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Covid-19 Critical Care Training Forum - Shared screen with speaker view
D. Robert Handy
08:04
There is a limit on how many hosts you can have
UCSD Fellow
12:43
Hi guys, Abdur here, I'll try and field some questions as well on the chat box.
adunp
14:36
Can we record?
Nirav Shah
15:04
Yes….we will be recording
sfied’s iPhone
15:14
Will this meeting be available to be watched later? If so, how do I do that?
Viren Kaul
15:53
Yes. We will be recording this meeting and share the Lin once that’s available
Viren Kaul
16:06
link*
sfied’s iPhone
16:16
Ok, thank you.
D. Robert Handy
16:21
Will CE's be available for this?
Onika Tanya Maraj
17:15
Hi everyone! Nicki Minaj here loves — make sure to follow me on Twitter and Instagram: @NickiMinaj! I’ll be tweeting/posting about some of my Zoom join ins, as I am joined by my media director who has arranged a male voice over to hide my identity! Stay tuned on my outlets to see what I join!
Tom
17:17
Same Zoom URL for meeting next week?
Onika Tanya Maraj
18:29
Comment your media handles and I will take a look at a few of them…but only if they’re BARBS!
Viren Kaul
19:08
CME not available for this session currently. Something to work on. Goal is to provide a learning and supportive platform in these tough times. Thank you for joining us.
Onika Tanya Maraj
19:15
NICKI
Onika Tanya Maraj
19:56
I can answer some questions too
Aarti Sarwal
20:45
@aartisarwal here !! thanks for doing this session.
Martin
21:16
Hello everybdoy! Thanks for doing this session
Onika Tanya Maraj
22:19
I am praying for those impacted!
Sunil Sahai
22:49
UTMB-Galveston in the house!
Tom
23:17
@tomhestonmd here. Thank you for these sessions
Tom
30:09
The PET scan is misleading. The left ventricle lights up randomly.
Tom
30:23
depending upon glucose vs lipid metabolism
Mazen Odish
30:30
You guys have hit your maximum of 500 members on Zoom, may want to increase to 1000 if you can.
Alex Cypro UCSD
30:50
Thank you everyone for joining! Please post questions you have for Dr Landsberg in the chat and we will get to them after his lecture.
Viren Kaul
30:50
Thank you for the feedback. We will share with Dr. Landsberg.
Viren Kaul
31:14
Also working to increase capacity to 1000 for next chat, next TUESDAY at 8 PM ET
Laura Crotty Alexander
31:37
The recording of this session will be posted on the Ats website freely
Laura Crotty Alexander
31:52
Next week we will have room for up to 1000 participants!
Michael Kahn
33:44
Thank you for doing this—can Dr. Landsberg please discuss this phenomenon of high altitude respiratory physiology referenced by the intensivists in Italy?
American Thoracic Society
34:10
we can ask questions once he is done
955502
34:24
Hi is it possible to get copy of slides and lecture
Nirav Shah
34:46
yes —they will be posted on thoracic.org once edited…
Emma Scott
34:47
Question - what clinical outcomes/data is this 94% goal from? Also, specifically in COVID, what is the clinical significance of this “silent hypoxemia” we are finding in our older patients?
gwyn rossi
35:11
It would be very helpful for review- getting copies of slides emailed
Viren Kaul
35:20
Thanks Emma, will ask Dr. Landsberg for you.
955502
35:51
yeah that would be great thank u everyone or at least placed on website to access slides
Dona
36:04
Is there a role for permission hypoxemia?
Viren Kaul
36:42
Thanks Dona, added to our list of questions to ask
Neal Jones
36:44
Thank you guys for the questions, we will be sure to ask him as soon as he is done with his lecture
dasweeney
37:12
2 recent NEJM 2020 papers addressed oxygenation targets: both were negative but suggestion that it is more important to avoid hypoxemia than to reduce hyperoxia.
Solmaz Afshar
37:41
what if they have underlying COPD? Is the SpO2 goal still >94%?
Laura Crotty Alexander
37:53
Dasweeney = Atul Malhotra
ER
37:54
Can you speak to HFNC?
markrolfsen
38:15
We will address HFNC in the next talk!
