The Canary in the Coal Mine: What Your Waterlines Are Telling You

So one of the ones that I see the most frequently is something called a dead leg. This is such a wild term for this, but a dead leg is essentially a water line that can get water, but it's for whatever reason, it's not getting shocked. So that can keep breeding, even though you've cleaned out the other lines. This is like, oh, like I had all this bacteria, like look at all this room for growth. Welcome to the Phil Klein Dental Podcast. Here's the thing about dental unit water lines. you can't see what's going on inside them. But that doesn't mean nothing's happening. If they're not tested and maintained on a regular schedule, they can turn into a perfect hangout for bacteria. And that's trouble for your patients, your team, and your practice. Today, we're going to talk about why staying on top of waterline testing is such a big deal and how it can give you an early heads up if something's off with your infection control protocol. We'll talk about the simple steps that you can adhere to to make sure your water is safe for your patients, your team members, and your practice. Our guest is Michelle Strange. She's a registered dental hygienist with a master's in dental hygiene and is a leading infection control expert with over 25 years in the field. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases. And our entire production team will really appreciate it. Michelle, it's a pleasure to have you on the show. Thank you so much. Always great to be here. Yeah, we've really been happy about having you on our programs in the past. You're always a great contributor to Viva Learning, both on the webinar side and the podcast side. So when we talk about our dental unit water lines, we know there is some level of general bacteria that is colonizing in the water. And our goal is to keep levels below 500. colony forming units, CFUs, and that's measured in milliliter volume, as we know. And that's, of course, recommended by the CDC and the EPA. The risk is that if the CFU gets higher than that, we could have a contaminated water line, which could lead to infection outbreaks among our patients and team members. And of course, as we know, it raises the practice's risk of lawsuits and fines. So that's why it's pretty important that we are meticulous. about testing our dental unit water lines in a summary. But you see water line testing as a tool that goes beyond just testing CFUs. You see it as something that serves as a good indicator of whether the office is carrying out adequate infection control protocol throughout the practice. It's like the canary in the coal mine. So tell us about that because I find that very interesting. Yeah, exactly what you just said, the canary in the coal mine. I do feel like it is an indicator that maybe we don't have a lot of the proper protocols in place. I would say this is similar to like your spore testing for your autoclave as well. If you don't have those records and you're not passing, that is a clear sign there is something happening in your workflow or your processes or your protocols that is a problem for patient safety. So I would say like. Like your waterline test results are your receipts, right? You can say your protocols are solid and you can hope your team is following those SOPs or your standard operating procedures. But unless you're testing, and I mean properly testing, you're just guessing. You're just working off of hope and prayers, right? And I think those results are really powerful because water lines, they don't lie. If your protocols are actually being followed, meaning routine treatment, regular shocking, correct product use, you're going to see good results. And if you're failing tests, especially repeatedly, that tells me there's a breakdown somewhere. Maybe it's human behavior. Maybe it's your workflow or lack of systems. Think about waterline testing like your clinical diagnostic tool, right? A failed result. is a symptom. So your job is then to find that root cause. Maybe someone skipped a shock. Maybe products were not used correctly. Maybe no one knows where the SOPs are that exist. And we can really see a breakdown in our protocols that way. So I assume it works both ways. If there's a breakdown in instrument sterilization, that also could be a canary in the coal mine for waterline management. I guess when one phase of infection control in one area of the office is not doing well, it is an alert to the rest of the staff to keep an eye on everything else and make sure that's running well. I think when you start seeing a breakdown in any part of your infection control, that is the sign that you need to... go and check some things, right? Like it's time to audit all of our SOPs. How did we fail over here, but we're passing over here? Is it a workflow? Yeah, that actually leads to my next question. It's a good segue. So what are some ways to spot common gaps in training, for instance, workflow that may lead to failed dental unit waterline outcomes? So the first thing I always look for, you know, depending on like, okay, where's the gap? Where is the issue? Is it a workflow issue? Is it a training gap? I look for who has ownership. So I'll say, you know, like I'll ask the team, like, who handles waterline maintenance? And if the answer is, well, we all take care of it. That to me is a red flag. Because when something belongs to everyone, it often ends up belonging to no one. What about if there's 12 chairs in the practice? There's 12 operating rooms. Right. So you can delegate. That's fine. Like, okay, Michelle, you're taking your operatory and you're going to do X, Y, and Z. But if no one owns that process and protocol. So I now as the ICC would go to me, Michelle and my unit one. And like today's the day where I'm in this clinic