Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Physiotherapy in Trauma Care: Insights from South African Physiotherapists Moira Wilson and Natascha Plani
This episode explores the crucial role of physiotherapists in trauma care. The conversation covers patient assessments, multidisciplinary teamwork, and the importance of mental health support for caregivers, while also providing valuable advice for emerging physiotherapists. Explore the essential elements of communication and advocacy in physiotherapy as Moira and Natascha shine light on the ways physiotherapists bridge gaps in patient care. Discover how they keep their teams motivated and engaged in high-pressure environments, ensuring no injury goes unnoticed and every patient receives comprehensive care. From ICU to discharge, their stories underline the collaborative spirit needed to enhance recovery and the strategies they employ to foster effective communication among healthcare professionals.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
‘Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
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Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. Welcome back and thank you for joining me for this episode where we will be discussing the role of the physiotherapist in trauma care. On today's episode, I have two guests Moira Wilson and Natasha Plani episode. I have two guests, moira Wilson and Natasha Plani. Both of them have more than 25 years of work experience managing patients with traumatic injury and therefore I trust that my discussions with them will be very insightful to you. I am at Moldpark NetCare Hospital, which is a private healthcare level one trauma center in Johannesburg, and I'm joined by Moira Wilson, a physiotherapist who has been working in the trauma unit at this hospital for several years. Moira, thank you for joining me this afternoon and for availing yourself to this discussion.
Speaker 2:It's my pleasure Prof.
Speaker 1:So, moët, as we start our discussion, please share with our listeners how you became interested in trauma care.
Speaker 2:I started my career in Scotland and always enjoyed traumatic injuries and neurotrauma. I was based in the Southern General in Glasgow, which has a massive neuro institute, and that was where my interest lay. Then, when I came to South Africa, I was asked to work in neuro ICU under Frank Sneakers's unit, which I did, stayed there for about a year or two and then they asked me to open trauma as the physio in trauma. So that was how I started. In trauma Trauma commenced with four beds and it's now grown to 30 trauma ICU beds, eight burns ICU beds, eight trauma high care beds and around 15 beds in the ortho ward which are at our disposal.
Speaker 1:Wow. So you've definitely got a quite vast experience in working in trauma care, and you've worked there for a long time, so can you explain to our listeners what types of trauma cases you often encounter here at Mill Park Hospital?
Speaker 2:It's a very mixed bag, Prof. It's a level one, so we get the sickest of the sick, so it's usually polytrauma. So it's head injuries, spinal injuries, chest injuries, pelvic injuries, orthopaedic injuries and often a conglomeration of all of those injuries and burns. Of course, so often the patient is very critically injured. The patients are very sick when they come to us.
Speaker 1:I've noticed that you've also had patients from other countries in Africa that have often come through for treatment at the trauma unit here. What type of injuries would they particularly have?
Speaker 2:Lately we've had a lot of American tourists that have fallen at Vic Falls in Botswana, at Chobe. They come on safari. They're relatively sort of over 70, this group and then they happen to fall downstairs and then a lot of them are on blood thinners for underlying medical problems, so they bleed quite a bit and they fracture and then they get evacuated to us by plane usually. I think we've had about six in the last month or six weeks or so six weeks or so.
Speaker 1:Okay, so you really see quite a wide variety of causes of trauma leading to patient admissions here. Based on your experience, Moira, how would you describe the role of the physiotherapist in trauma care?
Speaker 2:Well, every patient that comes into trauma has a comprehensive, detailed assessment detailing all injuries, blood results, x-rays, mechanism of injury and then treatments planned according to the assessment. There's no exceptions to this. Every single patient coming into our trauma unit is assessed and then our job is to manage the respiratory care, mobilise the joints, strengthen the muscles, gradually increase in mobility, improve coordination, balance, endurance. Early, safe mobility is important to reduce length of stay, reduce complications. For good functional outcomes, discharge planning is important and education of family improved quality of life. It's a very multifaceted, holistic approach when you have to consider all aspects of the patient Because, like I said before, they've got many different body systems that are injured and you need to decide how you're going to progress this patient forward.
Speaker 1:Yes, indeed, and I suppose one of the important things is that physiotherapists need to know what would be safe and what would not be safe to do. So I assume communication with the trauma doctors is quite important.
