Episode Transcript
[00:00:13] Speaker A: Hello. Welcome back to another episode of the Code 321 podcast. I have a special guest with me here today. Aaron Hart is joining. I appreciate you making the time for me, so welcome, Aaron.
[00:00:23] Speaker B: Thanks, Dick. It's nice to be here.
[00:00:26] Speaker A: Absolutely. So I would love to hear a little bit about how you made your way from you know, being an EMS to what you're doing today. Do you mind just telling the listeners just a little bit about what your journey was like and what you're doing right now?
[00:00:38] Speaker B: Sure. So it all started when I decided I actually wanted to be a physician. I think I was about three or four years old. I wanted to be a physician, and people kind of wrote it off. I grew up, my dad was a cop, ultimately became sheriff of our county. And so I was exposed to emergency services growing up.
Remember a friend of mine getting killed in high school and being fascinated with, you know, EMS and ambulances and what those folks were doing. I ultimately went for my interview for college. And I remember the pre med advisor said, oh, so you want to be a doctor, huh? I went, yeah, I want to be a doctor. She goes, why do you want to be a doctor? Well, I want to help people. She goes, well, that's great, but you could drive a bus and help people. You could be a teacher and help people. You could be a garbage person and help people. Prove to me that you want to be a physician. I said, okay, well, what do I need to do? And so she said, well, you can go enroll in a nurse assistant program, an EMT program. I didn't hear anything past that. All I heard was emt. And I'm like, oh, could be an emt. And so this was in the late fall.
I went back to my community. I'm from rural northern Michigan. And my dad, again, having connections, being a police officer in the community, ultimately found me a course. And I was in my first EMS course, I think three weeks later. So that was. I was a senior in high school. I went through my EMT basic course, you know, over period of about four months, tested, and then started working, went to college, that in fact, that college, and then did EMT specialist, which I think in many places now is advanced or intermediate, just depending on where you're at. And then that bug bit me. And I said, well, gosh, why wouldn't I become a paramedic? I want. I want to be the paramedic in that truck. So then I went through my paramedic program while I was going to college and then worked actually full time while I was going to college and rural mid Michigan. We service kind of the middle aspect of Michigan and just the south part of Michigan and just loved it. I love rural ems. I feel like from my perspective, you get to really be that provider in that truck taking care of those patients.
I would still be doing it today if somebody didn't give me some erroneous information and I let my license slap lapse.
But since having my license lapse, I've actually gone back and become a national registered EMT and plan to challenge the paramedic test because I just, I still, I love it. It totally made me into the person that I am today and into the physician that I am today.
[00:03:29] Speaker A: So, yeah, absolutely. That's really awesome to hear that journey. I mean, I'm so proud of you for going back and like checking the box and getting back your toe in the water with the registry. I know it can be easy to just like, let that drift away. So that's awesome that you did that.
[00:03:43] Speaker B: Yeah.
[00:03:45] Speaker A: Really cool. Yeah. Great. And so you're currently working as a physician, right? And what's your specialty? What do you do day to day?
[00:03:51] Speaker B: Yeah. So many people ask me how I got to this point. I'm a maternal fetal medicine physician. I work at Corwell Health west, which is in Grand Rapids, Michigan. And what that encompasses is we do a four year residency in obstetrics and gynecology, and then I did a three year fellowship, so additional training after residency in maternal fetal medicine. And so what that specialty entails is I like to tell people I am the internist, the critical care doctor, and the surgery for high risk pregnancies. So a high risk pregnancy could be anything from a mom having a significant medical or surgical condition to her baby having a significant condition to both of them having an issue. And we're the doctors that take care of them.
[00:04:41] Speaker A: Yeah, that's really fascinating. I know that must be a huge challenge. And one of the things we had talked a little bit about when we were, when we met at EMS World is this idea of access to OB care. And I think what, what I have experienced in my area is that, you know, there's really only a few games in town and they're several hundred miles apart. And so I didn't know if you want to touch a little bit about on, you know, what types of patients do you see and where are they coming from when they need this specialty care?
[00:05:09] Speaker B: So in many areas, as you've alluded to, Nick, we have what's called maternity deserts. So the maternity deserts are basically where a woman or patient, a birthing person, does not have or has limited access to obstetric care and may have to drive many hours to get to the hospital to actually deliver their baby. So what we're finding is more and more patients are requiring transfers via multiple levels of EMS to get the care that they need.