Bahi Malik
38:45
yes please
Viren Kaul
38:51
Recent article on O2 saturation targets in critical ill patients: https://www.ncbi.nlm.nih.gov/pubmed/31589844
Laura Crotty Alexander
38:56
Solmaz - in general yes. Because the reason we target 94% is because it better correlates with a paO2 >60
Solmaz Afshar
39:14
Thanks
Tom
39:48
Harvard 1-page guide for hospitalists recommends ID consult for all patients
Viren Kaul
40:01
Range of 94% to 98% optimal, poor outcomes on both ends of the curve. Also important to make sure they stay in that range for majority of critical hospitalization. Please see shared reference
dasweeney
40:26
https://www.ncbi.nlm.nih.gov/pubmed/11265981
Emma Scott
40:38
Thanks for the reference - appreciate it
dasweeney
40:43
prior lancet report on oxygen induced hypercapnia in subset of copd
Jesse Maupin
41:12
Your talk referenced NC at 10 LPM. In training I learned that NC maxes out at 6L/min because of narrow tubing used (Poiseuille’s law). Do you disagree?
Melissa
42:08
I thought we were not using BiPAP for Covid PT's at all?
Andrew Weber
42:37
I keep hearing some relaxation of that
Melissa
43:04
I am in Vegas so I know we are behind in getting all the correct information
Dona
43:24
viral filters are available; the circuit may need to be adapted
Viren Kaul
43:31
Thanks. Will ask speakers about 10 LPM via NC clarification and the questions about NIV
American Thoracic Society
43:36
We can ask question once the presentation is done
Nirav Shah
43:37
As Dr. Lundsberg mentioned, this is a moving target. We are using it but need to be cognizant of aerosolization of virus….
Emma Scott
44:31
Compared to HFNC (4-17 cm droplet distance), BiPAP is talking about 60-90 cm of droplet transmission. Something to consider, obviously w/in the resources you have where you are
Nirav Shah
44:54
100% agree Emma
D. Robert Handy
45:12
HFNC with a surgical mask on the pt seems to significantly decrease the distance droplets travel
Melissa
45:42
thank you! that helps a lot
Viren Kaul
46:12
Also there is data for safety of HFNO from SARS https://www.ncbi.nlm.nih.gov/pubmed/15364765
David V.
46:30
Why BIPAPand not CPAP?
iPhone
46:47
can’t see the slides
Viren Kaul
48:14
Wrote this for out team: Cheung et al noted that there were no transmitted infections among 105 HCW who cared for 20 patients with acute respiratory failure due to Severe Acute Respiratory Syndrome (SARS) who were treated with NIV3. Of the two strategies, HFNO has been reported to have a lower Odds ratio (0.4, 0.1 – 0.7)4 as compared to NIV (Fowler et al: 2.6, 0.2 – 37.5 and Raboud et al: 3.2, 1.4 – 7.2)5,4 of risk of transmission of SARS to HCW exposed to these procedures as opposed to those who were not6. Patient and personnel related factors found to be associated with higher risk of transmission were unprotected eye contact with secretions (OR = 7.34), APACHE II score ≥20 (OR = 17.05) and patient Pa02/Fi02 ratio ≤59 (OR = 8.65).
Viren Kaul
48:32
Raboud, J. et al. Risk Factors for SARS Transmission from Patients Requiring Intubation: A Multicentre Investigation in Toronto, Canada. PLoS ONE 5, (2010).5. Fowler, R. A. et al. Transmission of Severe Acute Respiratory Syndrome during Intubation and Mechanical Ventilation. Am. J. Respir. Crit. Care Med. 169, 1198–1202 (2004).
Stephanie Denise Sison
48:42
can we access the recorded lecture after this?
Alex Cypro UCSD
48:58
Yes, this session is recorded
Viren Kaul
49:14
Yes Stephanie, will be available later
Neal Jones
49:15
Hi Stephanie, this lecture will be posted to the ATS website
Sanket Thakore
49:18
where the number 60 of PaO2 comes from ?
Dona
49:20
Will the chat stream - or at least the references - be available? Thanks.
