Category Archives: Public Health

Are We Doing All We Can For Mental Health? St.Emlyn’s

stemlyns mental health

Is Mental Health a Problem in the ED?

Acute (and chronic) mental health issues in the ED, to me, represent one of the trickiest and perhaps most poorly dealt with presentations in Emergency Medicine.  I am not claiming to have experience of all the EDs in the world, and I appreciate I am relatively junior in my career, but it is something that just doesn’t sit well with me.

Mental Health is not a sexy topic like trauma or toxicology; there aren’t any awesome procedures and there is little innovation.  I think those of us who work in EM most enjoy making decisions under pressure and seeing the care we deliver make an immediate difference.  Mental health doesn’t tick those boxes for us because it requires a lot of time to make a difference and often we achieve very little with these patients in the ED.  I am guilty of sometimes being short-tempered and dismissive of some of these patients and I have seen the same in my colleagues from time to time.  Sometimes we are downright rude.

We may lose sight of why a patient with a personality disorder or a patient who has resorted to self-harm has found themselves in that situation.  We forget that some people have had an awful start to life and battled numerous social problems.  There is a temptation to see them as a recurrent attender who is a nuisance and that goes against the ethos of the care we deliver in the NHS.

How Big is the Problem?

Mental health is a big issue and we really need to tackle it.

The Mental Health Foundation presents some astounding statistics on its website:

  • A quarter of the population will experience a mental health problem in the course of a year.
  • Depression affects 1 in 5 older people.
  • Britain has one of the highest self harm rates in Europe (400 per 100,000).

To me these figures are pretty staggering.  The Royal College of Emergency Medicine is aware of these issues. The college has developed a toolkit for providing care to patients presenting with mental health problems and has outlined the following standards.  These are really great pointers to helping to deliver the right care to this group of patients in the ED.

  • Patients who have self-harmed should have a risk assessment in the ED
  • Previous mental health issues should be documented in the patient’s clinical record
  • A Mental State Examination (MSE) should be recorded in the patient’s clinical record
  • The provisional diagnosis should be documented in the patient’s clinical record
  • Details of any referral or follow-up arrangements should be documented in the patient’s clinical record
  • From the time of referral, a member of the mental health team will see the patient within 1 hour
  • An appropriate facility is available for the assessment of mental health patients in the ED

It’s not just in adults that we need to think about mental health.  The stats below are from an organisation called YoungMinds and shows the prevalence of mental health issues in children.  We can make a huge impact if we bear these figures in mind and act appropriately and sensitively in a timely manner.

  • 1 in 10 children and young people aged 5 – 16 years suffer from a diagnosable mental health disorder – that is around three children in every class.
  • Between 1 in every 12 and 1 in 15 children and young people deliberately self-harm.
  • There has been a big increase in the number of young people being admitted to hospital because of self harm. Over the last ten years this figure has increased by 68%.
  • More than half of all adults with mental health problems were diagnosed in childhood. Less than half were treated appropriately at the time.
  • Nearly 80,000 children and young people suffer from severe depression; more than 8,000 of those children are aged under 10 years.
  • 72% of children in care have behavioural or emotional problems – these are some of the most vulnerable people in our society.
  • 95% of imprisoned young offenders have a mental health disorder. Many of them are struggling with more than one disorder.
  • The number of young people aged 15-16 with depression nearly doubled between the 1980s and the 2000s.
  • The proportion of young people aged 15-16 with a conduct disorder more than doubled between 1974 and 1999.

Can we do better?

At the heart of this is compassion.  We need to remember that often the most challenging and disruptive of patients are the ones who need our patience and kindness the most.  We see these patients maybe once a week, maybe once a month, or maybe every day.  We see them for an hour or two before they get discharged.  We may offer the only opportunity for these patients to be met with respect and dignity.  I want to avoid sweeping generalisations and making inaccurate assumptions, it is simply a thought.  Increasingly I have tried to be mindful of this when seeing such patients. Patients may be scared, attending the ED as a last resort and we should be sensitive to this.

I would encourage everyone working in the ED to familiarise themselves with the guidance provided by NICE.  The guidelines available cover self-harm, depression, depression in children,  anxiety, personality disorders and alcohol use.