And so, for example, where I work on the western side of Michigan, we take transfers up from even into the Upper peninsula, down the whole west coast, into the middle aspect of Michigan, all the way down to Indiana.
So we average about 8,000 deliveries a year at my institution.
And those are again, coming from, granted, the city of Grand Rapids isn't a large city, but it's really coming from those rural areas or those regional hospitals. And that seems to kind of mirror what many academic facilities have, which tends to be, unfortunately, where maternal fetal medicine doctors are. I mean, we don't tend to be out in the rural areas. That's where our obstetrics colleagues or in other areas, emergency medicine colleagues are at.
[00:06:36] Speaker A: Yeah, And I think one of the things that we typically see, at least in my service, is a lot of the times the patients that are presenting to these critical access hospitals that are in the more rural areas of the service area I work in, they may not know that they have a high risk pregnancy because they might not be receiving continual OB care during their pregnancy. And I'm not sure if you've had any experience with, you know, kind of the lead up of people during their pregnancy just having a lack of access to actual, you know, routine checkups. And then all of a sudden they show up to their local hospital, you know, and they have this pregnancy that's complex. And the local doctor is like, man, this isn't. This isn't a bleeding or a pain control problem. This is a complex fetal thing. And. And how do I move that patient? And so if. If a patient were to present in, let's say, a critical access hospital somewhere within your service area, what resources do you have to try to get that patient to you or to get you to those patients?
[00:07:31] Speaker B: Absolutely. So what we see in my system is we have our regional facilities, and then obviously the facilities that aren't a part of our health system that reach out to us. So they call my service, which the maternal fetal medicine service, we are on 24 7, and they call our transfer center, who then ultimately has us talk over a recorded line, and then we assess what type of transport is needed. And as I'm sure many of your listeners know, and many of EMS knows It's not like we have trucks or helicopters just sitting around. So we do see time limitations, getting patients out of those critical access hospitals to the tertiary or quaternary care centers. And so it might be that that patient's sitting in that emergency department and that emergency medicine doc is having to manage the conditions. And they're not comfortable with that. Not because they are not good doctors, but they just don't have that training or that skillset to necessarily take care of these complex medical conditions that, yeah, like you said, might just be diagnosed in the pregnancy or in our pregnant people. You know, one thing that I see is a big difference is like how we treat hypertension. So, you know, if a, if a pregnant person comes rolling into the ER and say their blood pressure's, you know, 150 over, say, 96.
Right. That might be where an emergency medicine person might say, well, that's not that bad. But me as an obstetrician or material maternal fetal medicine is going to say, oh, what's going on with that blood pressure? Because that's elevated for pregnancy. And so that, that can be, I guess, an interesting difference in how different specialties manage a pregnant person.
[00:09:31] Speaker A: Yeah, absolutely. And I think one of the questions I always wanted to ask an OB doc and I have a couple OB doc friends, but, you know, I don't generally get a lot of time with them. And so some, some questions that I wanted to ask you would be, you know, in the different trimesters of pregnancy, what are some generalized high risk complaints that these hospitals might be stumbling on? Can you just maybe give me like an example or two of, you know, in each phase, what these doctors might all of a sudden discover that's going to indicate that they need to be seen by you?
[00:09:59] Speaker B: Yeah, well, a common fine or a common complaint or concern that pregnant people can have in the first trimester is something called hyperemesis gravidarum. So basically that's where a patient is nauseated and vomiting and nausea is common in many pregnant people. So is vomiting. But there, there can go on and be a complication where it actually becomes Hg or hyper. Hyperemesis gravidarum, where maybe they have electrolyte derangements. They're really not able to keep fluids down, you know, and they get IV fluids, they get antiemetics, and it's a temporizing, I guess, treatment. And ultimately do they have to be sent to a facility to manage that a little bit more acutely or I guess more critically, do they need to have like an NG Placed or a drop off, other treatments that maybe aren't something that the ER is going to want to manage.
Usually those people are coming by private vehicle. It's not necessarily something that EMS has to transfer unless somebody were really, really ill.
That tends to be a pretty common complaint in the first trimester. Another condition where you may see some instability would be perhaps if somebody has a miscarriage or like we see in the medical field, a spontaneous abortion and she starts bleeding pretty heavily, you know, do they. Does she need to be transferred for blood products or surgical management of that condition?
