Ep. 54 | Mahmood Eisa, MD, & Shelby McNeal, NP, Neurology & Sleep Medicine

Transcript

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- Snoring, insomnia, waking up exhausted. How do you know when it's more than just tired? And it's time to get some help.

- Welcome to What Brings You in Today, a podcast from SGMC Health. I'm Kara Hope Rockwell. And I'm Erika Bennett. And today we are here with Dr. Eisa and Shelby McNeal, who's a nurse practitioner with our neurology and sleep medicine services. So team, what brings you in today?

- So we're so excited to come this morning and introduce y'all to some things we treat at our office and sleep issues and neurological issues that we treat SGMC Neurology and just give some education to give to patients.

- Yeah, we're very excited about this particular episode 'cause sleep is something that impacts every, every person, right? We all have to sleep and we don't often know like when we need to seek additional help. So we're excited to learn about that. I do wanna take a few moments first to just if you'll each give your background and kind of what landed you here and then we'll get into the,

- I have a very long history of my medical career. Okay. You know, initially starting with the family practice and going into ophthalmology and I was board certified ophthalmologist in Kenya before I moved to America. And then I did neuro-ophthalmology, neurology, steep medicine and you know, that's the gist of it. So I was working.

- So what made you switch from the ophthalmology though? Yeah, that's interesting.

- When I came here I found that neuro-ophthalmology will be a very interesting field to go into. Yeah. And frankly speaking, ophthalmology was one of the most difficult fields to get in at that time when being a foreign medical graduate. Despite the advantage. So I was at Yale, I was the director of the movement disorder center, but I had a very good offer down south joining Dr. Patel and Grup and had two young daughters going into expensive schools.

- Yeah.

- So I had to make some more money.

- Yeah. - That's the gist of it. So I landed up here which

- Driver

- Really good because I really enjoy that. And I'm still in academics. I'm a professor with the Medical College of Georgia, also professor with Mercer University and I'm leading the sleep clinic and the neurology department as well.

- Very good. All right.

- Shelby, what about

- You? Tell us And then for me, my nursing background started in ICU. So I was an ICU nurse before I became a nurse practitioner. And then I did family practice urgent care for a short bit before I landed in neurology. So I've been with Dr. Eisa for five years this year. Yes. And it's just truly been one of the most rewarding careers that I could have ever asked for. Just treating our patients and the things we get to see every day is such a joy. And working under Dr. Eisa's just a blessing really.

- So speaking of patients, what type of patients do y'all see? Give us a little insight into that.

- Being a consultancy practice we get reference from family practice and all of the specialties as well. Yeah. So you see all sorts of neurological disorders as well as sleep problems currently. Yeah. And patients who are difficult to treat through primary care, they have difficulties treating them. They send them to us and we see them.

- So we see everything from seizures to migraines to Parkinson's disease, you know, even more complex issues of course A lot of sleep issues like restless leg and obstructive sleep apnea, insomnia, parasomnia, narcolepsy. We treat a lot of different things. Neurological really actually a big wide complex.

- Yes. Yeah. There are a lot of neurological problems associated with simple medical problems. For example, diabetes,

- You

- Know, there's a lot of neuropathies and other associations as well. Lot of strokes on high blood pressure, uncontrolled diabetes. So that ends up with a stroke and you know, sort of jack of all trades, put it that way.

- You kind of have to be

- Right. Yeah. You have to be.

- Alright well let's talk about sleep specifically. Let's kind of get into that and then we can go into, I think we'd also like to talk about dementia and some of those things that, some newer things that we're offering but sleep. When should someone seek a specialty consultation? When they're having issues sleeping.

- So I'd say one of my biggest recommendations is I think a common misconception is being tired is normal. You know, if you are tired every day, even if you sleep great, that's not normal. If you're falling asleep while watching your favorite TV show or eating or you know, especially if you're driving, you know, that's dangerous. So that's not normal. So if you are having red flags like that loud snoring, if your partner's like you're keeping me up all night long, I cannot sleep, that's not normal. If you're waking up gasping for air or choking, you know, those are things that we can treat and dig into more. So those are things, if we can educate patients in our community to be seen for we can help diagnose it quicker and treat it quicker.

- How accurate are those sleep scores that you can get from your watches? 'cause I know car hop and I have both. Yes. And I get like mad if mine gets low and I'm like blaming people for interrupting me and messing up my sleep score. Yeah.

