Category Archives: Administration & Leadership

Shared Narrative vs Personal Narrative in Apple Ad and why you should care

I speak on a number of topics, one of them being technology pros and cons for potential Fire Service Candidates through Fire Alumni.
It goes beyond the usual talks about the dangers of the evil social media and gives candidates tools they can use to better use the medium for their benefit.
In the presentation I discuss personal vs shared narrative as a way of addressing their desire to use the medium to communicate.  It’s not much use to tell you not to do something if I can’t explain WHY it is not a good idea.

Personal narrative is like a first person recollection of free cialis online an event.
Shared narrative is including others in the event while simultaneously removing oneself from the event in order to do so.

I give 2 examples.

One is where a couple witnesses a romantic sunset and decides to photograph themselves with the sunset behind them. While they did experience the sunset, they also had to interrupt their personal narrative to arrange the photo, in which they are no longer enjoying the very thing they are hoping to share.

The second example is when I finally talked my young daughters into wanting to watch Star Wars.

We got bundled up on the couch, drinks and snacks at the ready and I started the DVD. The Lucas Film logo appeared and I suddenly wanted to share this personal narrative with friends, family and the girls when they got older. I crouched down in front of them and snapped a pic.
However, while I was doing that my eldest said, “Daddy, what do those words say?”

I had missed the opening scroll. Forever. I will never have that moment back.
My desire to share interrupted my experience of the moment.

According to the candidates that approach me following the presentation, this message is well received.

In order to keep errors on social media at bay, focus on personal narrative.

Today this Apple ad was circulating the interwebs machine and I think it perfectly encapsulates the importance of personal narrative.
Have a look:

The kid in the ad is ALWAYS on his phone.  Like I am most days I’ll admit, but we assume from most of the ad he is texting or playing a game (Like I likely am, remember, I’ve fallen victim to the allure of the shared narrative) but we later learn he is making a clever little video.

We see the family becoming emotional at certain parts of the video, not because of what they see, but because of the emotions they associate with the memory of the events being shown.  They are being shown events they took part in.  The kid who made the video did not take part, he filmed them.  Each of the images has him removed from the event in an effort to later share it with the people in the image.  For the family it is a reminder of personal narrative, for the kid it is only shared narrative.

The exact same error I made with my daughters and Star Wars Apple wants us to believe is a good reason to use their products.

I love the idea of collecting and editing video on a handheld device.

I don’t love the assumption that ignoring the present to revisit in the future should be our priority.  Our priority should be to live in the now, be with the people we are with and in the place we are in, not to post a clever status or photo to include others, but truly experience life while it happens.  If that later leads to a sharing of events, so be it, but just wait.

 

Imagine the family Christmas celebration this family could have had if the kid on the phone had taken part instead of filming.  We’d have no clever little video, but we would have the same memories and perhaps even more to talk about instead of looking to technology to share every moment at the expense of the moment itself.  Just as powerful to me would have been if the child was constantly reading a book the whole time, then stood and recounted all the fun times he witnessed.  he still would have missed the events themselves while reading.  It’s not the phone that is to blame here, it is the desire to share the experience before the experience has been…well…experienced.

 

I tell Fire Service Candidates that social media is not dangerous, it’s how you use it that is.  Technology has made it so easy to share anything with anyone at anytime the urge to transfer personal narrative to shared narrative can be difficult to overcome, but the only way to be truly successful and enjoy life is to do just that: Live Now.  Post Later.

Mixed Signals at Youth Detention – NOMA

I was asked to accompany my supervisor to the local Youth Detention Center where they’re running a couple weeks of a modified almost career day program. They’re bringing in trades and professions from TV makeup to EMS and showing the kids that they don’t have to give up the hopes of moving on with their lives when they get out.

I think it’s a great idea since simply putting someone in a room and waving a finger at them seldom produces change in behavior. My 7 year old could have told you that.

We had a presentation prepared about the history of EMS, local and State requirements to achieve licensure and what to expect on the job. We had pros, cons, salary expectations and, most importantly to them, what your background needed to look like.
They were very interested in learning about the sliding scale of background infractions that will still yield a job taking care of people on their worst days. This many years without a conviction in this, that many years without 2 or more convictions in that…they were riveted and you could see them doing the math in their heads. “If I get out this year and don’t re-offend I can be an EMT in 4 years!”