When we talk about the second trimester, sometimes we see that tends to be where maybe people are if they have an unrecognized cardiac issue, maybe that starts to present with symptoms in the second trimester. Does she start having blood pressure issues?
The second trimester, I would like to say, is kind of usually kind of this golden period. The second trimester is from 14 to 28 weeks. So people, if they've been really nauseated, they can sometimes start feeling a little bit better. But the third trimester tends to be where things really under unrecognized medical conditions can be more recognized. So that's really where you start seeing that heart conditions can manifest. People start having issues with their blood pressure and preeclampsia.
Other conditions with fluid overload. If you have a renal disease, is it causing issues with how the baby's growing? So. And then postpartum as well, just with the fluid shifts can really bring out cardiac disease and pregnant people and postpartum people.
[00:12:46] Speaker A: Yeah. And I think they talk a lot about, at least in the EMS courses that I've been in, making sure that you don't write off the small complaints as small things, especially when people are, you know, nearing that second or third trimester pregnancy, you know, it might be something like, oh, I have a pounding headache. And it can be easy for us in EMS to just go, yeah, I mean, it's a headache, so just take some aspirin and relax, you know, or, you know, I feel dizzy or I'm having some double vision. Those little complaints like that, I think, can be pretty ominous signs for you, I would imagine. And what can you say to, you know, EMS providers that are running across what seem like nuisance problems but might actually indicate something else is going on?
[00:13:24] Speaker B: Absolutely.
The CDC put out the Hear her campaign, which is basically, it goes through some different symptoms that sure can be very, very normal in pregnancy, but we don't want to write those off. And so things that we commonly think of Just like you addressed. You know, if a pregnant person complains of a headache or even a postpartum person, you know, we, we don't want to negate what's happening with our postpartum patients if a patient's having significant trouble breathing. So there's a certain aspect of patients having dyspnea when they're pregnant, but we don't want to say that dyspnea is normal in pregnancy, especially when we're starting to see that in that third trimester. And again, postpartum fevers. So sepsis is a top morbidity or mortality cause in the United States. And so sometimes we think, oh, well, maybe she's just a little tachycardic or, yeah, she's just warm, you know. So I think the big message here is listening to our patients because. And that goes across pregnant or non pregnant patients, because I think they're really going to kind of tell us, if we listen, they're going to tell us what's going on. And so truly listening to our patient is, I think, key across any specialty and for any provider.
[00:14:52] Speaker A: Yeah, I still remember pretty early in my career, we had a patient, I think I was like, still an EMT or an A at the time, and I was working with a senior paramedic, and we were treating this guy with chest pain. And he kept saying, you know, I think I'm. I think I'm gonna die. I feel like, you know, I feel like I'm gonna die. I feel like I'm gonna die. And the paramedic was like, moving with significant purpose, even though there wasn't anything crazy that I saw on the monitor at my current level at the time. And sure enough, when he got into the er, he coded from a stemi. And it was one of those things where it's like he told me afterwards, he's like, you know, these patients, sometimes they have this like, sixth sense, and if they tell you that, like, that you hear that word, like, they probably are feeling something that they can't ex, you know, describe verbally in a medical way, but there's something going on underneath the surface. And sure enough, he was right. And I, I never forgot that.
[00:15:38] Speaker B: Yeah. I think another thing I like to think about kind of along that way is, you know, anxiety doesn't suddenly develop in pregnancy. Right. And so if we're suddenly seeing a patient that's anxious, we shouldn't be writing that off. It's, I would say, hypoxia until proven otherwise, you know, so.
[00:16:00] Speaker A: Yeah, exactly. You know, same thing with like our, our car accident patients. I always said that to, when I was precepting, you know, if you go to a car accident, you know, and they're, they were in a significant mechanism and their heart rate is 1:30, if you're evaluating them, and 10 minutes later they still want to sign a refusal and their heart rate's still 1:30. We should have seen a change. You know, it's not just about scratching daddy's Ferrari. They might actually be internally bleeding and having a compensatory tachycardia. And so I had a really good flight. Nurse at once told me when I was doing my orientations, you know, he said, like, if you have an, if an uncontrolled tachycardia without any known cause and there's trauma mechanism, there's probably internal bleeding. And I never forgot that because, like nine times out of ten, he's usually right. Like if there's mechanism and you see this persistent tachycardia that's unresponsive to, you know, coaching and verbal and all that stuff. I mean, you know, bleeding until proven otherwise. And that has always treated me really well going to these high acuity calls.