right now because I've been treating and shocking or testing and shocking the water lines. Somebody is doing it in this clinic. And I'm now here to ensure that all the things are actually happening because I own the safety of water lines here. But I'm delegating. I often compare this to ordering products in your office. OK. Do you have everybody doing ordering in your practice? I'm out of gauze, so now I'm the hygienist going to go order gauze. Or do I put it on a list, right? Like, am I now responsible for when I take the last thing out of the, you know, closet that I go write it on a list and then that person who owns ordering, they're going to take that on. I find it to be exactly that process. We're all responsible for it for, you know, am I putting tablets in my thing? Am I, you know, running, flushing my lines? That's my responsibility as a clinician in this practice. But the owner of the task and ensuring that everything is actually happening needs to fall on one person. Yeah, no, that makes sense. Yeah, no, absolutely makes sense. And the dental office manager oversees all of that and communicates with the dentist, right? Most offices that are fairly large have, you're shaking your head yes or no, I know our audience can't see it. You don't agree? No, I think it just, it is, like you're saying, it's very dependent on the size of the office. I don't... typically see the infection control coordinator or whoever is getting this responsibility, it fall on the office manager unless that office manager has a lot of clinical experience. So maybe it is that the ICC is typically the dental assistant. But then they're going to report back to somebody. Right. That's what I'm saying. If you're getting failed results. in your water line. The office manager needs to know about it, right? And then they need to tell the dentist, listen, the last two times we've had the CFUs are way over the limit to what the EPA recommends. So it just doesn't seem like it's working. Do we need to order new different kind of equipment or do we need to change our SOP regarding frequency of treating these water lines? So as we move through this podcast, I do want to touch on What are the common mistakes that dental practices are making when it comes to waterline management? One of the most common mistakes I see when it comes to waterline testing is not having good protocols and products that are compatible. So like, let me start at the beginning here. So you really have to test your waterlines before your shock. And that's one area that I think gets confused. And I would say a lot of times that I fall, I go into a practice and see that there's issues. It's more of a human behavior thing than a product thing. So the human behavior and the work practice controls around this is that we need to test that is your baseline. It tells you what's living in those lines before you touched. and shocked anything so if you shock first and then test which is a human behavior problem i see in the industry you're you're just um confirming that your shock product work and that's not what we're testing um those are like two different things you know i would say you need to test because you're testing for the treatment you're testing to make sure the thing you do day in and day out is actually working what's the frequency how often So that is also very dependent on the clinic. I personally do a test every month and then I send in that in office. So I do an in office test every month and then I send to a lab every quarter because a lab like is going to give you your slow growers, like real understanding of what. happening what's growing in there the test on a day or a monthly basis tells me that i i'm using it below those 500 colony forming units my water lines so so if you're shocking first you're giving yourself you're setting it up where you're going to get good results but it's only it's only the immediate false positive it's a false positive right yeah i mean maybe it's a false false positive or a false negative yeah yeah a false negative would be the right thing yeah what does it actually show you on this on this test that you do in-house. I know Sterosyl makes something called FastCheck 15. Is that something you use? Yeah, exactly. Actually, that's what I just did here in this clinic and got my results in 15 minutes. And it was nice because I just kind of like took it up by up, you know? How does that work? What are you actually doing? So I am taking the water from each line, every single line in your dental operatory. I do one test for one operatory. And I pool all those samples of water into this little vial. And it's very similar to a COVID test. Like you're going to get those results. It's like one line, two lines. One line is passing. Two lines means you fail. Even the faintest line. I also say it's like a pregnancies test, the faintest little extra line when you're pregnant, you know. So you're doing that and I'm getting my results in 15 minutes. And then I'm immediately shocking these lines. I'm not actually waiting for that 15 minutes or the lab test. No matter what, I'm shocking. Now, when I do this once a month. That I'm almost passing every single time. And if I'm always passing my waterline test, I really then just keep, I'm sorry, water lab test. I'm shocking on a quarterly basis. Oh, quarterly. Yeah, that's personally what I'm doing, but that's because I've gotten minimum of three, like, you know, passes for my dental unit waterline. So I know what I'm doing on a daily basis is actually working. The reason that I am testing on a monthly basis is to prevent any human error from happening. Like maybe somebody forgot to do something, you know, one week and I'm just like, okay, are we still on the right path? Yes. But then the shock is going to be wiping out those lines