Okay, so how many of you guys have taken any call yet for GI? Oh, wow, a lot. Wow. Okay. So a lot of people don't start right away, but so in getting you prepared for your on-call questions that you're going to get from patients in the ER, our next talk is the on-call call. So we have Dr. Robert Moran from MUSC giving this talk, thanks. Thank you. It's nice to be here and see all young, enthusiastic people starting off their career in this field. So this is a very practical lecture, and it's quite interactive, so there's lots of questions. We'll stop and ask questions. But also during it, if there's any questions, I'd encourage you to put up your hand. And I'm happy to stop once I've finished a point and address any questions. So my only disclosure is I'm a consultant for Cook Medical. And so the first question. PTSD, that's pretty impressive. Not being on call yet. Okay, so some of you feel your black clouds, some of you don't. I'm personally not a believer in this stuff, it's all just random, you know? The human experience is very different. Two people go through the same event and they have two different perceptions of it. Okay. Who sleeps a lot, by the way? I hope my, our fellows aren't here, are they? Okay, good. All right, so case one. It's your first night on call and you get a pager. Most of you probably don't have pagers, do you? It's probably on your phone at this stage, is it? Yeah, okay. This is a little antiquated. So it's a bleeder, it's a food impaction, you're worried. What's the call? It's a patient and he's calling because he hasn't taken his bowel prep and he doesn't know what to do. So how do you deal with this? I think the first thing, as a fellow, I'll tell you that the most important thing is just to be decent on the phone. You all have worked as residents and you've all dealt with fellows who are difficult on the phone and difficult to deal with. Don't be that person, right? And everybody's here to do a job and there's an expression, you know, you'll catch more bees with honey and that is very, very true. And if you're obstructionist on the phone and if you're a blocker, you'll just, you'll end up putting roadblocks up for yourself and give yourself more work. And more importantly, with a patient, you know, the relationship between a patient and a physician, the patient is the vulnerable and you're in the position of power, right? Your job is to take care of the sick and the vulnerable. So losing a patient doesn't help. Now that doesn't mean you should take abuse from patients, but I think that's the first thing I'd like to say. And there's a couple of points that this lecture brings up about, you know, how you can be professional and improve the patient's experience because that's certainly how medicine is going is the patient's experience. And the first one is, you know, answer the call as best you can in terms of time. You know, if you're doing a procedure and a bleeder, you don't need to stop your procedure to stop to answer a call about a bowel prep, but you know, don't leave it till the next morning or six or seven hours. Try to be relatively quick in terms of answering the call. And that's shown in the customer service satisfaction world that the quicker you get to a call, the happier the patient will be. And that's the same with us, right? Like you call AT&T and you wait for six hours, like you're irritated by the time you talk to the person. So remember, the patient is also going through an experience. And you know, you want to be accurate and transparent. And so don't waffle if you don't know an answer, just tell the patient, look, I'm not sure. I'm going to touch base with one of my colleagues and I'll get back to you. So in this case, this was a bowel prep question. One thing I'll tell you is you need to know what your unit's policy is for a bowel prep. Everybody does it a little bit differently. I think most people here will be on a spit prep where you take half at the night before and half at the morning of. The other thing you want to be aware of is what your anesthesia rules are. Typically with Clearliquids, it's two hours where I work, but you just want to kind of clarify when their last Clearliquids can be and when their procedure can be. And then know what bowel prep you use. One of the issues with these calls is you often get them at like nine o'clock at night. So like getting a patient to go out to the pharmacy and writing them a new prescription is just going to be very difficult. So one thing that is useful is I will tell you, is just know what a Miralax prep is. You know, if the patient hasn't picked up their prep and they've been on the Clearliquid diet, maybe there's still a chance you can give them a Miralax prep. And so a Miralax prep, I think is like 238 grams of Miralax in about two liters of water. I don't know what that is in fluid ounces. I've been here in this country for 12 years and I still don't understand fluid ounces. It just doesn't make sense. So I'll be kind of touched on most of this. You know, you can give them a bisacoidal, a stimulant laxative. And you know, I wouldn't say it's very useful. You know, you want to make sure if they're calling you at eight o'clock that they've actually been on the appropriate diet for that day, right? If they had dinner at