[00:16:55] Speaker B: Yeah, I think ob, you know, along that line, you know, when you were talking about tachycardia and compensatory mechanisms, I think that's an important thing for our EMS partners. Listening to recognize that, you know, it's, it's not normal to be tachycardic in pregnancy. So if you see a patient who's tachycardic, why. Right. Is she having a respiratory issue? Is she hemorrhaging somewhere? And I think it's just normalizing. You know, in a high acuity situation that you don't see frequently, you can sometimes get those blinders on and forget the ABCs. And so when I'm teaching EMS courses, I know you've heard I tell people, just go back to your ABCs. Go back to your ABCs. Because if you don't know what to do, we still all have airway breathing and circulation, right?
[00:17:53] Speaker A: Yeah, yeah.
[00:17:54] Speaker B: And so I think, I think it's my big take home message. I think in regards to pregnancy. And if people say, well, what should I do in this situation?
I would say, you know, what would you do for this person if this person wasn't pregnant? And that's, I would say, 95 to 98% the answer. Yeah.
[00:18:17] Speaker A: I feel like sometimes we see, you know, a pregnant woman and a big belly or a third trimester patient, and all of a sudden we like, forget the basics of, like, if they can't breathe, let's give them what they need, including oxygen, if that's indicated. You know, these. You know, they can have these anemias in these weird conditions where just because it says 100% on your SpO2 or 99% on your SpO2, if they look like they're in shock and they can't breathe and they are telling you they can't breathe, you know, you don't want to withhold oxygen saying like, oh, well, they're pregnant, so we're not going to give them oxygen. You know, we, like, forget the basics of being an EMT sometimes because we worried about how complex it can be. You know, we talk about this in courses all the time about you hear hoofbeats and you think of zebras, and it's like, you know, sometimes it's just horses and we just need to treat that.
[00:19:02] Speaker B: Exactly. And if mom can't breathe or mom's heart's not working, well, that's not going to help the baby.
[00:19:10] Speaker A: Yeah.
[00:19:10] Speaker B: You know, exactly.
Even. Even talking to other medical specialties in the hospital, you know, that's often the message, like, okay, if you take the baby out of the picture, what would you do for this patient? And then they. They've got the answer. They know what they want to do. Same thing with EMTs and paramedics. Right. You. You know what you're going to do, let's say, in a trauma. So, you know, you go up on a motor vehicle crash and a pregnant person's involved, and you. You don't want to just get stuck. You know, it's like when you go up and you see something really morbid. You don't want to just get stuck on that open femur fracture. Right. You want to look at the airway.
[00:19:46] Speaker A: Yeah.
[00:19:47] Speaker B: I mean, the femur fracture is important, but if. If that patient can't breathe, it doesn't matter that their femur FR Factor.
[00:19:55] Speaker A: Yeah, exactly. Life over limb, for sure. And I think one. One other question I had that I just wanted to run by and get your opinion on is. And I know this might be kind of dynamic because there's a lot of different situations, but what factors go into you making the decision to do a preterm cesarean with a high risk patient? You know, how do you come to the decision to say, you know, we can't wait any longer, We've waited as long as we can and, you know, to get to treat this baby appropriately and give it the best chance, we need to Take it out early. Are there conditions that cause you to do a cesarean before they get to full term?
[00:20:31] Speaker B: Oh, there's a bunch of them. So usually when we're talking about moms needing cesareans, and there's. There's obviously a few exceptions here, but a cesarean is really performed for fetal benefit. Right. Because giving mom a significant abdominal surgery isn't helping mom for the most part. And again, there's exceptions to that. So, you know, we define full term pregnancies greater than 37 weeks. Obviously, a preterm delivery is under 37 weeks. And so why a mom could need a cesarean for under. At under 37 weeks is vast. So she could be going into labor, and let's say maybe she's had two or three cesareans, and so that would be the indication to repeat that maybe she was in a motor vehicle crash and had an abruption.
And it was felt that due to the fetal status, that is, what does the baby look like on the monitor? Or if they were doing a fast exam just in the er, Was there some sort of reason why we thought that this needed to be expedited? Then that would be a reason.