Emma Scott
49:47
Here is the reference for droplet transmission distances for the group - https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.12071
Neal Jones
50:35
Dona, I will see about how get the chat saved but not entirely sure how we can do it
Stephanie Denise Sison
51:16
thanks so much :)
Martin
51:23
I always thought that a So2 of 90% corresponded to a pO2 of 60mmHg approximately
Tom
53:06
This works for me: To save the chat, click the box with the three dots just above where you type your text.
Neal Jones
54:17
Thanks Tom!
Laura Crotty Alexander
54:28
Please give feedback on this forum (including topics you would like covered next week): https://www.surveymonkey.com/r/J3CZRSC
Viren Kaul
55:25
Martin, that is broadly correct, but depends on the oxygen dissociation curve as Dr. Landsberg was saying.
Viren Kaul
55:29
See here: https://litfl.com/oxygen-haemoglobin-dissociation-curve/
Viren Kaul
55:41
Hence it ends up being a little bit of a range
Alex Cypro UCSD
00:55:42
This is a great opportunity to highlight the Best of ATS Video Series that has great, high yield content. Here is a sample that reviews the concept of driving pressures and lung protective ventilator strategies: https://www.thoracic.org/professionals/clinical-resources/video-lecture-series/mechanical-ventilation/drive-to-survive-optimizing-lung-protective-ventilation-strategy.php
Laura Crotty Alexander
56:08
If you are looking for a crash course in ARDS, check out this 15min ATS BAVLS video: https://www.thoracic.org/professionals/clinical-resources/video-lecture-series/critical-care/the-acute-respiratory-distress-syndrome-the-berlin-definition.php
Mark Rolfsen UCSD
56:48
Here are two great articles about proning.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026253/pdf/main.pdfhttp://jtd.amegroups.com/article/view/20601/pdf
Mark Rolfsen UCSD
57:05
(those two articles are the ones mentioned in this slide)
ER
57:16
Please speak to prone positioning in non-intubated patients
Mark Rolfsen UCSD
57:28
we will add that question, thanks
Neeti Kanodra
57:53
Yes, some discussion about patients on HFNC and self proning as tolerated. Need some guidance on that.
Viren Kaul
58:00
Open access link to the prone positioning article in NEJM: https://www.nejm.org/doi/pdf/10.1056/nejmoa1214103
Laura Crotty Alexander
59:03
Check out COVID-19 resources available at ATS: https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/covid19-clinician-resources.php
Dr Nauman
59:36
Please ask about when to extubate the Covid Patient as We extubated one patient as his lungs were clear and ABGs normal and he was fine and suddenly again CXR had bilateral infilterates and desaturation? So intubated again? Kindly highlight this
shyall
01:00:48
Role of APRV?
Liz Gosciniak
01:00:50
Yes, also are there increased/abnormal secretions in these patients that lead to difficult airways? We had a similar re-intubation of a COVID patient who seemed fine prior to extubation but then crashed within 30 minutes
pat
01:01:12
there have been some blogs/social media posts raising concerns about high peep strategies in covid patients with seemingly highly compliant lungs. people seem to be afraid of lung injury with high peep. this doesn’t make too much sense to me, or at least shouldn’t be a blanket statement to limit peep. so long as we’re assessing plateau pressures, driving pressure and hemodynamics response to peep, then this should be individualized to the patient. sccm and who seem to recommend high peep strategies— what is everyone else doing/ high peep or low peep tables?
María Fernanda Landaeta Manzanero
01:01:15
Same story here in a NYC hospital Dr Nauman , many get extubated but reintubated again
Laura Crotty Alexander
01:01:15
To join the ATS and receive updates on content available: https://www.thoracic.org/members/membership/join-the-ats/member-benefits.php
Dr Nauman
01:01:17
Exactly
Dr Nauman
01:01:26
Too much atypical cases are out there.
Dr Nauman
01:02:13
@ER
Mark Rolfsen UCSD
01:02:21
hey Pat, I will add PEEP level to questions to hopefully get you an answer
Satya Achanta
01:02:56
In COVID-19 patients, although they share some features of ARDS, compliance dynamics remain normal. In typical ARDS, compliance dynamics decreases along with hypoxemia. Is there any explanation for this?
Dr Nauman
01:03:01
I agree how about Proning Non intubated patients?