six o'clock and they're calling you at eight o'clock to do a colonoscopy, that's just not going to happen, right? They have to be on a Clearliquid diet really the day before. Some places will allow you to have a breakfast and then be on a Clearliquid diet for 24 hours. Our institution doesn't mandate a low residue diet two days before. We just tell them a Clearliquid diet the day before. What's a Clearliquid diet? It's very simple. If you pick up something with writing on it, if you pick up a container that has writing on it, when you look through the container, you should basically be able to see that writing. That's a Clearliquid. And examples of Clearliquids are obviously water, apple juice, orange juice is not, Gatorade is a Clearliquid, coffee, tea without milk or cream. That is what will kill you when you're doing an endoscopy, you know? Anesthesia will talk to the patient, be like, did you have coffee? I had coffee two hours ago. Did you put any cream in it? I did. And you're like, no, because then they have to wait four hours. So just be clear with that when you're talking to a patient as well. And we avoid red or purple colors as well, because this can cause problems seeing stuff in the colon sometimes. And what about meds? What kind of, the patient knows, wants to know what meds should they take in the morning? So which of these medicines should be continued and which should not be continued? You've all answered? Well done, excellent. That's the right answer. And so you should give them all their blood pressure medicines. You know, if you hold someone's blood pressure medicine and they have a procedure at four o'clock, there's a reasonable chance that they'll be somewhat hypertensive when they come in for the procedure. And depending on the anesthesiologist you have, if they're very hypertensive, that could delay your case. They may need to give them something orally then. So they should definitely take, obviously, their blood pressure meds, beta blockers, aspirin doesn't really need to be held for any procedure. Plavix obviously knows a different story that was dealt with separately. And then on the morning of the procedure, the patient should hold their oral diabetic medicines and they should take a half dose of their long-acting medicine and no short-acting medicine. And then there's been a whole really lecture on bleeding before, I believe, that I listened to. Again, you never stop aspirin. And so he calls back because now he's started his prep, he's run out to the pharmacy, it's open, he's got his prep and he's vomiting. So what to do? He also called back, you know, this is a poor guy, just give him a break. You don't need to be harsh on the guy. Think about your grandfather or grandmother calling you and that makes things easier. So if patients are vomiting, it's fine to stop. Give them, tell them to stop their prep, give it, you know, 30 minutes, an hour, and then they can take their prep at a slower pace. The other thing is if they leave their prep in the fridge, it's easier to drink. Sometimes this stuff can be a little bit nasty to drink. I don't know if any of you guys ever had Miralax, but sometimes Miralax is a bit chalky and it's not pleasant to drink. So if you keep it chilled, it works better. Some people drink it through a straw, interestingly, and that helps. And then they can also add flavoring to it too. Or you can just, if it's a Miralax prep, you can put the Miralax indicator in. And we've kind of touched on a lot of this stuff. You can consider prokinetics and antiemetics if they have them. Again, usually these calls are happening at eight or nine o'clock at night, and just the practicalities of getting a patient out to a pharmacy to get all this stuff is not there, but maybe they'll have something in the house that you can advise. A lot of this is really common sense. So he's happy, look at him smiling, and he's gonna get his colonoscopy tomorrow. Okay, great. Case two. Okay, great. Case two. So you get your second page. You thought you were gonna get a good night's sleep, and it's the ICU, and it's a bleed. So this is something that stresses you all out when you're on call, and this is the kind of fine art of figuring out call. It's who do you need to come in in the middle of the night for, who can wait till the morning? Because that's a big deal, right? If you're coming in the middle of the night, you have to activate all the nurses, they come in, you have to activate your attending. And so, you know, it's important. It's an important decision tree to get right. So emergent cases, they need to be scoped that night. Sometimes urgent cases can happen in the morning. There's also some nuance to that too, right? Like let's say something happens at five o'clock, it's emergent, and the nurses take an hour or two to get in, is it going to be the morning anyway because your endoscopy starts early in the morning? But urgent cases usually scope in 24 hours. So which of these does not require an emergency endoscopy? 