Life Right After the Surge: A Podcast with NYU Clinicians Ab Brody and Audrey Tan

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith

Eric: And Alex, we are continuing our COVID coverage on our GeriPal podcast.

Alex: Losing count, how many? Nine, 10, somewhere in there.

Eric: Somewhere in there. Who do we have with us today?

Alex: Returning as a guest host. We have Nauzley Abedini who is a palliative care fellow at UCSF. Welcome back Nauzley.

Nauzley: Thank you for having me again.

Alex: And from New York, we have Ab Brody, who did his PhD at UCSF. We miss you here. Ab is now the associate director of the Hartford Institute for geriatric nursing at NYU. Ab welcome to the GeriPal podcast.

Ab: It’s an honor to be here with you guys and have a fun conversation.

Alex: And we also have Audrey Tan who is the director of emergency medicine and palliative care in the department of emergency medicine at NYU. Audrey, welcome to the GeriPal podcast.

Audrey: Thank you very much. Very excited to be here.

Eric: So we’re going to be talking about, how COVID is affecting NYU and in particular the dual roles you guys play in both palliative care and emergency medicine, palliative care, working in the hospital. But before we get into that, we always start off with a song rec. Do either of you have a song recommendation for Alex?

Ab: Yeah. So we talked about this a lot and there were some, potential Disney options thrown around and their kids. So we decided against that for many reasons.

Alex: Thank you.

Ab: And instead have gone with, “Hey Jude,” which happens to be my four year old savored song. But if listen to the beautiful lyrics, it’s very apropos of what I think many of us are experiencing as we care for this patient.

Eric: Wonderful.

Alex: Your four year old has good taste.

Eric: Alex, you got like 15 seconds, right? Just 15 seconds.

Alex: One minute. You can’t short change Hey Jude.

Alex: (singing)

Eric: There was a negotiation not to have Alex do the extended version. Hey Jude-

Alex: It gets hard to stop. At the end, when you get to the, na na na na na, and that will go on for at least 20 minutes.

Eric: We’re going to get an email from zoom, we’re taking up too much bandwidth. Well, again, thank you both for joining us. Is there any particular reason you chose, Hey Jude?

Ab: It’s a beautiful song and so powerful in the moment, because there are so many moments that can let you down and also affect you, with the devastation that we’re seeing both for patients, for families and for everyone’s lifestyle, but that you can’t dwell on it. You have to think about the things that are going to make it better, not let it all get under your skin. And so I thought it really encapsulates the moments and the times that we’re in.

Eric: And Audrey, when we talking about… we usually don’t like battle analogies, but I’m going to go with it. You’re in the front lines of the front lines in New York city in the emergency room. What’s it like right there right now?

Audrey: So I have to say, it feels like a little bit of a reprieve. I think, no one is ready to say that it’s over. I think, we’re cautiously optimistic in New York city, our volumes are down. We’re slowly seeing non-COVID patients that are re-emerging. So, I saw a sepsis patient from UTI the other day, but actually still ended up having COVID, but we’re slowly seeing patients that have other things, other diagnoses that we feel like we almost forgot about.

Eric: When was the peak for you and what did that feel like?

Audrey: It was about two weeks ago. I spent some time in the main site here at NYU, at Tisch, but I actually do the majority of my emergency medicine just at a smaller, more community hospital in Brooklyn. And it was really, chaotic and packed, every day we were packed to the brim in our respiratory unit. We had a lot of really sick patients. At the very beginning it felt like we were doing screening and a lot of education and slowly the word was getting out to stay home. So we were seeing patients that were sick and really needed our support for the most part, and our volumes were quite high.

Eric: And Ab, what was it like for you?

Ab: I’m now serving in a more hospitalist acute care and p-role in the inpatient setting, in one of our, what is supposed to be a stable unit of patients who are on the mend and getting ready to go back home, which is a very new role for me is as usual a geriatric and palliative care consultant. And the patients that you think are stable are not always stable. And we have taken up what is normally an orthopedic hospital, mainly does joint replacements and traumatic hip fractures, and turned it into three full floors of COVID positive patients.

