News about the coronavirus changes daily, so to keep you informed about the newest research, statistics and guidance, each Wednesday, Idaho Matters brings in a panel of medical experts to answer your coronavirus questions. One big topic today? How best to safely reopen schoolsin light of Idaho's continued surging case numbers and deaths.
"If [a student refuses] to wear a mask, just like any other behavior a student might engage in that would pose a threat to others, they need to be sent home." -Dr. David Pate
This week, we're joined by:
- Dr. David Pate, former CEO of St. Luke's health system and a current member of the Idaho Coronavirus Taskforce.
- Dr. Michaela Schulte, Vice President of Medical Affairs at St. Luke’s.
- Dr. John East, a pulmonologist and ICU doctor at St. Alphonsus.
Have a question for the panel? Leave us a voicemail with your question and we may use it on next Wednesday’s show. Here’s the number to call: 208-426-3625. Or email us at idahomatters@boisestate.edu.
Read the full transcript here:
MELISSA DAVLIN: You're listening to Idaho Matters. I'm Melissa Davlin of Idaho Public Television, filling in for Gemma Gaudette. As we continue to cover the coronavirus pandemic, we know many of you have questions and concerns. And here at Idaho Matters, we want to answer those questions with facts. And the best way to do that is to bring in Idaho medical experts. Every Wednesday, we will bring in a panel of doctors and other health professionals to get us updated and to answer your questions. If you're a regular listener, think of this as the doctor's version of our Reporter Roundtable. If you have a question for our doctor, send us an email at idahomatters@boisestate.edu.
Joining us today, Dr. David Pate, former CEO of St. Luke's Health System and a current member of the Idaho Coronavirus Task Force; Dr. John East, a pulmonologist and ICU doctor at St. Alphonsus. And Dr. Michaela Schulte, vice president of medical affairs at St. Luke's. Thanks so much for joining us today.
Dr. Pate, I want to start with some breaking news today. Within the last half hour, Governor Little announced his intent to call the legislature back for a special session the week of August 24th. We don't know yet what the topics will be, though we know the legislative working groups are eyeing issues related to limited liability, elections and education. So as a member of the coronavirus task force, what will you be watching for?
DR. DAVID PATE: Well, I don't have any special insight, so I don't know what the legislature will be charged with, what specific items are going to be discussed, but certainly things that have come up are what you've alluded to -- how are we going to handle the general election this November and make sure that we keep Idahoans safe? There are certainly many questions about liability issues associated with COVID. You know, I would be very surprised if they dealt with it, but I have certainly suggested that we need to have a relook at how our public health is structured in Idaho. That law that implemented that system was in 1970, and it probably made sense back then. I'm not as convinced that it makes sense. So it probably some reforms that need to be made there, but I'm guessing they're not going to take that on.
DAVLIN: And you're talking specifically about how our seven public health districts are set up. Correct?
PATE: Yes, correct.
DAVLIN: Ok, some other breaking news from the last 24 hours. Last night, both West Ada and Boise school districts voted to delay in-person instruction until September 8th with the hopes that five weeks would be enough time to get the spread of the virus under control so they can safely bring kids back to school for in-person instruction. Dr. Pate, with the current trajectory of cases in Treasure Valley, is that realistic?
PATE: Well, it's a great question. You know, we are seeing some indicators that suggest maybe, and I'm really tentative about that, I'd like another week to be able to make a call on this. But we may be seeing some initial encouraging movement. And I think that is a combination of things. I think, number one, I think that the general public sentiment has moved in favor of masks. It's hard to tell that because those that are against masks have much louder voices. But if you look at surveys, more people are becoming accepting of masks. Second, I do think the places where mask mandates have been implemented, it does appear those are starting to bear fruit. And third is we've seen many national companies come out and put in mask requirements in their businesses. So I think all these things are helping. Now, we got a long way to go. So I don't know that we're going to get there by the end of August. Certainly not [inaudible] today. But if if all Idahoans got behind this and said, look, we do want our kids back in school, we do want to get life back towards normal. And the thing we can all do to help is to wear masks. And if everybody would stay home when they can, physically distance when they're out, wear masks when they can't physically distance, I mean, we really could bring this transmission rate down very significantly by the end of August. I'm just not sure there is that will in a broad enough group yet.