Speaker 2:Yes, it's very important and even for us. We've always got senior physios in the trauma unit, so we've got very much a tiered approach. So we have very senior physios and we have some junior physios and the patients are. We allocate the patient according to the physio's experience, but there's always senior physios on hand in the unit to assist the junior members of staff, to encourage them and give them support and help them with any queries that they might have.
Speaker 1:and help them with any queries that they might have. Yes, yeah, that's wonderful. You mentioned that you also involve the patient's family in your approach to patient care. Could you maybe just elaborate on that a little bit?
Speaker 2:Yes, Prof, that's very important. We are patient-centric, but the families are a real key to keeping the patient motivated and to explain the way forward. We have goal setting. We tell them exactly. This is what we're going to do. This is how we're going to progress. Your family member? This is a step-by-step approach. I give them my cell number. Call me at any time or stop any one of us and we'll help you. Call me at any time or stop any one of us and we'll help you.
Speaker 1:Okay, you know I think working in the trauma environment can also be quite taxing on a physiotherapist's mental health and motivation, and I know that you've got several physiotherapists that work with you in your team here at Moorpark. I was wondering how do you, as the senior physiotherapist, keep your team motivated to work in such a setting where you see severe injury and sometimes deformant of patients and you also encounter death and disability and you'll also encounter death and disability.
Speaker 2:It's a very challenging environment but it's very rewarding work. I've got an open-door policy. Anyone can come to me at any time. There's lots of support for junior staff. I rely a lot on my two clinical leads, my two senior physiotherapists. As I said previously, we've got allocation of of the types of patients that were given to the junior physios. Sometimes we have two physios working with the one patient, just because it's a complicated case and it needs two physios rather than one physio and a nurse.
Speaker 2:The patients are discussed between us often at lunchtime and if anyone's showing any, any problems, any of the staff members now, then somebody will take that patient over for them or go with them. They need to feel supported at all times and if I see them starting to get a bit stressed about it, then we we step in and help them. But we do discuss everything with them, even even if we have a, an adverse event. We don't. It's a general discussion and we talk about ourselves and this is how we, how we improve going forward. We don't pick the person out and we don't. We try and assist everyone to become better therapists at the end of the day and encourage people to to actually open up to us so a very supportive environment that you're creating for your staff.
Speaker 1:That's wonderful. Tell us a little bit about the other members of the trauma team here at Moorpark Hospital. Which professionals do you work with on a daily basis and how is your relationship with them?
Speaker 2:Trauma is very much a team sport. It very much involves everyone. So we're very fortunate to have occupational therapists, dieticians, speech therapists, psychologists, orthotists, ophthalmic surgeons. There's a huge team and we use electronic medical records, which has helped quite a bit. So everyone when they see the patient, they make notes so it's easy to go back and look and you can check everyone's notes. We also have an MDT meeting once a week, a face-to-face meeting with everyone, where we discuss each trauma patient and the way forward and if we're experiencing any problems then it's discussed there and how can we move forward.
Speaker 1:Okay, that's wonderful, and would you mind just elaborating a little bit on how you work with the dietician in the unit?
Speaker 2:Yeah, nutrition is very important, very, very important. So dieticians they see the patients every day. So one of the main things that we've learned in recent years that there is much better protein uptake for patients if they're given a protein drink after their physio session. So we make sure that we do that for maximum help of the patient. So dietitians are great and they work really hard and we're privileged to have the caliber of dietitians that we have.
Speaker 1:Wonderful you mentioned. One of the important aspects of physiotherapy and trauma care is discharge planning. I was wondering do you in your team follow the patients up for post-discharge continued rehabilitation, or are there other arrangements that you make for the patients that leave the hospital?
Speaker 2:Most of our patients go to rehab because, as I said before, they're very badly injured so it's unlikely that they go straight home. So usually they go to net care, rehab or some of the other rehabs, depending on where they're situated geographically, so just depends where they are. Then, before they go, we fill in a transfer document all the all the MDT fills in so that when the patient gets to rehab they're not going in blind. They don't know the details of what happened, so we ensure that they get that information. Yes, Okay.
Speaker 1:Do you have any thoughts to share about what can be done towards injury prevention in South Africa?
