The Kid Experts: Innovation at Children's Minnesota

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Tyler Mason  1:15  
Hi, there and welcome to the Medical Alley Podcast. My name is Tyler Mason and I'm excited today to be sharing with you a three part episode featuring some of the work that Children's Minnesota does in the community. They've been a great partner of Medical Alley's for a while now. And we're going to talk to three different experts on three kinds of different fields and services that Children's provides. So later in this episode, we're going to talk about the evolution of telehealth in the neonatal space and the work that Children's does there. We'll also look at neurosurgery and the pediatric neurosurgery suite that Children's has. But we're going to start today talking about the breast pump loaner program that Children's recently rolled out. So I'm joined by Ashley Johnson, who's going to share a little bit more about that and the work that is done there. So Ashley, thanks for joining the podcast today.

Ashley Johnson  1:59  
Thank you Tyler for having me. I'm excited to be here.

Tyler Mason  2:02  
Absolutely. Now if you wanted to start, maybe introduce yourself and tell us what you do with with Children's.

Ashley Johnson  2:07  
Yeah, so my name is Ashley Johnson. I'm a registered nurse here at Children's. I've been here for 15 years now. And over the last six years, I have been a lactation consultant for our Minneapolis campus.

Tyler Mason  2:22  
Now, can you just share a little bit about what a lactation consultant does for maybe those who don't know what that is? Or maybe they're just a little bit familiar, but don't know truly what what that work entails?

Ashley Johnson  2:32  
Yeah. So at Children's Minnesota, we have a group of lactation consultants that are really working with our moms and babies after delivery. All of our babies are admitted, we are a standalone children's hospital. So we're really working closely with the moms to get them pumping early to make sure that they are able to produce enough milk for their babies when they are able to breastfeed. Since most of our babies are here for weeks or even months before they're able to eat by mouth, then it is really important for our moms to get started as soon as possible after delivery. So early, frequent, effective pumping is really vital for making enough breast milk. And our nurses do a wonderful job of getting families started pumping and then we come in as lactation consultants and try to connect with all of our families within days after delivery to assess their progress, address any concerns they might have, and ensure that they have a good quality breast pump to use at home.

Tyler Mason  3:35  
And obviously the importance of starting early, as you mentioned, but Children's Minnesota recently launched a breast pump loaner program. Can you maybe share a little bit about what that program is and then why it's such an important option for for the moms that you see?

Ashley Johnson  3:48  
Yeah, most of our moms are planning to breastfeed, so an admission to the hospital means that that might change their plans for a short period of time. And so because of this, we need to make sure that they are getting a good quality breast pump after delivery. Otherwise, they might not be able to express their milk as effectively as they would if baby was going to breast on their own. So our lactation group saw that a lot of our moms were struggling with making enough milk for their babies because they weren't using a good quality hospital grade pump. And we came up with a creative solution to provide a pump to moms free of charge while their babies are in the hospital. So Children's actually purchased 20 of our own portable hospital grade breast pumps to loan to our moms free of charge while their baby is in the hospital. And by starting this pump loan program, we have been able to streamline our process making it much easier for families to get a good quality pump earlier and also eliminating some of those financial burdens and logistical stressors that a lot of our families are facing with the baby in the hospital.

Tyler Mason  5:01  
And for the moms that are wanting to participate in this, how do they go about that? How do they start that or I guess, tell me about the conversations that take place to make sure that these moms that are needing this can utilize the service?

Ashley Johnson  5:13  
Yeah. Because our lactation consultants are working so closely with their moms, we're really just trying to assess each situation individually and see where they're at, you know. Are they getting a good supply? Or are they really struggling? They're not getting enough milk? Is it painful? Could we make it more comfortable? What are some things that we can do to help them make their pumping as easy and comfortable as possible? Pumping is a lot of work. And so when they're in a hospital, we really just want to try to put them at ease as best as we can by providing them with the resources that we have to make it feel a little less stressful and a little easier.

Tyler Mason  5:53  
And you kind of alluded to it a little bit earlier, but that early feeding for newborns, especially in those first few days is very important. What difference does that make when they are getting the proper nutrition and eating properly? And how do lactation consultants maybe play into that just helping them grow, you know, right from birth?

