Home of Medicine with Dr Amie Burbridge and Dr Ben Lovell

Palpitations

• Dr Amie Burbridge and Dr Ben Lovell

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0:00 | 30:01

Real Cases, Real Thinking, Real Medicine

Amie and Ben discuss a case of 36 year old woman with palpitations. 

Can Ben figure out what is going on? 

As you listen, ask yourself: can you figure out the diagnosis? 

What would you have done in the situation?

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Disclaimer: All patient stories discussed in Home of Medicine are informed by real patient interactions. However, all identifying details have been removed or appropriately modified to protect patient confidentiality. 

This podcast is intended for education and professional development and should not replace independent clinical judgement or specialist consultation.

SPEAKER_00

Hello everybody and welcome to a new episode of Home of Medicine podcast in association with the Royal College of Physicians Edinburgh. My name is Ben Lovell, and I'm an acute medicine physician working in London. And here is my co-host.

SPEAKER_01

Hi, I'm Amy Birdbridge, a consultant in Acute Medicine and working at Lincoln Medical School, which I'll never get tired of saying.

SPEAKER_00

You should never get tired of saying that because it's a wonderful achievement. So those who've been following the order will know that it's my turn to present a case to you today. And it's an STEC case, same day emergency.

SPEAKER_01

Hey. Ooh, I like these ones.

SPEAKER_00

I know you do. I I could you like a bit of STEC. So it's a STEC 36-year-old lady, 36-year-old, referred in via GP for a same-day emergency review with palpitations. Intermission, intermission? Intermittent palpitations. Alright. Um, and I'm gonna say something now, and I want your reaction. Um, she says, I've had them my whole life, but I've never seen a doctor about them. But I've just registered with a new GP and he didn't like the sound of it, so he sent me in.

SPEAKER_01

Thoughts, please? Okay. About the palpitations or about the referral to Esther? Anything you like. Okay, my initial okay, so my initial response is seriously, she's had them all alive. Why is she coming to hospital? I guess I want to know what the whole of life is. Does the whole of life mean adulthood or does it mean childhood and adulthood? So I want some clarity around that as well. Um GPs don't normally send patients to hospital for no reason, so there must be something in the history that the GP felt a bit icky about and was like, I think this needs seeing.

SPEAKER_00

So that's a very kind. I had the same reaction. Palpitations whole life. GP wants the same day emergency review today. I mean, for real? Okay. Really? That's um, that's that's fine. Sometimes we react without getting the full picture. So this is yes, someone someone who has had palpitations their whole life, and she says, I do get them banging in my chest, very annoying. It's just part of normal for me now. I've had them as long as I can remember. Um, and I know exactly what triggers them. Um, it's lack of sleep. When I take big gulps of cold drinks, then I get them. And they can last for a few minutes or up to an hour, and I've just adapted to this now. I try to take small sips and warm fluids only. Um, but I I I just flew back from this um the States and I didn't get as much sleep. I was jet-lired, and there you go, I had a little bout of it, but they've gone now and they're pounding on my chest. Um, and that's about it, really. And that's what you've been out, and then I've I've learned to ignore them over the 36 years, and I sort of pushed them to the back of my mind.

SPEAKER_01

I mean, that's not normal to have to sip cold drinks because of the concern that this could lead to palpitations. So that maybe that does give me a bit, oh, okay. You've threw me in, I don't know if it's a red herring or something there, Ben, but you threw me in long flight. So I'm like, long flight, long flight, palpitations, P E P E. So I've got these that in my head as I've all automatically gone, right? I need to make sure she doesn't have a PE. So I'm gonna do four D dimers hourly. No, I'm not really just to check whether the dimer increases over the no, that's not true. I'm I'm telling tales. Um, so I want to think about acutely what could the concern be, and I'm gonna want to rule out a PE. Any shortness of breath, any leg swelling, any risk factors for that. Um I'm also thinking, ooh, cold drinks, arrhythmia, Wolf Parkinson White, SVT, hypertrophic cardiomyopathy. Is there any family history? Or is it all normal?

SPEAKER_00

So um, okay, so I'll answer your question. So um no leg swelling, no shortness of breath, and no chest pain. Um and uh past medical history was completely fine. Uh took no medications, no medical complaints. Um yeah.

SPEAKER_01

Anything over the counter or the oral contraceptive pill?

SPEAKER_00

Neither of the above.