The Company Man in me was on board with the message of inspiring these youths to look beyond their transgressions and wipe the slate clean. An opportunity awaits them to possibly get a job with me helping people.
Everyone deserves a second chance in life, especially the young.

Not on my ambulance (NOMA).

That’s what the EMS 2.0 inside me said. During the presentation I did my best to explain to the class just how easy it is to get an EMT cert.
“Only 120 hours of class needed guys!”
“2 days a week for 1 semester at the community college and you’ll be able to take the test. Pass it and you can apply to work on an ambulance!”

The conflict within me was well hidden I assure you.

While I agree that these kids need this message of how easy it is to get into EMS, I don’t want it to be so easy.

Taking care of people takes blind trust on their part assuming that the agency responding has done something to make sure you are a trustworthy person and are trained to take care of them. We extend our message of EMS with the promise of lights and sirens, driving on the wrong side of the road and try to temper that with tales of 911 abuse, vomit, urine, blood and guts. All this group seemed to be interested in was why my stripes were silver and my boss’s gold.

They’re kids.

We need to take this message to EVERY school and get kids excited about helping people and being selfish about it.

Yes, I said selfish. I don’t do this job to help people, I do it because the feeling I get from helping people is addictive and better than anything I know. I help people because if I don’t I don’t feel right. Trying to convey that message to a group of young men already 2 strikes down and out of their league doesn’t translate as well as one may hope.

One of them asked how we handle dealing with sick people and I told them it’s easy. It’s taking care of the people you shouldn’t want to that is hard.

I told the story of the child abuser that was confronted by a neighbor. The child had been transported by another crew and I was called to deal with the abuser and his mild injuries. That man got the exact same high level of assessment, care and transport as my mother would have received. Not because it was the law, or policy or the right thing to do, but that’s what I was there for. My sole purpose was to help those who asked and I did it with a smile on my face. Maybe not the biggest smile, but I helped and I felt better.

I wanted to share more about the realities of EMS with those kids but we ran out of time.

We didn’t talk about burnout, divorce, poor dietary habits, the sedentary lifestyle of 12 hour system status cars or the fact that in most communities you’ll need a second job to make ends meet.

In the end I don’t think it will matter.

The Company Man in me will apply whatever standards my employer sets forth when considering candidates, regardless of personal belief or Professional discretion. But if I was the boss, even if you carried the same license and all other things being equal, I’m hiring the kid that WANTS to be here, not one who took the easy road and wants to give it a shot because it took less hours than welding at the local college to get qualified.

Am I wrong? Maybe, but at least then I’ll know and can move forward.

What are your thoughts on reaching out to troubled youth about jobs in EMS?

CA SB556 – The “He looked like them” Law

Special thanks to Mr Herrera for bringing this back to the front burner for me.

Just a quick reminder: The views on this website are mine and mine alone and not endorsed, reviewed or supported by my employer, co-workers, mother or hair dresser.

That being said,

SB 556 s a giant load of Gou shi.

“Oh my Happy…language…”

It is Gou shi.

Somehow the legislature is concerned that Erma Fishbiscuit is going to be confused when the nice men from the fire department arrive to take care of her, but then a completely different group of men arrive to take her into the hospital.  The uniforms may seem similar, but if she puts on her glasses she’ll see the patch on the sleeve does not say Fire Department, nor does the ambulance, nor does the bill she’ll get in a few weeks.

 

Apparently the law makers want to make sure Erma is aware that her local Fire Department has no interest in taking care of her by making sure the Fire Department employees wear a patch that clearly states “Government Employee.”

Oh, wait.

Scratch that.  Reverse it.

This bill would require uniforms that are similar, but only those not a government agency, to read “Not a Government Agency.”

Are we that stupid?

Don’t answer that.

 

This bill had obvious beginnings, that being to make sure the guy AT&T sub contracted my install to can be held liable when he screws up, but it was clearly hijacked by someone, likely a Fire Department Union or 2 unhappy with the ambulance contracts in their area.

Disclosure, I’m a union thug myself.

Requiring private contractors to wear a patch or insignia that states “Not a Government Agency” is just as stupid (and would be shot down in a heartbeat) as asking all municipal fire, police and EMS agencies to wear a large orange hat, designating them Government Agencies.