DAVLIN: And in my mind, this is kind of inextricably linked to the question that you brought up of how public health districts are approaching this and how they're structured. Nampa and Caldwell, of course, are governed by Southwestern Public Health District, while Ada County is governed by Central District Health. And they, of course, have approached this in very, very different ways, although they're both hot spots. So if you were -- I don't want to say king for a day -- but if you had your way, Dr. Pate, how how would you restructure those health districts during a special session with the question of education and public health in mind?
PATE: You know, I think we need to -- first of all, we need to clarify what is their role and what is their role relative to mayors and city councils, county commissioners, the school districts. You know, for example, I was under the impression that the public health departments actually had the final say in whether schools opened. And that still may be correct. I'm not 100% sure. But what I've heard is that they are leaving those decisions to the various school districts. So I think there's a lack of clarity about who actually has the responsibility and accountability for that decision today. It appears to be the school districts, but I'm not sure that's actually the way this is set up. And then I think there's even confusion about what is the role of the director of the public health department versus the role of the board, because I've heard from some that say, no, the director can't issue a mask mandate without the approval of the board. And actually, I have just this morning heard from a board member who said actually the directors have that full authority and do not need to bring it to the board. The first thing is we just need a whole lot more clarity of responsibilities.
The second thing is from an infectious disease standpoint, if the purpose of the public health districts is to set medical public health measures in place to protect the people within that district, it makes no sense for the Treasure Valley to be governed by two different districts who may take two different approaches to managing the very same infectious outbreak as is happening today. From an infectious disease standpoint, all the communities that interact with each other, and what I'm talking about is where people live, where people work, where they shop, where they go to the doctor, all those things, and we know that there are people in Nampa and Caldwell that work in Boise but live there. And so there's a lot of movement and exchange between these populations. The virus doesn't respect those borders. So it makes no sense to have two different bodies overseeing that. So I think those are some of the things that we have to really relook at.
And then the third thing is and again, this gets back to the lack of clarity, what the role of the public health board is. As one board member has explained it to me, their role is basically to set out policy and budgets. If that's the case, it may make sense that we have politicians and so forth on these boards. On the other hand, there's been a common, perhaps a misperception, that these boards are charged with making these public health decisions, partly because if it's true that the director can make it, but the director is taking these decisions to the board no wonder all of us are confused. But if they're going to be making public health decisions, then we need people with public health expertise or at least an acceptance of basic public health principles.
DAVLIN: You're listening to Idaho Matters. I'm Melissa Davlin, filling in for Gemma Gaudette. Dr. Schulte, I wanted to bring you into the conversation. What's the latest from St. Luke's? What are you seeing in your hospital system right now?
DR. MICHAELA SCHULTE: Yes, thank you for the opportunity to speak here today. I think overall I agree with what Dr. Pate was sharing with regards to his observation that we're seeing sort of a stabilization of the numbers. We're still seeing pretty significantly high numbers, especially in our Nampa and Meridian facilities with regards to COVID positive patients, as well as a high activity of over all of the patients in the hospital, which is probably the aftermath of many patients delaying to seek care earlier this year. But it has been encouraging for me at least to see that we have seen the stabilization of numbers and not that further increase that we saw probably a couple of weeks ago, three weeks ago. That was highly concerning for our potential ability to safely care for all patients that are coming our way.
DAVLIN: And Dr. East, you're one of the intensive care unit doctors at St. Alphonsus, what are you seeing day to day at St. Als?
DR. JOHN EAST: Thanks for having me today. I think I would echo what's already been said. I've been in the ICU the last two weeks and we've seen a drop off in our total hospital numbers and in our ICU numbers, you know, we continue to see a spectrum of illness. And the patients that are in the hospital can be patients that may just simply require oxygen or they may be extremely ill on mechanical ventilation, requiring other means of support. So total numbers are down, but some of the patients that get admitted, particularly to the intensive care unit, they tend to be there for for quite a while due to the severity of illness and the support that's required.
DAVLIN: Dr. Schulte, Mark sent us this question. Do you see any progress on testing so far, specifically quicker response time? My wife was tested three weeks ago and has yet to receive the results with that kind of slow response time, what good is the testing?
