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This video is an excerpt from the AMA Advancing Equity through Quality & Safety Peer Network Equity Case Review session. This section is a Case Review simulation describing an example of a harm event with an equity concern. Faculty of the AMA Peer Network assume the roles of those involved in a harm event and role play the perspectives of the involved parties and the process for addressing the event.
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Karthik Sivashanker, MD: [00:31] So this is going to be a really fun exercise and a challenging exercise. So why don't we just dive right into it. So, important disclaimer, this case is being used for educational purposes, only everything that we're doing here is I would consider as kind of peer protected activities, kind of like in your hospital. So this isn't related to anything at the AMA in terms of people or staff, any and all identifiable patient or staff information has been removed or anonymized to protect the confidentiality of anyone involved. And so any resemblance to actual persons, living or dead, is purely coincidental. But these are grounded in real events. So you're going to see that it resonates because there's real stuff happening behind the scenes of this case. So we're going to hand it over to Donald and he's going to walk us through a few things, and then we're going to just jump right into it. So just sit back, be comfortable, be open and curious. Imagine that you're in the room when this was happening. And Donald, I'm going to hand it over to you now.
Donald: [01:39] All right. Thanks, Karthik. Hi, everybody. So here, you just see some of the things we'd like you to pay close attention to, in assisting you in cultivating your own process of becoming more and more aware with somatics, the sensations that you feel in your body in real time as things are happening as you watch the simulation. And then looking at how you take those sensations, and start crafting meaning and then noticing the feelings that are coming up for you. And from feelings into thoughts, the meaning making process. And then what are your reflections? What is the full experience like for you as you watch this? What do you see? What do you notice? And what would you have liked to have seen? And then connecting this to your lifelong learning. And that's the critical piece here as well. Is this really appreciating how this work is connected to our life's work? So we're just asking you to think in those in those terms, as you continue to build your process. And these things do matter, in terms of the framework, in your decision-making process. So that's why we want to continue to reinforce this.
Sivashanker: [02:52] Okay, so we're going to get started. Thank you, Donald. And that's the bell. So we're going to get right into it. Karen, please take it away.
Karen Fiumara, PharmD, BCPS, CPPS: [03:03] Oh, good afternoon, everybody. And I'd like to begin by thanking you all, for joining us today for our collaborative case review. Lou and Regan, I know that we spoke prior to this meeting. And I'm just so grateful for both of you joining us today, to review this case, I want to acknowledge that I know that it's likely going to be difficult for us to talk about this. We're talking about a case where one of our patients had an event and we're going to be working through that. And so I just want to thank both of you for coming today and for showing up in the way in which you are. I want to start by going over what we usually do during collaborative case reviews. And it's important for both of you and really all of us involved in this collaborative case review today to know that we do about 140 or 150 collaborative case reviews per year at Brigham and Women's Hospital. The goal of every review we do, whether it's related to a equity concern with a staff member, or a routine surgical instrument in our OR, the goal is the same. And the goal is to learn what happened and why and really try to understand what are the facts of the case?
[04:26] So some of the things that we're going to talk about is what do we know happened? And what do we believe happened? And you might be hearing those words and thinking to yourself, "What in the world is the difference between what we know and what we believe?" And there's actually been a ton of literature published in this space, primarily in the criminal justice system. That really shows us that when there's been an event and describing an event is anything that's emotional at all or anything that we as humans are trying to recall, what we find is that we often end up remembering our memories versus the actual events as they occur. Why is this important for us to all be thinking about today, and specifically Regan and Lou? I'm speaking to you in this case, is because it's very, very common. And all of these reviews we do to have different memories of the same event. And what I always say is that it's unbelievably important for all of us to share what our memories are. You might be saying, "Why is it important?" Because we have to solve for all of the various different scenarios.
[05:32] We'll also be going through what do our policies and procedures state and then what's actually done in practice. Another one of my favorite Karen-isms is that the only people who actually know what's said in a policy and procedure are the people that write the policies and procedures. And I feel pretty comfortable saying that because my name is on a lot of the policies and procedures. And to be honest, I'm not even sure I could tell you what's in there. So we know that we have policies and procedures in place to try to establish what we believe is how we want our staff to engage in...the practices that we want our staff to engage in. But we know that oftentimes we have to [inaudible] in practice can deviate from that. We should raise that because there are times that we need to course correct our practice. And then there are times that we need to fix our policies and procedures. So let's make sure that as we go through this, we're identifying those issues as well.