Ab: Some of them also have hip fractures. They fell because they had COVID and became either delirious or dizzy or whatnot, but it’s such a different role to be in that primary team management role, especially on nights, which is what I’m doing to balance family and lack of a babysitter issues. And so it’s both terrifying because you know that anything can happen at any time, but also incredibly redeeming as you get to wean people off of oxygen and see them getting ready to prepare to discharge the next day. And so you go back and forth between this rapid response team coming in versus helping people getting ready to go home, it’s a very different role.

Alex: It’s interesting, just reflecting on what you said, we have had a lot of conversations with people who are working in intensive care units or who are doing palliative care consults for very ill patients in the emergency department or the intensive care unit. It’s interesting to reflect that both of you are palliative care clinicians, but you’re also providers in another sense. And Ab, in your case, you’re just talking about being the primary NP serving in a hospitalist function here. And you’re seeing people, normally we talked to folks on a prior podcast and they’re talking about people who are imminently dying within the next few days, you’re talking about people who are getting ready for discharge.

Alex: And this is a very much a different story than what we’ve heard before on our podcasts. And I think it’s important to remember that, if you only listened to our podcast, you would get the sense that everybody with COVID has multiple complication that ends up dying and that’s not the case. I would just want to open it up to both of you and see if you have a moment to reflect further on the differences between, seeing patients in your palliative care role and in your role as NP hospitalist or emergency medicine provider.

Ab: Yeah, the role is so tremendously different. Audrey experiences this on a daily basis in her roles between emergency medicine and palliative care that I’m now only experiencing for the first time. And so she has a greater depth of this, but it’s a visceral change that comes with being on a primary team and being primarily responsible, being the one that’s calling the rapid response, that’s all of a sudden proning a patient, that is dealing with the elevated troponin and heart attack that’s just come on. And the automated response to just go ahead and do everything because that’s what you were trained to do. Even if the last time you did it was in 2005, which was the last time I had a tour role was back at UCF in 2005.

Ab: It still sits there. But having that frame of reference from palliative care and from geriatrics, so is this what we should really be doing? Starts to trickle in. And so there are cases where you stop that whole cascade and people who you were going to do everything, even for patients who already have had some goals of care around, do not resuscitate or do not intubate, going down this whole pathway of EKGs and pressors and other ventilatory support. It’s just this automated role but it creates a lot of distress when you know that in many cases it might also not work, but not knowing which cases it’s going to, and which cases it’s not going to work in.

Ab: So I think there’s this huge role shift but also these questions of, should we really be going down this path versus the disassociated palliative care clinician who’s coming in, maybe after the fact, maybe somewhere in the middle and opining without having to fully manage it. It just creates this whole different perspective.

Nauzley: Ab, wanted to ask you a bit more about the differences in how you’re viewing your role as a primary care provider in the hospital versus your role as a consultant. I previously worked as a hospitalist and can understand that dichotomy, but I’m wondering, how do you see this playing out for your colleagues who are hospitalists on the front lines, in terms of interrupting that cascade that leads to aggressive care?

Ab: We’re very blessed at NYU to have some really, really fantastic hospitalists. Our COVID unit with orthopedic hospital is all staffed by geriatricians. So our geriatrics division has become the team at this hospital. But then we also have other amazing internal medicine hospitalists at our main campus who, do some very, very good advanced schools of care work in the usual setting, not just in the COVID related zeal. But it is different, right? When you’re coming in and your primary lens is as a palliative care provider and now you’re the one who is ordering everything and doing somewhat invasive procedures that are uncomfortable, and could be causing suffering to patients.

Ab: Whereas before, you were the one having the goals of care conversation. Sometimes in a team format, sometimes not, but not going in and having to order and do all of those procedures, it just really flips that switch from what you’re used to doing as a consultant.

Eric: And Audrey. How about in your situation? I’m just trying to think about how, on one hand too, what we’re seeing is that there is a wide spectrum of how people, the prognosis with this illness, most people they don’t even know they have it, to people with mild disease, the people who need to be hospitalized, to people who end up in the ICU on a vent, where the prognosis looks exceptionally bad. How are you coming through this with both the emergency room and the palliative care lens?

Audrey: I think from an ED standpoint, it’s been a progression in terms of how we’ve been dealing with these patients in the emergency department specifically. In the very beginning, the conversation was all around, intubate early, and that was the mindset, because patients were coming in with significant respiratory symptoms and also there was a discussion around, super spreading events and making sure that our providers are in some way protected. So it was almost two pronged, the thought to intubate and protect airways early. And patients that come into rest into the ED in respiratory distress, putting patients on a ventilator is a common occurrence in the emergency department.