Speaker 2:I think we need much more publicity about injury prevention, Prof. The drunk driving and the fire safety and all sorts of things. Child-headed households, poverty it's tough, and we need households. Poverty it's tough and we need much more media. Most people have got phones now, so we think the media must be involved in trying to improve prevention. Yes, yes, trauma prevention.
Speaker 1:Yeah, no for sure. And then, just lastly, we may have some junior physiotherapists that are listening to this podcast. Do you have any words of wisdom to share with our junior listeners regarding work in trauma care?
Speaker 2:It's very challenging work, but it's very rewarding. It's very fast paced and you've got to think fast on your feet. There's no two patients are the same, and that's the challenge and that's great. There's multiple injuries, there's multiple ops, there's multiple anaesthetics. Motivation is key. You need to keep the patients, the staff and the families motivated for the best results and keep guiding them step by step as to the way forward. Keep informing the patients and family about their progress and celebrate the small successes.
Speaker 1:Yeah, I think that is actually the key celebrate the small successes. Moira, thank you so much for your time. I'll definitely be in touch as we discuss different types of trauma patients and how physiotherapists manage them in future recordings, but for today, thank you so much for your time.
Speaker 2:My pleasure, thank you.
Speaker 1:My next guest for this episode is Natasha Plani. Natasha is a physiotherapist that has vast clinical experience in trauma care and heads up the trauma physiotherapy team that works at NetCare Alberton Hospital, just south of Johannesburg, in the trauma unit there. Netcare Alberton is one of the few level one private hospitals in South Africa. Natasha, thank you so much for joining me.
Speaker 3:Hi Eliane, Thank you very much.
Speaker 1:Natasha, as we start our discussion, could you please just introduce yourself to the listeners and share with them what made you interested in trauma care?
Speaker 3:Sure.
Speaker 3:So I have been qualified for 30 years at the end of this year actually and I qualified from the University of Pretoria and then started off working at Baragwanath Chris Harney Baragwanath Hospital, which was public, and then moved to private practice to the then Union Hospital in Alberton, which was a four-bed ICU, and I think I always enjoyed hospital work and we sort of saw a little bit of everything, with occasional trauma.
Speaker 3:And then in 1999, the trauma group came and decided to set up a trauma unit at the Union Hospital and we expanded to a four-bed general hospital. But I think I ended up with great opportunities to work in a team with established systems and certain ways of doing things and really an environment where it encouraged best evidence and best evidence-based practice at all times and really this came from a place of wanting to deliver the best care to the patients in the area. At that stage the nearest hospital for major trauma was Mill Park and the whole East Rand basically had to drain there as well. So I think it was sort of developing the interest as we went along. But I just ended up finding critical care and trauma absolutely fascinating and also, especially with your longer term patients, very rewarding when they finally get better.
Speaker 1:Yes, indeed. What type of patients with traumatic injury do you see most often at your hospital?
Speaker 3:So we really see all types of trauma. As you've mentioned, we are a level one facility, so we really are equipped to see the worst of the worst. So our injuries can vary from simple things like snake bites or a few fractured ribs to very, very severe polytrauma. We see a lot of motor vehicle and motorbike accidents, as well as a lot of workman's compensation patients Unfortunately, it seems to go through waves but also, certainly at the moment, quite a few gunshot wounds, and sometimes it's really just unlucky.
Speaker 3:We've actually had two members of the hospital in the past year that ended up just being in the wrong place at the wrong time and ended up being shot. Yes, and both of them have had very long stays, but I'm happy to report that the one is back at work and that the other one is actually now just leaving ICU after a reverse love-ease colostomy. We also see, unfortunately, gender-based violence and assault, you know, and that's something that's also becoming, it seems to me, almost more prevalent. But I think what's important is that we have a full team of specialists that's equipped to handle anything, so we can refer to all specialties, which is what makes us a level one facility.
Speaker 1:Yeah, so you really have a very wide variety of trauma cases that you see on a daily basis.
Speaker 3:Yeah, absolutely Everything, from burns to fractures to amputations. We really do see it all gunshots, and sometimes more than one thing in one patient.
Speaker 1:Okay, yeah, so it can be quite complex.
