Ep 171 - May 2020 Round Up

Lots to chat about on the podcast this month, and not just COVID! There's been blog posts about clots, troponin and even telly, as well as the Journal Club series.

Keep a look out for the new St Emlyn's Lesson Plans that we hope will help usher in a new era of medical education in a socially distanced world. 

If you would like to donate to the fund in the memory Adel Aziz you can find the link here.

We hope you're finding all of our output useful. Please do subscribe to the website (in the top right hand corner) and rate our podcast on iTunes. 

Take care

Iain

Podcast edited by Izzy Carley

PS You can find the Lesson Plans here. Still a work in progress, but as you've read these "shownotes" you deserve to have a sneak preview... 

Ep 170 - COVID-19 Journal Club #7 (June 2020)

Welcome to our seventh webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn's.

The live event took place on Tuesday 26th May.

Today's panel will be hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Anisa Jafar, Prof Pam Vallely (Professor of Medical Virology), Ellie Hothershall (Consultant in Public Health), Prof Simon Carley and special guest Kelly Ann Janssens (Emergency Physician in Ireland) to discuss five papers about COVID-19 infection.

This will be the last weekly journal club, but we will be back with more EBM goodness very soon. Do let us know what you like to be included at stemlyns@gmail.com

Ep 169 - COVID-19 Journal Club #6 (May 2020)

Welcome to our sixth COVID-19 Journal Club Podcast.

The panel was hosted by Rick Body and included Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Anisa Jafar, Prof Pam Vallely (Professor of Medical Virology), Prof Simon Carley and special guest Liz Crowe (Advanced Clinician Social Worker and PhD candidate in health staff wellbeing in Brisbane) to discuss four papers about COVID-19 infection. We were especially pleased to welcome Liz this week, which enabled us to focus on the important topics of grief, loss and communication during the COVID-19 pandemic.

References

Ep 167 - Troponin Update and LoDED Study Review with Rick Body

Over the last few years many of us in the UK have started to incorporate high-sensitivity troponin into the assessment of patients presenting with chest pain.

We have seen these samples taken at ever shorter intervals, aiming to discharge low risk patients safely, sooner from the Emergency Department (ED). This has been driven in part by the "Four Hour Emergency Access Target"^​ as well as increased crowding in overwhelmed EDs.

In this podcast, internationally renowned researcher Prof Rick Body discusses the latest in troponin research and the recent LoDED study.

The Shownotes

The various organisations mentioned by Rick can be found here:

The Innovation Agency Webinar Series

The NHS Accelerated Access Collaborative

The CQUIN that will be implemented later this year (page 15 for the Troponin section)

The Draft NICE recommendations

Ep 166 - COVID-19 Journal Club #4 (May 2020)

Welcome to our fourth webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn's.

The live event tool place on Tuesday 5th May at 11.30am BST (10.30am GMT). 

The panel was again be hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Anisa Jafar (Academic Clinical Lecturer), Prof Pam Vallely (Professor of Medical Virology), Prof Simon Carley and special guest Justin Morgenstern to discuss six papers about COVID-19 infection.

There will be another COVID 19 Journal Club next week (Tuesday 12th May at 11am).

References

Podcast edited from a live webinar by Izzy Carley 

Ep 165 - April 2020 Round Up

It's been another busy month at St Emlyn's, with the publication of 15 blog posts and five podcasts, but there does seem to be an awful lot to talk about!

Of course there have been multiple posts and podcasts about COVID-19, and you can fiind all of these on our special St Emlyn's page. Highlights have included the three RCEM/St Emlyn's Webinars which we are delighted to host in podcast form.

It's not just been coronavirus though, we have also dipped out toes into exercise and nutrition, graphic design and horticulture!

Parts of the site have also undergone a bit of a redesign with the curriculum pages now easier to navigate to find that post to fioll an e-portfolio hole.

We hope you're finding all of our output useful. Please do subscribe to the website (in the top right hand corner) and rate our podcast on iTunes.