It’s good to know we solved the homeless problem and all the children can go to college free since we’re passing legislation to make contractors wear patches to tell the public what it already says on the side of their trucks.

 

This kind of crap makes me want to run for office just to slap them with the patch that says “Government Agency” and make them pay for it.

“That’s not fair, Happy” Yeah…I know…get it?

 

If you are for SB 556, I welcome your comments and ask that everyone commenting be respectful to one another, whether they be union thug or for profit people mover.

Response Time or Patient Outcomes – How do you measure your EMS system?

I know it’s been quite around these parts lately but a recent article caught my attention this morning.

High Performance EMS posted “Does Response Time Matter?” and it got me thinking.

The author states an example of a patient being “treated” by fellow citizens at an airport and having to wait 20 minutes for an ambulance to arrive.  The author goes on to describe how we need to arrive quickly to save the public from themselves.  After 30 years of telling them to call 911 for anything and convincing them that “seconds count!” what did we expect?  While I agree that a delayed response to certain patient presentations could result in an adverse outcome, that points out a glaring omission from the story.  Missing from the story is the patient outcome.  The outcome will allow us to marry all the data from the response to determine the answer to the author’s question in the headline.

The short answer is no, response times don’t matter.  And no, I don’t have to pee.  I have data that does not have any correlation between quality of treatment, outcome and response time.  From my perch here at the data hub of a quite busy EMS system we have been trying to determine the quality of our EMS system and we rarely look at response times.

Don’t get me wrong, we look and our Department statistician collects, quantifies, qualifies and reports to regulators the 90th percentile of all code 2 and code 3 calls to meet their requirements.  We report it, they receive it.  The document says nothing about the quality of care or patient outcome.  The reason being that we can not guarantee a positive patient outcome, but can measure when we left and when we arrived.  Imagine if we had to treat 90% of symptomatic asthmatics with oxygen within 5 minutes of arrival and document an improvement in condition.  Can your system guarantee that?  Why aren’t EMS systems measured by the quality of their care instead of the quality of their response?

Apply this metric to any other industry and it fails.  Industry is measured by their quality and efficiency, not the speed in which they complete their tasks.  So long as we only look at one metric with any regularity we will continue to shuffle ambulances 2 blocks at 5 minute intervals to meet an average instead of realizing just leaving them still would bring the same outcome.

That’s where I come in.  My Medical Director and I, unhappy with the lack of actual patient care quality metrics, created our own in an effort to determine the quality of care being provided.  We learned very quickly that our ambulances do not respond in a vacuum.  Each patient receives a call taker, dispatcher, first response, ambulance response, assessment, treatment and some get transported.  Once at hospital they receive a whole new level of care and review until they are finally sent home.  It is hard to argue that the time it took to get an ambulance from point A to B has an impact on this outcome without any review of the call taker’s coding of the call, the dispatcher’s assignment of the ambulance all the way to the destination hospital capabilities and location.

We can all sit at the Pratt Street Ale House in Baltimore and discuss short times that had a bad outcome and long times that had a good outcome, but the worst part of all of this discussion is that so few systems measure anything more than response time.

If you consider response time your metric of success you have already failed.  You have failed the patient who improves when you arrive “late” and discounting that response as a failure, yet trading high 5s when a 2 minute response yields a call to the Medical Examiner’s Office.

We all know the stories of companies staffing ghost cars near the end of the month to bring down the monthly response metric to meet guidelines.  It happens.  But I also wonder if that flood of ambulances to help more people had any other impact.

The complication in tracking outcomes is the relationship your agency has with local hospitals.  We may never have a seamless transfer of data but what we can do is pull data from the PCR to determine if the patient received the indicated treatments for the recorded chief complaint and observed complications.  By reviewing your policies and protocols as well as your patient demographics you can quickly spot your core performance indicators and design tools to track them.

It may be nice to know that we make our 90th percentile in 8 of 10 districts on a regular basis, but what if those 2 districts happen to have the highest number of cardiac arrest survivals to discharge?  Are they still a failure?

Widen your view to include more than how quick you can put the ambulance in park.  This goes far beyond the lights and sirens System Status Management debate and speaks to the core of the reason we’re out there to begin with:

To make someone’s bad day better

Delays can hurt, but not unless you look deeper into your system to find out if that is the case…or not.