SPEAKER_01

Okay. I often find that people don't think the oral contraceptive pill is a medication, so I always ask about contraception separately. I think I've mentioned that before. Okay. Um any family history?

SPEAKER_00

Uh no, nothing cardiac at all.

SPEAKER_01

Nothing, okay. Any thyroid abnormalities in the family?

SPEAKER_00

Uh didn't ask, to be fully honest.

SPEAKER_01

Okay, so I'm just now thinking of palpitations of what could the causes be? Hyperthyroidism, cardiac, hormonal uh life. I'm not that's terrible, isn't it? A terrible response, life. Um Do you know what? In this situation, I'm gonna take a full history. I'm gonna look at all of the different systems. I'm gonna look at bowel habit, any diarrhea that would suggest hyperthyroidism. I'm going to look at the cardiac history, the respiratory history, any headaches. Yeah, I'm just gonna do a full systemic inquiry. Yeah.

SPEAKER_00

So everything was fine. Um, this patient's quite bemused as to why she was there. Um and I think I said to her at one point, Well, what do you need from me today? She was like, I don't know. I only came in because I was told to, but there's nothing really, there's no real reason for me to be here today. This is something I've had my whole life, so I'm not quite sure what to tell you. But no change in bowel habit, I think you asked about. Um no other features of uh thyrotoxicosis. Um what else did you want to know? No signs of uh breathing abnormalities, no?

SPEAKER_01

Any recreational drugs?

SPEAKER_00

None.

SPEAKER_01

Has she had any pregnancies?

SPEAKER_00

No.

SPEAKER_01

Okay. What type of work does she do? She works in tech.

SPEAKER_00

And I don't know what that means, but I gather she works sitting at computers.

SPEAKER_01

Okay.

SPEAKER_00

I I don't really know what work in tech means. So you need to examine what's her pulse like so her health is 86 beats a minute and regular sinus. Okay. Um, her blood pressure is 131 over 81. Her saturations are 97% on air, her respiratory rate is 16, and her temperature is 36.1. All completely normal. All normal. Um yeah, but on examination of her chest, her chest is clear. There were no cardiac murmurs, um, there were no signs of heart failure or DVT. Um, and I was felt very clever, but I examined for a thyroid goiter and I couldn't feel any swellings on the neck at all because I had the same thought that you did, but uh hyperactive thyroid. Um, and that's where we were really a woman sitting in front of me with a lifelong history of intermittent palpitations, triggered by lack of sleep and gulping cold fluids, who was currently in sinus with him and completely well.

SPEAKER_01

Okay, so you're happy that she hasn't got a PE.

SPEAKER_00

Are you telling me or asking me?

SPEAKER_01

Um I'm asking you. Oh, yeah. You know, was that something that you were thinking of? I don't know.

SPEAKER_00

I I really, really wasn't. Because you're right, a lot a long flight, but on the background of pre-existing symptoms. It doesn't quite add up to me. No. Um, I suppose people listening are screaming out, what was on the bleeding ECG?

SPEAKER_01

Yeah, I know exactly. I'm waiting to ask you that.

SPEAKER_00

Uh the ECG was normal sinus within QT intervals, normal, PR intervals, normal, no bundle branch but morphology, completely normal ECG.

SPEAKER_01

So I guess the question is at this point, do we want to do any investigations in hospital?

SPEAKER_00

Exactly.

SPEAKER_01

So are you going to do some tests there and then? Are you going to do some tests at the bedside? Are you going to do a glucose? Obviously, we've done an ECG. And then are you going to do any blood tests?

SPEAKER_00

That's a good question because we pretty much lead everybody who comes.

SPEAKER_01

Yeah, I remember you seeing that.

SPEAKER_00

The nurse is standing next to me with a tray with a cannulation kit saying, What bloods would you like, Doctor? And I'm going, I don't know if I want any. Because I haven't got a question in my head.

SPEAKER_01

What about periods alcohol smoking?

SPEAKER_00

I've written that down. Caffeine and alcohol intake was I've written okay, i.e., fell well within normal limits and a non-smoker.

SPEAKER_01

Any any menstrual problems?

SPEAKER_00

Nope.

SPEAKER_01

Oh my gut instinct is to go, okay, do you know what? Let's watch and wait. But she's watched and waited for 36 years. So after 36 years and an admission to hospital to STEC, should we now do some routine blood tests? And I literally detest the phrase of routine blood tests. But while she's here, should we check her hemoglobin, her thyroid function, potassium, calcium, magnesium to make sure that they're all okay?