because we're, I always say it's like your periodontal patient. We're having them do their home care every single day, but they come to me as a hygienist every three months for their shock. So the goal is to be under 500 CFUs, but you actually shoot for less than that. Under 200 colony forming units, I think is an ideal, but because we are going off of what the CDC and, you know, ADA and everybody says, it's 500 colony forming units because that's drinking water. Right, it's drinking water. So then you put the tablets in if you see that it doesn't pass. So if it's over 500, you put the tablets in, right? Yeah, so if it's above 500 colony forming units, I failed that test. It doesn't matter, no matter what, above or below, I'm shocking the unit. I'm shocking the unit and I'm putting my little citrus sil orange tablets in there. We're running those lines until we see orange. It sits overnight. The next day I come in and I flush those. If I, while, you know, that 15 minutes has happened, I've already shocked the lines and I have failed for whatever reason. In five days, I'm going to test again. Because I want to know if that shock actually worked. Now, it could be that I just didn't do the test right. Like there's a human behavior component and it could be that the lines were never a problem. It was me, whoever did it, didn't read the instructions or something like that. So that's a possibility. I find that with your spore testing too, a lot of times it's failing because of a human behavior issue, not an autoclave issue. So I would test again in five days. The reason we want to do about five days is because we want things to grow in that line. next day after a shock i'm probably going to pass it just cleaned it out right so i want to give it some days to grow something and then i'm going to test again where do you document all this you got to have it documented so you could go to like a stereo so it has a portal that you could go in and you write all this into your dashboard your office's dashboard and it could be back to the basics of like we have a like a little document in a binder of our waterline testing. Same with our spore testing. We passed. We didn't pass. When you do have this documented, what you want to do is say, like, I tested unit one, it passed. Unit two failed. And then you put your remediation there. So we shocked, tested again in five days. You know, like you wanted to say what you actually did to remediate the problems. When do you do all this? It has to be after hours because if some... operatory fails you can't use it for the rest of the day right you shouldn't but the reality that's why i'm a monthly tester for this reason because if i am having an issue like i really want to get ahead of it if i'm growing something i don't want to wait until the quarter to like figure that out right because then we've used water on patients and maybe it was not below 500 colony forming units so that's why i'm a monthly tester so you have your own practice now congratulations it's very exciting in colorado is it denver then uh just outside of boulder yeah very nice um but before that you were traveling around a lot did you see offices remiss with a lot of the protocol that they performed regarding waterline is that something that was has been a problem in the past for you when you visited these offices absolutely not only just visiting and being a temp in those offices i did some training at one point for some companies where i'd go and teach them how to use the equipment and i have one time picked up one of these like air waters and pushed to go put the syringe in there and when i and it wasn't for patient care it was just for like demo so i didn't have gloves on it wasn't barrier wrapped and on my finger was black because of the bacteria that was in that. And they're like, oh, we don't use that side. I was like, big. So you think it's very prevalent that the offices... We haven't heard of a lot of cases where someone's gotten sick from waterline recently. I know someone... I don't know. You can get Legionnaires from Badwater, among others. Well, our biggest outbreaks in the United States have been in Anaheim and in Georgia where they got mycobacterium abscesses, which is a non-tuberculous, like a real fast-growing non-tuberculosis microbacteria. And so we have had huge cases from those where a lot of kids got very, I mean, insanely sick. Like these children will have lifelong complications because of these infections. Now we have had little outbreaks. here or there you know we have some in Virginia that we've heard about you know I hope we never see outbreaks like that but that's why we found it is because there were so many that the hospital treating these children was like hold on what is going on here maybe it's one person that got sick and like I don't know how do you discover where they got mycobacterium abscesses from. But we do know it's a problem. We do know that it's an issue. In some of those cases, they traced it to the dental office waterline. Yes, absolutely. So, I mean, all they got to do is test it, have an inspector come in and test it. So let me ask you this. What does an office need to have handy in the event there is an inspection by someone from OSHA or the health department? What do you see? Absolutely necessary for an office to show that inspector as far as record keeping, documentation, training. What kind of things are we looking at there? That's a great question. And, you know, I'm not, I don't do audits of offices, but I got friends that do. They work for the states and they go into these offices. And what I hear them saying is, one, tell me who your ICC is. Who, not just water lines, who is owning infection control in this practice? Two, if we're talking water lines specifically, what's your SOP for this? What is