- There's a lot of these devices which have come out and they use artificial intelligence to score them. And right now the F FDA A has not validated most of them except a few. One of them is, you know, the Apple watch. Yeah. And there may be a few others but the problem with that is they're based upon movement and they're based upon your cardio ballistic Oh it gets a little bit complicated.

- Yeah.

- But basically it doesn't tell you that you may be quiet and lying down and not asleep. Right. They may record that as sleep or you may be having movement disorders in sleep and moving and that may record that as a wake but you're asleep.

- Okay.

- So I mean that's sort of a screening way of saying that you know, you may be having CST problems but that's not a very accurate way of doing that.

- Yeah. I do think it is a good just to raise awareness Exactly. Of like, and maybe like get to bed on time and like doing things that you can do to kind of help Yes. With your sleep. That's, but that is interesting that you say that about because I did wonder like how can it really tell if Yeah, I'm asleep. Mine says 97 very high

- From last night. Well I'll have to figure out what mine

- Is later, but I don't think it was that because I was sleeping on the couch because my husband has a stomach virus. So we weren't doing that.

- I mean it is a useful tool tell you that something's going wrong. Go ahead and get some further consultation or assessment done.

- So what kind of assessments do you do when someone comes to see

- You for So first is, to me it's looking at the whole picture. Right. Because someone might come in and say I'm tired and treat this or I'm not sleeping through the night, gimme medicine for it. We gotta look past that. To me it's finding the culprit, right? So if we treat just the symptom, we might be missing the bigger picture. So you know, we first start with a good history and physical, you know, even looking in a patient's mouth, I can kinda lead to some further testing for that. And we have our sleep lab that Dr. Eisa is the director of. So we have actually something here at SGMC that we can do home studies or in lab studies to test patients for sleep disorders. And so really digging into their symptoms and what they're presenting with so we can see what the next steps of diagnosing or evaluating them for.

- There are many different problems with sleep. What of the commonest problems is poor health hygiene for sleep? Yeah. A lot of people are on their tablets on the TV screen playing games late into the night. Their habits are wrong. They drink alcohol at night. They have smoke so they take caffeine too late at night. All days will affect the sleep. Yeah. So sleep hygiene is very important and if people don't follow that they will have sleep problems. In reality that's AIC problem. From the pathological point of view, it's behavioral. Hmm. So if you can improve the behavior of people, educate them more on what is normal sleep, natural sleep that will cure a lot of perceived sleep problems.

- What are the recommendations for good sleep hygiene and how long you should be sleeping?

- Well God made the night for sleep and day for wakefulness. Next number one. Yeah. So at night you're supposed to sleep so you shouldn't be doing daytime activities like Las Vegas, you know? Yeah. So bright lights, blue lights, wake the brain up stimulation wakes the brain up. So what you need to do to get good sleep is have relaxation exercises, meditation, whatever, nice warm shower and then relaxing things to do. Like reading a book in yellow light not in blue light. 'cause yellow light does not wake the brain up as much as blue light in your face does. Yeah. And then your relaxation and go to bed at such time. So discipline is extremely important. So you gotta have a set time to sleep. A set time to wake up.

- Yeah. Because you can't make up sleep. Right. You can't like catch up on your sleep.

- I'll give you an example. One day of loss of sleep, let's say you only slept three hours, will take two to three days of catch up sleep.

- Yeah.

- And then if you do it on a persistent basis, you never catch up.

- And how important is sleep like for your body?

- It's extremely important because if you don't sleep, your brain doesn't trust and the brain controls everything. So when you sleep, your body regenerates. You read your, you know, invigorates, it takes up the trash for example. It calms down the body. Body did that. I like to have the trash. If you see inspire, I mean not inspire the inside out, inside out the mix picture movie, the Wal Disney movie that put it in perspective. That's what exactly happens. You know,

- I love that movie.

- So the next day when you wake up, you're fresh because the brain controls everything. If it's not resting, you are stimulating the heart. You're putting stress hormones onto the rest of your organs, your diabetes, high blood pressure, mood disorders and everything else gets worse. So you're gotta have your restful, peaceful, invigorating, restful sleep.

- And I always tell my kids, I'm like, you have to sleep 'cause that's when you grow. I mean for them like I'm like your body can't grow unless you are asleep And their boys they wanna be big, you know? So I'm like go, go sleep. It's okay.

- Yes. And is the recommendation eight hours?

