Supporting mothers and newborns together on the postnatal unit | Dr. Carl Seashore

[00:00:00] Kristin Tully: Welcome to the Advancing Maternity Care podcast. I'm Kristin Tully, founder and chief scientist at Couplet Care. In this podcast, we invite maternal, infant, and family health thought leaders to share their perspectives and work. Connecting around research and lived experiences is key for implementing more meaningful support for families and those who care for them. Welcome, Dr. Carl Seashore.

[00:00:28] Carl Seashore: Thank you.

[00:00:29] Kristin Tully: a pediatrician and professor in the Division of General Pediatrics and Adolescent Medicine at the University of North Carolina at Chapel Hill. His interests include quality improvement, newborn care, ambulatory pediatrics, and informatics. He was previously service line leader for newborn care and is currently an associate chief medical informatics officer a lead informatics physician for UNC Health Care, and he's the fellowship director for UNC School of Medicine's Clinical Informatics Fellowship. Dr. Seashore has worked extensively with the Perinatal Quality Collaborative of North Carolina on projects relating to newborn care across the state, helping lead several initiatives, including those aimed at improving services for babies with neonatal abstinence syndrome and risk for sepsis. Dr. Seashore is also an inventor of the Couplet Care Bassinet.

[00:01:30] Kristin Tully: Welcome.

[00:01:31] Carl Seashore: Thank you, Kristin. It's great to see you. Glad to be here.

[00:01:35] Kristin Tully: This is so exciting. Can you, just share a little bit more about yourself and what drives your work?

[00:01:41] Carl Seashore: Absolutely, yeah.

[00:01:43] Carl Seashore: So I've been a pediatrician for twenty some years now, and, in my medical career, my medical practice and some of my leadership roles I've had, I tend to take the approach of having to fix things that aren't working properly. And so that might be systems of care, that might be equipment, as we've done with the work on the bassinet, or those might be electronic health record tools, right?

[00:02:09] Carl Seashore: But I tend to approach things as a curious person, and with the hope of making them better. of course, those same principles apply to taking care of patients, right? The goal is if something is not working well or is broken, you try to fix it. and then of course, we do a ton of work around prevention in pediatrics and trying to keep children healthy and prevent them from having, illness or disease.

[00:02:33] Carl Seashore: And so much our experiences with the bassinet, we saw a problem that, equipment was really not designed with parents, and newborns in mind. it was designed with nurses and doctors in mind. and

[00:02:48] Carl Seashore: that was really the genesis of Couplet Care is, trying to build a better, piece of equipment that would serve moms and babies and foster their independence and togetherness in those first few days in the hospital.

[00:03:01] Kristin Tully: Yeah. Thank you. It's been so wonderful partnering with you and others around from clear unmet need, with regards to structure within postpartum rooms to co-developing something that is appropriate and fits, not only with the function that we need, but also with the context.

[00:03:22] Carl Seashore: Yeah. Yeah, you mentioned some of the perinatal quality, collaborative work and, the bassinet didn't exist when I was doing that work. But

[00:03:37] Carl Seashore: one of the things that I think ties a lot of the work that I've done together, whether that's, better risk evaluation for sepsis in newborns, care for babies at risk for withdrawal from substances, and breastfeeding, even just well newborn care, is the importance of keeping moms and babies together,

[00:03:52] Carl Seashore: in that early peripartum time, that, that immediate postpartum birth hospitalization.

[00:03:58] Carl Seashore: And those were all examples where a key part of what was happening in the care of many of those babies is they were being separated from their mothers, either because of a perceived risk of infection or increased risk of infection, or because of a perceived risk, of substance withdrawal, or just because they-- there was a sense of needing closer evaluation than could be provided with the baby staying with the mom in the room.

[00:04:27] Carl Seashore: And then there was that physical barrier of the bassinet being Inaccessible to the mother. And so all of that really ties back to the idea that if we keep moms and babies together in that perinatal period, both will do better unless there's tr-really a true indication for separation, a critically ill mother, a critically ill infant.

[00:04:48] Carl Seashore: Obviously, you need to have some degree of separation. But, for those healthy infants or infants with lower risk conditions that can be observed without separating the mom and the baby, I think that to me is one of the most important things. and the bassinet just takes it to the next level by giving the mom and the baby the ability to remain physically close and connected with each other,

[00:05:14] Carl Seashore: in a safe manner where, you know, the baby's not falling asleep or the parent's not falling asleep with the baby in their arms in the hospital bed, but rather the baby is in the bassinet, feeling that physical touch, having that connection and sense of safety and reassurance that comes with knowing that a caretaker is nearby.