[06:26] Again, the idea here is that we're here to identify areas of vulnerability and risk. This is not a fault-finding exercise. We evaluate every case in our organization using these exact same slides and this exact same framework, again, whether it's a case that has equity at its core, or it's a medication error that happens in one of our ICUs using an equity-informed higher liability framework. For more information on this, every time we send out an invite to a collaborative case review, we include links and information regarding that. Regan and, Lou, I know I sent that out to you previously, I'm hoping you had a chance to look at that. If not, it's fine. Reach out to me afterwards, I'm more than happy to go over with you. If there's any additional questions you might have as it pertains to the methodology we use. As we're working through these cases. It's also worth noting that this case is confidential and non-discoverable. What that means this is a peer review-protected forum. So heaven forbid, should a non, a med mal case arise from the proceedings here, nothing would be discoverable or admissible into evidence through that proceeding. I'm not concerned about that in this case, but I just want you all to rest assured knowing that.
[07:47] And finally, it's critically important that we all treat each other with respect and courtesy. I come from a big Italian family, so I have no problem jumping in if I feel like we're not treating each other with respect and courtesy, but I'm not worried about that at all today.
Fiumara (continued): [08:03] We can move to our next slide. It's also worth mentioning that during this review, and again, all the reviews that we do it for them [sic], we always try to think about what are the contributors to the event that occurred. Specifically, we think through and you'll notice that this word is "contributors," not "causal." And there's a huge difference there. We try to think through structural contributors. And when I say structural contributors, what I'm really referring to is all those macro economical social health policies, the systems of power that shape our social hierarchy, and the gradient that contributes to patient harm, and staff harm and employee harm. We'll think through social contributors, or I'd love us all to have these things front-of-mind as we're discussing this case. And this really refers to any individual-level social needs. Things like food insecurity, community-level conditions, also known as social determinants of health, that contribute to patient care, or can contribute to patient harm, we'll think through system contributors. So that refers to systems in place that we currently have to manage risk. And when again, when I say risk, I'm really thinking about any vulnerability within our organization, and the components of that system, including but not limited to, policies, procedures, technology, all those systems that we put in place in our organization.
[09:33] And then we'll also talk about how we like human reliability. And when I talk about human reliability, I'm really thinking about performance and behaviors. So what's the difference between performance and behaviors? Human performance contributors refer to anything--any factor that can affect our cognition as humans, so our ability to think as a human. It's things like distraction, fatigue, training. I usually think about knowledge, skills, abilities. When we're thinking about surgical misadventures in the OR, we often refer to human performance around issues of, surgical technical performance. So just to have that in your mind, and there are a lot of things that we know can affect our ability to perform as a human. And some of those things can be system driven, and some of them are personal. In example, if I'm a surgeon, and I'm in the OR, and I'm not able to complete a surgery the way that I otherwise would have, because I'm too tired, is that because I was booked for five surgeries back-to-back with absolutely no breaks? And that contributed to my failure to perform a surgery properly? Or was it that I was out at a Grateful Dead concert last night and was up until 3am, and came in for 6am surgery. That's a personal performance factor.
[10:55] So some of these things can be personal, some can be system-driven. So please have this front of mind as we're talking through the cases. And then behavioral contributors. And this really refers to the choices that we make as human. There's a policy and I'm making a choice to do something different from the policy. So that's something for us all to think about. Now, it's also worth mentioning that behavioral contributors can be conscious, and sometimes they can be inadvertent. So let's just keep that front of mind as we're working through all of this, hopefully, Lou and Regan, I know this is your first time during collaborative case review, I'm hoping that this all makes sense to you. Please feel free to let me know if it's not.
Fiumara (continued): [11:39] If we can move to the next slide, please. As we're going through the case, and for every case that we work through, we also always think about inequities. And we should start with really defining what inequities are. So inequities are systematic, unjust, and preventable, despite differences in health outcomes by race, gender, language, or other facts. If we go to our next slide, you'll see that it's really important for us to think through this and our frame today is to really consider how widespread inequities and the associated patient harms can be seen in health care. And it's worth mentioning that these often arise from broken systems, policies and practices. The intent here is not to blame individuals, but rather to think about how we can redesign our systems to advance high-quality, safe and equitable care for all. Lucian Lee put forward this quote, I think was in like 95 or something that accidents and errors are often the end result of a chain of events set in motion by faulty system design, rather than mistakes, the individuals' mistakes. And I just want us to all have that frame of mind to think through this. So if we go to the next slide.