- Well the take this with a better pinch of salt, the recommended time of sleep is seven to eight hours. So that's one of the misconceptions that

- Everybody

- Must have seven to eight.

- But

- There's a small proportion of people for them normal sleep is only four hours. They call 'em short sleepers. Mm. And there's another proportion of people who are long sleepers.

- That's me. Yep.

- 12. And they need at least time 12 hours of sleep. And that's normal for them.

- Yeah. - Yeah. But the majority of population required between seven to eight hours of sleep.

- Interesting.

- And as you get older you require less hours of sleep because it is broken As you get older, the sleep is broken up,

- The

- Sleep is not as deep and you can allow to take a nap after lunchtime. That's normal. Yeah. So you can take your siestas after that.

- I like

- That. That's, yeah, that's rest. Is

- There an adverse amount? Like can, would sleeping too much be a symptom of like if you find yourself where you're like I'm sleeping this excessive amount of time.

- Yeah. You know statistics show that long people who sleep too much, not long sleepers, too much time in bed have a higher mortality rate than people who are more sleep depriving have less hours of sleep. Yes. So I, getting the hours of sleep is important.

- So that's why I tell patients if you are waking up and going right back to sleep, that's not normal. Right. So if you're having to sleep really great and you feel like you woke up and you had an adequate eight hours, then an hour later you're getting back in bed and sleeping two hours, that's, you know, that's too much.

- Okay. All right. So what are some things you can do to help your sleep? If you go and you get diagnosed, what are some things that y'all offer?

- Well the initial thing is just finding out what's the cause of the problem. So that's just simple talking interview. Yeah. There might be other things which may be going on. For example, people with restless leg syndrome, one of the commonest causes are in deficiency. So a lot of women have that because they never catch up on their losses from various causes. One of the simplest treatment is just to treat the cause of the problem, which is behavioral problems take up with the lights, you know, take the blue lights, have some discipline. So there is what you call sleep hygiene things, what not to do and things, what to do to improve sleep. This is easily available everywhere on the internet and all that. As long as you go to a validated site and not some influencer. Yeah. So if you do that, you go to, you know,

- Are there sleep influencers? Because I could be that.

- Oh yeah. There are a lot of, you know, YouTube videos. Mom put a tip on your face and all

- That.

- So you know that's like snake oil selling snake oil.

- Yeah. I don't, I don't like the thought of so them being taped over my mouth, I'm sleeping.

- But you go to places like you know, the Mayo Clinic or Harvard University or you know the American Academy of Sleep Medicine or something which is validated the NIH or that. And they'll give you the proper information.

- Yeah.

- Rather than going to, you know, how many hits did this video have? Yeah, let's, so that's not the right,

- Let's talk a little bit about sleep studies. Yes. So I think some people might be a little bit intimidated by that, you know. And what's the difference in a home sleep study versus one that you get at SGMC Health in the sleep lab,

- The different levels of sleep study, we actually grade them level one or you know, two, three and four. So the most important and the most effective sleep study is the one where they come into a lab and we measure a lot of sleep parameters, which include an E, EG to look at the stages of sleep and EKG to see how the heart is doing. Leads on snoring, chest expansion, abdominal expansion and muscle movements and oxygenation. That's the most validated sleep study. Okay. That's the most important sleep study. And unfortunately it's a bit expensive and involving. So they've come up with what they call home sleep apnea chest. The simplest one is a level four, which is just oxymetry. So a lot of people go home, it's just an oxymeter and see if the oxygen drops. If it drops there might be something going on. We don't know what drops it though. So the level three, which is most of the home skip studies have a few more parameters. They look at the cardio ballistics and there's some others which look at the snoring and a band across your chest and you go home with the equipment you put it on, you're taught how to put on an oxymeter, maybe something on the throat to look at your snorting and breathing. And another thing to look at your heart and pulse and those are the home sleep apnea tests. The ones we use here at San Georgia Medical Center is a watch which looks at your heart rate, your pulse and an oximeter and another one which goes to the throat, which tells us how your breathing or snoring is. And that will tell us what's going on. It's an easy disposable thing. It's very easy to use. You take it home, there's an instructional video on an app. You just download the equipment information onto your app. You search on the device, that's all you do. You sleep with it the next day. You can keep it as a subir or dispose of it. And the data comes to us through the cloud and we read it. That's a study. Everything's

- Gotten so much easier. Yeah. It's a great option. You know for patients that are like, I don't wanna sleep in the lab or I don't think I'll be able to sleep in the lab. You know, how do we test for this? So the watch pat will help us, you know, really look if sleep apnea or something's a cause. But if it's more complex and we need to look at the sleep stages or the leg movements, the in lab will show that more detailed and yeah, those complex sleep disorders.