Speaker 3:Yeah, absolutely.
Speaker 1:So, based on your experience working in trauma care, how would you describe the role of the physiotherapist in your seating?
Speaker 3:I think that we are really an integral part of the team and I think what's important is that we really are there from day one and I suppose we're there even longer than the doctors sometimes because we follow these patients through to discharge and then try our very best to follow them up. We work as a very important member of the multidisciplinary team, I think, and I think when you look at trauma or any ICU type of work specifically, it has to be really holistic, you know, and we work hard with our physios to make sure that you don't sort of think in ICU it's just a chest. It's so much more than that. Sure, we want to do treatments that prevent complications and treat complications like maybe pneumonia, but we also an important member of the team when it comes to assessing readiness for weaning and extubation and whether patients will fail or whether they will make it, and then I guess also it's our job to help get them there when we think that they're ready. And that's for chest. If we then look at musculoskeletal, you know, all the time, look for problems, assess for readiness to mobilize, address any other issues that we can and, importantly I think, follow the patients through to the wards. We see with some of the other allied health people that sort of once they leave ICU, you know, they sort of get a bit lost in the system because they seem to be okay now. And then I always joke and say that we also the tertiary survey in trauma, because certainly when a priority one patient comes in, the main priority is to make sure that they don't demise and that we pull them through. So sometimes a thing like a torn anterior cruciate ligament or meniscus gets missed and it becomes obvious only a little bit later. And then it's certainly our function to alert the doctors and say we're worried about the shoulder, there might be a brachial plexus or this knee doesn't appear stable. So I think we play an important role there as well. And then I think we have a very important role in communicating with our patients, talking to them. We spend time with them, explaining their condition, answering questions, and something that we're trying to focus on a bit in our practice at the moment is also explaining to patients how well we think they can recover and what their expectations can be.
Speaker 3:And then we also advocate for our patients. You know, for example, we had a patient who went to a rehab unit and he's an old man. He's in his 60s and they gave him a sports wheelchair and he literally kept on falling out of the wheelchair because every time he leaned back he didn't have the balance. And it took us about three weeks because he was also a workman's compensation patient and of course that means that they can't exchange the wheelchair. So in the first place it was the wrong thing to have given him, but it took a long time. But my physio really persevered and advocated for her patient so we could get him an adaptation to this so that he could be more stable.
Speaker 3:And similarly it goes for braces as well. The medical aides are very tight on that. They don't want to provide them. So you end up with a patient who's lying in bed for an additional week because the medical aide won't cover his brace and the patient must now have found 25 or 30,000 rand out of their own pockets.
Speaker 3:So I think we're really important there, because if you've been in private practice for a bit, you do kind of know the tricks of the trade, baby. But it's also just reaching out and caring and finding out how we can help and in other situations also then reaching out to other team members you know, like, for example, if we see a patient's very depressed, making sure we contact the psychologist asking if they are seeing the patient, because this is what we pick up in our work with them. Because I think really, at the end of the day, I've come to the conclusion over many years now that our role is to create more than just ICU or trauma survivors. We really need to work hard to restore these patients back to as close, as fully functional as possible.
Speaker 1:Yes, definitely, and I want to pick up on a few things that you mentioned. The first one that struck me is the importance of continued reassessment of patients in the ICU and not just assuming that all injuries were identified at the initial assessment when the patient was in the emergency department. So I like that you mentioned the importance of physiotherapy in uncovering additional injuries that the doctors might have missed initially and then sorry, did you want to say something?
Speaker 3:No, I just wanted to say absolutely. And you know it's not a criticism, it's something that just happens and we are the people who are going to pick those things up. When we start doing functional exercises, like I said, a brachial plexus, start doing functional exercises, like I said, a brachial plexus, you know, it might not. You're not going to look for that initially, unless the injury very clearly stated that you have a suspicion of that. But it might be there and similarly, like a cruciate ligament or a collateral, you're not going to see them when the patient's bedridden.
Speaker 1:Yes, no, that's very true, and you know, the fact is, we're all there for the better of the patient, so it doesn't really matter who identifies a diagnosis or a missed injury as part of the multidisciplinary team that's really involved in patient care. The important thing is that it is identified and managed appropriately.
Speaker 3:Absolutely.
