Crash Cart Emergency Medicine

The Ohio State University
The Ohio State University
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The voice of Emergency Medicine at The Ohio State University

  1. 6d ago

    Amniotic Fluid Embolism

    A patient in labor suddenly becomes hypoxic and hypotensive. Minutes later, she arrests and then begins bleeding uncontrollably. Amniotic fluid embolism (AFE) is rare, unpredictable, and potentially catastrophic. AFE requiring rapid recognition and a coordinated resuscitation before the diagnosis is ever certain. In this episode, Drs. Caroline Bank and Kim Bambach discuss a practical approach to recognizing and managing AFE, including the clinical clues that distinguish it from other causes of maternal collapse, pregnancy-modified resuscitation, management of right ventricular failure and coagulopathy, and the importance of early multidisciplinary activation. They also discuss what happens after survival, from team debriefing to communicating with patients after a traumatic birth. This episode is part of the Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) series at The Ohio State University, supported by a grant from the Ohio Department of Children and Youth. Guest: Caroline Bank, MD; Host: Kim Bambach, MD; Editor: Nick Roesel Key Learning Points 1. Think of the “3 Bs”: Breathing, Blood Pressure, and Bleeding AFE is a clinical diagnosis. Consider it when a laboring or recently postpartum patient develops sudden: Hypoxia Hypotension Altered mental status Cardiovascular collapse or cardiac arrest Coagulopathy or unexpected bleeding The Amniotic Fluid Embolism Foundation describes the classic presentation using the 3 Bs: Breathing, Blood Pressure, and Bleeding. Symptoms like anxiety, restlessness, chills, or dyspnea, may precede cardiovascular collapse. 2. Timing and early coagulopathy are important clues The differential for maternal cardiovascular collapse is broad and includes pulmonary embolism, hemorrhage, eclampsia, and other causes of cardiac arrest. Two clues should particularly raise suspicion for AFE: Timing: AFE typically occurs during labor or shortly after delivery. Early coagulopathy: Sudden cardiopulmonary collapse accompanied by early DIC is particularly concerning. In hemorrhagic shock, coagulopathy generally develops as bleeding progresses and clotting factors are depleted. In AFE, coagulopathy may precede the major hemorrhage. 3. Resuscitate first, even if there is diagnostic uncertainty. When AFE is suspected: Secure the airway and optimize oxygenation. Establish adequate IV access. Support circulation with vasopressors, blood products, and appropriately selected fluids. Activate OB, anesthesia, the resuscitation/code team, and blood bank early. Anticipate rapidly evolving coagulopathy and hemorrhage. 4. If cardiac arrest occurs, use pregnancy-modified resuscitation Prioritize: High-quality CPR Airway and oxygenation Manual left uterine displacement Rapid preparation for resuscitative hysterotomy when indicated Maternal resuscitation remains the priority. The interventions that improve maternal circulation also improve fetal perfusion. 5. Think about the right ventricle Bedside echo can help identify right ventricular strain or dysfunction. Consider: Vasopressors Inotropic support Pulmonary vasodilators when available and appropriate Avoiding excessive fluid administration that may worsen RV overload 6. Activate ECMO early when available In refractory cardiovascular collapse, involve the ECMO team early rather than waiting until other options have been exhausted. Concern for hemorrhage or DIC does not necessarily preclude ECMO. Extracorporeal support can initially be initiated without anticoagulation while a patient is profoundly coagulopathic. 7. AFE resuscitation is multidisciplinary A critically ill postpartum patient may simultaneously require maternal resuscitation, hemorrhage control, massive transfusion, neonatal resuscitation, and advanced cardiovascular support. Clearly divide responsibilities according to team expertise: ED: code leadership, airway, vascular access, resuscitation OB: uterine and hemorrhage management NICU/neonatal team: neonatal resuscitation ECMO team: advanced mechanical circulatory support when indicated Early role assignment allows multiple critical interventions to occur simultaneously rather than sequentially. 8. The resuscitation does not end with ROSC Survivors of AFE may face substantial physical and psychological consequences. Coordinated post-arrest care, rehabilitation, and support for both patients and clinicians following a traumatic delivery. Further Resources Amniotic Fluid Embolism Foundation