999

Paramedics say the Darndest Things

Mutual Aid company Captain Chair Confessions has a new post up that made me laugh, smile, snicker, exhale, then almost cry.

I miss it.

I miss the witty banter between rescuer and patient, between rescuer and pseudo-patient and above all else I miss the banter between rescuer and liar.  Gods I miss that.

I miss the basic interaction of assessment.  I miss Erma Fishbiscuit and her 23 meds prescribed by 24 doctors.  I miss her son Bubba and his drunken insults, the relief on the face of a CHFer on CPAP and the chill you get from hearing the EMT say “I think I feel a pulse you guys” after 35 minutes of CPR.

I miss it.

From my ivory tower at Headquarters I read most of the charts, checking my check boxes that the crews checked all of their check boxes and fielding calls from angry nurses that the crews didn’t check the check boxes.

I turn off the light, close the door and head home, fire up the computer and live vicariously through you all.

Didn’t that used to be the other way around?

The post today seemed like something from 2009, 4 years ago, when I was at the height of my posting, fired up and ready to change the world!  It seems so long ago.

Turns out the world wasn’t in the mood to change.  They never got the memo, so I hand delivered it.

This therapy experiment we’ve been working on together has seen some incredible ups and some devastating downs.  We’ve shared war stories, ideas, concepts and solutions.  We’ve laughed together, mourned together and still cling to this one tiny thing we believe in above all else: EMS.

From PTSD to stress relief, from Chronicles to Seat at the Table, from Baltimore to Houston to Vegas this blog has not only opened doors but kicked them in guns blazing kickin’ ass and takin’ names.  Clinically speaking of course.

And now I wonder what it’s place is anymore.  Most of my frustrations about the system not working come out in written form to Chiefs, Medical Directors and regulators who take them seriously and many are being considered or have already been implemented.  Motorcop and I spar on our weekly video show and I get great satisfaction from that interaction.  I can’t tell even HIPAA cleansed stories because for each one I filter another pops up that fits that description.

Everything that made this forum what I wanted has found another outlet.

 

This forum, this community, you, helped me through a dark time and I came out shiny on the other end.

What’s next?

 

Official Fire Service Ice Cream Rule

To finally dispel the myths, rumors and falsehoods regarding the Fire Service Ice Cream Rule (AKA Steaks, Cigars, etc) I offer the following definitive ruling on the matter:

Official Fire Service Ice Cream Rule:

1.  Purpose

To establish when a Member of a Company owes Ice Cream to the other members of said company.

2.  Scope

This rule applies to all Fire Service personnel, both paid, paid call and volunteer regardless of rank, station or assignment.

3.  Definitions

Company – A unit or similar single resource.  This can be defined as an Engine Company, Station House or Volunteer Post.

Member – Any person in official capacity at the time of the incident in question.

Ice Cream – While an abomination in the eyes of the Lord your God, something with a crap load of ingredients.

4.  Enough with the bullet points!  Onto the rule!

Ice Cream is owed only if a member of a company is portrayed in the media, be it television, print, online or otherwise (social media not affiliated with a media outlet excluded (see rule 8))  portrays the member in activities not associated with the assignment they are recorded at.  Being filmed fighting fire, cutting a car, rendering aid or performing regular assigned tasks on the scene of an emergency response DOES NOT entitle the members of the company to ice cream from the member involved. Also, for rules on double parenthesis, see rule 9.

5.  Who gets Ice Cream

Only other Members of the offending Member’s Company are required to be appeased with the cold Ice Cream goodness.  Depending on Agency or Department, this may include all units assigned to a house or all shifts on that unit.  It DOES NOT apply to other Companies, units, houses or personnel who wander in to mention being “owed” Ice Cream.

6.  Who doesn’t get Ice Cream

Officers above the rank of front line supervisor (Lieutenant/Captain/Sergeant) unless they were at the scene and may have to answer to the activities of the member caught not performing duties relevant to the scene in question.  All other houses, members and companies not assigned to the offending Member’s HOME Company.

7.  Oh yeah, that reminds me, HOME Company

Ice Cream is only owed to a Member’s HOME Company, not the Company where they were assigned when said incident took place.

8.  Social Media not involving media outlet

That doesn’t get Ice Cream but instead a pat on the head for the person trying, because that wreaks of desperation.