[13:00] I want to make sure that we're also focused on our goal as it relates to equity. So we're really trying to enable reliable detection of inequities that can harm our patients and our staff members. We're going to socialize curiosity during this collaborative case review. And I want us all to try to be in a learning mindset. And I know that can be hard, especially when we're feeling stressed. We're promoting transparency with the ultimate goal of achieving high quality care for all of our patients. And in this supporting environment for all of our employees. We could please go to the next slide.
[13:34] I want to make sure that that we today… I'm going to be asking us all to introduce ourselves to each other. And I know that some of us already know each other. But as we're going through these introductions for today, I want to make sure that we're doing this in a very specific way to make sure that we're providing an opportunity for all of us to talk about our race, ethnicity, or how we self-identify our role in the organization as well as going over our window of tolerance. The reason why we're doing this one is to bring our identities into the room here today as we're doing this collaborative case review. I want us all to not be making assumptions about each other and rather just being upfront and forward with how we're feeling.
[14:28] So again, thank you so much, Regan and Lou and Nadia, for being here today. I'll start. So my name is Karen Fiumara. I'm the executive director of Patient Safety here at Brigham. I identify as a white Italian, Mom was born in Italy, Dad was born in Italy, too—first generation. I use she pronouns. I already went over my role in the organization. And truthfully I'm feeling a little hyperactive right now and say I'm like at a four and a five, and I really feel like this is an unbelievably important conversation, I want to make sure that I'm doing my best to make us all feel comfortable in the space. So I'm going to take a deep breath. And with that, I'm going to ask Nadia to introduce herself and then Nadia, if you could hand it over.
Nadia Huancahuari, MD: [15:19] Hi, everyone. I am Nadia Huancahuari. I am Latina, and born in Peru. And I use the she series pronouns. I'm a medical director of quality and safety, and I will be co- facilitating the CCR. And currently, I find myself at a plus three. I'm going to now pass it on to Regan.
Regan: [15:43] Thanks, nice to see you all. My name is Regan, I identify as white from German and Dutch ancestral background. I use the she series pronouns. I'm one of the critical care nurses here at the hospital. I've been here for about 10 years. I'm, I work the overnight but I'm very excited about this conversation. And so I'm also about a +4 (plus 4).
Louis Hart, MD: [16:10] Hi, I'm Lou, I am a Black man. I use the he-him. I'm a phlebotomist. I've been in the organization for about 10 years. And I don't think there's a number on this window tolerance that really sums up how I feel. I don't know how it can be a plus 10 and a minus 10. At the same time, but I'm not in a good place right now. Thanks.
Fiumara: [16:37] Before we go forward, I want to pause and ask Lou and everyone here. I'm going to ask for you all to just let me know, as I'm facilitating this, if there's anything at all I can do to make this easier for us. I know. Actually, I don't know. I can only imagine how hard it is for us to have this conversation right now just how hard it is to be having this conversation. And I know there's nothing I can do. But if there's anything I can do to make it a little bit more comfortable. And before we go any further, Lou, you know, we talked a little bit before the meeting. And I know I said this, but I just want to say it publicly. Thank you so much for raising this to us so that we can look at this as an organization and really think about how we do things moving forward. And, again, I'm sorry, and so unbelievably grateful. And please let me know if there's anything that I can be doing to make this easier. Okay. With that being said, I'm hoping that I can turn it over to Nadia, and we don't know much about this case right now. But Nadia, I'm hoping that you can just walk us through what we do know.
Huancahuari: [17:55] Thank you. As we start all our collaborative case reviews, we're going to start with information about the patient that will be what the case is about. So this particular patient's initials are JR, age 55, gender female, race white, ethnicity, Italian, the country of origin is United States, the primary language is English, and the insurance is a private insurance.
[18:24] Next slide, please. And again, as Karen had mentioned before, I'm going to go over some of the facts that we believe we know about this case. But we'll certainly learn more as the conversation goes on. But for those of you who were involved, please after we finish, feel free to add anything else. So this is the case of a 55-year-old white female and she was a patient in our Intensive Care Unit. She was intubated. She had been experiencing anxiety throughout the night of the event, and it appeared to have been progressing at times, requiring increased levels of sedation to the point that she had also required soft restraints to prevent extubation.