  2. Jul 1

    Critical Brain Resuscitation

    A patient with an intracranial hemorrhage can look surprisingly stable…until they suddenly don’t. Recognizing the subtle signs of rising intracranial pressure before herniation occurs is one of the most time-critical skills in emergency medicine. In this episode, Drs. James Nardini, Mike Prats, and Kim Bambach discuss a practical, evidence-based approach to critical brain resuscitation, from recognizing early deterioration to implementing tiered ICP management, choosing hyperosmolar therapy, optimizing sedation, and avoiding common pitfalls. Based on the Emergency Neurological Life Support (ENLS) framework, this episode provides a systematic approach you can apply on your next shift. Guest: James Nardini, MD, MS; Host: Mike Prats, MD and Kim Bambach, MD; Editor: Kim Bambach, MD Key Learning Points 1. Recognize deterioration early Elevated ICP often begins with nonspecific symptoms (headache, vomiting, confusion, gait disturbance). Serial neurologic examinations are more valuable than a single assessment. Track: Glasgow Coma Scale (watch for declining scores) Pupillary size and reactivity New focal neurologic deficits Mental status changes A >1 mm change in pupil size may be an early sign of herniation. 2. Understand herniation syndromes Subfalcine: contralateral leg weakness (ACA compression) Uncal (transtentorial): ipsilateral fixed dilated pupil decreased consciousness contralateral hemiparesis Tonsillar: occipital headache neck stiffness progressive brainstem compression eventual Cushing triad 3. Cushing triad is a late finding Hypertension Bradycardia Irregular respirations Waiting for the full triad means the patient is already critically decompensating. 4. Follow a tiered approach (Emergency Neurological Life Support) Tier 0: Optimize physiology ABCDE assessment Protect airway, maintain oxygenation and ventilation Normalize glucose Treat fever BP management Elevate head of bed (when appropriate) Provide analgesia and sedation Obtain urgent non-contrast head CT Minimize secondary brain injur Tier 1: Temporize while arranging for definitive care Hyperosmolar therapy Brief controlled hyperventilation if actively herniating Early neurosurgical consultation and if needed arrange transfer for neurosurgical consultation. You can advocate for your patient. 5. Hypertonic saline vs. mannitol Both improve outcomes and are reasonable first-line agents. Hypertonic saline may provide: more sustained ICP reduction better cerebral perfusion pressure superior ICP control in several studies Don’t delay treatment simply because one agent is unavailable. In selected critically ill patients, both therapies may be used. 6. Monitor sodium carefully Obtain a baseline sodium on patient arrival. Check sodium frequently after hypertonic saline. Typical therapeutic target: 145–155 mEq/L 6. Propofol is the preferred sedative Benefits: Decreases cerebral metabolic demand Reduces cerebral blood volume Lowers ICP Suppresses seizures Watch for: Hypotension Reduced cerebral perfusion pressure Maintain adequate blood pressure while sedating. 7. Common pitfalls A common pitfall is waiting too long to initiate hyperosmolar therapy. If you’re seriously asking whether the patient needs hypertonic therapy, that may be the moment to act rather than waiting for unmistakable herniation. 8. Emergency physicians are the bridge to definitive care The goal is to: Recognize deterioration Prevent secondary injury Optimize physiology Initiate temporizing therapies Rapidly connect patients with neurosurgical intervention 9. Ultrasound pearl Bedside ultrasound may provide additional information: optic nerve sheath diameter measurement optic disc elevation transcranial ultrasound (experienced users) Further Resources Emergency Neurological Life Support Course Emergency Neurological Life Support Intracranial Hypertension and Herniation Protocol Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients- Neuro Critical Care Society