SPEAKER_00

Okay, good question. I suppose let's think what's our clinical question here? What could be the diagnosis?

SPEAKER_01

Okay, so my clinical question is of these palpitations is are these palpitations number one caused by a cardiac abnormality? So we've done an ECG, fantastic. Do I want to look at her sodium? If we've got a sodium channelopathy, which can rarely cause palpitations. Do I think this is an electrolyte abnormality? Do I need to check a magnesium and calcium? Is does this lady have hyperthyroidism? You know, do I want to check a thyroid function test? Do you know I would take bloods?

SPEAKER_00

Okay, so Mike, I was I'm in an Ring, and my clinical question was has she got an undiagnosed paroxysmal arrhythmia? So PAF or paroxysmal SVT.

unknown

Yeah.

SPEAKER_00

That was the I guess if I had to make a guess about a diagnosis, could that be it? Lifelong? Well, okay, you can't be on Wolf Park isn't right. Yeah, yeah, no delta waves and ECG, but you could be have a lifelong structural or electrophysiological problem which gives you intermittent palpitations. Intermittent palpitations triggered by drinking cold fluids. I was not but you know what I made my peace with that, and I said, okay, theory theory that hypothesis I'm testing is has she got paroxysmal, atrial fibrillation, or superventricated tachycardia? So, in that question, I think bloods are reasonable to make her profoundly anemic or profoundly hyperthyroid. So I did do bloods as well, and that's how I rationalized it to myself. So I was answering a question, a clinical question. I was working up a clinical hypothesis. Does that make sense?

SPEAKER_01

It does. I guess what you're managing here is uncertainty. And you, you know, and it's you're uncertain about lots of things. You're uncertain about uncertain about whether she should have come to hospital anyway in the first place. You're uncertain about what the cause of the palpitations, and I guess you're uncertain about is this something I even need to be worried about?

SPEAKER_00

Yes. Should because and I think that's a relevant question because Estec, same-day emergency care, we're we're under the auspices of you know emergency care, the clue's in the name. And could should this patient just be in her GP surgery? And I don't say just the GP surgery to belittle GPs, but his primary care, not a better place to be working up a lifelong problem. But the fact was, we're here now, and I'm the doctor standing in front of her, and it's uh and there's a nurse standing there saying, What blood tests do you want? So there we go. So I did do those bloods, I confess. Anyway, didn't get me any further forward. All her bloods are normal. Uh thyroid function normal, FBC using E CRP, all completely normal.

SPEAKER_01

Did you do uh did you check LHF and FSH?

SPEAKER_00

No, why?

SPEAKER_01

The only reason I'm saying that is I know she's 36, but uh menopause, perimenopause, lifelong palpitation. Okay, okay, fair point. All right, okay, okay, that's a silly, silly question. I'm trying to uh the thing is now I'm biased because you're talking about this case on the podcast. I'm like, there must be something wrong.

SPEAKER_00

And we've had this conversation before. The fact that you brought this case to the podcast and there's a sting in the tail somewhere. Surely that's not the end of the story. She went home and they all lived happily ever after. Yeah.

SPEAKER_01

Maybe we have just discovered a new bias.

SPEAKER_00

Podcast bias.

SPEAKER_01

Podcast bias. Yeah.

SPEAKER_00

Yeah.

SPEAKER_01

Home of medicine podcast bias. Yeah. Yeah.

SPEAKER_00

Uh no, no, we'd have to call it uh after us. The Lovell Burberage bias.

SPEAKER_01

The Burbage Lovell bias.

SPEAKER_00

Maybe alphabetical. Okay.

SPEAKER_01

Okay, so we digress. So at the moment.

SPEAKER_00

What next?

SPEAKER_01

I'm going to do a um a problem representation of this patient then, because I find that helps. So when I'm not entirely sure what is going on, I like to go back to basics. I have a 36-year-old female who presented to her GP with lifelong palpitations. There are no associated symptoms. However, the palpitations are triggered by lack of sleep and cold drinks. There is no history of recreational drugs, a high alcohol intake or caffeine or smoking. She works in quite a sedentary job, no family history of note. Examination is normal, observations are normal, ECG is normal, blood tests are normal.

SPEAKER_00

The only asterisk I would add to that is ECG, while she wasn't having symptoms, were normal.