Neal Jones
01:03:21
Thanks for the great questions everyone, we will try to ask. Whatever questions we have not answered, we will attempt to get answer over the next talks or find another way to get some of the questions answered
Tom
01:03:28
What is the role of VBG's
Julie
01:04:21
I thought we were avoiding bronchoscopy due to high aerosolisation
D. Robert Handy
01:04:43
Stay Calm and Wash your hands. Best advice so far!
Laura Crotty Alexander
01:05:10
Let us know what you think about this forum, and what topics you would like covered next Tuesday 8-9pm EST: https://www.surveymonkey.com/r/J3CZRSC
Jeffrey Barry
01:05:17
avoiding different than withholding if need be
Laura Bartoloni
01:05:19
great advice!!! wash your hands and yes staying calm is key.
Neal Jones
01:05:21
We still do bronchoscopy when absolutely needed and try to minimize as much exposure to people as possible. Its been very rare though
UCSD PCCM Fellow
01:05:36
Yes we are avoiding bronchoscopies. However, if there is an emergent indication, for example a patient with mucus plug with refractory hypoxemia, we had to perform bronchoscopy.
Laura Bartoloni
01:05:39
we do bronchoscopies and we base it by patient.
Laura Bartoloni
01:06:09
we have prone patients on HFNC.
Laura Bartoloni
01:06:20
but so far it has not work to prevent intubation
Maria Castro Codesal
01:06:30
How long prone is recommended?
gwyn rossi
01:06:48
Would you please post web site link fo where the slides and information will be kept
UCSD PCCM Fellow
01:06:51
16-18 hours a day proning
Laura Crotty Alexander
01:07:45
This recording will be posted with the other COVID resources available at ATS: https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/covid19-clinician-resources.php
Bahi Malik
01:07:53
what is the advantages of ECMO and should we change the eligibility of ECMO?
allen
01:07:57
why do you think the compliance for these patients is so good despite horrible imaging with evidence of DAD?
Majid Shafiq
01:08:09
What's your take on tracheostomy for patients with ARDS not getting off the vent for >1-2 weeks
Laura Crotty Alexander
01:09:11
If viral testing negative x2, tracheostomy may be reasonable around 2-3 weeks (if the general idea)
MIKE’s iPad
01:09:27
any benefits of using inhale nitric oxide to these sever covid patients?
Bahi Malik
01:09:30
What is precautions taken for patients after extubations and plans for rehab/recovery after D/C?
ajantapatel
01:09:39
Dr. Malhotra how do we know this is ARDS?
dasweeney
01:09:52
we have debated trach but will probably do in OR as open trach rather than percutaneous
Judd Landsberg
01:10:04
if i didn’t answer any o2 questions in the chat please re ask
Dona
01:10:37
ATS has upcoming webinar - Pulm Rehab Assembly - on early Rehab and will be available later at thoracic.org
Jeffrey Barry
01:10:59
one of my nyc friends was reporting patients not getting enough RT care leading to increased mucus plugging, then needing emergent bronchs
Viren Kaul
01:11:54
Jeffrey I’ve heard the same. Like you mentioned it is possible from decreased suctioning. Keeping risk to HCW in mind, and attempts to bundle care, this is something that will need to be balanced for sure.
Viren Kaul
01:12:15
Again, having adequate, appropriate PPE helps to allay the exposures
Satya Achanta
01:12:20
In elderly patients, frequent positional maneuvers should be considered as they are more prone to pressure sores
Dr Nauman
01:12:38
Yes i agree lack of proper Chest Physiotherapy is an issue too
María Fernanda Landaeta Manzanero
01:12:52
yes Jeffrey Kaul, that it is true. We are pretty overwhelmed. We do suctions rounds
Judd Landsberg
01:13:40
no to early trach
David Chan
01:13:41
Any difference in morbidity/virulence between various COVID-19 strains?