Audrey: That narrative really changed as we realized that the mortality was really high and potentially putting patients on a ventilator was often a tipping point for patients that were critically ill. So then the whole conversation really changed towards, keeping patients off and using other modalities like high flow or bypass or other ways to support breathing that were noninvasive. And again, as the data around mortality really came out for older patients that were placed on ventilators, we became, I think the ED as a whole really realized the importance of palliative care.

Audrey: So, some of my work was educating my colleagues in the ED on how to have these conversations and then also making sure that palliative care upstairs was available to help the ED providers downstairs and having these conversations.

Eric: I can imagine, especially in the emergency room, one of the challenges we faced even before COVID, is that when you have goals of care conversations with patients who are having a lot of symptoms, including dyspnea, where the decision or not to do things like intubation or even advanced care planning, is really hard. Because there’s a lot of emotions, there are symptoms. It’s just not an optimal time to have these conversations, and that’s something that we faced prior to COVID. Now we’re in this situation where if you think it’s important to have these conversations, but we’re still, I’m imagining you’re still facing these barriers where it’s incredibly hard to have them, because of everything that’s going on. Is that right?

Audrey: Yeah. An N95 mask and a face shield and a high flow nasal cannula on the patients and some bypass and a yes, that’s exceptionally hard. But I think everyone realizes the importance of it, because we’re certainly not causing more harm than good by placing these patients on ventilators. And I think everyone, it’s been refreshing in some ways, sort of, having ED providers really acknowledge the importance of this conversation and we’re taking a moment to stop and say, this may not be the best thing for you. We need to talk about this before we do this.

Eric: And I think one of the other thing that goes along with that, that is not a change though, is the fact that when we’re talking to families, so a lot of the patients we’re seeing, also are coming from the nursing homes, have dementia or from home with cognitive impairments or have developed incapacity due to their illness, then you’re talking to families and can the families make a timely decision? That is not something that has changed so much. So you’re still seeing decisions that are having to be made in lieu of a decision by a family who are still trying to deal with these tough decisions. And so even if you’re using all of your palliative care skills, you’re still running into this issue of decisional ambivalence, or disagreement within family members, that then affects what you have to do on the front lines, I think as you said it here in the beginning.

Alex: I wanted to ask about moral distress. And it’s tough to ask about moral distress. Are you experiencing moral distress? People don’t generally identify, that thing I’m experiencing right now has moral distress. So, sometimes it’s easier to ask in terms of, if you ever felt conflict or questioned yourself, am I doing the right thing? Why am I going down this path? This doesn’t seem right, or feelings of compassion, fatigue or burnout, all might be underlying symptoms, that putting you in this really tough situation where you’re handling so many patients, such a high volume, so sick, so much death, so many difficult discussions and strong emotions. Audrey, maybe starting with you, is this something that you’ve been experiencing or your colleagues and if so, how are you managing it?

Audrey: Oh yeah, certainly. And I think just the volume, the onslaught of patients that we were seeing was terrifying. Honestly, we were packed to the brands and doing what we could to manage these patients, and the threat of running out of equipment, and having to gather those things on an as needed basis. And then seeing a lot of really terrible cases, where patients are not doing well. We’ve had to really come together I think as a department and support each other, and on ED providers I think are really good in terms of war analogy, putting their game based on and doing what they need to do for the moment.

Audrey: I wonder if when the dust is settled, this is going to be affecting a lot of people. I think we’re still in it, every day, though our volumes are down. But I think when we look back there’s going to be a lot of anxiety and sadness that we’re going to have to process after this is all said and done.

Alex: Yeah. I worry about that residue of moral injury, anxiety, sadness, burnout, compassion fatigue, all of those. Ab, how about you?

Ab: I think for me personally, I’ve had to start second guessing some of my instincts, and that has led to questions about what we should be doing. I’ve had successes where, we’ve converted patients over to more of a comfort care pathway and of life pathway rather than moving towards the default that have been uplifting not, because it’s not a sad ending because it is still a sad ending that this person is going to die in the hospital without their family around them.