Ashley Johnson  6:09  
Yeah, you know that early milk right after delivery is so valuable for any newborn, providing lifelong benefits for both mom and baby. But for our hospitalized babies, it really acts as a food and medicine by providing them with these really great antibodies to protect them against infections. As you know, any baby or person in the hospital can be exposed to many more, you know, things just in our environment. And when babies are born early, their gut is much more fragile. Their lungs, their brains, every organ, you know, is very fragile. And so any amount of breast milk that they can get is really very healing for our babies and helps to protect them. So mother's own milk is also you know, when babies are born prematurely, it's actually tailored for their baby. It has extra nutrients and proteins that are really needed to help them grow. So it's really a gift that only a mom can give. But it also comes with a lot of challenges. So that's why it's so important for our families, to have lactation support very early in their journey and help them to navigate that journey and get them to their goals for feeding their baby.

Tyler Mason  7:31  
I've got two young kids myself and with each of them, we worked with a lactation consultant right away in the hospital. And so I've seen firsthand the importance of that, and just the the wonders that they can do to help that process along. So, you know, kudos to you and the others who are helping with that. It's a very important service and helping these kids to start start their journey healthy, as we talked about. So you mentioned that there's been 20 of these breast pumps that are purchased for this loaner program. What's been the reception so far for those who have participated in the program?

Ashley Johnson  8:00  
Oh, it's been amazing. Our moms are just so happy and just so relieved to have this service to them. Since starting our program on March 1, we have loaned out over 70 pumps, while helping more than 85 infants receive more breast milk. And on average of the 20 pumps, we've had at least 17 being used each day on all three campuses. So we really, not only do the numbers show that we're utilizing this program, but just the feedback that we've gotten from the families has been so appreciative, and overwhelmingly positive, I guess. Parents have shared how the pumps have really helped with increasing their milk production. It's made the pumping more effective and comfortable, especially in the first week or two after delivery. That's really important. By doing that, it's also helped to decrease their stress levels. And most importantly, it's free. So our moms are just really happy to have this service. We know that if pumping is not easy, if it does not come you know easy or if it's painful, or you know, they're not producing enough, we know they are going to stop early. And if they're struggling then and they don't have that support, then that means less milk for their babies.

Tyler Mason  9:21  
So based on the success so far, is this something you see maybe even growing or maybe purchasing more pumps? And also do you see it as something that could be common in other hospitals or maybe does this exist at other hospitals that you know of?

Ashley Johnson  9:32  
Yeah, I mean, I definitely think this is something that could grow into being you utilize more at Children's but also on other hospitals. Other hospitals do provide options to rent these restaurants through third party vendors. But this comes at an added cost to our families. You know, our families with babies in the hospital are already stressed. So this pump program is really unique because it eliminates the need for an outside vendor. We currently have a quality improvement project at Children's Hospital or in Children's Minnesota with a goal of discharging more babies home on mother's own milk. And as part of this quality improvement project, we have a supply closet with donated items to help make their pumping even easier for families that maybe don't have the ability to purchase some of these items like pumping bras or different sized funnels. So both of these programs really allow our families to continue to pump their milk more effectively, which means more babies are going home on breast milk and hopefully making that transition into breastfeeding before they go home as well. So by doing these things, I think we're really putting our kids and families first by making more resources available, reducing some of these inequities and also eliminating those additional stressors for our families.

Tyler Mason  10:55  
Absolutely. It's a great program. And, you know, again, kudos to Children's for recognizing the need for this. Sounds like it's been going well, so far, obviously. Anything else that about this program that you want to share or anything maybe we didn't talk about that that is worth noting about this, this loaner program?

Ashley Johnson  11:11  
I think the most important thing is just knowing that, you know, all of our families need a lot of support while they're in the hospital. But I feel very lucky to help them through this journey. And I think the most rewarding piece is being able to see them, you know, go home and meeting their feeding goals for their babies.

Tyler Mason  11:29  
Awesome. Well, Ashley, thank you so much for joining today and for sharing about this breast pump loaner program that Children's Minnesota introduced earlier this year. Great to hear that it's been going well so far. And thanks for the work that you do and helping to make this a healthy community.

Ashley Johnson  11:43  
Yes, appreciate you having me. Thank you for so much.