Speaker 1:And then I also like the fact that you allude to communication with other members of the multidisciplinary team involved in trauma care. What practices do you have in your hospital that helps to ensure that communication between the team members happens on a daily basis and effectively?
Speaker 3:So I think we're very fortunate. Our doctors are extremely approachable. I must also say I think we make our own luck because we've worked with the guys for very long and I really think that knowledge is power and because we do encourage all our guys to really know all the anatomy and physiology and function etc. The doctors respect us and they respect our views and they ask our opinion. So they're very approachable. So we literally have a situation where if something's not okay for us, we will pick up a phone. You'll either see the doctor on ward rounds or we can pick up a phone to them and discuss with them and say we're worried about this patient for this reason. So that's communication with them.
Speaker 3:And then something that we've started with great success is a weekly allied health meeting. Is a weekly allied health meeting. So first thing on a Tuesday morning, myself or one of my colleagues if I'm not there so physio, ot, dietician, speech therapy, occupational therapy, social worker and psychologist all get around a table and we discuss all the patients and it literally we've got a 25 bed, 24 bed ICU. It literally takes half an hour to do this, but it is a fabulous tool for us because we really just run through all the patients, you know, and that would be my forum. So what we do in our practice, which feeds in very nicely, is on a Monday at lunchtime I have a virtual ward round on ICU and any other problem patients in the hospital in my practice. So that's just for my physios.
Speaker 3:So we then discuss all that but it's specifically for trauma ICU. So we discuss, they all give feedback about their patients. We discussed, they all give feedback about their patients and that's important for us because that's where we ensure continuity. Because you know, someone may say I could, he needed a sheet transfer to the chair, and then the person who treated the patient last week will say but we stood him last week, so what's happened, and we can analyze and interrogate that and make suggestions for treatment and work on aims and goals. But that also feeds into the Tuesday Allied Health meeting then because they will also raise with me that we think the OT should see this patient or we're really worried this person is vomiting all the time. It's hampering our mobilization, and that then gets fed back into the allied health meeting on a Tuesday and then outside of that we just communicate and personally with all members of the team if we think someone needs occupational therapy or they need to help us with something you know. People should just pick up phones.
Speaker 1:Yes, and talk to each other.
Speaker 3:It doesn't happen enough in my opinion. You know, people work in silos and patients don't get the best benefit if the OT only does the OT and the physio is only concerned with walking. I mean, we're all there for the same goal and the more we interact and work together, the better the patient does at the end of the day.
Speaker 1:Yes, I cannot agree more. So, natasha, with the trauma ICU setting being such an intense environment for people to work in, in relation to seeing patients pass away or seeing patients with severe deformities as a result of the injuries that they sustained. How do you keep your team of physios encouraged to work in this high stress environment?
Speaker 3:So I think it's a little bit. There's certainly recognition that it is very much that and we have to accept that, but it's also an extremely stimulating field. No two patients are ever the same. There's always diversity and we try and equip our staff as well as possible. So there is continued tutorials and upskilling and learning to understand the conditions and pathologies, because I think sometimes that makes it a bit easier as well.
Speaker 3:So if a patient doesn't do well and they do end up dem optimizing, if you can rationalize it and understand why, then I think it goes a long way to helping with that.
Speaker 3:And then so I like to think I've got an open door policy. I am in the unit most mornings and available for any of the therapists to come and discuss you know, any of their patients that they struggle with and look at x-rays and scans and discuss with doctors, and I guess that really is also leading by example, you know, making sure no one takes shortcuts. I also think that they're quite empowered by the fact that they can have discussions with the doctors and can really feel part of the team. What we also do is in recognition of the fact that it is emotional draining. Some of our patients are in there for three, four, six months. You can't see a patient for that long, so we try and ensure continuity by making sure that the same physio will see a patient, sort of from Monday to Friday, but in the next week we will rotate. Okay, and I think actually sometimes it's beneficial because you get fresh eyes on the patients and someone who tries something a little bit different as well.
Speaker 1:Yeah, I agree, yeah, and then I think for my guys.