[00:05:36] Kristin Tully: Yeah, thank you. And it's so-- What a complex relationship to try to actively support, and there's so much at stake. so many positive, experiences and learning each other's cues,

[00:05:51] Carl Seashore: Yeah.

[00:05:53] Kristin Tully: especially feeding cues. and then there's also things to, reduce risk, and you and I have published together around, preventing infant falls, and just how this...

[00:06:06] Kristin Tully: I'm so excited for the bassinet being useful for patient safety with

[00:06:10] Carl Seashore: Yeah,

[00:06:12] Kristin Tully: not only being able to pick up, your baby when you would like and for feeding, but also to be able to set them back down, and easily, stay connected. And could you tell us a bit more about your work around eat, sleep, and console?

[00:06:30] Carl Seashore: Absolutely. So

[00:06:45] Carl Seashore: Eat, Sleep and Console is a methodology that's becoming the standard of care for approaching infants at risk for neonatal abstinence syndrome or neonatal opioid withdrawal syndrome, it's sometimes called, where the mother was perhaps on medication-assisted treatment for an opioid use disorder during the pregnancy, with something like buprenorphine or methadone, and then that baby is gonna be at increased risk of withdrawal because those medications cause dependence, when there's a prolonged exposure, and that dependence can lead to withdrawal in the first weeks of Days or weeks of life in a newborn.

[00:07:11] Carl Seashore: And if I go back twenty years, twenty plus years when I was training, these babies were all taken away from their mothers and put in intensive care units and on monitors and on m-morphine replacement, and they stayed in the hospital for weeks, recovering from this withdrawal risk. And that was kinda how things were done.

[00:07:31] Carl Seashore: And I didn't like that. It didn't feel like the right thing to do to separate the moms from the babies. It undermined breastfeeding goals, if that was the mother's plan or hope to do. It removed maternal autonomy in a way that made them feel like they weren't truly parenting that child because it was attached to monitors and had nurses looking after it twenty-four hours a day.

[00:07:56] Carl Seashore: And that led the parents to then not be at the bedside because they weren't feeling like they were having the autonomy to care for their infants. And so sometime early in my tenure here in Chapel Hill, so this is going back to maybe two thousand and ten or so, a group of us around the country were talking about ways we could improve care for these infants.

[00:08:22] Carl Seashore: And one was just by letting them room in and stay with their mothers for those first twenty-four or forty-eight hours at least when they're not actively having harmful symptoms of withdrawal and see if that didn't help, decrease the symptoms of withdrawal because you take away the pr- the stress of parental separation and the beeping of monitors and the chaos of a intensive care unit environment for these babies and put them in a quiet room with their mother where they can do skin-to-skin safely and, and bond and do all those important things.

[00:08:55] Carl Seashore: And so that was one of the first things that, we worked on. We then worked on keeping the babies out of the intensive care unit, even if they needed pharmacologic treatment for their withdrawal, by instead of transferring them to an intensive care unit, transferring them to a regular pediatric private room where the mother could stay with them.

[00:09:14] Carl Seashore: And so the idea there was to keep the baby from bouncing between units, and with the mother continually throughout the hospitalization, even if it was prolonged. and at that time, I was starting to work quite a bit with the UNC Horizons program, which is the perinatal substance use treatment program here in Chapel Hill.

[00:09:35] Carl Seashore: It's a world-class, program for treating substance use disorders in pregnant women. and, we started... they started using more buprenorphine, and we were able to show that decreased risk compared to methadone. And so we did a lot of work to try to promote the use of buprenorphine for medication-assisted treatment during pregnancy.

[00:09:57] Carl Seashore: And, and with rooming in and buprenorphine, we got our length of stay for these babies down from two to three weeks to about a week. So we cut it significantly. and we got our medication use to treat withdrawal down probably by about fifty percent. Around the same time, up at Yale, Matt Grossman was doing some work on trying to identify a novel approach for assessing withdrawal.

[00:10:27] Carl Seashore: So historically, there was a scoring system that measured twenty or thirty different variables in the infant, and added those all up and gave you a score that said, "This baby's having clinically significant withdrawal." And based on that number, you would initiate medication treatment. And what Dr.

[00:10:47] Carl Seashore: Grossman identified as an alternative to that, a potential alternative to that, was this idea of eat, sleep, console, right? What are the three things a baby really needs to do to be successful at being a baby, right? They need to be able to eat. They need to be able to sleep in between when they're eating.