Tyler Mason  11:46  
You bet. Well as we continue our conversation with leaders from Children's Minnesota, we're now joined by Dr. Meysam Kebriaei, who's the director of the neurosurgery program at Children's Minnesota. And we're going to be talking about the first of its kind iMRI pediatric neurosurgery suite that children's rolled out earlier this year. Dr. Kebriaei, thanks for coming on the podcast.

Dr. Meysam Kebriaei  12:04  
Thanks for having me.

Tyler Mason  12:05  
Before we jump into the the iMRI suite and kind of its capabilities, do you want to share a little bit about your background in neurosurgery and how you ended up at Children's Minnesota?

Dr. Meysam Kebriaei  12:13  
Yeah, absolutely. I am a fellowship trained board certified pediatric neurosurgeon. I did my medical school residency training at University of Nebraska in Omaha and I went on to do a pediatric neurosurgery fellowship at Emory in Atlanta. Then I came back and joined the team at Children's Minnesota and I've been here for a little over 10 years. And I've been the medical director of Children's Minnesota neurosurgery for about a year and a half

Tyler Mason  12:37  
Great, well thanks for sharing a little bit about your background. We have you on today to talk about, as I mentioned that iMRI neurosurgery suite, which is something that childrens launched earlier this year. But before we talk about the suite itself, can you first explain what iMRI is?

Dr. Meysam Kebriaei  12:52  
Absolutely. So that MRI, magnetic resonance imaging, it's a big magnet, where as any of us who have had an MRI in the past, you go inside this tube, which is a big magnet. And it's able to get, in my in my case, in neurosurgery, images of your brain and spinal cord. And the the bigger the magnet, the better the picture you get. And so the iMRI, the i stands for intraoperative. So normally before the invention of iMRI, what we would do to remove brain tumors, we would do our normal surgery, remove the tumor under the microscope. And when we thought we were done, we would close up and get get an MRI scan either the next day or within the next few days after the surgery. The downside of that is if there's any tumor or any abnormal tissue left behind, then you have to make the hard decision of Will you watch that with more imaging down the road or do you have to come back and bring the patient and bring the child back for another surgery. And surgery, as you can imagine, it's tough on the team, it's tough on the patient. And it really leads to a lot of trauma as well to have to go through that twice. The intraoperative MRI, the beauty of it is that you're able to once I'm done removing the tumor, I'm able to get a scan at the time of care. And so the MRI comes out where the patient goes into the MRI. And we're able to get a scan, get an MRI image. I look at the images, our neuroradiologist looks at the images and we make sure that we removed all the tumor that we could safely remove and that also there are no complications like a blood clot that we could deal with at the time before we close up. And this is really great because brain tumors a lot of times, they look and feel as the rest of the brain and so even though we may think using our experience, vision and tactile field that the tumors all out, sometimes you can leave a little bit behind and that makes a big difference as far as prognosis and outcome for that child.

Tyler Mason  14:43  
And thanks for kind of helping set the stage a little bit for this suite, this iMRI suite, which is located at the Minneapolis children's Minnesota hospital. Nearly 3,000 square feet, so pretty good size. Can you tell me a little bit about this suite and its capabilities?

Dr. Meysam Kebriaei  14:56  
Yeah, well first of all, this suite is bigger than the apartment I grew up in. So It's huge. And it houses three rooms. So one room is where the MRI rests in its home, if you will. And so that room, when a patient comes in from outside or from the inside the hospital, they come in just to get an image of their brain or spinal cord. And at the same time, there are doors that open up to two operating room suites. So myself and my partners could be operating on two different patients at the same time while we're getting MRI scans on patients that are coming in from outside or from the hospital. And what makes this unique is that you can use the two rail system where one, you have a moving patient and the other room, you have a moving MRI. So that makes it the first and only of its kind. The other thing that makes our MRI really unique is the fact that MRI is all about magnet size, like we talked about. And so this standard of care right now for imaging is 1.5 tesla. Tesla is the way you, the unit of measure the magnet. And so this MRI is three tesla. So I would say it's akin to watching a football game on your cathode ray tube with the bunny ear atenna versus high def televisions. It makes a huge difference in how much detail I can see and our neuroradiologists can see and seeing what's what's diseased tissue, what's pathology and what isn't normal, if you will normal tissue. The and the other aspect that's really exciting is that you can get an MRI on patients with spinal cord tumors as well, in addition to patients with brain tumors. In the past, with other intraoperative MRIs that were that were in use, you can get imaging of the brain but not the spinal cord. And with the spinal cord, even those those tumors are not as common as brain tumors, they are really tricky in that the spinal cord itself is very small. It's the size of your pinkie as far as diameter goes. And so there's a lot of real estate and also the spinal cord tumors even more so than brain tumors look and feel very much like the normal spinal cord. So having access and opportunity to be able to get an MRI when we think we're done with removing a spinal cord tumor really goes a long way to treating patients and giving them the best outcome of being disease free.