 

Screenshot 2015-05-10 10.30.53MoodGym is an awesome resource developed by National Institute for Mental Health Research in Australia.  It is a fantastic online cognitive behavioural therapy (CBT) tool.  For those unfamiliar with cognitive behavioural therapy it (very basically) explores the relationship between our thoughts, feelings and behaviour.  If we change the way we think, we can change the way we feel and behave.  CBT has been demonstrated to be effective in many personality disorders, schizophrenia, anxiety and depression.  We may not be able to help patients in the ED but we can put them on a path to helping themselves.

Treating patients with mental health problems in the ED is challenging. Mental health resources are overstretched in the NHS.  There are no easy solutions.  Some patients will never be able access the resources they need.  We can offer a kind ear and a friendly face and we must try to be patient.  However lacking the onward services our patients need, we must continue to treat patients with dignity and respect.

Most of all, be kind.

 

Cheers!

Rich

 

Before you go please don’t forget to…

PODCAST update with Mark Wilson on the GoodSAM app at the London Trauma Conference

Mark Wilson GoodSAM stemlyns

 

 

Earlier this year we published a blog on the GoodSAM app, a device developed by Mark Wilson and colleagues in London that has a real potential to save lives. Since then we have heard him speak at a number of conferences including an inspiring talk at the London Trauma Conference. Iain was lucky enough to catch up with him there to record the following podcast. Listen, learn, and then download the app. You might just save a life.

Don’t forget that Mark will be at SMACC this year (you should be too).

We have more to come from the LTC so keep an eye out for those and other St.Emlyn’s podcasts in 2015. Related to this post is the concept around Impact Brain Apnoea with Gareth Davies. If you’ve not already listened to that then do so now as these two posts link really well.
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Before you go please don’t forget to…

JC: STI’s at Christmas. St.Emlyn’s

 

Image by OpenClips on Pixabay
Image by OpenClips on Pixabay

We frequently get asked to do ‘a little bit more’ in the ED. Over the years we have been asked to screen for lots of conditions that may be opportunistically screened for, or which may be associated with the presenting condition. Alcohol consumption for example is related to many ED attendances and so it is reasonable to screen patients for hazardous and dependent drinking behaviours. So there are many conditions that we either actively or inadvertently screen for.

  • alcohol consumption
  • drug use
  • blood pressure
  • asymptomatic haematuria
  • growth and development (paediatrics)
  • weight/BMI
  • HIV
  • the list goes on…

Many of these are incidental in our assessment of patients and we may do little more than raise awareness with the patient (and in the UK, their general practitioner) but if you stop and think about it there are potentially great benefits to screening in the ED. While these questionnaires may feel arduous it’s important that we remember that these are opportunities to improve public health and potentially reduce future healthcare encounters.

Our population is different from many other healthcare settings and I always like to remind colleagues about how diverse our population is, not just in terms of language and ethnicity, but in particular we have contact with one group of patients who hardly ever access routine healthcare at all. Young men. The ED population is the only one in my group of hospitals that has an excess of this group, so think about that next time you are asked about your equality and diversity strategy: diversity in the ED goes beyond the obvious 😉

So the ED has some population advantages for screening, and our patients are a captive audience for healthcare promotion. Sitting in the waiting room, waiting for triage, review of X-rays of the results of tests, they are bored and restless as anyone who has spent time in an ED as a patients knows only too well.

How could we use this opportunity for our advantage?

As EM physicians perhaps we shouldn’t, we are busy enough dealing with the patients who require our skills, but what about opening this opportunity up to those who are interested in screening our population. Why couldn’t/shouldn’t we have a screening service based in the ED in order that our patients may get targeted evidence based screening?

The reason I’m thinking about this today is this recent RCT in Annals of Emergency Medicine article on screening for STI’s in the ED. It’s also a great excuse to show this video again around Christmas as it appears that attendances to STI clinics may peak in January (Ed – why’s that then?).

So, if that’s filled you with festive cheer, read the abstract and paper below. This rather took my fancy as it involves screening for STIs in the ED. I spend quite a lot of time with our local GU docs (long story) and we have had several conversations about this as for the reasons stated above, we see a lot of young sexually active patients, and with plenty of cheer on offer in the bars and clubs of Virchester this Christmas I’m fairly sure that the love will be shared over the next few weeks.