[19:19] Next slide, please. At approximately four in the morning, our phlebotomist, Lou, was called in to perform a blood draw. It was noted that the patient was becoming more anxious and more agitated during that time. After Lou left, the patient was able to communicate with the nurse through writing that she had been assaulted when she was five years old during a hospitalization, and she stated that she had been assaulted by a Black male. She had requested that no Black male staff provide care to her. And so at that time, the primary nurse for the patient after learning this information, placed a sign on the patient's door to ensure that no one went into the room without clearing it with the primary nursing team first. Lou was doing his rounds. And he came back to the room many hours later, earlier in the morning. And he was able to see that he saw this note on the door. And we understand that when he went to inquire what was the reason for not being able to go into the room, he was told that it was a patient's preference. Next slide, please.
Fiumara: [20:56] So at this point, the one Regan...I know that what we put on that slide is really high-level bullets. We'd love to, hopefully, if it's okay with you, Lou, would love to really start with you. In just trying to get a sense of...one is what we record, does that accurately reflect...my guess is it's doesn't. But if you could just let us know...if you were on rounds last night, can you just tell us a little bit with your, from your own words regarding what happened?
Hart: [21:34] Yeah, [sighs] I don't even know where to begin. And obviously, there's going to be a lot of different perspectives, there are a lot of people involved. But I'm going to tell you what I felt. I was, the ICUs have been busy. It's for all of us been a draining past two years that never seem to be ending. I've been at the institution 10 years, but I've never had one complaint filed against me. I'm pretty darn good at my job. And I was making my rounds through the ICU. And I'm pretty friendly with a lot of the ICU clinicians. I work closely with them. And I've gotten to know them pretty well over these years, especially over the past two. And I was making my rounds, I was in this patient's room. And she was she was intubated, she was sedated, I was kind of inferring from seeing that she was potentially doing a little bit better. So I was very hopeful for her, I was excited to see...that she was doing better. When I entered the room, though, she did seem to get a little bit more distressed.
[22:36] And oftentimes, my job can do that to individuals, to our patients. Because sometimes, blood draw can hurt. I do everything in my power to ensure that it's as minimally invasive as possible. And that, you know, the patients don't feel any of the pain. And if they do, it's very temporary. But again, I've been doing this a long time. So this wasn't something that struck me as something that would have been causing her a lot of pain in terms of the actual getting of her blood that morning. Unfortunately, I looked over at her vitals and her heart rate started going up. And it seemed like she was kind of moving around a little bit more. So I tried to be as quick as I could, I was able to obtain the samples, and I moved on to see the next, I think I still had another 15 patients after that patient.
[23:21] But I went about my business. Later in the shift, I came back to do my second blood draw. And she was getting blood draws, I think it was every either 6 or 12 hours. And I saw the sign and it just said "all members, please see Regan," who's a really good friend of mine. Again, we've worked really closely. And I said, okay, sure, you know, maybe it's the patient resting, are they doing a procedure? And you know, I'm not sure I'm not privy to all that information. So I went over, I spoke with Regan. And Regan told me that the patient didn't want me to come in there. And I said, why? And she said that, the patient had a preference that she communicated, which obviously I didn't understand because the patient has a breathing tube, I didn't know how they communicated this, but that they didn't want me to come in because I'm a Black man. And that that somehow made the patient uncomfortable. You know, I actually didn't know that she was a victim of something in her youth. I had no idea. All I was told is that because of the beautiful color of the skin that I was born in, no matter how good I am at my job, they told me I couldn't come in. I wouldn't be involved in the care of that patient going forward.
[24:34] And honestly, I don't even know. I mean, it's heartbreaking. You know, as much as the patient was obviously going through something, I almost feel like the victim and in health care, we're so self serving [sic]. We only care about our patients and we forget to care about ourselves too often. But you know the range of emotions from being sad, being angry, being let down, feeling like I was discriminated against at an institution that's supposed to promote healing? I think the worst part is that, you know, in these kinds of situations, it seems like racism, which a lot of people are talking about, it's always on me to fix. I always have to be the victim of it, and I have to fix it for other people. And I'm not saying that this person hates black men. But obviously, my presence made her uncomfortable. And...most people might just go about their business and say, "Hey, this is America, TIA, you know, I'm used to this kind of stuff here." So this is, unfortunately, not my first time experiencing this. But I felt, I've been here a long time, I said "The buck has to stop with me."
[25:45] So I told my manager at the end of the shift, a busy night shift, that this happened, and my manager was livid. My manager was like, "No, we have to take this over to our safety team. And we have to be able to talk about this so that this doesn't happen to anybody else. And that we can ensure that we have policies and procedures in place to protect all parties involved, patients and staff." So I feel supported that we're having this together...having this time together to talk about this. And again, I'm just giving you my perspective. But I'm really hurt and let down and I'm sorry for the patient. I'm sorry that she had this experience, terribly sorry, bottom of my heart. But I don't think this was handled the right way. And I think we got to do better next time. Thank you.