SCHULTE: That's an excellent question mark. I would say, generally speaking, an ideal test would obviously be 100% accurate, 100% tell us that whether you have a disease or you don't have a disease and would do so in a quickly time to provide the valuable information we need to make decisions regarding treatment or further evaluation of potential other causes, and especially for COVID would then allow us to decide whether somebody should continue to self isolate or can they be returned to their usual activities. And the further out we are from the time of testing, the more is the decrease in the value of a test with regards to the information that it provides. Two or three weeks out, the natural disease process will have, for most people, taken its course and therefore would probably only provide very limited information. So I can understand Mark's frustration in that. Overall, I would say we have seen a significant overall increase in the testing capacity in our ability to test quickly. If you consider that we only started this pandemic about six months ago when it hit our shores, however, we're still significantly underpowered with our ability to meet the demands of testing at St. Luke's as well as across the state here in Idaho, and the recent increase in community transmission, for example, that I said St. Luke's, that we had to start sending tests out for those patients who were less severely ill with an increase in the turnaround time of those national laboratories that were performing the test for us. And with that, obviously, the information that the test can provide has decreased. So I'm hopeful that we continue to see an increase in the testing capacity as well as our turnaround times, and that these tests will therefore become more valuable to guide our decisions. However, I cannot, you know, say something about testing without addressing all the other important aspects that help us decrease the disease transmission. And, you know, testing plays such an important role. But we also know that we need to follow all of the other things that we do know work to reduce the transmission.
DAVLIN: Dr. Schulte, as a follow up to that, if somebody is waiting several days or in some cases a couple of weeks for their test results, what should they be doing in the meantime? Is it realistic to ask that person to isolate for that entire time?
SCHULTE: Well, that's an excellent question. Yeah, so my recommendation would be to contact your primary care physician and really discuss a little bit: your symptom onset or time of exposure that you might have had and discuss how long you really would need to self isolate and limit your exposure to other people. I think for most people, we would be able to find a solution that would allow them to return to regular activities within the 10 to 14 day period that the CDC recommends. So there's also a symptom based strategy for presumed positive cases that we can help people with. So I would recommend, reach out to your care provider and discuss it if you happen to wait really long for your test results.
DAVLIN: Dr. East, a related question for you. Can you talk about the more limited COVID testing in the Treasure Valley? Kate wants to know if this affects our interpretation of our daily infection statistics. Can we assume that there are more uncounted asymptomatic cases and therefore more spread in Ada County and the surrounding community?
EAST: That's a very good question, and I think that the answer is absolutely we can assume that. And why I say that is we know that there is a substantial portion of people, particularly younger people, who may not even be aware that they had an exposure or may not have symptoms. And so they're not tested. And yet those people who may not have symptoms, may still be shedding the virus and spreading the disease, so there's absolutely a greater number of cases out there than is reflected by the actual testing.
DAVLIN: As we are getting ready to open schools, Dr. East, or do we have the capacity for what we can probably safely assume is going to be an increased demand as we see at the very least, more concern about community spread once our kids get back in the classroom in September?
EAST: Now, to understand your question, you increase capacity for specifically what?
DAVLIN: Specifically testing the samples that are collected, if there is concern about outbreaks at schools, the additional stresses that that might bring to the already stressed system.
EAST: Yeah, I think this is a point of concern that we all have, you know, part of the problem with testing is, is not necessarily the number of tests, it's the number of cases. Right, where our cases, both here and in many places across the country, have exploded. And and it's true that we're doing a lot of testing. We've been testing a lot of patients and if our case numbers were what they were back in June, we wouldn't be having these kinds of issues with testing, we'd be having more rapid turnaround times because the total test numbers would be sufficient for the patients who needed to be tested. But as this has gotten out of control and has spread, we don't really have the capacity. And I think an important part of trying to make sure that we have the capacity is not just expanding that capacity, but, you know, this is an infectious disease. We need to try to control the spread of the disease. And that means following the guidelines that have been set down in terms of trying to prevent transmission. So I don't know where everybody sits in terms of the exact tests that are projected to be available come the start of school. But but I think that that's a very valid concern.
DAVLIN: Now, along those same lines of capacity and stresses on the system, Dr. Pate, Marco emailed us last week with this question: How many contact tracers does it take to handle about 450 cases a day, which is about the seven day average of confirmed cases statewide right now. How many working contact tracers are there in Idaho statewide today?