9.  Multiple Parenthesis

Nah, looks weird…or like math, which is WAY worse.

 

Show me the Money

Friend of the blog Bill Carey posted on Facebook wondering why so many in EMS think that salary is the one thing holding us back.

Curious, question for EMS folks on FB: It appears, based on comments to various news stories in the past, that the greatest solution to all that ills EMS is greater pay. Respect is restored, working conditions and staffing improve and the general idea of professionalism is better. Fire-based, hospital-based, third service, doesn’t matter, just pay us more and the service will get better.
Really?

No, not really.

The same issues I had when I got the paid gig for $4.35/hr are here at my current gig where medics average $65,000 to start (according to indeed.com).

EMS in general is paid what the market allows and what we are worth.  Keep in mind that EMS does not require a degree and Paramedics can get licensed in as little as 1 year in some places.  If some kid walked into my office and told me he went to school for something for a year my first question would be “When are you going back to finish?”

Pay is a result of our goals, not our goal.

Increasing our education standards and proving our worth to the industry is step number one.  But of course the stumbling block to education is how to pay for it.

If you think the reason you are not treated like a Professional is the size of your paycheck I think I know where your priorities are.  If your first concern is that you don’t have access to enough education I’ll ask where you live and why you’re still there.

There are high paying EMS jobs out there, folks, I’ve had one for 10 years, but you have to be willing to put the effort into it.  No one is going to wander into the station or yard one day and say “You guys are great, here’s a raise.”  Your employer has no incentive to increase your compensation unless they desire a particular set of skills that bring that kind of salary.

EMTs are entry level and their compensation reflects it.

Paramedics have more responsibility and therefore more compensation.

A flight medic has even more responsibility, so more compensation.

A Firefighter/Paramedic has a different skills set, different compensation.

 

You get the salary you’re getting because that’s what you’re worth to your employer.  If you started off at $10 an hour, got your degree, teach on the side, and are still making $10 you need to talk to your employer about the increased value you can bring to the organization.  Maybe you’re in line for a promotion or reassignment with your increased education and experience.

It all comes back to education.  If you learn more, not only can you increase the care you can give to your patients, but you become a more responsible care giver and show your manager that you’re not just in the seat for a thrill, but to make a difference.  Folks like that make less errors, collect less complaints and are more likely to collect extensive billing and demographic information.

That makes you a keeper and worth more to them.  You increased your value.  That is the only way you will increase your compensation.

 

Let’s imagine that I’m wrong and simply snapping our fingers and giving you more money is the solution.

Now you make twice what you did yesterday.  Now what?  Now will you go back to school?  Teach?  Where is the added value we’re paying for?

The patients are the same, your rig is the same, your protocols haven’t changed and you haven’t changed.  There isn’t much we as EMTs and Paramedics can directly control but our own attitude and education are the easiest to improve in a short amount of time.

Just raising your pay won’t improve your attitude or the attitude of your co-workers.  It won’t help your manager see the worker bees from the cling ons and it surely won’t help your patients.

If you think you’re worth more to your organization than you’re being compensated, tell them, and get ready to pack.  The high paying jobs are out there, but you’ll likely be in a busier system and competing against higher education and higher motivated applicants for the extra money.

 

Case in point: me.

When I left my last job I was a Firefighter/Paramedic serving a suburban area working on both the Engine and Ambulance.  I was making just under $10 an hour on a 24 hour schedule.

When I got my degree in EMS and began teaching I knew I could reach out an look around for something better and have a good chance of landing it.

When I got hired in San Francisco as a Firefighter/Paramedic assigned to a 24 hour Ambulance I had tripled my salary.  Tripled.  But the cost of living was double and my old shifts of sleeping most nights turned into 32 run paramedic pinball sessions that I loved, but took their toll.

I moved 800 miles to get that gig and I have the broken down UHaul story to prove it.

You can get a high paying EMS job.  They exist, but you have to work for it.

What are you willing to do to prove your worth to EMS?

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A new kind of intern

For the last two Tuesdays I have had an intern.

I can hear you now, “That silly Happy, he has a desk job, how can he have an intern?”

Well, a local High School has expanded and offered an EMS Intern position.  One of the local Rescue Captains has assisted in designing the program which will give this student an inside look at not just field time, but supervisor time, administration time, radio time and even a few days with the regulators (Remind me to ask her to ask about proof spine boards are a good idea.)