35-year-old guy with chest pressure spitting up saliva after eating, a 65-year-old patient with ascites vomiting blood, a 70-year-old man on warfarin who has some blood clots per rectum, and an 85-year-old with distention and a coffee bean shaped loop of colon. So what's the issue with A? Why is that urgent? The food impaction, yeah. So you need to commit for that. And B, why is B urgent? Yeah, so you're worried the patient could have a virus in B, yeah. And then what about D? What's going on there? Problems, yeah. So all those things typically need to be done there and then. And then why not C? Yeah, exactly, he's hemodynamically stable. There we go. So who do you want to do a CT scan for? An urgent endoscopian. Obviously, somebody who has massive life-threatening bleeding, right? If they're hemodynamically unstable, that person needs to be scoped. And if you're unsuccessful, you may need to send the patient to IR or radiology afterwards. So hemodynamically unstable patient, you need to scope. Now, you need to make sure they are ready to be scoped, and we'll touch on that in a little bit, but they need to be scoped. If you suspect somebody with a variceal bleed, patients who typically have variceal bleeds, one, the bleeding is massive, and two, usually they're a sicker substrate. You know with variceal bleeding, if you're a child C, your mortality rate is much higher than if you're a child's A. So they're a poor substrate with a massive bleed. And if you delay those cases, then they'll have a worse outcome. Bleeding after a high-risk intervention. So something like an EMR, post-polypectomy bleed. Post-polypectomy bleed, you know, can occur anywhere up to 14, 21 days later when the eschar forms and falls off, and after sphincterotomy. A post-sphincterotomy bleeding can be very, very large. And even, I'll tell you as a general GI doc, you know, some people feel that this has to be done by an interventionist, and yes, I think an interventionist makes it different like a therapeutic doc, but even with an EGD and a cap, you can see the ampula pretty well. And so that's one thing to say. Although ideally in a bad case of post-sphincterotomy bleeding one of the treatments is to put a stent in, and if you're not a therapeutic person, then you can't put the stent in. The other thing I'll tell you is if anybody, if any of these things happen, you should also send a message to the provider who did this. One, it's courtesy. All my fellows have my cell phone number, and if any of my patients turn up, they text me to let me know. And if my patient has a complication at two in the morning, I get up and I go into the hospital and I do that person. You know, you did the procedure. There's an onus. I feel personally, my own personal belief, some people are different, that I have to take responsibility. I did the procedure. Then also if you did the procedure, you already know the anatomy. You're the person best situated to actually deal with that. And then food impaction or foreign body, they're obviously something that needs to be done straight away. Somebody as well as batteries in the esophagus aren't very good, a sharp object in the stomach. Not all foreign bodies need to be done. And if the foreign body is already passed through the stomach, then, you know, there may be limited utility in doing an emergent endoscopy. And then obviously a chronic lobulus. This is an extreme case of a sigmoid lobulus. Okay, and you basically could go in, detorsion that and then put a tube in to decompress it. And the other thing I'll tell you is, you know, you may have been the best resident that the hospital has ever had. And you would presume that somebody would treat a patient like you treat a patient. But not everybody will always be like you. And so almost presume that the resident knows nothing. Obviously don't be condescending, but you know, check all the basics. You know, are they on blood thinners? What have you done to reverse the blood thinners? Are they on morphine? What have you given to reverse that? And where is the patient? The patient's on the floor and they're hemodynamically unstable. They should be in the ICU. So make sure you kind of tick all those boxes yourself and check up that the stuff is done. Just because you asked for something to be done, you'll start to realize now on this end that it may not always be done, right? You know, the resident orders the platelets, but there's a delay in the lab. They've called the nurse. The nurse has called somebody else, the wrong person. And the patient's just about to come down for the procedure and the platelets aren't given. And then the patient's in the room and the patients aren't given. So just follow up on this stuff yourself because it gets missed a lot. And then also when you're at home on the phone, you can also kind of figure out a little bit more and do some triaging, figure out where the bleeding may be coming from. And you know, is this a cirrhotic patient and so on? Do they have risks of cirrhosis? You know, a patient may present, the first presentation of decompensated cirrhosis may be a variceal bleed. So ask all the other things. What are their platelets when they come in? And do they have any other signs of cirrhosis? This is, well, it's July now. Yes, I remember. You're a July fellow, but you may be dealing with a July intern, right? So we kind of touched on some of this, you know, be specific with things. I will tell you that the best way to deal with stuff as a consultant is always when you finish the conversation with them, that person should always feel