your standard operating procedures? What is the frequency? Like, what do you use to treat the water every day? Is it a cartridge? a straw system what tests are you using where are those results and have you passed or failed any tests in the last i'd say maybe let's call it a year right and what was your remediation i think those are standard things that somebody would ask and then quite honestly i would go and ask employees Like, what do you guys do for water lines? Because they really should be able to tell you. We have a cartridge system, and once a quarter, somebody comes to me and says, it's time to shock. Like, they should know that rhythm as well. Yeah, so that's a very good point, really good point, Michelle, because I know cases where inspectors have come to the office and they actually interview the employee in the break room and ask questions without the dentist present. So these employees are being asked questions and they're documenting what the answers are. And if it doesn't jive with what the dentist is saying or the office manager, big trouble. So I think legally, of course, our main interest is the health of the patient and the team. But legally, the things you mentioned that we need to have is of utmost importance in the event of a lawsuit, right? Because, you know, you could say, listen, we've done everything that... falls within the guidelines of cdc we've done everything we have sop we have uh all the stuff all the training every employee knows about it they're on board from within four weeks from the time they're hired they're doing they're they're in the groove of doing these things that mitigates the damages dramatically but if you don't have all yeah if you don't have all that because i mean The judge could say, listen, it's a terrible tragedy what happened, but at least you were following protocol. And for whatever reason, the colonization got really high. Maybe something happened that was acute. And it's just one of those things. But if you don't have that in-office SOP data and everything else, if it's not written down, like you said on a previous webinar once, and I laughed when I heard it, you said, if you don't write it down, you didn't do it. Oh, absolutely. Yeah. So those are your words. You remember those words? Yeah. No, I say if you didn't document it, you didn't do it. Like that's the reality of it. And I just want to touch on that. And then I would like to go back to a point about bleach if I could. But the thing is, is that when I do talk to people that do, maybe they are expert witnesses for litigation and stuff, because I'm lucky to like run into these people and like get all their gossip. Right. I would say what I hear from them is that if an office attempted to do anything and when we talk about anything we're talking about CDC guidance because when even though you're off your state might not say okay we've adopted CDC guidance into our state practice act which I think is something that people get wrong quite a bit is they're like well it's just guidance it's not required well it depends on your state if your state said yeah no we're adopting CDC guidance into our practice act that's something you are required to do now but even in the states that don't they're gonna go and say like this is the bare minimum standards why couldn't you manage to do the bare minimum for patient safety we've had this guidance since 2016 and we continue to get more and more guidance and so like it's like this is the bare minimum right um and then just talk on the bleach um because i do know some teams that still use diluted bleach to shock their lines and like i get it maybe that's what you've always done maybe someone recommended it or it feels like you know most affordable option. But there are some common errors I see with bleach use as a shock. One is that the dilution isn't always understood or like done correctly. Another one is that there are no IFUs, instructions for use for dental unit water lines to do shock. So you're often just relying on word of mouth or what somebody saw, you know, somebody else do in a practice. And another thing is if bleach sits too long in a line, it could potentially cause some damage to the equipment. So you really have to be very on top of the timing. Like it can only really sit for about 10 minutes at a time. So while bleach may be effective at reducing bacteria in the moment, I think we really need to consider what's going to be your long-term protocol. And that's where products that are meant for the dental unit are going to be a better choice. So using products. Like, you know, we're talking about Stericils. They have all these compatible products that were meant for your lines. What I like about the Citrusil shock is that if it were to be run through a part of your system. So for instance, I'm in this clinic and a coupling was left on one of the hand pieces and its shock was run through it. But that's okay. Like they freaked out because they're like, oh my God, we just ruined. I'm like, no, it's actually, you did it with the right shock, right? What is in the Citrusil shock tablet? that makes it so antibacterial? Well, silver is the basis of a lot of the Sterisil products. So silver and iodine usually are the two that, there's some other outliers out there for sure for waterline maintenance or management, but silver is the one that the Sterisil products use. Yeah, and that goes right after the biofilm. I mean, that just destroys the biofilm pretty fast. Well, we love our silver diamine fluoride for in the mouth, right? Yeah, no, absolutely. So tell us also about, the difference between the straw, I guess it depends on your system. You have a straw and you have a inline cartridge for maintenance. What is that all about? So this is actually a great question. And I think where semantics