PATE: Yeah, this gets exactly exactly to the point that just was being made about the need for our testing and the need for our contact tracing to be totally dependent on how well or not well we're controlling the community spread. So to answer the question, today, we have 275 contact tracers. Now, there's more to it than just contact tracers. There's investigators, there's epidemiologists. So they all play a role in this. But the specific question around contact tracers is 275.
Now, to put that in perspective with this point that both of the other doctors have made, is that in April, when our spike was less than half of what we're having now, it was projected that we needed 544 contact tracers. Today, given the tremendous amount of spread and understand that the reason we're having so much spread is people coming into contact with more people, each person. So this doesn't go up linearly, it goes up exponentially. So for today's volumes, we would need 2700 is the projection. And of course, there's no way that we're going to be able to do that. Now, the state of Idaho has made an investment in technology that is greatly expanding the the capability of the people we do have for this monitoring. So that's helping.
But the other problem, too, to get back to Dr. Schulte's point about the test delays and how it is just not as helpful when it takes a week or two weeks to get your test results back. The other problem is it makes contact tracing less effective because we only do the contact tracing when we have a positive case. If it takes us two weeks to figure out that you were positive and then, you know, I can barely remember what I was doing yesterday, let alone who I might have been into contact with two weeks ago. It just makes this so much more challenging.
DAVLIN: You know, and there's so much I could say about that capacity and the stresses on the system. But a related question on contact tracers, once you do get those phone calls, this is from an anonymous listener. I've been hearing stories about calls that people get from people who say they're contact tracers that sound very suspicious. What kinds of questions can people expect so they don't fall victim to a scam? Dr. Pate.
PATE: Well, and in fact, you're right, there are a number of scams going on there, so the first thing is, you know, verify who you're talking with, find out who they say they are with. If you're being contacted, it should be a kind of a contact tracer or an investigator with your local public health department. So if they say they're with the CDC or they're with some other federal government agency or whatever, then you know, that's not the case. The second thing is they should not be asking you for anything that is sensitive information about your finances, your banking. They shouldn't be asking for any kind of payment. There should be nothing like that. They're just going to be asking you about your exposure. So be careful. And and in fact, if you get a call, find out what the person's name is and then you can check with your local health department to make sure that that person is one of their employees.
DAVLIN: Dr. East, Marie sent us this really interesting question that I would love to get your take on. She writes: Clearly, this virus is not going anywhere anytime soon. Rather than canceling elective surgeries that are established hospitals, why not use abandoned buildings around town, for example, the empty Shopko stores and convert them into dedicated COVID treatment hospitals? I know it would be very expensive, she writes, but so is canceling elective surgeries and laying off employees and the hospital systems. Now, I have to say at first I kind of laughed at this question, but there were temporary hospitals set up in places internationally that were hotspots, I'm thinking Wuhan, and places in Europe. So what's your take on that, Dr. East?
EAST: Well, I think that's a that's an interesting question and it raises several points. I think the first point I'd like to make in regards to elective surgeries and I can only speak to what we're doing at St. Al's, but what we've done there is we've physically separated the part of the hospital where outpatient elective surgeries are taking place from the remainder of the hospital. So there's not really an easy means of communication between those two parts of the hospital physically, certainly not for the public. And, you know, every person, every time, every day they go into the hospital, they're screened for symptoms and temperature so that that environment is safe. The patients that have have the virus, they're cohorted in specific parts of the hospital where those resources are available, like the ICU or other areas where there are negative pressure rooms or floors set aside for specifically and exclusively taking care of COVID patients. So, you know, we've come a long ways from where we were at the beginning of this where we did have to cancel some elective cases. But at least in terms of our outpatient cases, we're still going ahead with those as planned. And there are cases from the standpoint of more complex cases that are elective, that require hospitalizations. And and that's a balance. You know, it's a balance for the hospital to ensure that those cases that need to be taken care of in a timely manner get taken care within a timeframe that's safe and appropriate, but also balancing the capacity of the hospital to deal with any surge that may be coming in terms of COVID admissions and in terms of utilizing other buildings. Certainly it's possible to set up facilities that are not hospitals to be, you know, almost like a MASH unit, where where you bring those resources in. I think back to the beginning of this, where that convention center in Chicago was set up and the Army Corps of Engineers came in and and I -- the utilization of that ended up not being not being very much at all. So it's a huge expense to create a hospital and a big expense even to create a temporary hospital, because hospitals are complex buildings with a lot of physical infrastructure. And a lot of special considerations need to take place in terms of ensuring that you control potential transmission of a virus that is airborne and could be transmitted in an open facility. So I don't think it's an easy thing to do. It's a very expensive thing to do. I certainly hope we never get to the point in this community where we have to do something like that. And even within the hospitals, every hospital that takes care of these patients has plans in place that allow for expansion of ICU space and taking care of patients that are higher acuity. And and there would be a lot of challenges that I would say would be impossible to overcome, that would be difficult to overcome in that kind of environment.