Screen Shot 2014-12-17 at 15.30.21

What type of study is this?

Well, the clue is in the title. This is an RCT which is great as many studies looking at screening in the ED are observational or single cohort studies. The authors here have tested the hypothesis by randomising patients to brief intervention and investigation vs. the offer of investigation alone.

Who was studied?

The population chosen is women aged 18-35 years of age. That’s interesting as we are seeing a rise in STIs at all ages in the UK across all age bands, and in particular in men who have sex with men (1). Young women are an at risk group, but this study seems a bit limited. In Virchester, which has a large MSM catchment, this restriction presents difficulties with the generalisability of the findings. Similarly as this is only a 2-centre study we must be cautious about interpreting the findings for my and your population.

How many patients were studied

171 patients were studied, which is a fairly small population. A sample size calculation was performed based on a 20% increase in screening. The authors relate this to similar rates for HIV screening, but I still think that’s a rather ambitious difference in screening rates. Such a large difference means that you don’t need that many patients, but it does mean that you are committed to finding a big difference to gain statistical significance.

What was the intervention?

Potentially eligible patients were approached in the ED. Those who agreed to participate were randomised to either a brief intervention designed to encourage participation in testing. All patients completed a data collection process that included information on condom use, sexual history, substance use and attitudes to screening. Arguably that is an intervention in itself.

Those receiving the brief intervention met with the research team directly after baseline data collection.

Participants were then invited to take a chlamydia/gonorrhea test in the ED.

What are the main results?

The main outcome measure was the proportion of patients accepting screening. 48% in the intervention group accepted screening vs. 36% in the non-intervention group. That’s a 12% difference which is not statistically significant and does not reach the 20% in the sample size calculation but I cannot help thinking that they should have just studied more patients. A 12% difference (if true) is still quite high.

7% of asymptomatic patients were positive for chlamydia which is in keeping with other studies. No patients tested positive for gonorrhea.

Other issues.

There are many, but I’ll pick a big one, and that’s the outcome was testing in the ED, not testing over time. It is entirely possible that patients may have sought further testing in another setting so it would have been great to see some later follow up with patients. In the UK this could have been with the GP, though I am unsure as to such arrangement in the US health system (maybe it does not happen).

So where does this leave us?

It’s difficult to take anything definitive away from this study. It’s too small, too parochial and too focused to allow any form of generalisability to my patients here in Virchester, but I suppose it does prove the concept that we could do STI screening in the ED. We sort of know that though, it’s been done for HIV before so no surprises. We should also take note that screening does not have to take place in a traditional health care setting. Workplace, education, pharmacy, out reach and drop in screening services may also offer opportunities to capture individuals at risk.

Maybe dogs could do it better?

So, until we have one of these dogs in the ED we don’t have a definitive answer, but please let this paper make you stop and think about whether those boring hours in the waiting room, with a captive audience, of patients who are not routinely seen in other settings might be better used.

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1. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/345181/Volume_8_number_24_hpr2414_AA_stis.pdf
2. Urine based screening for asymptomatic/undiagnosed genital chlamydial infection in young people visiting the accident and emergency department is feasible, acceptable, and can be epidemiologically helpful T Aldeen1, A Haghdoost2, P Hay1 Sex Transm Infect 2003;79:229-233 doi:10.1136/sti.79.3.229

3.What are seasonal and meteorological factors are associated with the number of attendees at a sexual health service? An observational study between 2002–2012. Sex Transm Infect 2014;90:635-640 doi:10.1136/sextrans-2013-051391

 

 

 

 

 

Q&A with a Virologist: Ebola in the ED at St.Emlyn’s

EbolaThis week Sarah Payne from the North East of England joins St.Emlyn’s. Sarah is no stranger to blogging and is a keen #FOAMed advocate as her bio below clearly shows.

Specialty trainee in Emergency Medicine in the Northern region, currently out of program as a Simulation Teaching Fellow across the Newcastle Hospitals trust and Associate Clinical Lecturer at Newcastle University while studying for MClinEd. Interested in #FOAMed and medical education, particularly simulation and reflective learning. I also tweet on behalf of @NEsimulation, @NEFOAMed and @TASME_Northern. Outside of work my life revolves around being a taxi driver for my kids. Advocate of women in medicine in general and EM in particular.