SPEAKER_01

Good point. So I always ask myself this question Does this patient need to be admitted to hospital? No. The patient can go home. Do they need follow-up? Do they need further tests as an outpatient? Am I going to do a 48 to 72 hour halter monitor on this patient? No. Yes. No. Yes.

SPEAKER_00

Goodness me.

SPEAKER_01

And as I'm saying no and yes, your eyes are going up and down. And I'm doing what? In clinical practice, no, I wouldn't. I wouldn't do a halter monitor on this patient. Whether that's right or wrong. And I'm sure there are lots of other people who would.

SPEAKER_00

Yeah. I think if you do a halter monitor, that you're then committing your service to follow up results because we always follow up results of tests we organize. You can't say also results back to GP. That's a that's not how it works. So do you want to take that on as your STEC team to arrange a halter? I don't know what your halter turnaround times are. Are there many weeks, if not months? Um, and then follow up the results of that, and then you know, act upon it. And a 24-hour halter, 72 a week, you know, those are the sort of decisions that you're making. And I found a bit of a halfway house um for this was a very intelligent woman who'd been living with symptoms for long and was a bit perplexed as to why the doctors were so interested. I said to her, um, she she volunteered to me, my dad has that um Apple Watch thingy with the cardia attachment on to monitor his heart rate.

SPEAKER_01

Which idea?

SPEAKER_00

Can I just use that if I when the next time I get symptoms? Because I will get them, or I'll even go home and have a big cold drink and trigger them, and then I'll do it, and then then we'll know what's what.

SPEAKER_01

That's a fantastic idea.

SPEAKER_00

And I said, you know what, that let's do that. I trust you to do that. Um, and I thought that would be the last I ever saw of her. End of the episode. No, just joking. Um, and we I sent her home very pleased with myself, and four days later, she rang our seven-day safety net service we have in our STEC, with a little phone number you can ring any morning if you were a recent STEC patient, if you're not white. And she rang it and said, Oh, something happened. My dad's cardiac thingy has says I've got something that I need to show to a doctor. So I said, Please do come in. I said, How do you feel? She went, I feel fine. I had a burst of symptoms, did the thing on the on the Apple Watch, and this is what it's telling. And she came in and she showed me um this strip as a screenshot on her phone because she'd taken a picture of her dad's watch. So a bit blurry, and it's a screenshot of a one lead ECG trace as you get from these little devices, a bit out of focus, but showing atrial fibrillation. But it had her dad's name on it. Oh, it says something, let's say it said Bob Smith, atrial fibrillation. Yeah, but that that's my dad's name because it's registered to him. But that was my finger on the button, and it was me, honestly. Um, yeah, and that was when I had, and I I went home and I went to my dad's house and I had a big drink of cold water and triggered, triggered the symptoms, and then I put my finger on, and there you go. So Bob Smith, whoever whoever has now got AF somewhere out there, but is Bob Smith my patient? She says it is, did an ECG, she's back in normal sinus rhythm again. Where do we go from here?

SPEAKER_01

Do you know what? I I'm gonna speak to the cardiology reg on call and get some advice actually. Well, I I need you from well, because I'm because uh podcast bias. What I'm going to do is so we've got a couple of options. Number one, does she have any transient loss of consciousness when this happens?

SPEAKER_00

Okay, good question. So now we're wondering about does she have any signs of unstable tachycardia? Yeah. So you're asking about syncope. No, she doesn't. The other three signs of instability would be chest pain. She was negative for chest pain, heart failure, and shock, i.e., hemodynamic compromise. And admittedly, we've never done a blood pressure in the moment, but she's she never felt pre-syncopolar run well. She just it was annoying.

SPEAKER_01

Okay. So I guess what you're looking at on the on the tracing is paroxysmal atrial fibrillation, which has inherent risks associated with that. No. So, number one, I could do a halter monitor, aware that it could take a long time.

SPEAKER_00

Yeah.

SPEAKER_01

Number two, an implantable cardiac device is a potential. Number three, have a chat to the cardiology team and get some advice. Number four, get her to get her own watch with her own name on it and to keep an eye on this.

SPEAKER_00

Well, they're expensive. Are you gonna go into the no, maybe not?

SPEAKER_01

They are expensive, aren't they? Uh would you admit for observation to put on a monitor and to drink cold water in hospital or in STEC to try and activate it so you actually see it when it happens?

SPEAKER_00

I did think about that. I did about think about going to the water cooler.