- Yeah. And that lab is very nice. It is. It's like a nice hotel room I call it. It's like a nice hotel room. It's not, it's not like your typical hospital room. Right, right. So it is designed to be a little bit more comforting, comfortable you. So that's good. So what about, so if you do find something, what are the most common treatments for sleep? Like is it the CCP paps, is it the, you know what, I feel like a lot of people are nervous 'cause they don't wanna get put on one of those. So

- I tell patients, you know, for obstructive sleep apnea of course the first thing you think of is the CCP PAP P people automatically think of the big mask over your face and that is still the gold standard. You know if you do have obstructive sleep apnea is A-C-P-A-P but they make tons of different masks. They have kinds of just go in your nose or a little in your nose over your mouth. So there's a lot of different types that we can find comfortability with through these medical supply stores here in town. We are super excited now that we are offering inspire therapy at SGMC neurology and actually our neurosurgeon here at SGMC is actually about to start placing inspire as well. So we are about to start offering this service completely in Vata.

- Yeah. This is service for people who cannot tolerate the mask

- Because

- The pressures too much or their nose get blocked or for various reasons they're claustrophobic, they can't use it. So these are one of the alternative ways of treating sleep apnea.

- So there's a lot of different types inspires for moderate to severe patients that can't tolerate the, the CPAP weight loss can help with sleep apnea severity. There's mouth pieces that can actually use that piece to move your jaw forward to keep your airway open. So a lot more options. There's more options that people wouldn't think of. Yes.

- And maybe a couple of years down the road there'll be some medications.

- Yeah.

- To help with the sleep apnea as well.

- Talk about the

- Inspire a little bit. What does that do?

- Yep. So inspire, it is actually a little device. It looks like a little pacemaker they place right here in the upper right chest. And it's a little electrode that's over the tongue nerve. So you know A-C-P-A-P uses air pressure to move the tongue outta the way to keep their airway open. So inspire, there's a little remote so the machine essentially is inside of you. So you're the machine. So the remote at night patients actually turn on that stimulator and they go to sleep. So there's nothing on their face, there's no machine that they're working with. And we actually set the parameters in the office where when they breathe at night, it's sending a gentle signal to their tongue nerve. They don't feel it, patients are sleeping through it but it actually moves that tongue out the airway. So it is only on while they're asleep they can pause it in the middle of the night, they have to get up and use the restroom or take a sip of water and then they turn it off the next morning. That's

- Fascinat.

- It's a really cool thing to see. Yes.

- Wow. And it reminds me of what Dr. Mackey was doing with the vagal nerve stimulators.

- That - Kind of similar to that. It's the same type of thing except for different, A different nerve. Exactly. We've come a long way.

- We have, we have.

- Yes. Alright, well that's good on sleep. Let's move over to dementia because there's a lot of stuff that y'all are doing in that area and I know that impacts so many different people now. It seems like everybody I know these days has a family member or relative who's

- Suffer. Yeah you you know the, it's the demographics of the whole country. The baby boomers are getting older and then not enough younger people that replace them. But the demographics are sort of top heavy. So a lot of people are getting older and they're living longer and more and more dementia is being diagnosed. The data from 2024 shows that about 80 to 84 million people now have dementia, which is diagnosed. But this is just the tip of the iceberg. There are a lot of people who have what we call mild cognitive impairment or early dementia, which has not just yet been diagnosed. And there's so much need and there's so much cost to the population because family members to look after their demented patient, you know, parents and all that often have to leave work to become full-time caregivers. Yeah. Because there's not enough care going around that.

- Yeah. - So the goal is to catch dementia early on and it, because currently there is treatment for Alzheimer's dementia, not the other types of dementias. These are infusion therapies which will stop the progression. The current data shows that it may in some cases also improve the memory a little bit. If it's caught in time. Now we can use this treatment for early dementia but not for ED once dementia. 'cause then the damage is beyond repair and it may still progress due to other factors. And now we have this new infusion treatment, which shall be tell you a lot. Yeah.

- So us

- About who would like qualify for that, kind of how that

- Works. Yeah. So my first thing I like to say is it is for early dementia or and when we're in that mild cognitive stage. So I always tell patients if you have a family member or a loved one and you're starting to notice a memory issues speak up. Because if we can catch this early, we can treat it early. So that's what these infusions are meant for. So like Dr. Eisa said this is the first treatment on that's FDA approved.