Ab: And so the most you can do in some ways is to comfort the family and sit in the room and hold the hand of that patient in their families stead. Which, certainly when I was a bedside nurse, I did a whole lot in the UCSF palliative care comfort suites. But also, when you have that patient who is crashing and you’re being asked by the family to do things that you don’t think are going to help, the 90 something year olds who, all of a sudden goes from setting in the 90s, to setting in the 50s, and the family says do everything and you don’t think it’s going to end very well and you start to prone them.

Ab: And start to do other invasive procedures, starting to prepare them for intubation, can be distressing when you think that there is no good pathway that it can occur here. But actually, I’ve had a patient now who we did all of that and has now left the hospital. So, you start to second guess your instincts, which brings its own distress along with it. I think the biggest distress so is in the ICU, where I have hundreds of former students who are now working in intensive cares across New York city and elsewhere. And this huge distress, sometimes having no patients that they’ve cared for alive by the end of the day. And just this sorrow and this heaviness, just seeing patient after patient pass away, some more intensively, some with terminal extubation, some somewhere in between.

Ab: And so I worry a lot about our intensive care friends, both intensivists, particularly the nurses who are sometimes caring for double or triple the number of patients they would, because of the intensity of this. And so I think that’s where I’m really concerned, is are our ICUs going to be hollowed out, and are our clinicians going to leave the field because of that injury that they have now suffered. I’m not talking to suffer being exposed to COVID, which they all have as well. But the suffering of being exposed to multiple patients dying every shift that they are there, no matter the best care that they provide.

Nauzley: Thank you for sharing that concern and that worry. And I’m wondering, as you’re thinking about your colleagues and their wellbeing and their longevity in the field, have you found things that are helpful in supporting them both in the short term and also thinking about their coping longterm?

Ab: It’s tough and my normal instinct is to give a hug, right? And we’re not allowed to do that right now. So elbow bumps are about the extent of our physical contact with each other. But, being there and listening for them, when you get that email, from this former student you haven’t talked to in a couple of years, who looks you up and wants to talk about something.

Ab: Just being there for people, is all I can think of right now and stopping everyone who you see in the hallways, from our food service workers, our engineers, our nurses, our intensiveness and just thanking them for everything that they’re doing and being there. That’s how I’ve chosen to address the problem right now and being open to people, but I don’t know the full extent, besides providing psychological services and really what is going to be PTSD counseling after the fact, I think are some of the things we really have to think about.

Ab: Like you work in the VA, I used to work in the VA. Actually at Fort Miley as well for a little time, in San Francisco, but also in New York. See a lot of vets returning from the army with PTSD and I’m worried that we’re going to see that in our clinicians now and start having to work through some of that as well. And I don’t know that we have the answers for clinicians with PTSD versus people who have had PTSD due to traumas.

Eric: Yeah. What about you, Audrey? I can imagine, in particular with the emergency room physicians, you get through it, you have tasks, you get through it. How would you answer that question from Nauzley?

Audrey: I think normalizing right? Normalizing that anxiety and normalizing the sadness. I think that’s not something we’re used to acknowledging in the emergency department. And again, we’re a group that plows forward and deals with things in the moment. But there’s certainly been tears, there’s certainly been breaking down, people that have broken down just from the weight and the stress of the work, and I think letting people know that it’s okay. And certainly I think one of the most helpful things I’ve heard is, I think everyone realizes that we need to support each other, but buddying up has been something that’s been helpful, because I think, broadly speaking, everyone realizes we have to support each other through it, but making sure that we are teaming up and checking in on each other specifically, so that we’re not losing each other in this mix and that we are truly supporting each other and checking in on each other.

Eric: One of the unique things about this outbreak is, usually in medicine you have the option of not taking it home with you, leaving it at work. Obviously your emotions and everything still comes with you. In particular with a viral outbreak, especially we don’t know exactly what the prognosis is, but people are often really worried about bringing it home, both the virus and just the weight of all of these decisions that you’re making. What’s it like for you to bring it home? What are your worries around that?

Audrey: I was just talking to a colleague about this. Always there feels like there is a low leveling of anxiety at all times. It’s that you can’t truly let go of work and then, because the circumstances at home, often there is also stressors at home, whether it’s home stressors that are compounding, this inability to release, and I think the stress of what you succumb to in your day, it’s been a lot. It’s been nice that our institution has offered support groups and our psychology colleagues, our psychologists have really offered their services. And I think that’s something that we need to take advantage of, because it is a constant level of stress these days.