like they can just touch base with you again anytime they want. You know, have that kind of friendly discord that, look, I'm here to help. And that's what you are. Your job is to help another doctor. Another doctor is asking you for your opinion. So your job is to help. But always, when you finish that conversation, always make sure that they know they can come back and call you. And if you're that type of person, that actually makes your life easier. And you get on with people and life is just better. And again, then be very specific again with what you ask somebody to do. You know, again, you could be dealing with a July intern. So case two. This is a person who has cirrhosis, who started vomiting blood and is hypotensive. What should we do? We come in. You know, if you're going to scope somebody in the middle of the night, typically we do that in the ICU, right? And the justification there, if you have a variceal bleed, if you have a bleed in the middle of the night, they're the unstable patients. They need to be done in the ICU, right? It's unlikely that you're going to be doing that person in your endoscopy unit. But that's varied. I'll tell you, the way my, our unit works is that sometimes we'll actually, we have the staff for therapeutic cases overnight we'll bring the patient from the ICU with a travel team down to our unit, just because in our unit, we've got all the tools and equipment we want. And so it's very accessible. But those patients should be in the ICU and they should be appropriately monitored. And, you know, make sure you're asking questions if a patient just had a procedure and make sure you think about other things that could be going on. Remember, you're going to have more knowledge about this. You may not feel that you have a ton of knowledge already, but you're going to have more knowledge about this than the intern or resident that you're talking about. And then the other thing is, you know, do you get a sense of what's going on if this is a terrible, lower GI bleed, right? You know, you might want to do an upper endoscopy just to make sure it's not from an upper source, which is a very reasonable thing to do, but you may be telling the resident, look, just let I or no, it's 10 o'clock, right? You want to let the I or no fellow before they go to bed that they could be getting a call in the middle of the night for a beater. So you could be like, look, just touch base with the I or fellow to let them know that we may need to, they may be needed. And the other thing you need to do is, you know, these are all very basic things that you think will happen. And again, this is part of following up, but you can't do an endoscopy if someone is crashing, right? So just make sure they've got their platelets and their blood and their hemodynamics stable and their access is there. And if the patient is set up nicely during your procedure, your procedure is going to go much better, right? You're trying to do an endoscopy on somebody and they keep on crashing. They keep on getting hypotensive and you keep on having to stop and code the patient and all the rest of it. So just make sure they're resuscitated properly and follow up on that stuff yourself and make sure there's nothing else going on. And then it's always a risk balance, right? Which is the bigger issue. Is the bleed going to kill the person first or is it something else? So you have to kind of figure that out too. A lot of patients will need to be intubated. Obviously, if you're having massive upper GI bleeding, those patients need to be intubated. If they have altered mental status, those patients need to be intubated. And I can tell you that, you know, I trained in a country where we did everything with conscious sedation initially. And since I've come here, we have anesthesia for everything. Anesthesia for a sigmoid colon is ridiculous. But for big GI bleeds, the patient being intubated is just very easy. It means the airway's totally protected and the anesthesia team can just worry on all, sorry, concentrating on all the other stuff. So I have a very low threshold to have somebody intubated for a procedure. Okay. So, and again, it's all the stuff that you need to just tick the boxes and make sure it's done. You know, do they have good access? Do they need a cortis? Do they have more than one peripheral line? You know, have they got their PPI? Have they got a triotide? Have they got antibiotics? It's a cirrhotic, right? So just, again, just follow up and make sure that all this stuff has been done. Because while you may know it, and it's just, you know, so clear to you at this stage, you're like, how could someone not know this? Again, you can be dealing with a July intern. It could be somebody doing a preliminary year, is not that invested in medicine. So just follow up on all this kind of stuff. And then obviously call your attending, right? So early on, you will not have that spidey, tingly sense in terms of who needs to be done right away and who can wait. So call your attending for any questions overnight. Do not be scared to call your attending. It's much worse if you don't call your attending and in the morning a problem happens because you didn't call them. You know, people get cranky in the middle of the night. I get cranky in the middle