They'll be much more to come in May I am sure.

Take care

Iain

Podcast edited by Izzy Carley

Ep 162 - Beyond the ED: COVID-19 and Critical Care with Dan Horner

In this podcast, Dan and Iain talk about the clinical journey of a COVID-19 patient, beyond the ED, with insights from the critical care unit. There are some concepts here that we don’t have time to do full justice to in the podcast, so there is a comprehensive set of "show notes" and all the references at www.stemlynsblog.org/covid-19-and-critical-care

Ep 153 - December 2019 Round Up

Our regular round up of the best of the blog from December 2019. Published a little late, largely because of Coronavirus issues and general business.

Ep 150 - REBOA with Zaf Qasim

Simon and Zaf talk about the practicialities of REBOA and discuss whether it's ready for prime time in the UK.

Further reading

Ep 137 - Beyond ATLS with Alan Grayson at #stemlynsLIVE

Alan Grayson takes us through his thoughts on ATLS. Is it really as terrible the #FOAMed world makes out?

Ep 136 - Wellbeing for the broken with Liz Crowe

This is the podcast that links to the following two posts on how to deal with some of the hardest events we have to deal with in emergency and critical care.

You can read more about the topic on the following two blogs.

https://www.stemlynsblog.org/wellbeing-for-the-broken-part-1-liz-crowe-for-st-emlyns/

https://www.stemlynsblog.org/wellbeing-for-the-broken-part-2-st-emlyns/

This is a tough listen so if you are affected by the content do chat through with colleagues. 

Ep 132 - Aortic Emergencies with George Wills at #stemlynsLIVE

Back in late 2018 we gathered in Manchester for the inaugural #stemlynsLIVE conference. Our friend Dr George Wills gave a great talk on Aortic Emergencies.

All emergency physicians know that it's all to easy to miss an aortic catastrophe. Listen to George's wisdom on common pitfalls and top tips to make you a better emergency clinician.

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Also check out these excellent #FOAMed resources.

• Subscribe to the blog (look top right for the link)
• Subscribe to our PODCAST on iTunes
• Follow us on twitter @stemlyns
• PLEASE Like us on Facebook
• Find out more about the St.Emlyn’s team

Ep 127 - The Journey that Matters with Clare Richmond at #stemlynsLIVE

This podcast and presentation was recorded at the St Emlyn's LIVE conference in Manchester 2018. In this presentation Clare takes us through the rationale, principles, training and practice that we need in order to continually develop as prehospital and resuscitation practitioners.

You can read more from the event at http://www.stemlynsblog.org 

This is a great presentation for anyone interested in continually developing their own and their colleagues practice, delivered by someone who really knows what they are talking about and who works for one of the best developed resuscitation services in the world.

Clare is an Emergency Physician and specialist in Pre-Hospital Care and Retrieval medicine based in Sydney, with Royal Prince Alfred Hospital and Sydney HEMS. She has completed a fellowship in simulation based education, and enjoys training with “real” people - patients, bystanders and the other clinicians we come across as we treat our patients every day. She is a lecturer with the University of Sydney, and is involved in education for the NSW Institute for Trauma Injury Management. When Clare is not working on helicopters or training teams, she is studying yoga or hanging out with her puppy, Archie. 

Ep 125 - November 2018 Round Up

November was a busy month for the St Emlyn's team with a variety of blogs on conferences, EBM, philosophy and education. Here's the podcast and the links to the blogs mentioned in November.

Ep 122 - Beyond ALS with Salim Rezaie at #stemlynsLIVE

Salim Rezaie from the REBEL EM podcast takes us through the optimal management of cardiac arrest and also explores some of the controversies and difficulties that make the difference to our patients. 