- Yeah. - That's actually affecting the disease process. Yeah. Up until now we've been symptomatically treating dementia. Yeah. So now we have a treatment that is actually affecting Alzheimer's and slowing down the process. Which I think is very hopeful, you know, for patients and family members. And we're offering those infusions now at SGMC neurology. So you know, getting that word out that we can treat this early. And so patients can go to primary and you know, primary can be educated to start working up that hey this is an early memory issue, let's send them to neurology and get it seen about. But we are doing it now, which I think is amazing because up until now as well we've been sending patients to Shands or Mayo Clinic to get this treatment. But we have the access here now for our community and surrounding communities.

- That is, so this would be the main infusion treatment for the whole of South Georgia and possibly North Florida as well. Once you know, it's already started and people are already in the pipeline for treatment. But the key thing is diagnosing it early. Now a lot of primary care doctors are a little bit afraid of you know, the diagnosis of what to do and they don't know if they do do the testing, what is the next step to do? So we are going to try to make it a bit better. We have tried to join the Georgia Memory Network, which is a statewide organization which will reach out to primary care physicians and other things to make them aware and send patients to a center like this where they can get treatment. And there are easy diagnostic steps. Anybody can do what you call a mini mental status examination as a screening tool. Simple questioning. And they're currently what you call blood-based diagnostic tests. It's a simple blood test which you can do, which can tell us if the patient has Alzheimer's dementia or not.

- They - Don't have to go through specialized testing in the past, which is a spinal tap and PET scans and different things. So the catchment population is out there. The treatment is easy, it is FDA covered and we should be able to get a lot of people treated this way.

- Is it hereditary?

- There is a small component which has a gene like the a e four gene. If you have two alleles, it means two copies of the same gene. Your risk is higher. It doesn't mean that if you have it, you're going to get Alzheimer, you dementia.

- Right. So it's not a diagnosis, a factor,

- Something. So it's

- Be aware of like

- And those Yes. So there is a genetic factor to this. Yeah.

- And that's something we test for when we are working up our dementia patients. We're looking at that risk and seeing if that gene is there.

- Well I know there's probably a lot of stigma that goes around just like with any kind of mental health issue. Like it's just raising an awareness that like you need to voice these things if you notice them happening within yourself or your family members to what you said feel more comfortable talking about it early. Especially if now there's options that could be out there versus kind of suffering in silence.

- Right. Well I had no idea it was just a blood test that can help you identify that.

- Yeah. A lot of people still don't know that. Yeah we need to make the public aware of this.

- Right. And it's just so easy to test for now. Right. You know, when we, if I'm even concerned with it and we're landing in that area, those memory testing that we do, that they could be a candidate for these infusions. I offer, Hey let's go and see if this is something we're dealing with so we can treat it if it's there. So it's so it's too easy not to check for it now. Absolutely.

- Now to put things into perspective, you know there's such a shortage of medical doctors and all that and getting into see Neurology has a wait list of six months and all. So we at South Georgia Medical Center and now training nurse practitioners to take up a lot of the load and get people in quicker for example within the next couple of weeks for sleep disorders. So we have Jennifer, our nurse practitioner and we have, you know, for dimension all that Shelby and we'll probably get some more and make things so much easier for primary care physicians and for the public to get into to be seen for these disorders now.

- Yeah, I think that's absolutely great. I mean as a health system we're definitely having to evolve in that space because I mean it is a issue just nationally enough physicians and enough nurse practitioners in general. So I think patients shouldn't like, feel like they're getting any less care. Know that it's a team approach and y'all in this together. So, but just getting the patient in quicker and being able to do that diagnosis is the goal.

- Just the sooner the better the treatment. Yes. Yeah.

- Very good.

- Other than sleep and dementia, what would you say is one of the other top things that you see and treat?

- Numbers wise? Headaches is stress.

- Yes. My grades are very prevalent.

- Yeah,

- For sure.

- So that's another very, very common problem. Migraine headaches, specifically difficult to treat but there are good treatments out there now. The different types of headaches following that and nerve problems from diabetes, you know, and injuries to the spine and all that. And then there are other things like epilepsy is not uncommon. Yeah. It's also a very common problem. So these are some of the more common things we see. Yeah. There are a lot of uncommon things as well we see. But these are the, I think the top most

- Yeah.