Speaker 3:You know I'll step in and advocate for them if necessary. We I think we have a very high standard of early mobilization and getting patient going and that's really what our doctors expect. And sometimes it can be a bit much and if someone has made an error or a mistake, we will acknowledge that. But if the guys are unreasonable, it's about supporting the team and being there and, I think, important as well, and we've seen that especially this year. We've had five of our staff doing a postgraduate course and it's a lot for them and just recognizing those signs of burnout or distress and actually just saying are you okay and I know you don't like to, but maybe you need to take a day's leave- yeah, okay.
Speaker 3:Yeah. And then the last thing sorry I want to say on that is, the other thing that you have to do is you have to celebrate the wins. Yes, for sure, when you have those patients that succeed against all odds, those are the ones that we really celebrate.
Speaker 1:Yeah, and it's so rewarding to see how patients respond to your therapy in an unexpected manner and that it has such a wonderful outcome in the end. Natasha, I want to touch a little bit on post-discharge care for patients that are discharged from the hospital. Do you, in your practice, follow them up or do they go to a rehabilitation hospital? Can you maybe just talk about that a little bit?
Speaker 3:Sure, so it's a very challenging situation. A lot of our patients go to rehab facilities and some do go home. If they go to rehab, they often get lost in the system and I think it's for a multitude of reasons. Sometimes patients may not clearly understand that they need to follow up as outpatients. Sometimes I think they're just sick of us. I think they've got health provider fatigue and all they want to do is just go home and not have more time with us.
Speaker 3:But we've tried in various ways. We tried a multidisciplinary ICU follow-up clinic and it was very disappointing because we'd make appointments for patients and all of us would mark our books off and then the patients would cancel in the morning or not show up and I've never been able to quite figure out why something a free clinic that could identify potential problems is not something that people would want. But we've now come to the stage where we keep record as our patients are discharged and then we follow them a few weeks later because it's very important. I talk about the 70 percenters out there, and these are the guys who are 70% recovered and they don't know that they might not be 100%, but they could be 85 or 90. And that 15 to 20% is infinity in my books.
Speaker 3:But patients don't realize it. So we try to follow them up with phone calls. If they discharged home from the hospital, it's easier and we'll make an appointment for them while they're still in the hospital to come to the rooms if they require ongoing physio, or provide them with a contact for a physio if they live further away and unable to come to us. But my latest brainchild is actually to probably in the new year we'll pilot a list of survey questions that these patients can fill in when they revisit their trauma surgeon, because they all pitch up for those follow-ups and sort of see if it's a list of really easy questions that they then take into their trauma surgeon and that can guide him. Like you know, questions about anxiety, about being back at work, are you in your job? Really simple things but that can show the trauma surgeon need to send to OT, need to send to physio, need to send to dietician.
Speaker 1:Yeah, that's a wonderful idea.
Speaker 3:To try and give a clearer pathway and see if that helps and works.
Speaker 1:Yeah, natasha, as we draw our discussion to a close, do you have any final thoughts or words of wisdom to share with junior physios? That might just be stepping into the trauma environment.
Speaker 3:Yes, you know, I think physio is really such a great profession and in the trauma area it's so satisfying and rewarding because we can track patients from admission to full return to function, and I think that's a privilege that I'm not sure everybody thinks about all the time. My advice to young physios would be never stop learning, keep evolving, keep it interesting for yourself. We always say anybody can walk into a unit and pat someone on the back, but that's not what it's about. It's about being stimulating, understanding the challenges that you met with these patients, because if you do that, then you can work it out and you can clinically reason it out and the rewards are so great for you and the patient. And then I think, keep your patient at the center of your care.
Speaker 3:Whatever we do in our practice, whatever ideas I come up with, when the answer always comes back to because the patient benefits, then I know we're doing the right thing. So if you do that with, I guess, not just trauma patients, with any patients, if the ultimate goal, however you work it out, comes back to for the benefits of the patient and so that the patient receives the best care, I think you've nailed it. And then finally, maybe just a word on especially something tough like a trauma environment, to say keep your own health and your own mental health in mind and it's okay to not be okay for a second and to be tired and to recognize that and to protect yourself from burnout. I think it's really important.
Speaker 1:Yes, I totally agree, Natasha. Thank you so much for sharing some of your experience with us today and for your time. It's really appreciated.
Speaker 3:Thanks, Ileane.