You can read a lot more about the background to this talk, see the evidence and watch the video on the St Emlyn's site. Just follow this link. https://www.stemlynsblog.org/beyond-acls-salim-rezaie-at-stemlynslive/ 

Ep 120 - The pursuit of excellence with Nat May at #stemlynsLIVE

This presentation was given at the inaugural #stemlynsLIVE conference on the 8th of October 2018 in Manchester. You can read more about the presentation and the conference here. https://www.stemlynsblog.org/in-pursuit-of-excellence/

Ep 108 - February 2018 Round Up

Iain and Simon review the best of the blog from February 2018.

Simon Carley

Ep 107 - January 2018 Round Up

Iain and Simon round up the blog posts from January 2018. You can listen to the podcast below. Links to all the blog posts mentioned are listed below.

As 2017 ends and we look forward to 2018 it’s time to reflect on a year with the St.Emlyn’s team. Despite our chronological and geographical dispersal it’s really felt like a team effort in 2017. We have travelled, learned, listened,…
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JC: Devastating Brain Injury. Complex decisions in the resus room. St.Emlyn’s

Simon Carley January 4, 2018 3 Comments Social media can sometimes give the impression that all is rosy in the world of resuscitation. We hear of the amazing saves, the wonders of ECMO, helicopters and heroic acts with great outcomes, but the reality is of course very…
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[caption id="attachment_31228" align="alignleft" width="300"] northern emergency medicine conference[/caption]

St.Emlyn’s goes further north – NEM Conference #NEMC18

Chris Gray January 9, 2018 0 Comments It’s the second time I’ve been to the Northern Emergency Medicine conference, this year held in the sunny city of Durham. I say sunny… I needed my jacket. Last year’s programme was great and included some fantastic speakers, including our…
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JC: Can I safely discharge dizzy patients from the ED?

Janos Baombe January 12, 2018 4 Comments  Last month, I came across a clinical review published in the Annals of Emergency Medicine1 that got me really excited! It got me excited (in a geeky professional sense of course…) as it covered a topic that causes significant…
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On Reflection

Natalie May January 16, 2018 3 Comments On Reflection I’ve been reflecting on reflection for some time now, at least since I started formally collecting my lessons from Sydney HEMS and probably even before that, because this sort of meta nonsense is something medical education enthusiasts like…
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CRYOSTAT-2 with Ross Davenport

Richard Carden January 21, 2018 2 Comments You might be aware that an exciting new trial has started called Cryostat-2.  This is exciting as it has the potential to improve patient outcomes, but also because it will involve all the Major Trauma Centres in England and 8…
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The End of the ‘Roid? JC: ADRENAL

Dan Horner January 22, 2018 4 Comments So another year, another Critical Care Reviews meeting. Rob is doing an absolutely fantastic job with these, inviting lead authors from major critical care trials to present and defend their work. In fact, this is going so well that this…
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Belgian EM at BeSEDiM 2018.

Simon Carley January 28, 2018 0 Comments Last weekend, the BeSEDiM (Belgian Society of Emergency and Disaster Medicine) organised their annual symposium. It is the scientific organization of the Belgian emergency physicians with Said Idrissi as chairman. 13 years ago, Belgian Emergency medicine was born as a…
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Is there anything else I need to know? Working in Africa.

Simon Carley January 29, 2018 0 Comments This is a guest post from our good friend Stevan Bruijns aka @codingbrown Stevan has been an advocate of international emergency medicine for many years and he, like us feels that there is much that high income countries can do…
Read more

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@EMManchester

Before you go please don’t forget to…

• Subscribe to the blog (look top right for the link)
• Subscribe to our PODCAST on iTunes
• Follow us on twitter @stemlyns
• See our best pics and photos on Instagram
• PLEASE Like us on Facebook
• Find out more about the St.Emlyn’s team

Simon and Iain belatedly reflect on a tough winter and the posts in January.

Check out stemlynsconference.com if you want to know more about #StEmlynsLIVE

S

Ep 104 - Managing Perceived Devastating Brain Injured patients with Dan Harvey and Mark Wilson

In this podcast Simon talks to Dan Harvey (ITU) and Mark Wilson (Neurosurgeon) on the management of complex patients with a perceived devastating brain injury.