Jeffrey Barry
01:14:24
have also heard about early trachs due to sedation shortages in nyc
Laura Crotty Alexander
01:14:42
Let us know what you think about this forum, and what topics you would like covered next Tuesday 8-9pm EST: https://www.surveymonkey.com/r/J3CZRSC
jyotir’s iPad
01:14:58
we do prone patients on HFNCwith 80% FiO2 .I have seen improvement in saturation
Souheil’s iPhone
01:15:17
studies from Italy discouraged early trach. 20% rate infections for providers/surgeons
sallysuliman
01:15:25
There has also been some discussion between institutions about monitoring CRP, D-dimer etc before extubation and ensuring they’re trending down- unclear if helpful
Viren Kaul
01:16:12
Re: Tracheostomy, tea re in same boat. Here is a helpful quick listen on this topic with commentary from Dr. David Feller - Kopman: https://www.youtube.com/watch?v=3rFzCD7KUQw&list=PLz2NeO-gj6IWIi_UL76u4n0Ff31GrfDhi&index=12
Laura Crotty Alexander
01:16:39
For an intro to mechanical ventilation (or looking for a way to teach mech vent yourself), check out this ATS BAVLS peer-reviewed video: https://www.thoracic.org/professionals/clinical-resources/video-lecture-series/mechanical-ventilation/introduction-to-mechanical-ventilation.php
Laura Crotty Alexander
01:16:53
By the brilliant Richard Schwartzstein, MD at BID
Adel
01:18:23
and a very good free online edX "COVID-19 mechanical ventilation" course from Harvard: https://online-learning.harvard.edu/course/mechanical-ventilation-covid-19
Laura Crotty Alexander
01:18:52
It is a great time to be in the field of Crit Care - so much sharing of knowledge!
D. Robert Handy
01:19:13
And don't forget to use the resources you have in house, like your Respiratory Therapists
allen
01:20:14
why do you think there is a difference between the sat of 97% on pulse ox and ABG of 88? was the ABG accurate?
Laura Crotty Alexander
01:22:17
Let us know what you think about this forum, and what topics you would like covered next Tuesday 8-9pm EST: https://www.surveymonkey.com/r/J3CZRSC
Mark Rolfsen UCSD
01:22:25
I don't think those two were taken at the same time, just appear close on the Epic chart
D. Robert Handy
01:22:39
Asked by Wheeler Jervis
D. Robert Handy
01:22:41
rising d-dimer and decrease in plt is what we have seen in Acute deterioration after initial stability / improvement
D. Robert Handy
01:23:13
I think it’s a microvascular issue that drives the deterioration
Sandra Molina
01:23:45
Thanks so much
Wheeler Jervis
01:24:20
I think microvascular derangement drives the deteriorations
Wheeler Jervis
01:25:21
has antiplatelet/ anticoagulation been discussed?
Neal Jones
01:25:25
For this part of the talk, please contribute any stories, concerns, or anything you've seen your hospital do that might help as everyone goes through this!
awithers
01:25:41
Thank you Dr. Landsberg for your fantastic talk about hypoxaemia, that was so clear and helpful to go back the basic principles of physiology :)
Melissa
01:26:01
did the test come back positive?
Enriqur Villarrea
01:26:08
ANY COMMENTS ON IVERMECTIN
Melissa
01:26:11
were the nurses correct?
Kenneth Chen
01:26:32
the repeat testing was negative.
Laura Crotty Alexander
01:26:42
No - the test was negative. But it was reasonable for them to be worried. The sensitivity of the test wasn’t terrific at the time
Melissa
01:27:19
we have had multiple tests come back negative then repeat tests come back positive on our admitted PT's
Wheeler Jervis
01:27:38
one thing about response to proning
Ali Asghar
01:27:53
Have seen a similar case as well of a negative that turned positive in the micu
Viren Kaul
01:27:59
Initial sensitivity was reported at 70% appz with repeat testing showing apps 20% positive.
Viren Kaul
01:28:13
However, this is likely to change with newer tests and well as changing prevalence of the disease
Armando Martinez
01:28:14
during my time in the ICU I noticed pretty frequent hesitation to discontinue PPE precautions despite a negative COVID test (sometimes even 2 negatives) and low suspicion of COVID
Wheeler Jervis
01:28:24
in many pts response to proning lasts many days
UCSD Fellow
01:28:27
Anti-coagulation is a good topic for future talks. So far we have been only using standard DVT prophylaxis.
Junaid Farooq
01:28:42
We also had first negative then positive that resulted in admission of positive exposed family members
Chisom Ikeji
01:28:48
Question - How are goals of care conversations going?