In addition Sarah is rather conveniently married to a virologist. With Ebola in the headlines she shares her family’s knowledge about this devastating illness…..

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2014-05-24 06.51.19
Sarah Payne

Last year I sat at the Northern Emergency Medicine trainees’ conference and listened to Professor Richard Bellamy, one of our local Infectious Disease Consultants, talk about imported infections.

As he talked about Ebola and other viral haemorrhagic fevers I found myself thinking that this was interesting but ultimately a bit of waste of my time…I mean seriously… Ebola? In the UK? Never going to happen.

Fast forward a year, and we’re facing just that reality. My home turf ED (Newcastle) was the site for one of the Ebola resilience simulations last weekend, and the Infectious Diseases (ID) department is preparing to take cases once the capacity of the Royal Free is exceeded.

Thanks to some very extensive planning and preparation by the ED and ID teams the weekend simulation exercise went swimmingly, but it’s genuinely scary stuff. Particularly so in my household, as I’m married to a Infectious Diseases/Virology doc who works at the same trust. I’ve spent a fair amount of time quizzing him about it over the past few days, and thought it might be useful and interesting information for other ED docs.

Q: What’s the scale of the problem?

A: There are predicted to be tens of thousands of cases in West Africa over the next few months. In contrast, the prediction for the UK is a single figure number of cases. The UK has capacity for 26 beds over the 4 sites of the Royal Free, Newcastle, Sheffield and Liverpool.

 

Q: So are we all overreacting?

A: No. Definitely not.The problems in Spain and Dallas tell us that we need to take this very seriously indeed. Given the potential for even small amounts of air traffic from West Africa and an incubation period of up to 21 days, it is inevitable that we will see some imported cases in the UK. It is clear that these will put health care workers at significant risk unless protocols are rigidly adhered to.

 

Q: How infective is Ebola?

A: The things that are in our favour is that it isn’t infectious by the respiratory route and there isn’t a presymptomatic infectious period. Transmission is by direct contact with bodily fluids only. However, all bodily fluids, including sweat, are potentially infectious, and the infectious dose (amount of pathogen required to cause infection) is very low.

 

Q: So I could catch Ebola from touching a surface that an infected patient had sweated on?

A: That’s a bit dramatic and the honest answer is that we don’t know at the minute. Contaminated surfaces are certainly a risk for infection but this is likely to be predominantly surfaces contaminated with blood or vomit. We don’t know for sure how infectious, for example, a door handle contaminated by sweat might be – if at all.

 

Q: How do you kill Ebola in the environment?

A: It’s sensitive to standard disinfectants such as bleach based products.

 

Q: I noticed in the practice run that the stuff the ED team was wearing looked different from the ID team… What’s that about? Are we at lower risk?

A: The Public Health England (PHE) guidance for managing a high possibility case is double gloves, disposable gown or suit, apron over gown, eye protection and FFP3 respirator (mask). In addition, the CEM guidance advises overshoes as well. EDs should be stocking this kit for suspected cases. The risk of contamination increases progressively as the patient deteriorates, particularly if they develop haemorrhagic complications, so additional measures are needed when nursing a patient for a longer period and that’s why the inpatient team may use different kit depending on how the patient is nursed, for example whether the patient is contained in a trexler tent or not.

 

Q: My concern is people who don’t know they’ve got Ebola – for example those unknowingly in contact with a case who just present with fever. Is this a likely scenario?

A: Over the next few months the most likely scenario is of someone recently returned from West Africa (especially Sierra Leone given the strong links with the UK) developing symptoms shortly after they return. I’d anticipate that this person would recognise themselves to be at risk, be worried and seek healthcare promptly and if they are triaged either via telephone or in the ED, mechanisms should be robust enough to pick up this travel history. The situation of someone becoming infected by person to person transmission within the UK is unlikely because of the very low chance that an index case would go unrecognised in the UK health system. In the event of any case in the UK the relevant Public Health body would activate extremely extensive contact tracing.

However,, PHE guidance would change if the epidemiological risks shifted significantly. Also, as a general principle of any febrile returned traveller it is good practice to consider the need for PPE, and to seek advice early. Also remember that universal precautions make a huge difference, particularly in early cases.