Ab: And I think there’s the added layer on it, just because you come home and you can’t really process either many of us. So I came off of a night shift on Sunday night, a 12 hour shift. I came home at 7:00 AM, and my wife went out to go take care of her COVID patients as an occupational therapist at Bellevue, which is a city hospital, which has also had a fairly large number of patients. And so then now my kid is smacking me in the face as I fall asleep reading a book to him, dose off. So you don’t really ever get that chance to process, because there is no aloneness. And then for the people that are going home to no one, they have the opposite side of things where they have no one to have companionship with.

Ab: We used to, after our 12 hour night shifts, go out to a bar as a nurse, many moons ago at least, and have a drink and commiserate after a particularly terrible shift. And we can’t do that now, and as much as I love zoom, it’s not quite the same thing. And so the community piece is not there, and so there are people that are not… not that alcohol is the best way to cope with things, I don’t want to give that up. But, the community piece is lost because you can’t gather together with other people as well. And so it’s, how do you figure out how to make community, how do you address internally that the strife that you’re feeling without taking it out on others as well. And I certainly don’t have an answer. I don’t know if you do Audrey, but that’s some of the things that I personally have been going through and I know many others are as well.

Alex: I wanted to shift gears if I could from this topic and talk a little bit more about the geriatric side of things. I know that we’ve covered impact on providers. We’ve talked about palliative care and dual roles. I just wonder if you have any pearls or insights taking care of older patients, and you’ve mentioned some of the issues that have come, some of them had falls, have had hip fractures, showed delirium as a concern, either on the floor or in the emergency department about conditions you’re seeing that are exacerbated by COVID that are geriatric, or challenges to caring for geriatric patients, either in the emergency department or on the floor due to the coronavirus epidemic.

Audrey: I think what we’re seeing that is distressing to the patient, distressing to the providers and the families, is the inability to have visitors, has been really difficult. So older patients that are used to orientation by their family members, are a comforting presence, we’re not able to give them that currently. So we’re trying to figure out other solutions like an iPad, so that at least they can see their family members and talk to them. I just took care of a 92 year old in the emergency department that I did a palliative care consult on, who has COVID and is at baseline oriented, but is having confusion because she’s on high flow nasal oxygen and she’s having a really hard time. All our family wants to do is speak to her, but she’s in a room by herself, on isolation with no familiar faces.

Audrey: So, that’s been really a struggle that’s been at the forefront, that we’re trying to manage, and whether that’s us being present bedside as much as possible, or us taking our technology to the bedside and letting patients, at least see their family members. It’s not ideal none of this is ideal, but we’re just doing the best that we can to help these patients.

Alex: Ab, how about you?

Ab: One other clinical thing that I don’t think that’s been talked about a lot, but relates a lot actually to my favorite GeriPal video ever, which is, I don’t know if you can guess it, but it involves Ken and a bowel prep regimen, maybe a taste test of sorts, but I say to every student I ever teach and every clinician I ever go out into the field and do inservices with, is the number of people that we’ve now seen who are getting obstructions and aliases. And I don’t know why, I’ve just noticed the pattern that’s occurred, so this is not probably what Audrey you’ve seen on the front end of things, no pun intended. Right?

Ab: We are seeing patients that are having completely irregular GI patterns. So they’re, they’re having diarrhea and then for some reason, then they stop having great transit, and leading to some aliases, obstructions, and other GI problems that are subsequent to that, what is normally a fairly simple issued to monitor and treat, is one of those things, but the family isolation issue and we have had some exceptions, and the organization loosened up a little bit now in terms of their policy, probably not in the emergency rooms, but at least in other areas of the hospital to a small extent.

Eric: And Ab, what about delirium precautions, all those great things that we know that helps with… completely thrown out the window? What’s it like for you right now on the wards?

Ab: We have this wonderful delirium order set baked into epic that our lead hospitalists have reminded again and again, our hospitalist teams to be using. Problem is the doors are closed, right? The doors are closed to all of these rooms, except for the non-COVID patients, which are few and far between, some of whom have C-Diff, so then the doors are closed anyway. And reorientation issues, the issues around anti-cholinergic medications, while some of these you’re giving for other reasons, and so some of that stuff is a little bit thrown out the window. You can’t have volunteers. So as much as I love the help program and Sharon in her ways, amazing work and all of her team, a lot of that stuff we can’t do right now, for one reason or another, other that we can.