[00:11:07] Carl Seashore: And if they're fussy, we should be able to console them, right? They need to pee. They need to poo. They need to do some other things. But eating, sleeping, and con-- and being consolable are the sort of core tenets of succeeding in infancy. And so he proposed assessing those a little bit more, objectively still, with some wiggle room around, how you define success for those parameters.

[00:11:33] Carl Seashore: and to measure the functional outcomes of the newborn rather than a series of data points about whether they have a diaper rash or if they had a high-pitched cry and all of the other parameters that were part of the old scoring system. And he proposed that if a baby can successfully do those three things, it doesn't need pharmacotherapy for withdrawal.

[00:11:56] Carl Seashore: And so that meant working with moms on consoling a fussy newborn, teaching them how to swaddle safely, leaning into skin-to-skin and breastfeeding promotion where it was safe to do so otherwise. In other words, not in active substance abuse, but in, in someone who's stable in treatment. and so Dr.

[00:12:15] Carl Seashore: Grossman originally published their experience with that at Yale, and it was subsequently replicated. Some of my colleagues here in Chapel Hill were able to replicate that, that study With our population, and like I said, it's really become the national standard of care for these infants. And it gets back to that core tenet I talked about at the beginning, which is that if you keep moms and babies together, if there's not a real compelling reason to, to separate the outcomes are gonna be better for both because their engagement, the bonding, the autonomy and empowerment that comes from being there to care for your baby with the support of a team of nurses and doctors and lactation consultants and others.

[00:12:59] Carl Seashore: but the parent retains that core responsibility when they're still with the baby. And we've now cut our length of stay for opioid-exposed newborns to five days. some of the ones who are in our treatment program, we discharge as early as three days because we know they're coming to a residential program where we have supports in place for them.

[00:13:20] Carl Seashore: And that is, a huge decrease in stress for the mother's, financial improvement in terms of savings. It opens up that hospital bed, which is a precious resource for a patient who needs it more. and I think probably most importantly, enables the empowerment of the mother to see that she can care for this child successfully and help it do those three things: eat, sleep, and be consoled without having to expose the child to additional medication or the risks of being in a hospital for longer than that.

[00:13:55] Carl Seashore: So yeah, that was, 10 years of work probably

[00:13:59] Kristin Tully: Yeah,

[00:13:59] Carl Seashore: wrapped up in a couple paragraphs. But, it was a really fun time to be working in that space 'cause it was really the first sea change in management of that particular problem that we have seen in decades, and I think was long overdue.

[00:14:17] Kristin Tully: Th- that's wonderful. Thank you so much for sharing that story. of the, things that you described as being really important for infants and their caregivers is skin-to-skin contact. Could you talk a little bit more about that, broadly about, what that means and what, happens, biologically with that?

[00:14:39] Carl Seashore: Yeah, absolutely. So

[00:14:40] Carl Seashore: skin-to-skin care is, also referred to in, in some places as kangaroo care, but it's essentially the practice of being chest-to-chest with a mom or a dad or a grandparent and the infant, in the immediate postpartum period, so right after the baby is born and is just getting that initial assessment of airway, breathing, circulation, Apgar scores, all that good stuff, to put the baby while the cord is still attached right up chest to chest with the mother.

[00:15:10] Carl Seashore: and that helps with thermoregulation or keeping warm. So we still dry the babies off, obviously, but we use the mother's body heat as a radiant warmer to help the baby maintain their temperature and, learn how to do that independently. It helps with glucose regulation, in part because it's helping with temperature regulation.

[00:15:32] Carl Seashore: it helps with heart rate, control and respiratory effort. It helps the mother's placenta, deliver, or detach, and then her uterine contractions to be stronger through release of, pitocin and other hormones. And so you basically keep that skin-to-skin for the first ninety minutes of life if the baby and the mom are otherwise stable.

[00:15:57] Carl Seashore: and that transition of being supported through a placenta inside the mother to being independently breathing and functioning on their own after the cord is cut, to be more successful. and in the remainder of the birth hospitalization, it can be a really strong promoter of breastfeeding, because if you're putting the baby close to where breastfeeding occurs, then you're gonna be able to initiate feeding with the earliest of feeding cues.

[00:16:31] Carl Seashore: The baby's just starting to turn their head or shift a little bit or stir, and it's much easier to latch a baby who's calm and looking calmly for the breast than it is to latch a baby who has gotten to the point of crying or being agitated and then trying to latch them. And so we continue to recommend skin-to-skin throughout the birth hospitalization periodically as, as much as can be done safely and comfortably with the family.