SPEAKER_01

Yes, that's what I was thinking. You know, should you I wasn't really on board with that whole correlation?

SPEAKER_00

Um I understand.

SPEAKER_01

Yeah.

SPEAKER_00

Yeah. I just didn't know I wanted to go down that road.

SPEAKER_01

What happened?

SPEAKER_00

Well, but I want to push you to a to a commitment. Okay. Okay.

SPEAKER_01

You want me to know what my plan is.

SPEAKER_00

Yeah.

SPEAKER_01

So I'm already imagining if I speak to maybe the cardiology team, they might say admit for observation.

SPEAKER_00

Okay.

SPEAKER_01

Or some people Yeah, some people might say hold a monitor, but aware that that could take a very long period of time. I could speak to the cardiophysiology department and say, is there any chance you could fit one today?

SPEAKER_00

And when they'd finish laughing at me down the phone, then what was your next option be?

SPEAKER_01

Okay, I'm gonna do an outpatient 48 to 7. I'm gonna do an outpatient 72-hour halter monitor.

SPEAKER_00

Mm-hmm. Okay, great. And then just follow up the results as and when they're available and safety the patient and say absolutely whilst the halters on, if you fancied a big cold drink, yeah, uh, then you go for it as long as that's safe and we'll see what happens.

SPEAKER_01

But also saying, as you've got your dad's watch, if this happens, maybe try and record the tracing.

SPEAKER_00

And again, any consents, maybe email me the tracing or okay, you know, pop give patients your email address.

SPEAKER_01

I've never done that, Ben. I don't know why that's no, that that thought never has never come to me before. I don't know why I said it.

SPEAKER_00

Not in a in a profession where we see hundreds of patients or no, I think it'd be very difficult, wouldn't it?

SPEAKER_01

Yeah.

unknown

Yeah.

SPEAKER_00

Um, all right then. So I the conversation I had with myself was I've got some evidence that this woman is in PAM. I've got a dodgy screenshot of an ECD recording with the wrong patient's name on it. But she's telling me that's her recording. Do I have enough evidence to start treating her? And if so, with what? First of all, AF, this is our bread and butter in acute medicine, rate control, anticoagulation. So do I offer her a low dose beta blocker just to maintain sinus rhythm moving forward? Like 1.25 with bicep blade? Or do I offer um, and I thought about that and I thought, no, because I I don't think medically legally I have enough evidence to say I diagnose PAF in this patient yet. Do I anti-cargulate her to prevent her from having a stroke? She's had it for her whole life. That doesn't mean you don't anti-cargulate someone with known PAF. What's her ChadVasc score? Her Chadvas score comes out at one for being female, and the Chadvasp one Chadvas score says you don't need to offer antibiotics. That one point is just for gender. That's okay. That's a relief. So I don't have to. If she was 76 rather than 36, then I'd be thinking, maybe I should be trying to pin this down because she could have a catastrophic stroke. So I said exactly what you did. I said, let's do a halter and let's just see what's what if this is someone something that happened with you lifelong. I think we can afford a few more weeks. And I requested um a 72-hour halter, which is what you said.

SPEAKER_01

And I said you do 72 hours as well.