Ab: And so there are those issues that keep coming up, and even though in our hospital, the three medicine teams that we have are all led by geriatricians, we have some tremendous geriatric nurses in that hospital as well, because our orthopedic hospital mainly sees geriatric patients. And so we have a lot of geriatric nursing specialty there. They’re so busy dealing with either trying to titrate down oxygen or the delirium is caused by a lack of oxygen, or you can reorient people and you don’t want to go into the room every minute because of the exposure issues. It’s not out the window and it is still on the forefront, but it’s hard to actually address to some extent.

Eric: My last question is, a lot of people compare this to tsunami and the wave hits. It sounds like the wave has hit, but the water has not yet receded. The land is flooded. And I’m wondering, not from a peak level, but where you are right now, where you’re still caring for a lot of individuals with COVID. Is there one lesson that you’ve learned for what you’re doing right now that you’d like to convey to our audience?

Audrey: I think what I’ve learned with this illness, which is so unique to COVID, is being really receptive to learning on the fly. We I think had a mindset about how to deal with this illness. We have been learning new things so quickly, proning patients, maneuvers like that. We’ve been creating CPAP machines, out of a bag valve mask. We’ve been realizing that patients are really coagulopathic, but all this new information comes out within days. And we’re just learning so quickly every day about new ways to manage these patients, I’m not sure we’re going to encounter this, I’m going to encounter this ever again. It’s actually been really great because we’ve been able to learn from our colleagues and keep those lines of communication open and being flexible like that, I think has really offered these patients better treatments.

Eric: How about you Ab?

Ab: I’ve actually heard from some of my colleagues at the other hospital on Twitter, before the information actually filters down. So, not that I take medical information from Twitter, but they’re talking about their experiences on the wards for the last seven days and then, you can take that and obviously make sure it was them that was tweeting that out. But, bring that back, because it does take a while for things to filter around, even if you’re communicating very well as an institution. I think for me though, the biggest thing has been, putting the shoe on the other foot.

Ab: So, as a consultant now being in a primary management role, recognizing again for the first time in 15 years, what it’s really like to be in that primary management in the inpatient setting role, and taking that back as I go back into hopefully in the next month or so, back into consultation as a palliative care geriatrics consultant. The compassion, and the lack of judgment that sometimes when you get in your own box, you think about, what are they doing when you come into this train wreck of a patient and you realize that the train wreck was… I see you smiling, Alex and Eric, we’ve all had that feeling coming in, we probably don’t say it, but we think it, what the heck were they thinking?

Ab: And really having that compassion that the day to day moment and making decisions on the fly is very different from coming in from a consultant perspective, and making recommendations and helping facilitate goals of care conversation with a difficult clinical situation, is such a different situation and to have compassion and understanding and, we ask why of our patients and their families, and we ask a lot of questions of them. I think remembering that we should be asking questions of our primary teams as well, can you share a little more, right, those types of questions so that we understand what the underlying situation wasn’t and don’t come back in with that judgmental piece has been the biggest learning for me.

Eric: I think that’s a great point. I think, for most of Micra as a palliative care doctor, I was also a ward attending and I always felt that made me a better palliative care doctor. And I love the point of just, we’re talking about empathy to our patients and families, but empathy to our colleagues too. And speaking of empathy to our colleagues, Alex has been burning to play, Hey Jude, more. I also want to acknowledge Alex has been very good at not singing that song throughout the course of this podcast. But the before Alex can sing more of Hey Jude, I just want to thank both Audrey and Ab, for joining us, Nauzley joining us too. Alex, do you want to give us a little bit more, Hey Jude?

Alex: A little bit more, Hey Jude.

Alex: (singing)

Eric: Alex is so happy again. Thank you very much for joining us today, Audrey and Ab.

Audrey: Thank you so much for having us.

Ab: Thank you.

Eric: A very big thank you. Nauzley, you’re always welcome to join us here too.

Nauzley: Thank you. Thank you all.

Eric: For all of our listeners, thank you for listening to our GeriPal podcast, and thank you Archstone foundation for your continued support.

Alex: Thanks folks. Till next time.