of the nights because you woke me up. But you know, we're all grownups here and we move on, okay? Nobody's gonna hold it against you for calling them. So you've got four more calls. It's now four in the morning. You haven't slept at all. You have a clinic all day and it's a motility clinic. And so you're tired and stressed and you get another call. So which one of these patients may need an urgent ERCP? Okay, great. So what's your rationale for cholangitis without sepsis? Why would that person need to be done? Yeah, yeah. Typically, the vast majority of patients with cholangitis, once they get some fluid and some antibiotics, will stabilize out and you can wait on those patients. It is rare, but it does happen that a cholangitis patient comes in, they get their antibiotics and their fluid, and they start to tank a little bit more. Those patients do need to be done urgently. A bileak after liver transplant, that's actually the right answer. But I think that's also a variable answer. It depends when the liver transplant was, how sick the person is. Malignant biliary obstruction, they never need an urgent ERCP, right? We have patients who come in with pancreas cancer and the bilirubin's 20. And if you look at studies about decompressing patients before surgery and then taking them to surgery or just going straight to surgery and elevated INR, in those studies, none of the patients followed who had malignant biliary obstruction developed cholangitis. So you don't need to do a malignant biliary obstruction urgently. And then gallstone pancreatitis, the thing to remember with gallstone pancreatitis is that 80% plus stones pass spontaneously. And remember, it's the small stones of gallstone pancreatitis, the ones that are less than five millimeters that typically cause acute pancreatitis and because they obstruct the pancreatic orifice as they're making their way out of the bileucin and the ampulla. So the vast majority of gallstone pancreatitis do not need to be done, do not need an ERCP and do not need an urgent ERCP. However, if you have cholangitis in somebody with gallstone pancreatitis or progressive biliary obstruction, that's a little bit of a different story. Bileucin after liver transplant. And also that will probably be mandated that that has to happen because transplant surgeons usually get their way. So what else do you need to know about emergent and urgent ERCP? When do you contact the ERCP staff? I think this is going to be so variable based on where you are and how it works. You know, we don't have a, we have an ERCP person at the weekend, we don't have one during the week. Usually I think for our fellows, what they would do is they would talk to the attending and who's on call, which may be one of us. And the attending would make the decision as to whether you need to contact the one of the, find one of the therapeutic doctors to do an ERCP. So I think that's going to be dependent on where you are. If you have a therapeutic doctor on overnight, then you may want to contact them. But obviously, cholangitis, anytime a patient's unstable, right? That just makes sense, right? If someone is hemodynamically unstable with cholangitis, you need to decompress their bile duct. And a bileak post-surgery. That is not necessarily true in terms of a cholecystectomy. We leave bileaks after cholecystectomy for a while. Typically those patients that have a drain in place as well, right? So like they're not going to be very peritonitic often. So some bileaks you can leave. So case three, it's now 12.30. I'm totally lost. I feel like I'm on call myself at this stage. So you're home and you're getting ready for bed. You get another patient call. I had a colonoscopy this afternoon. I'm having a lot of pain. Is this normal? So what do you think? Is pain after colonoscopy normal? Well, lots of people get abdominal pain after colonoscopy. And when you go see your patients directly afterwards, a lot of them will have abdominal distension and pain, right, they get CO2, but over time that CO2 should be absorbed and that pain should go away, right? So post-procedure they can have pain, but by this stage, by the time they've gone home, the level of pain to call the doctor, like that already must be triggering something in your mind, right? Someone's called you at 12 at night because they have severe pain, right? Maybe it's a very anxious person, but that should already trigger something in your mind. So again, this comes back to just let, it's a courtesy to let the person know who did the procedure call them. The other thing is the person who did the procedure may have some insight. They're like, you know, you may read the report and just see X, Y, Z, but there may be some nuance in the report or that procedure that wasn't either documented there or that you may miss. So, you know, it's a very big polyp and you're worried you were very deep into the muscle and there could be a high chance of a perforation and so calling the attending who did the procedure is sometimes useful to figure out those extra bits. So you obviously want to know when the procedure happened. I mean, again, this is just a lot of common sense, right? And what was done during the procedure and hopefully the procedure note is done and you can read that. That's not always the