    Critical Brain Resuscitation

  3. Jun 30

    Day in the Life of... an EM Chair

    What does it actually take to become the chair of an academic emergency medicine department? In this episode, Dr. Edleda James, PGY3 and future simulation fellow interviews Dr. Jeffrey Caterino, Professor of Emergency and Internal Medicine and Chair of Emergency Medicine at The Ohio State University. He shares his career journey to become department chair, the realities of leading a large academic department, and the leadership skills that aren’t taught during residency. They discusses mentorship, developing financial and administrative expertise, intentionally building leadership skills, and practical advice for trainees and junior faculty interested in future leadership roles. Guest: Jeffrey Caterino, MD, MPH; Host: Edleda James, MD; Editor: Kim Bambach, MD; Audio Editor: Nick Roesel Key Learning Points Leadership is rarely a straight path. Career interests often develop after becoming faculty and gaining insight into how departments function. Mentorship remains essential at every career stage, including for department chairs. Peer mentorship can be just as valuable as traditional mentor-mentee relationships. Seek advice broadly. Leadership is a learnable skillset that requires intentional development, including: Running effective meetings Hiring and personnel management Delivering difficult feedback Motivating teams Financial literacy Organizational leadership Experiential learning is invaluabl. Serve on committees, observe leaders, and gain exposure to departmental operations before stepping into leadership roles. Leadership courses offered through institutions and professional organizations can provide practical skills and invaluable insights from experienced leaders, such as leadership courses from SAEM. An MBA or administrative fellowship can be helpful, particularly for hospital leadership, but they are not prerequisites for becoming a department chair. The key is acquiring the necessary business and leadership skills by any effective pathway. If you’re considering a leadership role: Talk with multiple people currently doing the job. Learn what skills they actually use. Intentionally build those competencies before you need them. Final leadership advice: pursue opportunities with “magnitude and direction“. Be intentional about the experiences and skills you choose so they align with your long-term goals. Further Resources Administration Fellowship at The Ohio State University SAEM Chair Development Program SAEM Emerging Leader Development Program EM Resident- What You Need to Know About EM Administration Fellowships

    Day in the Life of... an EM Chair

  4. Jun 29

    Drowning: Rescue, Resuscitation, and Prevention

    Drowning deaths have increased in recent years, making it more important than ever for emergency physicians manage effectively. In this episode, Corey Williams, MD, reviews current drowning terminology, the pathophysiology that drives treatment decisions, and practical pearls for resuscitation, observation, and disposition. We also discuss common misconceptions and key prevention strategies to share with patients and families (and your own!). Guest: Corey Williams, MD; Host: Kim Bambach, MD; Audio editor: Nick Roesel Key Learning Points: Use the modern drowning terminology: Fatal or non-fatal drowning (with or without morbidity). Avoid outdated terms such as near drowning, dry drowning, and secondary drowning. Demographics: Young children, adolescent males, and patients with alcohol use, seizure disorders, or developmental disabilities are at highest risk for drowning. Pathophysiology: Drowning is primarily a hypoxic injury. In cardiac arrest, provide ventilations in addition to chest compressions. Compression-only CPR is not sufficient. Hypothermia: Consider hypothermia when a patient has a drowning event, even in warmer months. Active rewarming remains a critical part of management. Trauma: Consider cervical spine injury only when the mechanism or examination raises concern (e.g., diving injuries, unwitnessed events, neurologic deficits). Mythbusting: Fresh water versus salt water does not change management. Clinically significant electrolyte abnormalities from aspiration are unlikely. A normal initial chest X-ray does not rule out delayed pulmonary injury. Patients with non-fatal drowning who remain asymptomatic should generally be observed for at least 4 hours before discharge. Routine prophylactic antibiotics and steroids are not recommended after drowning unless there is concern for heavily contaminated water exposure. Prevention matters: Early swim lessons, four-sided pool fencing, close supervision, and CPR training for caregivers remain the most effective ways to reduce drowning-related morbidity and mortality. Further Reading: Davis CA, Schmidt AC, Bierens JJLM, et al. Wilderness Medical Society clinical practice guidelines for the treatment and prevention of drowning: 2024 update. Wilderness Environ Med. 2024;35(1):101-120. doi:10.1016/j.wem.2023.12.004. Dezfulian C, McCallin TE, Bierens J, Dunne CL, Idris AH, Kiragu A, Mahgoub M, Shenoi RP, Szpilman D, Terry M, Tijssen JA, Tobin JM, Topjian AA; on behalf of the American Heart Association and the American Academy of Pediatrics. 2024 American Heart Association and American Academy of Pediatrics focused update on special circumstances: resuscitation following drowning: an update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2024;150(23):e473-e501. doi:10.1161/CIR.0000000000001274. Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012;366(22):2102-2110. doi:10.1056/NEJMra1013317. American Academy of Pediatrics. Prevention of drowning. Pediatrics. 2021.

