Pediatrician or a nurse practitioner, pediatric nurse practitioner, right? Who can follow you guys? Who will follow you? Pediatric cardiologist. Pediatric cardiologist. Do you understand what I'm saying? So if it's trouble, make it trouble and if it's no trouble, don't make it. The way they'll ask this question is they'll say, You are teaching the parents of a child born with Tetralogy of Fallot. What will you teach them? And it will say, this decreases life expectancy, this, do you see what I'm saying? Or it'll say, it's just fine, it's no problem. Well, which one do you pick? Well, it depends on whether it's what? Trouble or not. If it's no trouble, what do you tell the parents? They deal. If it's trouble, what do you tell the parents? Whoa, not good. Now, boards will not give you pictures of defects and ask you what they are. Why? That's not your job. You don't make the diagnosis, the radiologist does. What do you do? What's your role in congenital heart defects? Teaching the parents the implications. And if that's your job, if it's trouble, teach them things that it's going to be a lot of trouble and if it's no trouble, pick the answer that says this is no trouble. Do you see that you're going to be able to pick the answer out? How many agree you'll be able to know what to teach the parents as long as you know whether it's what? Trouble or not, correct? Okay, now the other thing about trouble is they always want to know, does the defect shunt blood right to left or left to right? Remember that? How many remember left to right, right to left shunt? Okay. Look in the word trouble. Look at the way it is spelled. Is there any help for us in remembering which way trouble defects shunt blood? Why did you say right to left? Because R comes before L in the word trouble. So a trouble defect is right to left. Why? Why is a trouble defect right to left? Because it recirculates the oxygen in the blood. No, because that's the way it's spelled. It's too late for me to teach you all this stuff. If something can be simple, let's make it what? Simple. And I am not teaching you the word tolerver. I am teaching you the word what? Trouble. And in the word trouble, what comes first? R then L. So trouble defects are right to left because trouble is spelled that way. So what way are no trouble defects shunting blood? Left. That's right because that's not the way trouble is spelled because it's not trouble. So if a kid has a right to left shunt, what do you tell the parents about surgery? If a kid has a right to left shunt, what do you tell the parents? Right to left. Right to left. That's the way trouble is spelled. So it must be trouble. I'm telling the parents what we have. Okay? What about the kid that has a left to right shunt? What do you tell the parents about the growth and development? Left to right. Left to right. That's not the way trouble is spelled, so it cannot be trouble. So we say normal. Are you getting this? Okay, the other thing they want to know is, is the kid cyanotic or asynotic? Remember that? Cyanotic. Asynotic. What does cyanotic mean? Blue. Blue. Do we have anything that can help us with that? B. B. The word B. The letter B in trouble. See, we're using the consonants. We're not going to use the vowels. We're just going to use the consonants here. So B means blue. So what types of shunts are blue? What types of shunts are blue? Right to left. Right to left means blue. So left to right means not blue. Which is? Pink. Asynotic. You got me? So why are right to left blue? Because trouble is spelled that way. Yes. Don't talk to me about the oxygenated blood, because I don't care. I just want to know, can you do this? Okay, now what do you know about a congenital heart defect? If you know that it's trouble, start listening to things you know about. If it is trouble, what do you know? Shunt blood what? Right to left. Asynotic. Needs. Delays. Decreased. Life expectancy. Needs. Pediatric. Exercise intolerance. Needs some meds. Needs an apnea monitor. It's going to stay longer. Parental guilt. Financial difficulties. Caregiver stress. Right? Because it's what? Not trouble. But if it's no trouble, what do you tell the parents? No trouble. You know it's left to right. You know it's blue. You know it's no big deal. So with trouble, you should go, ooh. With no trouble, you should go, eh. Right? Now, there are 40 some congenital heart defects, correct? Some of them are trouble, and some of them are not. How do you remember which ones are trouble? Well, just memorize them, right? Memorize which ones are trouble, correct? And then you'll know which ones are, and the others are no trouble, right? No. Because I told you to memorize what? One word, and that would be? Trouble. And that would be memorizing more than a word, wouldn't it? You'd be memorizing a list. Well, what consonant have we not yet used? T. What position does T hold in the word trouble? First. By total sheer coincidence, that all congenital heart defects which start with the letter T are trouble. If it does not start with a T, it is not trouble. So, do you see where it says examples of trouble, examples of no trouble? Let me give you some examples, and you tell me where you're going to put it. You have a patient with ventricular septal defects. Ventricular septal defects. What is it? No trouble. Why? It starts with a V. That's not a? T. T, so it's not? Trouble. So, it's chunks of blood from the? Left. That's where the right kid is. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. A. 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