Tyler Mason  16:58  
What's been the response to this so far to the suite, both from maybe patients and their families, and also from you know, yourself, your impressions and your team at Children's Minnesota?

Dr. Meysam Kebriaei  17:07  
Well, I mean, like you alluded to, I mean, it's been really exciting. Because there are a lot of stakeholders, it's of course for the patient and for giving them the best outcome. So patients and families are really excited about it, knowing that, you know, they've got access to the latest and greatest technology. You know, having your child diagnosed with a brain tumor is life changing. Nobody wants to hear that. It's really the worst news you could hear. And it really changes the family of that child and the life of that child and that family forever. And so being able to reassure the family that not only do we have the best people, the best specialists, we also have the best technology that will assure the best outcome for patients. And with brain tumors and spinal cord tumors, the number one factor in outcomes as far as making sure the patient is disease free or survives their tumor is how much of that tumor you're able to remove with surgery. And so the intraoperative MRI suite really offers us the opportunity to make sure that we've removed all the tumor or maximize our tumor removal to give that patient the best outcome. And then of course, as a surgeon, as a surgical team with anesthesiologists, we're really excited to be able to offer this to our patients. You know, I'm always proud to work at a hospital where I'd be happy, I'd be proud to bring my children and my family too. And I'm really proud to do that. And our team and we they really are excited about the technology as well, too. They self select to be in our rooms and be part of our team. And as a matter of fact, one of our best scrub techs, she's been with the working with us a children's for about 40 years, and she was looking to retire but she postponed her retirement so she could join the team and really work on this technology and be part of this exciting new, innovative technology and also train the younger folks that are coming through.

Tyler Mason  18:45  
Wow, very cool. And you kind of alluded to it a little bit there. But you know, we're talking about innovation, and it's particularly Children's Minnesota on this podcast. And here at Medical Alley, our vision is to make this region the epicenter of health innovation and care. When you think about innovation, what does it mean to you personally to practice at a place like Children's that has value on innovation,

Dr. Meysam Kebriaei  19:03  
You know, it makes me extremely proud to work here. You know, it makes me confident that I'm giving my patients the best outcome that they deserve, the best care that they deserve, and that we're the right place for those patients. And so it makes me very proud that we have this and it really makes me proud of our hospital and the community as well, too. It makes me proud of our board. And really a generous community. We you know, innovation costs a lot of money, and that's the thing about innovation is that it costs a lot of money. And as a not for profit hospitals, Children's Minnesota really depends on our generous donors. Like for example, the iMRI, you know, would not have been possible without a very generous $4 million donation from the Schultz Family Foundation, and to put a little plug in for through 2023 they're also doing a $1.5 million match challenge as well, too. Every dollar spent is a lifesaver. You know that this really directly affects outcomes for patients wioth tumors and seizures and other surgeries.

Tyler Mason  20:03  
Yeah, absolutely. You know, as we kind of wrap here, you've done a nice job of outlining the capabilities and some of the innovation going on. But is there anything else about whether it's this iMRI technology in particular, or anything else that goes along with this that you'd like our audience to know?

Dr. Meysam Kebriaei  20:16  
I'd just like them to know that we're extremely proud of not just who we have here, we really feel like we have the, you know, the greatest specialists here at Children's who are extremely dedicated to patient care, but also, you know, everyone in the hospital, from from our custodial staff all the way to the executives, everybody in between, our board, our donors, we're really dedicated to making sure that we are able to offer our patients the best people and the best technology that's out there to make sure that they're able to get back to their lives.

Tyler Mason  20:45  
I think that's a great way to wrap it up. And Dr. Kebriaei, I want to thank you not just for taking time today to talk on the podcast with us about the iMRI capabilities, but for the great work that you and the rest of the team at Children's Minnesota do to to make this Medical Alley community a better place. So thank you again for your time today and keep up the good work. 