    Drowning: Rescue, Resuscitation, and Prevention

  5. Apr 29

    Thin Air, High Stakes: Altitude Medicine

    Dr. Jonathan Thompson dives into the fascinating world of high-altitude medicine, explaining how hypoxia affects the body and lead to conditions like acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). He highlights how hypoxia is a universal concept relevant to emergency and critical care medicine, and that understanding altitude illness can improve care for patients, whether you practice on a mountain or not! Bio: Dr. Jonathan Thompson is a former Green Beret in the U.S. Army Special Forces and former U.S. Army Special Operations Mountaineering Instructor that taught in Colorado, Alaska, and Wyoming. He completed a Masters in Physiology at the University of Michigan with a thesis on nitrate supplementation in the prevention and treatment of acute high-altitude illnesses. He is an annual, returning guest lecturer (2020-present) at the University of Michigan’s Department of Physiology instructing undergraduate and graduate students on high-altitude physiology, pathophysiology of acute altitude illnesses, and relevant treatments. Guest: Jonathan Thompson, MD, MS; Host: Kim Bambach, MD; Audio editor: Nick Roesel Key Learning Points: The unifying concept: hypoxia Decreased oxygen delivery impairs cellular metabolism and underlies all altitude illness. Risk of altitude illnesses begins around 5,000 feet Risk increases with rapid ascent and poor acclimatization. The classic setup is flying in and ascending quickly. Physiologic response to altitude Hypoxia triggers the hypoxic ventilatory response → ↑ respiratory rate and tidal volume ↑ sympathetic activity → ↑ heart rate and blood pressure Respiratory alkalosis from hyperventilation → renal compensation → bicarbonate excretion → diuresis Over weeks, erythropoietin → ↑ red blood cell mass Altitude Illness Spectrum Acute Mountain Sickness (AMS): Symptoms include headache, nausea, fatigue, and insomnia. This is usually mild but a warning sign. High Altitude Cerebral Edema (HACE): Characterized by neurologic dysfunction, such as ataxia and altered mental status. HACE can be life-threatening. High Altitude Pulmonary Edema (HAPE): A form of non-cardiogenic pulmonary edema. Symptoms include dyspnea at rest, cough, pink frothy sputum. HAPE is the leading cause of death. Treatment Descent is the definitive treatment. Give oxygen if available (but it’s usually not in austere environments). Give Acetazolamide for AMS and HACE (both prevention and treatment) Give Dexamethasone for HACE (remember “HACE is AMS on steroids!”). Give Nifedipine for HAPE. The Bottom Line: The best treatment is descent, and everything else is a bridge. When you’re out adventuring, don’t forget to go slow to acclimatize! Check out Dr. Thompson’s lecture for the World Extreme Medicine Organization here! Other Resources: Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update Auerbach PS, Cushing TA, Harris NS, eds. Auerbach’s Wilderness Medicine. 7th ed. Philadelphia, PA: Elsevier; 2016.

    Thin Air, High Stakes: Altitude Medicine

  6. Feb 20

    In Your Patient's Neighborhood

    Where you live is a significant social determinant of health that impacts health and emergency care. In this episode, Dr. Kim Bambach (Assistant Professor of EM) interviews Dr. Amogh Krishnagiri (PGY-3 Chief Resident) about how built spaces and the connections they create ultimately influence health. From transportation access and food availability to education, housing stability, and local resources, a patient’s built environment directly affects their ability to follow up, fill prescriptions, and heal. Key Learning Points: A neighborhood is more than a built location It reflects the social connections, infrastructure, and resources that shape health outcomes. Social determinants of health impact emergency care Transportation, food access, housing stability, income, and education all directly affect whether patients can follow through on ED discharge plans. Consider what’s in your patient’s neighborhood Not all neighborhoods offer equal access to pharmacies, clinics, grocery stores, or safe transit. Expecting identical follow-up success across different environments is unrealistic. Transportation is often overlooked If patients cannot physically get to appointments, pharmacies, or community resources, the plan fails. Take the time to make a safe discharge Safe discharge planning requires feasibility, not just medical accuracy. A brief conversation about barriers can prevent bounce backs and unnecessary admissions. Connect to your community resources Emergency physicians are uniquely positioned to connect patients to community resources. Get to know the resources in your community and your ED social worker. Bottom Line:Understanding your patient’s neighborhood — especially their access to transportation and community resources — is essential to creating discharge plans that are safe, realistic, and truly effective. Resources: Close.City Columbus Street Card Central Ohio Area Agency on Aging Columbus Metropolitan Library Ohio Domestic Violence Network Columbus Food Pantries