Fiumara: [26:26] Lou, thank you so much for sharing that. I do want to make sure that we have an opportunity to hear from Regan. And Regan, I'm guessing that I don't want to ...pretend like I know, but I'm guessing that this is not easy. Lou, I want to acknowledge part of me...not part of me, all of me feels really, really bad that what you just said always happens is like what's happening here again. This happened to you. And again...your home, you just worked the night shift. And now I'm like, Dude, can you please call up Colin and...tell us about this. And we live it. And I just want to acknowledge, we're doing it again, and super sorry. And I know that those words don't mean much. But just please know that 100% we're acknowledging it. And I'm so grateful that you brought this to your manager. I'm so grateful that we have a chance to talk about it. Regan...love to hear a bit from you from your perspective.
Regan: [27:34] Yeah, thanks, Karen. And I'd start with, as Lou said, he and I have worked together for a decade. Being in the ICU is like being in the trenches together, and so my point of view on this has always been that our primary job is to serve our patients. And so this patient has been critically ill, in our ICU for over 10 days. She had complex cardiothoracic surgery. And she's finally to what Lou said. She finally been turning a corner. And so we're so happy that she's been able to have her sedation lightened, which is probably honestly why we hadn't noticed this before. And this morning, her sedation was lightening because we were trying to test her for breathing trial in the morning.
[28:16] And when Lou came in to do her blood draw, just as he said, she got agitated, she got tachycardic, she got hypertensive, which we know is bad for a post-op cardiothoracic patient. We didn't want to up her sedation, because that will move her in a wrong direction. And so then after he left, I went into tried to settle her down. And she's just for the last 12 hours been able to finally communicate with the whiteboard and erasable pen, and was able to, in a limited way communicate that she had a history of trauma and abuse when she was a child, right. And so it seemed to me like our best interest was in protecting our patient, and try not to put her in a situation where she gets anxious. And then we see all the bad tachycardia, hypertension, right? I've been asked not to take care of patients before when they didn't like me as a, as a provider, and it felt to me like the right thing to do in this case, to try to figure out a different way to get a blood draw to move her in the right clinical direction.
Fiumara: [29:24] Totally understand. I see where both, where the intention here was so well intended. And one of the things that we often have to think about and talk about, especially in cases like this is the difference between intention and impact. And while from my perspective, and it's just my perspective, the intentions here were all the best of intention to protect our patient, to care for our patient. We have to acknowledge the impact that it had and is having on our staff members. So Regan, just a question for you is, prior to putting the sign on the door, was there…did you have any resources available that you could kind of go to to see like how to deal with a situation like this? Have you ever been in a situation like this? Is there like a… How do we, as an organization, usually respond? And did you try to escalate at all or speak with any of our, we have many diverse staff members. Were there conversations with anyone to kind of just say, what should we do, thoughts on how to handle this?
Regan: [30:46] I mean, I feel like I'm being called here to be called a racist. And I'll be honest, I put a sign on the door that said, "Please talk to the nurse, please talk to me," I didn't say, I didn't put a sign that says, "No Black man," or "No people of color." I put a sign that said, "talk to me" so that I could handle this discreetly. I talked to my nurse manager, she thought that was the right plan for the night. And we were hopeful that in the daytime, when we got more history, we could figure out a better way forward. But it was like four and five in the morning, and the resources are limited.
Fiumara: [31:18] No, I hear you loud and clear. And I think one of the things that, and this is really hard and I do not have expertise in this. So I'm going to ask Nadia to jump in in a minute. But one of the things that often...sometimes I shouldn't say often, but sometimes happens is we go to these terms like racist or non-racist, and to kind of like dichotomize this, like, oh, bad and good. But really, I think that what we should, if we're—not if. We are serious about really trying to understand how we can have a system and a structure within our organization that supports our patients, and our staff, and leverages the amazing diversity of our team. So this conversation, really, I'd like us to try if we can to stay away from those types of terms, because I just think it dichotomizes things too much. And I get it, Regan...I'm not, please don't let me... I don't want you to for one second think that I'm diminishing the way that you're feeling about this.