This podcast is linked to the blog on the St.Emlyn's website.

http://stemlynsblog.org/jc-devastating-brain-injury-complex-decisions-in-the-resus-room-st-emlyns/

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Ep 91 - Critical Appraisal Nugget 7: Relative risk, Absolute risk and NNT in 5 minutes

A critical appraisal nuggest on simple ways to understand the true effect of an intervention. Also see this more in depth podcast done with Iain Beardsell

https://ebem.podbean.com/2011/11/03/statistics-2/

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Ep 89 - March 2017 Round Up

In a new podcast format Simon (@EMManchester) and Iain (@docib) discuss the month's offerings from the St Emlyn's blog and podcast (www.stemlynsblog.org).

It's been a month full of interesting posts on subjects as diverse as Thrombolysis in Stroke (Alan Grayson), The Future of Emergency Medicine in the Social Age (Simon), Cardiac Arrest Centres (Simon), Love in Critical Care (Liz Crowe), Transfers (Nat and Simon), Thrombolysis in PE (a guest post from FOAMed legend Anand Swarminathan) and Benzos in Back Pain (Janos). Head to the website for the articles themselves and all the references and links you need.

We're aiminig to make this a regular monthly podcast - let us know if it's useful and enjoyable and how we could make it even more educational.

Ep 87 - Critical Appraisal Nugget 6: Retrospective and Prospective studies

Rick and Simon talk about the merits of prospective and retrospective studies

Ep 83 - The Teaching Course in NYC Round Up

A quick round up of events from the excellent Teaching Course in New York (https://flippingmeded.com/) with guests Ross Fisher (@ffoliet), Ashley Leibig (@ashleyliebig), Sandra Viggers (@StarSkaterDK) and Camilla Sorenson (@Camillabirgitte).

For brilliant summaries of each day, with details from every talk, visit http://scanfoam.org/teaching-course-nyc-day-1-ttcnyc16/ (Day 1) and http://scanfoam.org/teaching-course-nyc-day-2-ttcnyc16/ (Day 2)

Ep 74 - ED Handover in the resus room: A panel discussion at SMACC DUB. (Part 2)

Part 2 of our podcasts on major trauma handovers. This follows on from the discussion at SMACC and is intended to operationalise the concepts we talked about then. This is aimed at a UK audience but should apply pretty much anywhere. So hands off, eyes open and listen in, here we go.

Ep 73 - ED Handover in the resus room: A panel discussion at SMACC DUB. (Part 1)

Whilst we were in Dublin at the SMACC conference we took the opportunity to get some great minds together on the subject of ED handover at the point between prehospital and hospital teams for the critically ill or injured patient in the resus room.

This is an area of some difficulty in many areas (prob shouldn't be, but it is) and we thought it would be fun and useful to get perspectives from both sides.

As ever, we are not here to be definitive and your service may have a fantastic model that works well. This podcast is to help you think about what you're doing and to consider whether it can be improved.

Doug Lynch is a retrieval doctor from Australia
Ashley Voss-Liebig is a flight nurse from Texas
Natalie May is a retrieval doctor from Sydney (Virchester Alumnus)
Rusty Carroll is a senior paramedic from Virchester and a great supporter of the ATACC group.

We don't have all the answers, but we do have the ideas.

In Virchester it can certainly be improved.....

Tell us what you think and keep an eye out for the blog post on the same subject coming soon.

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Ep 61 - Londoon Trauma Conference 2015 Day 2 Summary

Our summary of Day 2 of the excellent London Trauma Conference. A unique threesome from Nat, Simon and Iain.....

Ep 60 - Londoon Trauma Conference 2015 Day 1 Summary

Greetings from the London Trauma Conference!

As has become our pre-Christmas custom, Iain and I have been hanging out at the fabulous London Trauma Conference, hearing about advances and controversies in trauma care and tracking down some of the speakers to find out exactly what they really think (and recording it, for podcasts we'll release in due course).