If a mom has eclampsia, we get her stabilized. Sometimes we would deliver via cesarean for that reason. But after she's been stabilized, if, let's say she has preeclampsia, where she's having significantly high blood pressures remote from delivery, she could need a cesarean for that. Or if she goes into preterm labor and the baby is breech or butt down, then that would be another reason for a cesarean.
[00:22:13] Speaker A: Yeah.
[00:22:14] Speaker B: So the list is vast.
[00:22:15] Speaker A: Yeah, exactly. Right. And. And I think that's always been fascinating to me when we. Because sometimes we'll move, you know, pregnant ladies with high risk. And one of the things, you know, we're always thinking about is, you know, obviously if they can let that fetus develop as long as possible inside of the womb, that's going to be great. But there are some cases where that can happen. And I think one of the next questions I would have for you is, it looks like there's been some really good improvements with vaginal birth post cesarean, and I wondered if you might be able to talk a little bit about, you know, what. What the risks truly are, and then if there's anything that can be done to try to mitigate that, and is it happening more than it used to happen?
[00:22:53] Speaker B: So when we talk about vaginal delivery versus cesarean, you know, there were. There was an article gosh quite a ways a while ago, talking about, like, avoiding the first cesarean. So with, with the patients that I'm taking care of, they're definitely at higher risk for cesarean because of their medical problems or fetal problems. But in a low risk patient, you know, we really want them, in all of our patients, we want them to get vaginal deliveries or have vaginal deliveries as often as possible because it decreases the risk of complications that can happen when somebody's had multiple cesarean deliveries. Most commonly, you think of something called placenta accreta, where that placenta grows in abnormally into the uterine wall. And so in some, in many forms of that, because it's a spectrum of disease, that would be the lady's final pregnancy when that occurs, because the ultimate treatment in most situations is a hysterectomy. So that's why there has been the push again to get more women into having vaginal deliveries and even doing what's called a trial of labor after cesarean.
And so when we're talking about risks of trial of labor after cesarean, the risks are really very low. So if a patient's had a previous cesarean delivery, her risk of having what's called a uterine rupture, where that uterus basically kind of splits open during the delivery process, is less than 1%.
Even after two cesarean deliveries at risk is only still about 1%.
Now, that also depends too, on the type of incision that the mother has. So if she had an, what's called a classical or basically an up and down incision on her uterus, that risk of uterine rupture is about 6%. So if we can keep a mom from having to have a cesarean delivery, it's hoping to optimize her health kind of long term for her future childbearing years.
[00:25:01] Speaker A: That makes a ton of sense. I know there are some women out there that, you know, they, they've had a cesarean and they're worried that they'll, you know, won't be able to deliver, you know, vaginally in the future. And I think the medicine and the technology and the research has come a long way to say that, you know, I think it sounds like what you're telling me is that we're going to do everything in our power to try to make sure that if that's. That's what they're looking for, that that's what they can do.
[00:25:23] Speaker B: Some of it, too, though, Nick, is limited by facilities, so you might even encounter this in transport, where a patient would come in wanting to do a trial of labor. But if they're at a smaller regional hospital, you know, that doesn't have 24. 7 anesthesia, this isn't going to be something that the institution will feel safe and supporting.
And so it's not uncommon for patients in the rural setting, if they are desiring that to have to, again, travel to a facility that will offer them a trial of labor, or they just have another cesarean, which is unfortunate, if they're a good candidate for a vaginal delivery. And then another scenario we can get into is if a patient doesn't want to travel to that facility, then they say, well, forget that. I'm just going to have a home birth, which is less than optimal, and something that EMS can definitely get called for and have it be an emergency.
[00:26:23] Speaker A: Oh, absolutely, absolutely. This is very common, especially in the area that I live in it. It kind of has a very natural vibe. You know, there's a lot of. A lot of people that just love to live up in the woods and live off the land and be homesteaders. And so that world is pretty popular to try to do things as naturally and as outside of the healthcare system as possible. And so not only do we have to do the medicine component, but sometimes, you know, we have to do a good job of being ambassadors of the healthcare system to help make sure that they recognize, you know, it's not just going to be a room of fluorescent lights and masks. It's going to, you know, it's going to be, Dr. Erin Hart's going to be there. You know, she's great. She works really hard. And trying to convince these patients, you know, if it's truly what's best for them, you know, to get the help they need is try to, you know, kind of pitch them the services that are available in a way that sounds appealing to them. You know, rather than just scooping and driving to the hospital with, you know, three male providers in the back. We got to do a better job of that.