[00:16:59] Carl Seashore: We encourage fathers to do it or other family members. In the NICU population, NICU babies get skin-to-skin care even when they're on ventilators, and that's been shown to improve outcomes, both here in the United States but also around the world. That's a hugely important practice in global health.

[00:17:18] Carl Seashore: and then we encourage parents to continue at home, af-after discharge, again, as long as they're doing it safely and Again, to pivot us back to the bassinet, one of the amazing things about it is you have that skin-to-skin contact. Maybe the baby's fallen asleep, maybe the mother is starting to feel drowsy, or maybe the nurse happens to be in checking on them and says, "Hey, are you still comfortable like that?"

[00:17:40] Carl Seashore: Or, or another support person. The mother is capable of getting the baby into the bassinet independently without having to call for help, and, still have the baby close by, still maybe rest a hand on its head or on its belly, and still have that visual proximity, and connection without falling asleep with the baby in,

[00:18:01] Carl Seashore: in their arms and potentially, having a fall or something like that.

[00:18:07] Kristin Tully: Yeah, thank you so much for talking through, especially emphasizing how skin-to-skin is recommended and really wonderful and beneficial forever, but, s- not... beyond, the immediate postpartum

[00:18:20] Carl Seashore: Yeah. Who doesn't love a good hug?

[00:18:22] Kristin Tully: Yeah. Yeah, I know. and, thank you too for talking through, baby's feeding cues and, and how important that and how much, smoother things can go when you're able

[00:18:39] Carl Seashore: Yeah.

[00:18:40] Kristin Tully: and to respond to them.

[00:18:42] Carl Seashore: Yeah, and again, that proximity, that ability-- Say the baby's not skin to skin, the baby's been resting in the bassinet for a little while, and you hear the diaper explosion and realize it's gonna be time to get changing on that, or, the baby's gonna be hungry soon. You can see those cues, you can feel those things, and you have, again, the autonomy to pick the baby right up or to move the baby o-over to you i-if they're off to the side.

[00:19:05] Carl Seashore: and the bassinet allows the mother to do that independently, and so she's more likely to get the baby latched while it's calm, rather than pressing a call button, waiting for a nurse to come to be that facilitator of what's really the most important thing for a baby to do.

[00:19:22] Kristin Tully: Yeah.

[00:19:22] Carl Seashore: it's been so interesting, being, for me, being both a researcher and filming and watching

[00:19:30] Carl Seashore: Yeah.

[00:19:31] Kristin Tully: interactions and seeing people, hold their baby and then look to the bassinet that's

[00:19:36] Carl Seashore: Yeah.

[00:19:40] Kristin Tully: to the bed, and others might not think like What a barrier that is because of the, But because of the height of the wall and the position of the bed, and then the, the structure of the walls

[00:19:56] Kristin Tully: too. and then I've lived that, and you, I think, probably both as a father and, a-as a clinician seeing people

[00:20:05] Kristin Tully: daily,

[00:20:06] Carl Seashore: Yeah.

[00:20:07] Kristin Tully: that navigation. So it's been, so wonderful to, be accommodating to what people actually

[00:20:15] Carl Seashore: Yeah.

[00:20:17] Kristin Tully: and

[00:20:17] Carl Seashore: Yeah.

[00:20:19] Kristin Tully: well.

[00:20:20] Carl Seashore: Exactly. I think, again, getting back to that concept of autonomy and really helping parents from those very first hours feel like they can do this, and they can take care of their child. They can call for help whenever they need it, right? and we encourage that, of course, but just having that, that one barrier removed makes it that much easier for them to enjoy that autonomy and build their comfort and confidence as new parents.

[00:20:48] Carl Seashore: I'm-- it's be so frustrating in the world, including in health, when we offer guidance that feels nearly impossible to achieve, Yeah.

[00:21:00] Kristin Tully: this is about safe sleep en-enabling that, which is really exciting,

[00:21:06] Carl Seashore: Yeah.

[00:21:08] Kristin Tully: to the efficiency and the joy and the, and the physical outcomes.

[00:21:12] Kristin Tully: But

[00:21:13] Carl Seashore: Yeah.

[00:21:15] Kristin Tully: great.

[00:21:17] Carl Seashore: former colleague of mine, used to call the birth of a newborn a happy crisis, right? it's a time of great joy, but also very intense feelings and, stresses and, sleep deprivation and just... it's joyful, but it's also a bit chaotic. and so anything that we can do to help parents, feel empowered, feel confident, I think is critical.