I am proud to announce she was officially bored out of her skull in the CQI office.  What we do can be distilled down to the high school level, but the finer points of QA (stop laughing already) can be lost.

“We apply the rules, regulations, policies and protocols to each chart and determine if variations warrant review, coaching, counseling or reprimand.  And after completing those reviews we analyze the results to determine trends and act on them.”

She was unimpressed (Seriously? Stop laughing.)

So we read a narrative I was reviewing.  It went a little something like this:

“Police activated EMS for man defecating on sidewalk.  Male present alert and oriented, steady gait near pile of human feces.  Male has no chief complaint and has no signs of traumatic injury.  Male states “Just cite me and go away” without slurred speech.  Male does not give consent to treat or to assess vital signs, threatens to pick up and forcibly relocate feces, EMS agrees male may leave area under own power.”

“Why did the cops call if he wasn’t hurt?” She asked.

“We’re working on that, but I expect your generation to get that sorted out for good.”

 

She had a chance to meet the Chief of EMS and talk to him a bit about what it means to be a Paramedic these days and looking forward.  He is of the same mindset as me, that we make bad days better and go home safe to our families who will never know the truth of what we’ve been through.

I told her that the gauge of a good EMS leader is someone who, when asked if they would go back to an ambulance answers “yes” without the slightest of hesitation.  You can be away from the ambulance for only so long I have learned and the farther away, the more you miss it.

 

Next Tuesday is her last day in the Administration track and we’ll stop by the fleet yard and let her observe a World Class System deploy to chaos.

 

Ambulance Facility Must Haves

Many an article looks at ambulance design, Paramedic training, policies and protocols but I’ve been wrestling with a different kind of barrier to quality: The Fleet Yard.

 

More specifically, I was wondering what your must have list is for an ambulance deployment center.

 

Is it indoors, well lit, vending machines, training on site, locker rooms, showers, supply techs, drive through ambulance wash…

Here’s my must haves if I could build a brand new facility:

  • Drive through restocking and shift change
  • Onsite mechanical repair
  • Onsite scheduling, CQI and training
  • Indoor secured fleet and employee parking
  • Vehicle Service Techs for restocking
  • In-unit mobile data gateway repair (after I get them installed that is)
  • Crew lounge
  • Locker rooms with full showers
  • Gym

Let me know what your must haves are, maybe you’re thinking of something I’m not.

 

The hour is late

Recently a close friend asked why we even try.  Why do we try so hard to achieve all the goals we have been chasing?  Who cares?  Isn’t there someone else who can fill in what we’re doing better?

No.

No there isn’t.

If there was something better that could be done, we’d be doing it.

This forum used to be updated every few days, some days even multiple times a day.  My duties have consumed my time, heart and vision.  Previous posts about not being able to change the system have turned into meetings that are changing the system.  For every crazy story I try to tell, I read an actual chart that mirrors my edited version and the tale can’t be told.

We’re on the verge of some major opportunities in my system and that seems to be monopolizing my time.

Go figure.

13 months ago my priorities changed and this therapy experiment has suffered.  It was created for one purpose and one purpose only and that was to serve as a pressure release valve.

Boy did it ever.

But the pressure might be too high this time around.  The troubles aren’t with those in charge of the system, or the system itself, but within myself.  My dreams of an EMS 2.0 world were destroyed by regulators, bureaucrats and the realities of a for profit system only to be rebuilt by a single EMT doing the right thing despite our policies to the contrary.  Our late night discussions in Baltimore, Vegas, Houston and other places all build into a mural of a future for our Profession only to be sidelined by technical issues and personnel conflicts.

We were dreamers.  We looked at a future that was built around quality patient care, not realizing the first question would be “how are you going to pay for all that?”

I checked…the Police Department has yet to post a profit.

It isn’t an uphill battle we in EMS are fighting, it’s an all out war.  There are those who wish to take over, give up, concede, demand even take a seat on the fence and wait to see who wins to declare their allegiances.  We can get frustrated, rant, moan and complain or we can give 100% to the one thing that matters:

 

The patient.

 

My posts may slow, my twitter may stagnate, but only because I have a chance to make a difference for more patients and I’m taking it.

Join me?

 

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