The conference extends over four days, incorporating the Air Ambulance and Prehospital Day and the Cardiac Arrest Symposium; unfortunately we can't stick around for those but our colleagues over at the RCEM FOAM network will be podcasting from those days too, so keep an eye on their site and podcast feed too.

Ep 58 - Clinical Judgement for the Emergency Physician

My talk from the RCEM conference in Manchester 2015.

Linked blog post here. http://stemlynsblog.org/making-good-decisions-in-the-ed-rcem15/

Slides are here http://www.slideshare.net/simoncarley7/making-good-decisions-rcem-2015-manchester-wednesday

Have fun and enjoy your emergency medicine.

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Ep 48 - Intro to EM: The patient with back pain.

Another induction podcast on a common condition in the ED. Back pain in the ED - it's not all musculoskeletal and there are some really risky diagnoses out there that you need to think about.

Ep 44 - Tim Draycott on Obstetric Trauma (LTC 2014)

Iain interviews the wonderful Tim Draycott on the management of the Obstetric patient with trauma.Tim is a consultant Obstetrician from Bristol and is a great speaker on this rather terrifying topic!

Ep 43 - APLS 2015 updates for the management of the serious injured child

A short podcast updating the UK Advanced Paediatric Life Support (APLS) course guidelines for the management of trauma in children.

Don't forget to read the blog post here. APLS Updates: New kids on the block,

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Ep 42 - Paediatric Major Trauma with Ross Fisher (LTC 2014)

I recently met Ross in the flesh. What a super chap. A great clinician who really wants to improve care for injured children in the UK and around the world.

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PS. If you ever get to hear him speak.... then do, he's awesome. Check this out.

Ep 40 - Opiate overdose in the ED

Simon and Iain debate how the management of opiate OD has changed in the ED.

Surely you're not still giving massive doses of naloxone IV and IM are you? Really? Maybe this will make you think again.

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Ep 39 - Prof. Tim Harris on Shock Assessment (LTC 2014)

Do you think you're awesome at assessing shock?

Think again!

The stupendous Prof Tim Harris (who St.Emlyn's loves) tells us that all is not quite as it seems.....

Listen, learn, be awesome.

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Ep 34 - Intro to EM: Problems in Early Pregnancy

The number of patients seen in each ED with problems relating to early pregnancy in the UK is very variable - some hospitals have rapid referral pathways for patients who know they are pregnant. It's still worth thinking about early pregnancy problems though as all EDs see young women and many of these may not yet know that they are pregnant.

Our induction podcast covers our approach to women presenting to the ED

Nat and Iain :-)

Ep 33 - Impact Brain Apnoea with Gareth Davies from London HEMS (LTC 2014)

First of our podcasts from the London Trauma Conference.

A fantastic episode with Iain talking to Gareth Davies (from London HEMS) talking about Impact Brain Apnoea.

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St.Emlyn's

Ep 31 - London Trauma Conference: Day three round up.

It's prehospital and helicopter day at #LTC2014! Iain and guest podcaster Caroline Leech chat through the key points of the day.

Ep 27 - Intro to EM: The patient with chest pain

Iain and Simon discuss the dilemmas of dealing with the patient presenting with chest pain to the ED.

Blog post link here

Ep 24 - Getting started in Emergency Medicine Research

The Challenge and Value of Research in Emergency Medicine: at DGINA 2014

Rick Body's talk from DGINA on the need for research in EM.

Check out the associated blog post at http://stemlynsblog.org

Ep 23 - Smacc Chicago update

Iain and Simon talk about the upcoming SMACC conference in Chicago and do their very best to persuade you to come to the best conference in the world

Ep 22 - Button Battery ingestion in children

Simon and Nat with a linked podcast to the blog post on the ingestion of button batteries by children.
http://stemlynsblog.org/button-batteries/

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Ep 21 - Code for Cash and Credibility

Simon and Iain discuss what might appear to be a rather dull subject, but it's not. Coding is a key to developing your department and also to secure the functions of UK emergency departments.