SPEAKER_00

Yep. And I said, um, if you can trigger these whilst the monitor's on, that might be really useful information for us to have. Do you did you do an echo? Oh, that's a good question. I thought about an echo because AF and a young patient, you looked at causes. At that point, again, I did feel I had enough evidence to prove that my patient had PAF, at least nothing that would look like it would make sense to a second reviewer, you know, years down the line. All I had was that screenshot. Um, I guess you could say, would you offer a young person with palpitations, even with normal sinus rhythm, an echo to look for structural heart disease? Yeah, could I chose not to. Okay. Okay. Um, so I I uh booked her at the halter, I sent her home. She was happy with that plan. She's like, this is a lot of fuss about something that's my normal. Um, and I booked her into our results um clinic, which is run by a registrar, um, and they chase results of um longer time weight investigations like halters and outpatient echoes. Um, and um I thought that was the last I'd ever see of her. Chapter three. Yeah. So eventually um her halter monitor came back, and it was the most beautiful diagnosis of intermittent paroxysms of atrial fibrillation, fast AF. That completely correlated with the patient's diary, which she'd symptom symptomly, she's symptomatically, she's had a little diary, and every time she had symptoms, she wrote it down. And she even very helpfully wrote things like large cold drink here, followed by um palpitations, uh which matched up perfectly with her with her symptoms. Well, this is a person who'd had lifelong PAF. Um, and I rang her, I rang her and I said, We've got your diagnosis. You have something called paroxysmal atrial fibrillation. You've probably had it for years, and we actually managed to nail down the diagnosis. Um, and what we need to do now is refer you to um a cardiac uh uh electrophysiologist, a cardiologist with the with an interest in EP, and they will be able to discuss options for you, such as ablations and things like that. She said, No, thank you. Oh I've done some reading about that to do cardiac ablations, they have to scar your heart, and I don't quite fancy that and the risks. Uh I'll just avoid cold drinks and I'll be fine and moving forward. And I sort of went, Can we stop with the cold drinks thing? Because it's just nothing I've ever picked up in a med medical textbook. And I said, Look, with a bit of niggling from me, do you mind just going to meet the cardiologist? I'll make an outpatient appointment and you don't have to do anything you don't want to do. All they'll do is suggest treatment options, but you've got to hear in the crowd so you can understand all the risks and benefits, rather than you know, chat GPT or Google it or something. She agreed to a referral. I did a referral. And I did some little research. I was like, what is this gulping cold fluid thing? And I found this. Um, actually, there are multiple case reports of patients who um can induce a paroxysm of atrial fibrillation by gulping large um boluses of food or water or by having very cold drinks. Wow. I summarized in a study in 2019 where they interviewed patients and said, what are your triggers, the most common triggers for your paroxysm AF? And they listed them. Now, what do you think is the most common trigger identified by patients to bring on a an ad of AF?

SPEAKER_01

Alcohol.

SPEAKER_00

Alcohol, number one, 35% of patients. Number two, physical activity? That's number three. Number two is caffeine, 20. 23% said intense exercise.

SPEAKER_01

Yeah.

SPEAKER_00

21% said lack of sleep, which was relevant in my case.

SPEAKER_01

Yeah.

SPEAKER_00

10% of patients identified large meals.

unknown

Okay.

SPEAKER_00

And 7.5% of patients cold drinks. Wow. And there's a theory that it's some kind of vaguely mediated response due to the coldness or the um or a very large bolus of food or fluid going down the esophagus can cause activation of the vagus nerve, and that increases parasympathetic tone, which can bring about or can lower your threshold for going into atrial fibrillation. She was talking a lot of sense, and she actually had managed to um to make it work by avoiding cold rigs. Wow. Isn't that interesting? I had never heard of that before.

SPEAKER_01

So when she saw the cardiologist, what was the plan going forward?

SPEAKER_00

Uh she hasn't seen them yet.

SPEAKER_01

Okay, okay, fair enough. It brings into a lot of shared decision thinking about shared decision making as well, doesn't it? There as well, like the patient really doesn't want treatment, but we're like, you need to have treatment. So at what point do you yeah? It's wow. Do you know what? Do you know what that tells us beautifully, Ben? Listen to your patient, they are telling you the diagnosis.

SPEAKER_00

I thought it was a lovely case, and I I really enjoyed talking to her. She was a fun, fun lady, and um I learned something from that which I thought was really important. Did you was it a good one? Did you like that?

SPEAKER_01

I loved it, and I kept thinking there's gotta be something. There's gotta be something in this. Um yeah. I've not heard of Path lasting that long. You know, it's not something we see very often in younger people, is it?

SPEAKER_00

Well, she definitely needs an echo now, doesn't she? Now we've confirmed diagnoses to look at the structure of our problems, and that's something that's in the pipeline as well. Wow. So, and on that happy note, I'll bring us to the close of that episode. Um, I hope you enjoyed guessing along at home. Um, and maybe you can keep that little nugget in your back pocket. So when you're talking to your patients with PAF, you can ask them, cold drinks ever happened to you? And they'll look at you and go, gosh, how did you know that? And then you're very wise indeed. But thank you so much for listening, everybody. And we do ask if you enjoy if you could um rate or review us on wherever you're listening to the podcast, because that bros our listeners and it means we can reach more people. Um and we love it when we get some feedback as well. So please don't be shy about dropping us a message because we always respond. Thank you, Amy, for playing along.

SPEAKER_01

Thank you very much, Ben. Thanks for listening. Bye.

Contributor

Dr Amie Burbridge

Host
Contributor

Dr Ben Lovell

Host