 

Q: So what do you look out for?

A: It’s difficult. The initial symptoms are non specific and flu-like with fever or a history of fever. The disease then typically progresses through diarrhoea and vomiting to haemorrhagic manifestations such as easy bruising. By that point they’re likely to be pretty ill. At the minute the key is the travel history and fever.

 

Q: So what do I do as an ED doctor if I have a patient with fever and a travel history from west Africa?

A: Well, hopefully you’re not reading this with a patient like that in your department!

All EPs should know where the PPE is, how to don PPE and more importantly how to remove it correctly. You also need to know which is the designated holding room in your ED. In terms of PPE training, different trusts are probably at different stages, but it’s reasonable to think it should be happening across the country over the coming weeks. It can take up to 15 minutes to put on your PPE and you should have someone check it before you go into the room. It’s also unpleasant to wear; although it can be worn for up to 3 hours at a time, in reality it’s very uncomfortable and difficult to tolerate for more than an hour or so. Taking PPE off is also something that needs to be carefully done and practised as the items need to be removed in a specific order to prevent contamination.

The patient should be immediately isolated and someone will need to suit up and assess the patient to make a risk assessment before liaising with your local Virology/Microbiology or Infectious Diseases consultant. Local arrangements will differ and it’s important that you know what they are. You will be expected to take routine bloods and malaria films in the ED unless your hospital can immediately divert to an ID bed. The College of Emergency Medicine has produced an excellent flow chart which you can download and display in your ED.

 

Q: What happens to the bloods? They must be pretty high risk for the lab.

A: Most routine analyses are run on large automated machines. The risk of transmission from these is considered very small due to the large volume of dilution involved, therefore initial samples can be run on normal automated analysers. The lab staff should be made aware as there are implications for sample handling and waste disposal. It’s up to the ED consultant to decide what tests should constitute essential investigations but I’d think as a baseline you’d be sending your standard ED sick patient package plus malaria investigations. Remember it’s more likely that this patient has something other than Ebola.

Your local infection Consultant will then arrange transfer of samples to Porton Down to test specifically for Ebola. Bear in mind that the patient may well remain in the ED until that test is performed, and this could be up to 12 hours.

 

Q: Are there any treatments for Ebola?

A: Not specifically. There are a couple of experimental drugs which may be tested in the field over the next few months but they’ve been very much rushed out and it remains to be seen whether they will be effective. The mainstay of treatment is supportive care.

 

Q: If you’re caring for a patient with suspected Ebola and you get blood on yourself, what do you do?

A: You mean other than panic?! (Don’t do that!) You’d need to liberally wash the area first of all, and then inform your national Public Health Body (Public Health England, Public Health Wales, HSC Public Health Agency in Northern Ireland,  Health Protection Scotland, or the Health Protection Surveillance Centre in Ireland) . You’d  be subject to active monitoring for the next 21 days,

 

Q: What does that mean? Would you be quarantined?

A: You’d have to take your temperature twice a day and phone it to the relevant public health body. Quarantine arrangements are unclear at present and will be decided on a case-by-case basis. Staff who’ve managed an Ebola patient with no recognised breach in PPE should undertake passive monitoring i.e. self monitor for symptoms for 21 days. That might change in the light of the Spanish and Texan cases.

 

Q: Do you think there is a risk that people will become blasé about it?

A: I’d hope not, with a mortality rate of over 50%. We need to take this seriously. Everyone should read advice for the UK in addition to the relevant local advice. Some of the information produced by Public Health England is relevant to the whole of the UK but if you live in other parts of the UK or in Ireland be aware of your national public health body too.

PHE & Dept of Health Guidance – click here

England – click here

Scotland – click here

Wales – click here

Northern Ireland – click here

Ireland – click here

2014-05-24 06.51.19Brendan Payne

 

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Sarah Payne & Brendan Payne

 

Further reading:

  1. UK Ebola guidance from College of Emergency Medicine
  2. Ebola Special at FOAMCast (US guidance): Blog & Podcast
  3. NEJM Ebola information
  4. Lancet Ebola information
  5. Ebola Editorial by US ED Resident Jeremy Faust at Slate

 

Free Open Access RESUSCITATION – the GoodSamApp with Mark Wilson

 

 

Screen Shot 2014-08-27 at 08.53.07Mark Wilson.