A great primer for everyone coming up to FCEM and to anyone interested in how Emergency Departments are funded in the UK.

Follow this link to the associated blog post http://stemlynsblog.org/show-money/

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Ep 18 - Victoria Brazil on great presentations with St.Emlyn’s

Vic Brazil of #FOAMed and #SMACC fame came to talk to the St.Emlyn's team in Virchester.

Listen in for top tips on looking great and sounding super.

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Ep 17 - Diffuse Axonal Injury with John Hell

John Hell is a Neurointensivist at University Hospital Southampton and very kindly gave up an afternoon to record his thoughts and share his considerable wisdom about Diffuse Axonal Injury.

I also managed to get him to discuss some other topics including the choice of induction agents and intravenous fluids in patients with head injury.

Please listen, enjoy and comment. We'd love to hear from you, and don't forget to visit the blog site for additional information, slides and content.

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Iain Beardsell

Ep 16 - Intro to EM: The patient with syncope (transient loss of consiousness)

This podcast is part of our induction series for new docs starting in UK emergency departments.

You can check out the full post and supporting materials over at the main St.Emlyn's website.

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Ep 15 - Understanding Troponin Part 2

Recently we published part one of our series on cardiac troponins.  If you haven't checked it out yet, you can find it here.    In the second part, we're going to take a look at high sensitivity troponins and some of the more advanced areas around understanding cardiac troponin and its use in practice.  We'll give you a quick run down on the troponin lingo - the language you need to be able to speak in order to fully understand how to use high sensitivity troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile.

We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet:

What if we called it "low specificity troponin" instead of "high sensitivity troponin?" Would that knock some sense into people?

— Joe Lex (@JoeLex5) October 9, 2012

So, check out the associated BLOG POST here and listen to the podcast. There is more on diagnostics and troponin to come very soon.

Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you.

Rick

DOI: Much of my research work involves HsT. To help with this I have received reagents from companies who make HsT assays, but I not received any other financial benefit or gifts in kind as part of my work and have no financial ties to any companies.

Ep 14 - Exeter CEM conference with Adam Reuben

In addition to being generally awesome he is also the convener of this year's College of Emergency Medicine conference in Exeter from the 9th to the 11th of September 2014. There is still time to come and the program looks really good and features some fantastic presenters.

#AWESOME ALERT - CLIFF REID WILL BE THERE - YOU HAVE TO BE TOO!!!!

I'll be there with many others from St.Emlyn's so if you see me say hi.

You can see the program here

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Ep - 11 Understanding Troponin Part 1

Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)?  When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI.  The way they were managed is a million miles from what we do now.  Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days.  We'd measure CK, AST and LDH.  'CK' was the so-called 'early marker', which would rise early after the start of an AMI.  Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis).  AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3.

Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal?  It's completely unthinkable.  That's how much cardiac troponin has changed our practice.  We rely on it so completely to diagnose AMI.  And yet, it's one of the most misunderstood tests in medicine.  Given how much we use it, I guess we feel that we all should know lots about this test.  But doctors still have so many questions.  Here are just a few:

• What is cardiac troponin?
• Why is it a marker of AMI?
• What else causes a raised troponin and how?
• Should we be doing troponins at 3 hours, 6 hours, 12 hours?  What's the difference and what's the evidence?
• What is a 'delta troponin'?
• What do you need to 'rule in' AMI?
• How do you use cardiac troponin in patients with renal failure?

This is just a brief list.  With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot.  There are loads of questions that people ask - but there are lots of themes in common.  We thought it was about time we produced a handy run down in the true spirit of #FOAMed.

Take a listen to Part 1 of our troponin podcast.  While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast.  I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff.

We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo.  Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more!

Rick

Ep 10 - Intro to EM: Staying safe in your first job

If you're starting out in EM then it can be a scary time. Iain and Simon talk through some of the initial anxieties and ask what you need to know to be safe, sensible and super.