- Neurological problems that we address.

- Tell us a little bit about medical education. 'cause that's kinda, I mean you know, we've evolved as a health system, got much more, many more students, many more physicians here are getting trained. How do you feel about that and kind of what's your take on it?

- Well we've been training medical students and taking in people from high schools and schools and having them shadow us. Especially at the neurology clinics. Like I've been a professor with the medical college at Georgia since 2009 and as a professor at Yale up to 2006 before I moved here. So we've always been training students and all that and we encourage them to come into the medical field. Hmm. Now, I dunno if you know it or not, but the Medical College of Georgia has a sort of a shortcut for people in the local area through the Albany campus. We call it the southwest campus. The neurology clerkship director there as well to get our students of the local areas into the stream so they can get into medical school. Now Mercer University has also started the stream and they're going to open up a medical school here as well. Down the road it'll probably get bigger. So we have two medical schools, which you know, have their presence in South Georgia Medical Center. And you can get more people into the field of medicine or into nursing or whichever medical field it is, the better it is 'cause there's such a shortage. Yeah. So we encourage people to come inquire about this. Yeah. And get, get into the medical field. Yeah.

- We need you.

- We need

- You. We have our volunteering program for the high school students over the summer. We've got, you know, college volunteers, the shadowing. I mean there's so many opportunities for anybody who's maybe interested in medicine and you kind of wanna get that inside look.

- Yeah. I just had a college volunteer program attending with me for probably what, four months. And she was great. But I feel like, and she told me, you know, I kind of helped show her this world and she's going into nursing now, you know, so kind of given that experience to see what we do and the, you know, the complexity and the people, we get the help.

- So we are collaborating with the Valdosta State University nursing program. We're trying to get, you know, the nurses from there to join us for specific training.

- Yeah.

- For neurology. And I'm sure in other specialty fields as well. We will be starting up a, what do you call, a sleep technician training program at where sleep facilitate through the American Academy of Sleep Medicine. It's accredited and it's called the aep. So we'll be starting that soon and getting students come in to be trained as sleep technicians.

- Yeah. There's so many healthcare related careers that are in high demand that you just don't even realize. Such as a sleep technician or Yeah. So there's so many opportunities for people that are, would consider a medical career, but maybe don't wanna go be a full-fledged doctor. You know, they're not that committed but they still wanna help people in some way. So it's good to be aware of these different avenues 'cause they could be, you know, very impactful for someone.

- Absolutely. Well I think that's all of our questions, but we do have one more

- Yes.

- That we ask all of our guests. And that is, what is your favorite meal to eat here at SGMC Health? In the cafeteria or the allspice?

- Well I'm not eating that on spice.

- We're the Yeah. Campus though,

- So I can make a comment on that's But I can tell you the Smith North View

- Does a great job.

- They have things up there,

- They're pork chops Smith Northeast pork chop chops are great.

- Yeah, I hadn't heard that one. So that one's good. Alright. We always like to give them a shout out 'cause they keep us all fed and running. That's right. So we're very thankful for them. Yeah. 'cause we don't really have a lot of time to eat usually, you know. All right. Well I just wanna say thank y'all for coming on today. It very informative.

- Thank you for having

- Us. Is there anything else you wanna share that we might have missed on before we wrap it up?

- Not sure. I mean, you can get the word out to the public that that's great.

- Yeah. I say if you're having any issues, headaches, sleep issues, obviously the more complex seizures. Parkinson's MS multiple sclerosis or MG myasthenia gravis. You know, we're here, we're, we're in Valdosta, we're, we love helping our patients. I love being accessible to our patients. So just getting the word out that we're here and we're offering these new treatments and new things that we're just really excited about because Oh

- Yes.

- You know, we're kind of a small system if you compare us to what we've been sending to, to these tertiary care centers or teaching hospitals. But we're doing that here and now. So we're kind of moving up and

- Really excited about it. Well congratulations on that note to your teams for taking on these new advanced treatments and getting those implemented and doing the work behind the scenes that it takes to make that happen. 'cause I know it's not something that just happens overnight, but truly does impact our patients here in our community. So we appreciate that.

- Absolutely. Thank you. Thank y'all.

- Alright, well thank you for tuning in. We'll of course put links and contact information so they can get in touch with you. And then of course, if you haven't already, you can always like and subscribe so that you can stay abreast of all of our new episodes. And we just thank y'all for tuning.