One of the things I love about medicine is the cross-fertilisation of ideas and techniques from one discipline to another. I worry that as more subspecialisation occurs, cross-fertilisation will be lost. Emergency medicine and critical care, spanning so many areas, are unique in that they may be the last places of true open-minded generalists. It’s in these environments that innovation can flourish.

Being involved in pre-hospital care allows you privileged access to the few moments immediately after an injury has occurred. Physiology is very different at this time. One thing that occurs in animals who sustain head injuries, and we believe also occurs in humans is a phenomenon called Impact Brain Apnoea. There are many historical articles reporting it but it seems to have been largely forgotten in modern literature. A bang on the head, even with minimal or no parenchymal brain injury, can result in a period of apnoea – with obvious consequences if sustained and untreated. We wanted to find a way to minimise this phenomenon. Suggestions included training paramedics better airway skills, but they already have great skills – its just they are not there…

It dawned on us that, like you are never more than 10 feet away from a spider, you are probably never more than a couple of hundred metres away from a doctor, nurse, paramedic or first aider… Harnessing this community would not just be beneficial in traumatic brain injury, but more importantly in cardiac arrest.

And hence the GoodSAM App (www.goodsamapp.org) was born. Consider the scenario. Someone collapses in a bookshop. If a bystander opens the App, it automatically dials 999 (or the appropriate number for whichever country you are in). It simultaneously alerts a trained and registered responder, who may just be in the coffee shop next door. It is the equivalent of shouting for help, but being able to shout through walls. The ambulance will still arrive (in London about 70% arrive within 8 minutes for category A calls); but with a trained responder arriving earlier, they should be less hypoxic have had high quality CPR and may even have been defibrillated if appropriate.


Now if reading this you may be thinking, but I don’t want to be called when out shopping! And that’s fine! If you are a registered responder you can switch the App off and if you can’t go when alerted, that’s fine, the next nearest responder is alerted. When responder densities are high (nearly 1000 in London) the chances of you being alerted are actually very small.

How many Neurosurgeons also work in prehospital care?
Mark in prehospital guise with London HEMS

We also built a defibrilocator into the App – it now has nearly 2000 defibrillators across the UK in it. If a responder sees an Automatic External Defibrilatior (AED) attached to something fixed (e.g. in a tube station), they simply use the App to take a picture of it and state the opening times of the location. Using the Geotags of the photo it is then put on the GoodSAM map.

You may have some concerns about this App – that’s ok – we had too. Questions such as “how will you stop abuse”, “how do you check people who register”, “what about indemnity” are common and we have addressed them as best we can here.

This is something of a social experiment! But the Good Samaritan community seems to be building rapidly both in the UK and internationally. If it works, it might really make a difference, not just in maintaining airways in trauma, but by providing high quality CPR and early defibrillation in out of hospital cardiac arrest.

Get in touch at info@goodsamapp.org to tell me more and to share the word, but before you do that please consider downloading the app and joining the team. You might just save a life…..

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Mark Wilson

 

 

Guest Blogs at St.Emlyn’s

Mark Wilson
Mark Wilson

This week’s guest blog comes from Mark Wilson. Here he talks about the GoodSam app which we think is marvellous. Mark is a super chap who is an inspiration to all of us in #FOAMed, Meducation, PHEM and Neurosurgery. I met him at SMACCGold where he did an amazing sessions on Neurosurgery for everyone (you have to watch this) and ICP monitoring. You should also check out the links below to see examples of his contributions in the past.

However, he is not guest blogging on the past, but on the present. He has developed the GoodSamApp with help from the #FOAMed community and it’s just an amazing idea and one that really deserves widespread dissemination and adoption.

Please read Mark’s thoughts above and please, please, please consider joining in on this amazing idea.

Mark asked us not to be so gushing. He’s much more devoted to the project and to making the world a better place than to any self promotion. He is rather modest, but to be honest we couldn’t resist. He’ll be at SMACC in Chicago next year so why not book your flights now and come meet him in person.

What we really need is some momentum….. anyone know of some organisations that might promote and support @goodsamapp… I think I do.

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