[00:21:43] Carl Seashore: One of my favorite things to do, in my years of running the newborn service at UNC was just teaching parents how to swaddle a newborn,

[00:21:50] Carl Seashore: A relatively simple thing. It takes just a less than a minute to do on rounds. It's not part of, the recommended thing that we're supposed to do as part of a checkup of a newborn.

[00:22:02] Carl Seashore: But just that little bit of, "Hey, here's h- here's a thing that you can do to help calm your baby if they're fussy." and teaching a new mom or a new dad how to do that and seeing them get it is-- it's that little thing can make such a difference for the next few weeks and months as they adjust to parenting a newborn.

[00:22:23] Kristin Tully: That's great. And, equipping people, I think is

[00:22:25] Carl Seashore: Yeah. That's a great word for it. Yeah.

[00:22:29] Kristin Tully: that in

[00:22:29] Carl Seashore: Yeah

[00:22:33] Carl Seashore: and, and the skin-to-skin, having a whole range of options to see, what works for you and at certain times, like for your family, Yeah. Yeah. And, you teach half a dozen tools to, to every family, and some of them pick one or two or three or four. Some of them, h- come in with their own skills already from previous children or have a grandmother there who's really on top of things. But I feel like there's definitely room to help every family learn something that they didn't know before that equips them to pick that word you chose, for success moving down the road.

[00:23:09] Kristin Tully: and with our story, it's been so great to be actively listening to families in this human-centered

[00:23:15] Carl Seashore: Yes.

[00:23:16] Kristin Tully: where, starting, from observational research and then moving... We had a big online survey where we got people's

[00:23:24] Carl Seashore: Yeah.

[00:23:25] Kristin Tully: what would be helpful

[00:23:26] Kristin Tully: to their postpartum

[00:23:27] Carl Seashore: Yeah.

[00:23:29] Kristin Tully: from that,

[00:23:30] Carl Seashore: Yeah.

[00:23:32] Kristin Tully: in a better bassinet.

[00:23:34] Carl Seashore: make lots of iterations and get feedback from families and a whole range of clinicians at different site. That's been, a continuous, improvement process, and I'm so grateful for all of that expertise that we've really tried to, be responsive to.

[00:23:52] Carl Seashore: Yeah, I think

[00:23:56] Carl Seashore: it was critical in the design process for the bassinet, once we got to, what's physically possible with the early graduate sem- graduate student seminar and the students at NC State who did such wonderful work,

[00:24:06] Carl Seashore: in contributing to design ideas for it. But then taking those early concepts to par- to new parents who had just experienced being in the hospital with a newborn and, letting them try out the early prototypes, obviously without babies in them, but with-- We, we had a weighted doll that represented roughly the size of a newborn and weight of a newborn and, had them in a hospital bed and interacting with the bassinet and getting their feedback as people who were truly subject matter experts in using a bassinet as a parent.

[00:24:42] Carl Seashore: but also then nurses, who push the babies up and down the hallways or, are in there con- setting things up, teaching parents how to use a bassinet or change a diaper. doctors who are rounding and having to examine newborns or respond to emergencies. we brought all that different feedback in through each iteration, of the early bassinet prototypes so that it truly represents community-based design and that human factors engineering.

[00:25:11] Carl Seashore: And, some of that ties directly to the work I do with electronic health records as an informatician, is how do we Design EHR tools so that they're intuitive to use, that they're efficient to use, that clinicians can find what they need and do what they need to do easily, so that those tools are facilitating, higher quality, better care, rather than, getting in the way of it, which is still a challenge we're working through, in, what are still the early days of a digitized health system.

[00:25:46] Kristin Tully: When you think about, if the systems of care are working well, what are some of the, what are some of the measures or what are some of the, the outcomes that inform your understanding?

[00:25:59] Carl Seashore: Yeah, I think the w-

[00:26:06] Carl Seashore: the word that, that puts it together most neatly for me is friction. if you're eliminating friction, whether that's reaching my baby when I'm seeing hunger cues or putting an order in for a medication in the computer that then goes to a pharmacist for review, that gets sent to a computerized system that dispenses the medicine, that then a nurse has to pick up and take and administer to the patient and scan a barcode to make sure they're getting the right dose and it's the right route and all those important patient safety things.