Susil
01:28:55
Thank you so much for this wonderful discussion. Good luck to you all!
Melissa
01:29:02
what about talks about some of the severe COVID PT's going into DIC?
Laura Crotty Alexander
01:29:30
Let us know what you think about this forum, and what topics you would like covered next Tuesday 8-9pm EST: https://www.surveymonkey.com/r/J3CZRSC
Sophia Leticia Hernández
01:29:44
The data talks about 1% of patients develop DIC.
Viren Kaul
01:29:49
Thanks for the topics that are of interest to everyone!
Wheeler Jervis
01:29:49
obese pt on 70-80% supine on day 12 only needing 50% supine with same peep
Junaid Farooq
01:30:18
What's the sensitivity of current testing overall in the states
Hector Garcia
01:30:49
Discordant results in ABG and pulse oxymeter
Neal Jones
01:30:53
Hi Chisom, I can personally say that goals of care have been somewhat more difficult. We now can only have these talks over the phone since patient's families aren't allowed into the hospital but under special circumstances. This seems to create poor rapport with families from the start and takes a lot more time to get that trust.
Wheeler Jervis
01:30:56
Peep was not optimally titratred and able to get to 60% with higher peep supine
Alex Cypro UCSD
01:31:05
From Osler in regards to Aequanimitas: "coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness...the physician who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients."
Viren Kaul
01:31:26
Junaid, hard to know, little bit of moving target with different tests and this will also change as more people are tested
Ali Asghar
01:31:53
https://jamanetwork.com/journals/jama/fullarticle/2762997
Junaid Farooq
01:31:59
Thank you Viren.
Adil
01:32:04
thank you for sharing the day to day experience - im a PCCM fellow at university of Oklahoma, and this hits very close to home
Junaid Farooq
01:32:25
Thank you Ali for sharing the paper
Adil
01:32:40
Especially other specialties / echo techs e.t.c not going in the patients' rooms
Michael
01:32:40
>95% for RT-PCR with sample containing 100 RNA copies/mL is what we were told
Chisom Ikeji
01:33:13
Thank you Neal - We are having the same issues here. Trying to set up a palliative/geri consult team to help. The VitalTips App has added some helpful guidelines.
Ali Asghar
01:33:39
That study says 63% sensitivity for nasal swabs which is the most common form of testing I've seen.
dasweeney
01:33:50
there are reports of positive imaging with negative nasal test; sometimes turn positive a few days later; also important to sample nasopharyngeal rather than just nares;
Rosa Maria Galvan
01:34:01
Diagnostic Protocolo in health workers, please
Ali Asghar
01:34:08
Normally more accurate from sputum (72%) per the JAMA article.
Laura Crotty Alexander
01:34:24
Let us know what you think about this forum, and what topics you would like covered next Tuesday 8-9pm EST: https://www.surveymonkey.com/r/J3CZRSC
dasweeney
01:34:31
thanks to Dr. Crotty-Alexander and to the ats staff for making this happen.
adunp
01:34:33
Thank you so much for providing this info. God bless and be safe.
Laura Crotty Alexander
01:34:40
Check out COVID-19 resources available at ATS: https://www.thoracic.org/professionals/clinical-resources/disease-related-resources/covid19-clinician-resources.php
Kat Vasquez
01:34:57
Thank you
Junaid Farooq
01:34:58
Thank you all.
Viren Kaul
01:34:58
Thank you for all the interactions everyone, we will be back next Tuesday at 8 PM eastern!
Alnardo Lora
01:35:02
Thank you
Ali Asghar
01:35:06
Thanks!
Viren Kaul
01:35:07
With an increased capacity!
Dra. Monica Egozcue
01:35:13
Thank you!
Alex Cypro UCSD
01:35:22
Thank you everyone!
Judd Landsberg
01:35:29
be well and don’t miss hypoxemeia
Priya Srivastava
01:35:30
Excellent talk! Thank you!
jeanninewalters
01:35:33
Thank you!
TYGH RT
01:35:46
we are Taiwan RT, thank you all.
Lauren Dallas
01:35:47
thank you
Susil
01:35:48
Thank you everyone!!
Junaid Farooq
01:35:53
Stay safe everyone
Melissa
01:36:01
thank you