can get teams into trouble. So I think in your SOPs or standard operating procedures, you need to have definitions so that everybody is working with the same lingo because I have found myself doing this as well as I will call that blue. intake straw that typically you find in your water bottles with a straw and then I'll say we're going to change out the straws meaning the cartridges with the actual medium that is or the media that's you know the silver working so i think it's really important to make sure everybody knows what they're talking about so the intake straw is usually that blue straw that is bringing water into the system and then a cartridge the inline cartridge is the something that you're going to put on and it's going to have your treatment in it so every time water is brought through that inline cartridge and goes through your air water your high speed whatever that now has treated water going through yeah so two different things yeah that's a continuous treatment exactly yeah exactly The straw, the blue straw, you could use that with a tablet system, meaning you drop a tablet every time you fill that water bottle and that would be pulling treated water through it as well. So that's why I say like, let's make sure that we're not talking like we're not confusing terminology. Pick a term and stick with it with the team and write that into your SOPs and then define it in your SOPs. That way, if a new person comes in, they know it too, right? So you could have the inline cartridge. And that just means like every time you fill your water bottle, you just attach it back on there and you have that cartridge that is going to feed that low level treatment into your water. And that could last, what, three months to a year? Like, are there timeframes on the product? Usually, yeah, 365 days is what they say. But the reality is, is you got to test. Because there's some chemistries of water that might kind of, you know, do something with the silver, eat it up a little bit more, if you will, in a very elementary way of saying that. So you just need to know, is my straw actually working? And you would know that. Quite honestly, there's been people that have done some things to straws. Maybe they use a different product, like a liquid ultra. Through a Sterisil straw, if you use their Citrusil shock, you don't have to take off that cartridge. You can shock. through the straw. Love it for that. It's less steps, right? But maybe somebody heard we shocked through the straw and they used a different product. That's going to tear up the medium and that's not going to work anymore. But we need to know that it's working based off of the test that we're doing. That's the key thing. Yeah, the test. What about the daily maintenance? Is there some daily maintenance that you do on water? Maintenance tablets? Yeah. So the daily, I would say, is more of a human behavior thing, not so much a product or a chemical. And that's essentially flushing the lines in the morning. So we want to run our lines, kind of flush things out, get things moving within our system. And then between patients, we want to flush. So we're just trying to, again, anything that might have been like a retraction, maybe we don't see it as much. At least I don't hear it as much. I might be incorrect. this but like your air water syringe when you take your finger off that button there is a potential if something spattered onto that air water it could go kind of back into it and so what we're doing is trying to push that pathogen out so i went to the dentist the other day and i sat in the chair and they did some rinsing with the air water syringe so i'm hoping that they flush that out before i sat down but they may not have It may not have. They may have turned the room over, whoever's doing it, and done all the surface disinfection and decontamination. But you're saying they need to actually put their fingers on the air water syringe and flush it for what? 10, 15 seconds? About 15 seconds, yeah. And I'll be honest, I don't always remember to do this in my op turnover. But when I do it, it is prior to patient care. So let's say I sat you back and I am now going to... Bill, tell me how was that interdental brush? And I'm like flushing my line. I do the same with my ultrasonic. If I try to train the dentist that I work with, I'm like, just run that high speed a few seconds before you actually put it into the patient. Yeah, when I was practicing an adonist, my high speed would always go into the sink. The patients, we had, you know, what do you call that? where the whatever that word is oh the cuspidor yeah the cuspidor yeah that's been a while yeah so uh i didn't know they still called it that that's like a 1885 term yeah i still see them sometimes it's been a while but it does exist yeah we had them um so i would spray my handpiece into that to flush it out i just did it because i just thought it was better because i just didn't want anything pulled back in there with you know some sort of tiny vacuum gets created when you turn the handpiece off. Yeah, retraction. And we have anti-retraction valves on some things now, but not all. So it's just like one of those very good work practice controls to kind of get into. But like I said, I don't remember to do it on the end because I'm usually hustling to get that room turned over. But when I lay the patient back, it's in my routine to just kind of like spray the water before I do any kind of rinsing procedures. I run my ultrasonic before I put it in the patient's mouth. And I usually chit-chat, you know, like tell me, what was the thing that you did last week that you were so excited about? Like you came in here and you were talking, like chit-chat if you want to. I like to do it around home care. Tell me what's your routine every day to manage