[32:20] And, again, I can't even imagine...this is hard for everybody. And I think that there's the piece that if we say that we're racist, then we clearly have work to do. But if we're not racist, then maybe that means we don't have work to do, but ultimately all of us have work to continue to do in this space. And this is about being curious and open and having a learning mindset. So we can try to develop systems and structures so that next time, we care for our patient, as well as making sure that our staff are feeling supported. And if nothing else, I'm hoping that we get that out of out of the session today. I would love to hear from Nadia a little bit. Nadia, anything that… I'm sure I'm using the wrong words and misspeaking. I would love you to help me as we work through this. I think our goal for right now and for today really does... I want to hear from Nadia, and then we really do need to come up with what's the plan for today? And what's the plan for moving forward with this patient? And then hopefully, we can come back once we have a little bit more time. And then of course, I want to make sure I hear from Regan and then again Lou before we close. But Nadia first over to you.
Huancahuari: [33:43] Yes. I do want to go back a little bit to the point that Regan made about how it is not just our institution, how the health care system does everything possible to move the patient care forward in that time at the expense of the providers, of the staff that is supporting that care. And I do want to say that it's true at times a patient will require a different person to provide the care, they do fire people. And that does happen and we do accommodate them, having being an emergency physician. Also, there are people that are intoxicated, there are people that are altered and a number of things do occur. But I think what is important to recognize is, to what extent do we accommodate patients' requests and where do we draw the line on that and to what extent do we protect ourselves as well, because we need to continue to provide care in a space that we feel safe, that we feel value.
[34:54] And I know that that this particular case is so important because of that, because at this point, I think, after hearing Lou's comments and experience, we clearly know that this has had such an impact on him, and wonder to how many unreported events similar to this experience, if not worse, continue to occur within our walls. So this is a really important opportunity to take the whole picture and make decisions as to how we're going to move forward not just with this patient, but as an institution so that we don't continue to have this type of impact on our frontline providers.
Fiumara: [35:44] Nadia, thank you so much for that. And...I know that...we don't have much more time. But Regan, if I can just say, specifically to you, I want to make sure that we as an organization, the reason why we're talking about this is to make sure that we're not putting all of our staff members in situations where we don't know...what is the right next step that we put in structures in place [stet] to try to make things a bit easier to take care of our patients and our staff members at the same time and hold both of those things, which I know, we were all 100% intending to do. And I think we just have to acknowledge the impact that our best of intentions had into that. And I'd love, Lou, you know, thoughts on next unit from you on, on anything that you'd want to share?
Hart: [36:43] Yeah, I mean, the path to hell is paved with good intentions. And Regan, I hear you, I got your back, I understand what you're trying to do for our patient. But just the approach, it just, you know, we're trying to create these healing and safe spaces for our patients. But where's the healing and safe space for me? Where's the healing and safe space for you? The system put us into this position. This wasn't probably easy for you to do, to tell me, [inaudible] doesn't want you to go in there because you're Black, it couldn't been easy for you. So I feel for you too. But we have to figure this out. Someone who was more junior than me, someone who is just going to let this stuff happen, this would eat them up on the inside. And obviously it's eating me up, but I feel empowered to speak up. So whatever it is, we have to figure out what that fine line is between a patient's choice. And what is discrimination? Because how do we know that this patient didn't just like me, because of the color of my skin, that they just told you a story? I'm not saying they did. But we have to figure this out so that someone else doesn't have to be on this call in a month or two.
Fiumara: [37:51] Thank you, Lou, you said it so much better than I ever could have. Thank you so, so, so much. Regan, I know, we need a plan for this patient today. You know, I did speak with the team, I think the plan is you know, she's progressing well, we're going to lighten up...her sedation bit more. And I know you have such a great relationship with her and the nurse on the day shift now has such a great relationship, they're going to continue to work on this and have a conversation with the patient regarding the fact that we do have, a diverse population of staff members that care for our patients. And that we stand by our employees and we'll continue to work through that. But we have a meeting later on today to discuss how the patient care is going. Lou, I want you to know that we're doing that. And once the patient's, some of the sedation has lightened up, we're going to have this conversation. And make sure it's clear that these are our employees, and we're going to support them and that all of our employees provide phenomenal care.
[38:58] And so then we'll have that conversation, and then we'll go from there. So at this point, we're going to end the meeting. Thank you again, for everything, Lou and Regan. You know, we've talked about EAP. That's our employee assistance program. I'll make sure that you guys get calls. This is hard. And I want to make sure that we all have an opportunity to feel supported as we work through these cases. And thank you both so much for engaging in this conversation. I know it doesn't feel like it right now. But I promise you, this is making our hospital better. And we're going to learn from this and move forward. Thank you.
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