    In Your Patient's Neighborhood

  7. Jan 15

    First Shifts: Intern Mini-Series Pt. 2

    In Part 2 of the Intern Mini-Series, Drs. Edleda James (PGY-3) and Nick Cummins (PGY-3) continue their deep dive into intern year, focusing on the remaining core rotations and how to truly thrive during them. They reflect on experiences in EMS, anesthesiology, ultrasound, and pediatric emergency medicine, highlighting what each rotation offers, key skills to prioritize, and resources that make the learning curve more manageable. The conversation expands beyond rotations to include practical advice on studying for Step 3 and the ITE, managing time and energy, and maintaining wellness during demanding months. Throughout the episode, they emphasize perspective, relationship-building, and self-compassion as essential tools for navigating residency and growing into a confident emergency physician. EMS Where you learn how emergency care begins and gain deep respect for prehospital medicine. Pearls: EMS clinicians are your coworkers and learning their workflow improves ED handoffs. Ride-alongs highlight the physical, logistical, and cognitive challenges of prehospital care. Dispatch centers teach you how calls are triaged, mapped, and prioritized. Critical care transport offers insight into mobile ICUs and interfacility transfers. Relationship-building pays dividends later when you see the same crews in the trauma bay. This rotation can spark interest in EMS fellowship or prehospital leadership. Anesthesiology (with Ultrasound) A controlled environment to refine airway skills and a time to learn foundational ultrasound skills. Pearls: You get out what you put in- be proactive about getting your reps. Don’t just intubate: learn preparation, medication setup, and backup planning. Bag-valve-mask technique is a life-saving skill. Practice seal and positioning. Use the OR’s controlled setting to build muscle memory and troubleshoot difficulty. Show up early to walk through meds and equipment before the patient arrives. Ultrasound training is robust and longitudinal. Image review and feedback matter. Pediatric Emergency Medicine A high-volume, high-acuity pediatrics experience that builds confidence with sick and well children. Pearls: You’ll see everything from critically ill, medically complex children to low-acuity complaints. You’ll often be the primary resident communicating with consultants so document clearly. Child Life Specialists are invaluable for patient comfort and family support. Suture techs teach more than technique. You can observe how they calm and engage children. Pediatric clinical pathways (asthma, abdominal pain, ortho injuries) are excellent learning tools. Skills learned here translate directly to community ED practice. Studying & Exams (Step 3 and ITE) A short but eye-opening rotation that changes how you think about poisoning and drug exposures. Top Resources: Rosh Review Tintinalli’s Emergency Medicine (goal: ~3 chapters/week), OSU library digital access UWorld Step 3 QBank Pearls: Plan early for Step 3. Intern year is often the best window. EMS, OB, Tox, and Ortho may be better study months than anesthesia/ultrasound. Consistency beats cramming for the ITE. Pair studying with enjoyable activities (walking, climbing, downtime). Didactics count and active participation is real studying. EM physicians often have a natural advantage on Step 3 due to focus on acute care. Be honest about your learning style and build routines around it. Wellness & Thriving as an Intern Your chance to get hands-on with labor and delivery. Top Resources: Employee Assistance Program GME Counseling GROW (Gearing Residence for Overall Wellbeing) Program leadership, chiefs, and senior residents RAFFT mentorship and community Peer support and co-resident friendships Pearls: Perspective matters. Every rotation is short and intentional. Be open to correction; you are not expected to know everything. Ask for expectations and recommended resources early. Build relationships with nurses, techs, CRNAs, and staff. It improves care and joy. Maintain hobbies, therapy, movement, and sunlight when possible. Plan trips and social events when schedules allow. Lean on your people. Residency is hard, but you don’t do it alone. Final Takeaways It is okay to not be okay. Asking for help is part of becoming a good physician. Intern year is challenging, humbling, and finite. It is shaping you into the emergency physician you are becoming.