your mouth at home. What products are you liking to use? And I have the patient talking while I'm running my lines. Yeah, no, that's a great habit to be into. And, you know, you never know if it was done, so why not do it? So if you're seeing repeated failures in your waterline and it's most likely, due to the fact that they're not treating the water lines properly. There's not something, they can't be doing everything the way you're talking about now and still getting failures month after month, right? It's going to be, these results will be good. They'll be negative, which means they'll be below 500 CFUs. Time and time again, if they maintain by protocol and if they want to use Stericel or other products, whatever it is, they stick to it. Is that what you believe? Yeah, I think if you did start seeing some fails, like let's say you were passing and then all of a sudden you just stopped seeing passing or failing. For me, again, that goes back to human behavior. And so one of the ones that I see the most frequently is something called a dead leg. This is such a wild term for this, but a dead leg is essentially a water line that can get water, but it's for whatever reason, it's not getting shocked. slow speed hand pieces are often the culprit and your ultrasonics are often the culprit somebody forgot that they had the ultrasonic because maybe it's in like that drawer underneath your like dental unit at 12 o'clock and that's where you like you got to remember to pull it out maybe it's the assistant going into a hygiene room that's not used on a regular basis they didn't even know there was ultrasonic in there that's the kind of stuff that happens um so like they didn't test or they didn't shock their ultrasonic so that can keep breeding even though you've cleaned out the other lines this is like oh like i had all this bacteria like look at all this room for growth all the room for activities now so it's going to go feed those lines so something maybe that was not getting shocked and then the next person did test it and it never got shocked right so those are the behaviors again um it's usually a human behavior somebody forgot to do something somebody didn't put tablets in the slow speed being like people didn't realize that water could go through it so they didn't shock it so a lot of times like you know you'll have let's say it's in the doctor's practice right in the doctor's operatory they're not using slow speed on a regular basis right so they'll maybe the assistant is uh testing shocking the high speed lines but the slow speed sits over here it can get water through it and it should be shocked and it should be a part of that test if it's not getting shock and nothing's ever happening in that line even flow because there's no flow it's going to be so stagnant it's going to be breeding some stuff okay that's the dead leg that's the dead leg so that's often what i'm finding and what i hear And when I talk about this, people come in my DMs and they're like, I keep failing, keep failing. I'm like, if it gets water, is it getting shot? Are you confirming that every single line, not something tucked in, you know, the 12 o'clock position unit that's been forgotten that that's hooked up? those things matter so making sure you're doing all of the yeah excellent excellent recommendation there yeah for sure we got to be careful we're dealing with human lives and people are opening their mouth and there's bleeding and uh everybody's vulnerable to these bacteria. And us, we are breathing in all of these aerosol generating procedures. And when we look at some of the new data after COVID, when we started doing more research on aerosol generating procedures, we found that it wasn't a whole lot of the patient's saliva that was getting aerosolized. It's the junk in our dental unit waterline. Someone like you who teaches this stuff and who's crazy, you know, by the book, when you see those two lines on that test result, what do you have a panic attack? No, I guess for me, like, yeah, I mean, I'm obviously my heart skips a little beat and I'm like, okay, what are we going to do here? What's our, what's our next step? Does it happen once in a while to you? Sure. Actually, one of these units just got two lines and I was like, all right, our next step is we're going to shock. We're going to let this sit. We're not going to use this unit and we're going to test again in five days. And then if it fails again, for me, I'm going to go with a liquid ultra that is going to strip those lines. And then I'm going to have them do that shock three nights in a row with a liquid ultra. That thing is going to wipe clean. Is that a Sterisol product? no that's from a cross-text product and it's just a really high level and i know stereo does recommend this when they have a hard time and then we're gonna get back we're gonna come back to our sop and be like why did this fail so that's like the power play that's the yeah that's the big one yeah yeah yeah so i'm gonna make sure it gets shocked i'm gonna make sure all these things i have a feeling again it might just be human behavior somebody forgot that that one you know high speed hand piece needed to have like water coming through it and you know, we'll solve the problem. Michelle, thank you so much. You've been great. We love having you. Enthusiasm. Thank you. You have so much to share with our listeners. And I'm sure a lot of us got a lot out of this. And they'll be checking their lines starting tomorrow after they hear this podcast. I do want to recommend to our audience to check out Michelle's recent webinar on VivaLearning.com. Title is, Would You Pass the Test? what water lines reveal about your infection control protocols. Great webinar, great presentation. Have a great evening and thank you so much for your time. Thank you.