DAVLIN: And that just addresses one part of it, the ICU beds and the surgical capacity there, but there are so many other stresses too. Dr. Schulte, I want to bring you into this part of the conversation. Jen wants to know if anyone has voiced concerns for PPE shortages moving forward, especially with potential surges with schools and with flu season coming up. What's the status with PPE?
SCHULTE: So thank you for that question, and that is definitely a question that's on the forefront of our minds every day, probably multiple times a day when we very carefully assess our resources that we have on hand. I'm glad to say that presently for where we are today, we are able to have adequate resources. However, as we have discussed here today and on previous roundtables, it's very clear that it is so difficult to predict the future in that regard and predict the needs that might occur in schools, in our long term care facilities and in other places. Fortunately, the business community has responded and multiple businesses have started to produce PPE that might have produced other products in the past and have been able to raise some of the capacity and overall availability. It is currently adequate. I am, I would say, mildly optimistic that if we are able to continue to contain the virus, especially in our community here, that we are able to meet the demand. But much will depend on our personal and individual behaviors that we are putting forward that will affect the spread of the virus.
DAVLIN: Let's talk a little bit about those behaviors. We've had a number of questions about how people's activities that you would think would be less risky -- getting together with family outside -- might be contributing to the problem unintentionally. Dr. Pate, how safe is it for, say, a family get together in a park?
PATE: Well, I'm glad you brought this up, because we are seeing a change in how people are most commonly getting infected. Now, let me just say, at the end of the day, there's still multiple different ways people are getting infected. But if you look at patterns, of course, early on, we're all aware of the outbreaks that we had associated with bars, for example. And while initially we were concerned about very large gatherings, actually, if you look right now, more of these spreads are either in areas that are confined -- so, for example, long term nursing care was earlier the big problem, right now, we're having a big problem with prison and jails -- but aside from those specific situations, it's really the family barbecue, the family get together. And by family, I'm talking about when you have extended family that doesn't live with you, we're not concerned about the getting in your backyard with the people you live with and having a barbecue. We're talking about when you invite extended family that doesn't live with you and your friends, that is now one of the most common situations where we're seeing this virus get spread.
DAVLIN: Are there safe ways to get together with extended family outdoors, Dr. Pate?
PATE: If you mean safe is risk free, there's very limited ways to do that. The way to do it is, as you said, be outdoors and get a lot of physical distance between you. That will prevent the virus from being spread to the largest degree. But if you're talking about situations where families want to be in close contact, hugging, sitting close to each other and talking, there are things you can do to make it safer. But there's always going to be risk when large numbers of people that don't live together get together are doctors.
DAVLIN: We were just talking about not necessarily safely getting together as far as eliminating all risk, but doing it in the safest way possible. So let's turn that conversation to schools. Dr. Pate, we spoke earlier about the West Ada and Boise School District's decision to kind of push in person learning to September 8th and really hoping that five weeks is going to be enough to lessen the spread. If we're not there at at the beginning of September, since the virus is airborne, how safe is it to send kids and teachers to school if they potentially teach outside right now?
PATE: So in general, anything you can do outside is going to be safer than doing it inside. However, one should not imagine that just because you're outside means you have no risk if you're outside and you're going to be in close contact with people, you still need to protect each other. But outside is always going to be safer than inside. You know how safe or not safe schools are going to be. We really don't know the answer. You know, we do know some things that are concerning. And that is if we look at other countries that have opened their schools while we've had our schools closed, there's been variable results and we don't really quite understand why that is. Some countries have not had any significant problems. Others, despite having much less disease transmission in their communities than we have opened only to have outbreaks and have to close their schools within a month. Israel had to do that. South Korea had to close their schools. Both of those countries had far less disease transmission than we have here in Ada and Canyon County. Germany, that had more transmission than Israel or South Korea, but less than the U.S., they've had problems and they had to close a number of schools. So I just don't know.