[00:26:33] Carl Seashore: designing those systems so that it feels frictionless and you're not, needing too many refreshers on how to do something, right? So with the bassinet design, it's here's how you park it, here's how you lock the wheels, here's how you loosen the mechanism so the tub can move, and the, here's how the patient can do it themselves.

[00:26:54] Carl Seashore: Here's how a helper in the room could do it. Here's how the nurses should do it. It's relatively low setup time, and even for a new parent who's never interacted with any kind of bassinet, never mind a baby before,

[00:27:08] Kristin Tully: Yeah.

[00:27:12] Carl Seashore: use. and Ty and his team in particular were super creative in finding ways to, to meet those goals, with just subtle little clues and simple signage and instructions on the device itself.

[00:27:28] Carl Seashore: Again, in an electronic health record workflow, it should be easy for the doctor writing the order to open up the computer and get to the right patient and put that information in. It should be clear to the pharmacy when they're receiving it what's being requested. It should be clear to the nurse when they're administering it, what they're giving and how they're giving it and when they're giving it, why they're giving it.

[00:27:53] Carl Seashore: And so if those systems are frictionless, I think you get better outcomes in terms of patient care. You get better satisfaction. You get better efficiency in redesigning neonatal withdrawal syndrome care, right? We eliminated a ton of friction. Transfers, transferring patients between units, which means transferring between care teams, which means new faces that the parents are meeting, new environments they're having to adapt to.

[00:28:20] Carl Seashore: Eliminating friction really, I think, is the hallmark of good design.

[00:28:26] Kristin Tully: And then when that works well, sometimes you get some really great feedback, and I think that as a doctor, you've, cared for some patients who had the Couplet Care Bassinet and got to hear directly from

[00:28:37] Carl Seashore: I've had several now, families come in and in one particular case, the staff had seen that they were-- the family was planning to come to me for the child's follow-up and mentioned to the parents that I had been involved in the bassinet design. And, I had never met this family before.

[00:28:54] Carl Seashore: It was first baby, wonderful young couple. and the grandmother was there at the visit and, we did the whole thing about adjusting to your newborn. We reinforced skin-to-skin. We talked about her feeding goals. We, checked in on jaundice and all the other things you look at in a healthy newborn and answered the questions.

[00:29:13] Carl Seashore: And as, as they were getting ready to leave, the grandmother spoke up and said, "Now, we heard in the hospital that you were part of those fancy bassinets they're using up there. Is that true?" And I said, "Yeah. I was a small part of a big team, but yeah, that's, that, that's me. that's correct."

[00:29:28] Carl Seashore: And they just went on to rave about their experience with how easy it was to use, how empowering it was, how comfortable it made them, and that they were just really excited that it happened to be in... it was re-relatively brand new at that time, and

[00:29:44] Carl Seashore: to time their birth s-such that they could experience it.

[00:29:46] Carl Seashore: And so that was a joyful moment. But yeah, since then, I've had several more babies whose moms have experienced it and, and hear good things. So it's exciting.

[00:29:57] Kristin Tully: Thank you for sharing that. it's really wonderful to, partnership, together and with so many

[00:30:03] Carl Seashore: Yeah.

[00:30:05] Kristin Tully: co-create, something useful. And we need so many other things. And,

[00:30:09] Carl Seashore: Yeah.

[00:30:12] Kristin Tully: is really wonderful.

[00:30:13] Carl Seashore: Yeah. Absolutely.

[00:30:17] Kristin Tully: there any other, things on your mind that you might like to share? appreciate your time.

[00:30:24] Carl Seashore: Oh, absolutely. I think this was a great discussion and a good reminder about, why we do these things, and the importance of being intentional in the work that we do and, the willingness to take risks when you see that there's a problem that

[00:30:37] Kristin Tully: Yeah.

[00:30:37] Carl Seashore: doesn't have the right solution in place yet and going about and trying to change that.

[00:30:42] Carl Seashore: I hope others will feel empowered to do that if there's a, a thing in your work environment or your home environment that's not right. do you need to define the thing that, that fixes it and, be brave and go out there and, and try it. And I think most importantly, find a group of friends, a group of colleagues, a group of people you enjoy working with, and team up and do it together because, in my experience, things work, work w- work much better when you have a team.

[00:31:10] Kristin Tully: Yeah. Yeah. Yeah. Essential and, yeah. So thank you so much, Dr. Seashore. This is really wonderful. I'm really grateful for the collaboration and, the reflections. Thank you.

[00:31:21] Carl Seashore: You're welcome. It's great to talk to you as always, Kristin. I appreciate the opportunity