[00:27:18] Speaker B: And we really try to meet people where they're at. You know, I recognize when somebody comes to the hospital after trying to labor at home that this isn't where they really want it to be. This isn't what they wanted their birth experience to be. And so when we're talking to those patients, and even prenatally, because, you know, we get patients referred to us that have been seeing, let's say, lay midwives or, I should say licensed midwives, and, you know, they come to maternal fetal medicine, we are the exact Opposite of what they wanted. You know, if. If you're showing up as the paramedic crew ready to transport this patient to the hospital, this is exactly not what she had in mind. Right. So us really meeting those patients in the middle and saying, listen, we are really here to help you and your baby. We're not forcing you to have an epidural. We're not forcing you to have a cesarean. We're not forcing you to do X, Y and Z. We're here to help.
I have a midwife friend out in Washington state, and she had often talked to EMS folks because she herself was also a paramedic. And she had said, you know, one of the things that she talks to EMS groups about is when you are coming to, let's say, a home delivery, recognizing that that midwife has been with that patient for, you know, up too many hours or days laboring, and that they still want to partake in that care of that patient, and they may even want to ride with that patient to the hospital or be almost in a doula, like, role when they come to the hospital and we become involved and just recognizing that they have a part in that team. I remember her just talking about that importance as well.
[00:29:04] Speaker A: Yeah. One of the things I try to pitch in as many lectures and teaching roles as I can is this idea of, you know, it's not emergency medical police, it's emergency medical services. You know, we're there to help assist the patient and get them the care that they want. And there's a really good study that came out of Australia that I've used in a couple talks where it looks at the way that the. That the laboring woman felt that they were treated by the EMS service. And they give examples of quotes that they remember, you know, and, you know, where these women are going through this really special birthing experience. And, you know, they. They talk about some of the negative experiences they had where people show up and say, like, you know, why did you try to do this at home? Like, do you not want to be safe for your baby? Like, these. These things are really, like, critical and nasty that they're saying to the patients who are going through this, or, you know, the providers are grabbing their arm and putting an IV in without talking to them and poking them and, you know, cutting the baby's cord and checking the blood sugar without including the parents. And then they give some really positive examples of, you know, hey, you know, what would you like us to do with your placenta when it comes out? Like, just including the mother. I recognize that you're in the back of an ambulance, and this is probably not what you imagined, but what can we do to continue to make this special for you? And it's always really eye opening because I think in ems, we focus a lot on the medicine and what to do operationally and algorithmically and, you know, with the systems. But sometimes we forget that they're people. You know, we don't want to just look at them like we're a mechanic fixing a carburetor. You know, we need to treat them like they're human beings. And ultimately, this may be one of the most special moments of their life. And we have the opportunity to help, you know, do what we can to continue that same vibe for them.
[00:30:42] Speaker B: Yeah. And ultimately, then they're calling you to help with their parents or their grandparents or whatnot. And it builds more trust, I think. Like, oh, they took good care of me when I was pregnant with Johnny.
I know I can trust them when Grandpa's having that big mi.
[00:31:03] Speaker A: Yeah, absolutely. So I guess I'd like to wrap up just with a little bit about if you could connect with EMS providers via this podcast, what are a couple tips you have to help them be prepared to do the best that they can if they're called to a high risk OB situation.
[00:31:19] Speaker B: First of all, I will say thank you for being there. I understand where you're at. And I didn't always like ob. I was terrified of ob, actually. So this didn't happen overnight.
And thank you for what you're doing. It's. It's a challenging field to be in, and I recognize that. So from my heart, I just want to say that I think take home messages are number one again. What would you do for this person if she wasn't pregnant? And that's usually the answer. I would say number two, always go back to your ABCs because they're gonna help you out every single patient, every single time. And then number three, call for help. That's why we have partners. That's why we have medical control. That's why we have police or fire to just help. Maybe we just need somebody there to be our cheerleader, so to speak. Don't be afraid to ask for help, because help is there.
[00:32:22] Speaker A: Well, thank you, Aaron. I really appreciate you making some time for us today. And I hope that you stay warm up there with all the lake effects now. I'm sure you're getting plenty of it this winter.
[00:32:32] Speaker B: It's looking great. Thanks, Nick.