We did have a school in Indiana that has already opened. And the first day a student was positive. There was another school, I think it was Arizona that opened and they had cases there. So, one has to imagine -- but we don't have any evidence of this -- but one has to imagine that if you have students and teachers coming from communities that have high degree of disease transmission, you're going to have more risks for outbreaks in schools. That certainly makes sense. That remains to be proven, but it makes sense. And so I do think we need to be cautious about that. And I think at the end of the day, whatever the decision is made, whether students will do online education, which obviously is the safest of all, but if we are going to have in-person classes and there certainly a lot of reasons we all want to get kids back to school, then the critical thing is going to be what are these schools' plans? How are they going to handle it when someone comes up sick? And I think that these poor principals I mean, I feel terribly bad for them. They are, by and large, not public health experts. And every fall we have a situation where respiratory viruses circulate and kids and teachers get sick. And in past years, you would just keep your kid home for a few days if they were sick and they got better.
This year, every parent is going to be worried their kid has COVID. And that's going to make a lot of impacts on the health care delivery system that I think Dr. Schulte made a reference earlier to the demands that it could create on testing, which is already compromised. This is going to be very, very tough to manage. And then on top of that, we can certainly expect a flu epidemic. So, you know, this is just a really, really tough situation. But we don't have another country to look at that I know of that has had this degree of community spread when they've opened their schools so that we could see what happen.
We did see what happened with summer camps. And there are some important differences between summer camps and schools. So the analogy is not perfect. But on the other hand, what we did learn from the first study of a summer camp outbreak to be released is that kids of all ages got infected and the attack rates were quite high and the virus spread throughout the camp in less than a week. So we have to be prepared.
DAVLIN: Along those same lines, a question from Sean, who is a teacher. He says, If a student chooses not to wear a mask and we let them into our classroom, how do we determine who sits next to this unmasked student? What if students don't feel safe sitting next to them? As a teacher, I don't feel comfortable making the decision of who has to sit near the unmasked student. Actually, I don't feel comfortable being in the same room as that student. So more of a commentary than anything, but it raises a lot of interesting questions about the stresses that are placed on these teachers, about decisions that they have to make. But, Dr. Pete, is there any safe way to have a mix of masked and unmasked students in a classroom?
PATE: If we're talking about Ada and Canyon counties or other counties with high disease transmission, no, I mean, that is very clear. That is a recipe for disaster. And what I mentioned before about operational plans, part of that operational plan needs to be that it is the responsibility of everyone to have a mask on, including kids. And it is a responsibility of parents to make sure when they drop their child off, they have a mask and everybody needs to set that as an expectation. And if a child shows up and doesn't have a mask, there needs to be a mask that we can give the child. Or if they refuse to wear a mask, just like any other behavior a student might engage in that would pose a threat to others, they need to be sent home. They do not need to be in a classroom.
DAVLIN: Dr. Schulte, I wanted to bring you into this. I sat through two school board meetings yesterday, one of which had a number of people testify that we don't need to be concerned about children getting the coronavirus. I wanted to get your take on this. What are you seeing in your hospital as far as pediatric cases?
SCHULTE: So there's certainly been a lot of misconceptions around children and whether or not they can get coronavirus, how severe the ill they then are and whether or not they can serve as effective transmitters. And I don't think we really know everything at this point yet. We do know that the majority of children does not appear to be developing a severe illness in the acute phase. We've certainly not seen very large numbers of hospitalizations, but I believe in previous sessions here, a doctor paid to share some experiences of a multisystem inflammatory syndrome that some children are experiencing. I'm not aware that this had a case in Idaho of that so far, but that is causing some very severe disease and otherwise healthy young children that is believed to be directly related to coronavirus. So children are certainly not without risk in that case. We do also know that children definitely sort of above the age of 10, there's strong evidence that they are probably as effectively transmitting the virus as others and adults are doing. So I think we have to bear this in mind.
DAVLIN: Dr. Schulte, I have to cut you off there. Thank you so much. We'll continue to follow that. If you have a question for our doctors roundtable, send us an email at idahomatters@boisestate.edu. I'm Melissa Davlin, filling in for Gemma Gaudette. Thanks for listening.