Dr. Meysam Kebriaei  21:01  
Thank you. It's been an honor. 

Tyler Mason  21:03  
And we now come to our third and final part of this three part episode talking with experts from Children's Minnesota about the different capabilities that Children's has, and we're now joined by Dr. Mark Bergeron, who's the Medical Director of Digital Health Transformation. We're going to be talking to him about the Children's Minnesota's neonatal virtual care stabilization program. We'll get into that in just a minute. Dr. Bergeron, and how are you doing today?

Dr. Mark Bergeron  21:26  
I'm great. How are you? Tyler?

Tyler Mason  21:27  
I'm doing well, thanks. So let's kind of take a step back before we talk about that program, which launched a few years ago. Children's Minnesota has been offering virtual care prior to COVID when it seemed to be kind of the the trendy thing. Can you share a little bit about the early years of telehealth at Children's?

Dr. Meysam Kebriaei  21:43  
Yeah, so I'm a practicing neonatologist. So we had never really considered telehealth at all. It was just like everything is bedside care for us until about 2018 when a rural hospital here in Minnesota said hey, you know, telehealth is all the rage. We would love to have neonatal telehealth support in our nursery. What do you all think of that? And I scratched my head for about three seconds and said, hey, it's an opportunity. Let's do this. I'm a Luddite when it comes to technology and so the chance to do something new outside of the NICU was fresh and exciting for me.

Tyler Mason  22:20  
Sure. Now fast forward a little bit to 2018, the neonatal virtual care stabilization program was formed. Can you tell us about what that program is and also why it was launched?

Dr. Mark Bergeron  22:29  
Yeah, so it is exactly as it's entitled, it's a virtual care stabilization program for neonates. So an infant that either like a preterm birth at a rural hospital is anticipated in moments, or a delivery that's going with some concerns in real time, or a baby that's just been born and has immediate, acute needs that needs stabilization. We're in a virtual sense on standby for those situations. And we bring our expertise in neonatology to the bedside. Even if you're, you know, miles and miles away from us, it's activated in a moment's notice. And we're, like I said, on standby at any time to assist in these types of situations.

Tyler Mason  23:10  
Tell me a little bit more about launching that program. And were there challenges I'm sure that were involved, or what what kind of went into getting this program off the ground?

Dr. Mark Bergeron  23:18  
Yes, when we were approached with our initial partner hospital, it was like, well, we've never done this before. So it sounds great, it sounds exciting. So we went out and did a site visit there, looked at what they had, and they were very well equipped to handle pediatric and neonatal emergencies. So that's a great starting point. And you have a highly engaged community of pediatricians that really wanted this type of backup in a virtual program. And so we use human centered co design principles. They're the client, they told us exactly what they wanted. And then we went out and built it with them. And then you would think that there would be some kinks in a new program. But I think we did it well in its initial design that we really, the program today looks exactly like it did in 2018 when we launched it as a pilot with a single site. And then you know, we go through the virtual consult, we act as an advisor, in very much a peer to peer fashion. We don't take over the care that's best rendered by those local providers at the bedside, but we supplement their care. We help them think about the neonatal resuscitation algorithm, which everybody that takes care of babies knows, but maybe doesn't put into practice every day, like those of us in an ICU do. And so we're one step ahead of them and say, Okay, well, here are the emergency medications that you need to drop next, or here's the next procedure and how to do it in real time. And we basically kind of add to their self efficacy of being able to execute these very high stress situations.

Tyler Mason  24:39  
And what sort of impact have you seen this program having particularly, you know, as you talked about in those rural areas, which I think is kind of the main focus of this?

Dr. Mark Bergeron  24:46  
Yeah. So I think one of the things that we've noticed is that it's a more seamless transfer, you know, from the patient in their rural setting to get to us at Children's Minnesota. In the old sense, we would advise them over the phone, really not seeing everything and really relying on somebody else's take on the situation. And then our transport team would arrive and sometimes be surprised at what the situation was and how it was unfolding in the interim since the initial call and dispatch. So definitely better communication, more seamless transfer, earlier notification that there's an infant that needs to come to our facility. Better follow up with the parents. We can talk to the parents now face to face over the virtual link and tell them here's what we're going to do for your infant. You know, I would say an unintended consequence, but it's certainly a great one is that we can recognize babies that maybe don't need to come to us. There's scant literature for neonatal telehealth, but about maybe 40% of babies that would have come to us maybe don't need to, because we recognize this baby has the potential to turn around. We're here watching with you. And the local providers maybe aren't as concerned about getting this baby out as fast as possible as they used to be when they know that we're virtually in the room with them making these decisions.