    First Shifts: Intern Mini-Series Pt. 2

  8. 11/08/2025

    First Shifts: Intern Mini-Series Pt. 1

    In the first episode of the Intern Mini-Series, Drs. Edleda James (PGY-3) and Nick Cummins (PGY-3) share what it was like to begin residency and how they learned to balance the steep learning curve of intern year with personal growth and self-compassion. They share their paths to emergency medicine and experience transitioning from MS4 to intern. Finally, they walk through the major rotations of the first year, highlighting what each block teaches, helpful resources, and practical strategies for success. Emergency Medicine Rotations Where you start building your identity as an EM physician- learning to juggle patients, manage uncertainty, and lean on your team. Top Resources: UpToDate Medscape, MDCalc (for scores like PERC, Wells, HEART) WikEM EMRA Antibiotic Guide Full Code Pro, Safe Local, PediSTAT apps Suture and Fracture apps Corependium Rosen's and Tintinalli’s Emergency Medicine textbooks, OSU library digital access Pearls: Focus on forming solid habits: think through your differentials and double-check doses. Learn from physicians and other team members including nurses, RTs, and pharmacists. Keep a few go-to resources on your phone and actually get comfortable using them. Check your university library before buying textbooks- you probably already have access. Orthopedics A hands-on month to get comfortable with procedures and take the perspective of ortho consultants. Top Resources: Tintinalli’s musculoskeletal and ortho chapters Radiopaedia (for imaging examples) OSU orthopedic guidebook (linked on the phone list) Online case blogs Pearls: Practice reductions and splinting as much as possible- these are core EM skills. Watch what ortho looks for: imaging, markers, mechanism, and documentation. Ask questions about how they manage injuries after you hand off the patient. Use this block to refine your comfort with musculoskeletal exams and joint taps. Surgical ICU / MICU Where you really start learning how to manage critical illness. Top Resources: EMCRIT ICU nurses and respiratory therapists (invaluable teachers) Fellows, pharmacists, and attendings during rounds Pearls: Focus on vent settings, pressors, sedation, and team communication. ICU nurses and other team members can teach you workflow, priorities, and troubleshooting. Trust your instincts- you know more than you realize. Build relationships with surgery, anesthesia, and ICU teams; off-service months are great for networking and understanding hospital systems. Toxicology A short but eye-opening rotation that changes how you think about poisoning and drug exposures. Top Resources: Goldfrank’s Toxicologic Emergencies Central Ohio Poison Center Pearls: Watch how poison-center staff and toxicologists reason through cases. Don’t hesitate to call the poison center- they are a tremendous resource. Follow cases beyond the ED; seeing outcomes helps connect the dots. OB/GYN Your chance to get hands-on with labor and delivery. Top Resources: Rosen's and Tintinalli’s Emergency Medicine textbooks, OSU library digital access Refreshers on labor terminology and fetal-heart-tracing basics Pearls: Work closely with midwives- they can help you with meeting your required number of deliveries and solidify your understanding of normal labor. Learn the language of OB- it builds confidence when calling consults later. Pay attention to positioning, hand placement, and what to do when deliveries don’t go smoothly (shoulder dystocia, breech presentations, etc.). OB attendings are very approachable and eager to teach. Cardiology A great month for sharpening EKG skills and understanding what happens after you consult cardiology in the ED. Top Resources: ECG Weekly (Amal Mattu) ECG stampede Mentorship from cardiology and EM faculty (including ECG elective) Pearls: Review EKGs and telemetry- repetition builds pattern recognition. Understand how cardiology stratifies risk and decides on further workups (echo, coronary CT, cath). Tie what you see in the ED to later care. Final Takeaways You don’t have to “drink from a firehose.” Learn it one manageable piece at a time. Intern year is busy, humbling, and transformative — but completely doable. Each rotation adds something valuable to your EM skill set. Build relationships, ask for help often, and give yourself grace.

    First Shifts: Intern Mini-Series Pt. 1
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