case. You want to know if they're on blood thinners, right? And that's important. And then, you know, just be aware of any really worrisome symptoms. And, you know, if it's the relative calling them, calling you, we're like, why isn't the patient on the phone, right? Like that's strange too, right? So just be aware of any kind of alarm symptoms. I would say not totally if you're in doubt, but if you're worried, just send the patient to the ED. It may be a wasted trip to the ED, but, you know, the patient will probably actually feel better. They may be annoyed that they have to wait in the ED, but they'll probably feel better and you'll certainly feel better and you'll be able to sleep better if you send them to the ED. If you're worried about a patient and you try to go back to bed, trust me, one thing that happens when you start doing this as an attending anyway, is you get insomnia because you worry about your patients nonstop. And so if you're worried, I think it's reasonable to send the patient to the ED. But again, look for alarming things. Do they have evidence of an infection? Do they have a lot of bleeding? If it's an EMR and they have amalekesia, and do they have evidence of altered mental status? And that could be indicative of an infection or bleeding. And as I said, when in doubt, send them to the, I said ED, ER. So significant discomfort is not expected after which intervention? Okay, so biliary sphincterotomy shouldn't cause you pain. So, you know, if you've done a biliary sphincterotomy and the patient's in severe pain, calling you in the middle of the night, that's alarming. And that's alarming. And pegs are very painful. And patients will talk about pain around the peg site all the time, especially when you place it. Banding, interestingly, patients can get a lot, a lot, a lot of pain afterwards. Esophageal stents can cause a lot of pain. I've had to take out stents because patients haven't been able to tolerate them. You know, these are patients in cancer. I put an uncovered stent. I have to take them out a couple of days later. And the pain from an esophageal stent can be persistent. And it's not really a pain. It's more like a pressure and can last for days. But biliary sphincterotomy should not cause pain. So if you have someone with pain after a biliary sphincterotomy, something, you should be thinking about something. Okay, so this is a case tree continued in our lady who called you because she's having a lot of pain. You review the patient's colonoscopy report. She's this polyp that was removed with snare corduroy. So what specific problem can happen after you've removed the large polyp that can cause pain? Or what things may be causing pain? Perf, yeah, you're all worried about a perf, right? So in this lady, she's calling you at midnight. She's elderly. I'd probably send her to the ED, right? Because you're worried. What else can cause pain? Post-polypectomy syndrome. Very good, yeah. So post-polypectomy syndrome is the injury when you're doing the corduroy is transmitted through the layer of the bowel and cause a lot of inflammation. It can clinically look like a perf. They can have guarding rebound tenderness and high white cell count. This can often be mistaken for perf, but obviously on the CT, it would look different. What things do you think about after colonoscopy? You know, they kind of stretch pain from luminal distention. I don't know, do any of you guys use air or does everywhere use CO2? Yeah, I think pretty much everywhere switch for CO2 because the data was so compelling and for the patients, it was great. They just feel better afterwards. Even after ERCP, patients can get very distended and usually that goes away pretty quickly because CO2 is absorbed pretty quickly and it's so much safer than air. So better for patients and safer. Perforation is uncommon after colonoscopy, but can happen anywhere between 0.1 to 0.01%. I don't know what happened there. Oh. Post polypectomy syndrome is almost as common as a perforation. So again, just be something to be aware of. And then you can have rare things like based on how much torsion was on the scope and how much of a loop you're in, you can have a tear of the mesentery or you can have a spenic rupture. And I have never seen a spenic rupture, but we actually had a conference last week and one of the attendings was telling us about a case that he had a long time about a spenic rupture, very rare. So you send the patient to the ED, they get a CT scan and the patient is treated for post polypectomy syndrome. And you go back to bed. So you get one last call. This has already been answered. Interesting. So you get one last call from the patient who had the ERCP and had the sphincterotomy. When you think about ERCP complications, and what do you think here is right in terms of percentage? Okay, so bileak is very rare after ERCP, you know, sometimes I've seen bilomas in the liver from a guide wire being jammed high up in the liver, but a bileak, unless you cut all the way, slice all the way to the duodenal wall and effectively have a perforation, bileak is not something we think about too much. Post-pharynctorotomy bleeding is common, but it's not 8%, 1-2% of people get post-pharynctorotomy bleeding. And post-pharynctorotomy bleeding is exactly, you