Tyler Mason  26:03  
Now can tell me a little bit more about the scope of this program, how I guess, you know, how many hospitals have been using? Or is it only within the state of Minnesota? Is it other states as well?

Dr. Mark Bergeron  26:12  
No, actually, our numbers of sites out in Wisconsin outnumbers Minnesota now. So single site, we started and we've added about two or three sites a year since the program's inception. So we've just added our 14th site and gone live this summer, and then we'll probably add, you know, if we're keeping up our trend another couple of sites this year. 

Tyler Mason  26:31  
Okay, very cool. And kind of looking at some examples of the impact this has had I know WCCO TV here in the Twin Cities had a success story of a newborn girl who had a collapsed lung that the Children's Minnesota was able to help their the team there. What does it mean to you both on a personal and professional level when you see these sorts of stories taking place where you're able to make this impact?

Dr. Mark Bergeron  26:49  
Well, it's incredibly gratifying. First of all, anytime you have a good outcome and can, you know, talk about that and celebrate with the family, in a way like that television story, that's great. I remember the first time I talked a family practice provider in a rural site in Minnesota through that needle decompression procedure. And I was as terrified as she was because I know how to do it. But doing it blindly over the phone, telling somebody what to do with a needle into a chest of a newborn baby is terrifying. But the way it goes now with our partner sites is that we can see the procedure, a very delicate procedure and how it's going and much more confidently advise a provider that maybe it's done on a mannequin, or maybe real life once in training, but to do it in practice, it's a much better situation to to see it and advise with this technology.

Tyler Mason  27:41  
Absolutely. And now last one here for you as you think about obviously this program has continued to grow and there's other telehealth capabilities. But what does the future hold, do you think, for neonatal telehealth at Children's Minnesota?

Dr. Mark Bergeron  27:52  
Well we really focused on the front end, right, of getting babies to us with improving the access, particularly in rural sites using virtual care. Where I think virtual care is gonna go next for us in neonatology is looking at rounding, daily rounding, so not acute settings, but more the routine daily rounding local sites manage babies that they've opted to keep. And then I think telehealth has a role in helping us transition out of the NICU and home sooner. So we've had some success over the last couple of years in getting babies early discharge still with nasogastric tube feedings going on. And we interface with families using audio visual connection into rounding in the home. And I think that's only gonna get more important as healthcare moves away from brick and mortar, you know, locations to do more home based care.

Tyler Mason  28:44  
Is there anything else, I guess I'll leave it up to you, anything else you want our audience to know about this program or just about the work that is taking place at Children's?

Dr. Mark Bergeron  28:52  
Well, it's a really fun program and a lot of sites, you know, be it a pediatric adult are using telehealth and novel ways. I think what's unique about our program is that where you look at most children's hospitals, they're doing something similar with telehealth with hospitals in their network. What's unique about us is that we're Children's Minnesota, we don't have a presence physically out, you know, with a network of hospitals. So these are all independent hospitals that have come to us and said, we want to partner with you as a community hospital not affiliated with you. And I think that's unique in that we're able to meet the client's needs when they're not, you know, affiliated officially with our system.

Tyler Mason  29:31  
Well, Dr. Bergeron, I want to thank you for the time today to share more about this program and for the great work that you and the rest of the team at Children's is doing.

Dr. Mark Bergeron  29:38  
Great. Thanks, Tyler. I appreciate the opportunity. 

Tyler Mason  29:41  
Absolutely. And to everyone out who's listened to this episode today. I want to thank you for taking the time to hear more about the work that's being done at Children's Minnesota. Thanks to Children's for the opportunity to meet with some of their experts and some of the leaders in health care. Of course, you can find more episodes of the Medical Alley podcast at medicalalleypodcast.org, or on Apple podcasts, Spotify, or wherever you get your podcasts. And as our usual host Frank always says, if you can share this episode with just one other person, it would help spread this story and get the word out to the community. So, again, thank you to everyone for tuning in today. Have a great day.