should think about it in the same way as you think about post-polypectomy bleeding. You can have delayed post-pharynctorotomy bleeding for two to three weeks afterwards because that eschar forms, falls off and that's when you bleed. Perforation is rare. It's not uncommon, it's more common for ERCP than other procedures. Perforation is probably, I'd say 1 in 500 is a good estimation, some people say 1 in 1,000. Some studies have shown a little bit higher instance of perforation. And pancreatitis is the most common complication that we deal with, and 5% is generously low. I think if you look at most literature, it's a 5% to 10%, and then depending on the individual and what you're doing, that risk of pancreatitis is higher. Most pancreatitis though in ERCP, post-ERCP pancreatitis is mild. You can have severe, but most post-ERCP pancreatitis is mild. And then when you think about perforations, there is two different really types of perforations in ERCP. One is where the scope has gone through the wall, that's really, that patient is going to have to go to the OR to get that fixed. And then the other one is if you have a perforation at the site of the ampula. And that's a little bit more nuanced in how we manage that, and a lot of those patients don't need an operation. A lot of those patients can be managed conservatively. Okay, pancreatitis, yeah, we talked about all this. You know, as I said, even in the ERCP, my patients can have lots of pain afterwards from gas. You know, sometimes it's hard to get a great view of the ampula and you have to blow in a lot of CO2 to see what you're doing. We talked about pancreatitis, post-sphincterotomy, bleeding, we talked about perforations. And then another interesting phenomenon that I've seen and that we see not infrequently is sometimes the stent, you see there in this picture here, there's a stent. Sometimes that end of the stent, especially with 7-fringe stents, can dig into the other side of the duodenal wall. Patients may have some symptoms from it, although I don't fully believe they have symptoms that may be related to that. Sometimes that can cause a perforation, so you can see a contained collection. And then what happens is the tissue walls off as the stent is being pushed in. So usually when we see these dug into the wall, we pull them out and don't even close the hole. But you may be called and somebody may be very worried about a CAT scan because they think the stent has perforated through the wall. But the question then to ask is, is there an associated collection with that, right? And if it's causing a problem, then you should see something in imaging to say it's causing a problem like fluid or something else like that. So yeah, I think, you know, you should always be worried. I think most physicians, you know, suffer from this, right, where we always think worst case scenario. And I think that's not a bad way to start because you certainly want to make sure that patient doesn't have that worst case scenario. Early on, you should communicate with your attending. I would tell you for any big decisions and depending on the attending, you should always call the attending. You know, ultimately it's the attending's responsibility on call. If something, God forbid, something ever happens and this ends up in a medical legal case, the attending is brought into court. So always, you know, for big decisions, even if you're a third year and you feel great, I would call the attending. You know, I, by the time I did two fellowships, one in Ireland and one in the US, and I always called the attending even when I was finishing. And I think it's also just a courtesy to call the attending. And then notify other specialties early in the process. I think this is an interesting one for therapeutics is that you'll find certainly where I trained before this and where I work now is you end up developing relationships with certain surgeons. So if you need a surgeon, you generally have a, I generally have a relationship, I call people in order. And so, you know, the only thing I'll say is if you get in contact with the therapeutic attending and they need to see a surgeon, ask them who they'd like to see. Usually the therapeutic attending will say, but that's something that I would just think about is, you know, sometimes if the surgery resident get involved, another attending gets involved, the next morning that other attending has seen the patient. And then I come in and I'm like, well, actually I didn't want that person to see that person. So maybe some clarification around that and maybe figure out for the therapeutic attendings you have anyway, is there specific people they like to work with and so on. And I would honestly ask the therapeutic attending, do you want me to call you overnight if something happens to your patients? And as I said, all our fellows have our cell phone number. That's dramatic, isn't it? Okay. And you went to sleep eventually. He looks, he's never been on call. This is clearly somebody who doesn't do medicine and doesn't do call. He looks way too comfortable. Usually on call, you're like, eyes are scrunched when you're sleeping, you're stressed. Do you have any questions? Okay. Great. Thank you. Appreciate it.

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