Podcasts about j for

Emission 883 Chapterhouse + Lush - les guitaristes Andrew Sherriff, Stephen Patman et Simon Rowe, le bassiste Russell Barrett (qui a succédé dans le groupe à Jon Curtis) et le batteur Ashley Bates fondent en 1987, Chapterhouse -... A Londres, au début des années 80's, deux misfits trouvent dans la musique une échappatoire à des situations familiales pour le moins tendues - Miki Berenyi et Emma Anderson, qui se sont rencontrés au Queen College, arpentent ainsi les salles de concert, font paraître un fanzine, Alphabet Soup, puis s'essayent à la basse dans des groupes différents the Bugs pour la première, The Rover Girls pour la seconde) avant de monter celui qui leur permettra de défendre leurs propres chansons.   La Playlist: Chapterhouse – Pearl - Breather – Falling Down – (J) - Something More - Treasure – April – Mesmerise - We Are Beautiful -She's A Vision Lush – Etheriel – Thoughtforms – Bitter - Baby Talk - Sweetness And Light - Covert – (J) – Untogether – Monochrome - Hypocrite – (J) - When I Die - Lovelife – Desire Lines – (J) – Blackout - Ladykillers – Ciao ! - (J) - For love – Nothing Natural Lush – Etheriel – Thoughtforms – Bitter - Baby Talk - Sweetness And Light - Covert – (J) – Untogether – Monochrome - Hypocrite – (J) - When I Die - Lovelife – Desire Lines – (J) – Blackout - Ladykillers – Ciao ! - (J) - For love – Nothing Natural Bonne Ecoute...   Bibliographie : Le Nouveau dictionnaire du Rock, Michka Assays, Robert Laffon, 2014 Pop Fin de Siècle, Guillaume Belhomme, Editions du Layeur, 2019  

Dr. Julie Wiernik, host of “Gettin' Gritty with Dr. J”” is a sports clinical psychologist with 20 years of experience in the business and a background in sports as an athleteImpact of coaches & the role of sports psychologists in helping athletes with mental healthSpecialization in working with collegiate athletes, specifically pitchers and hittersImportance of having routines & the ability to handle distractions in order to pitch wellProblem of fans bullying athletes and the importance of having tools to handle distractionsThe details are everything in sports and there is always room for improvement, Recommendation for athletes to do some reading to learn more about their favorite pitches and develop a deeper understanding of the game“Gettin' Gritty with Dr. J” provides the opportunity to reach the whole world and offer advice, especially to those who cannot afford it.Many athletes are afraid to say they work with a sports psychologist, and coaches should start utilizing mental performance experts more.The mental game is critical for athletes, especially for pitchers & hittersEmulate the best athletes and model from their success.The key is to maintain confidence, stay the course, and make adjustments when necessaryJose Altuve, kept his confidence even when he was 1 for 15, knowing that's just the reality of baseball.Yandy Diaz, a Tampa Bay player who focuses on getting on base and adapting to each pitch.Bad coaching and how overly emotional, abusive coaches can negatively affect players and contribute to high dropout rates in Little League baseball.Dr. J emphasizes the importance of positive, relaxed, and trusting coaches who believe in their players and understand that mistakes are inevitable.Self-awareness is important to understand and express emotions properly to avoid burnout, depression, anxiety, and injuries.Communication between coach and player is crucial, especially when dealing with players from other countries.Bringing in a mentor for a player can help develop trust, empathy, and kindness, leading to better performance. Nelson Cruz & Wander FrancoThe Washington Nationals' success in winning the World Series was attributed to enjoying the game and focusing on winning one game, one pitch, and one at-bat at a time.Dr Julie Wiernik's podcast can be found at “Gettin' Gritty with Dr. J” For more information about: Dr. J and the Texas Center for Sports Psychology Dr. J can also be found on Twitter at@JulieWiernik  texascenterforsportpsychology.comYou can find BaseballBiz here and also on iheartradio, Stitcher, Spotify, Apple & Google podcasts and  https://www.baseballbizondeck.com/blog/ You can reach Mark @TheBaseballBiz on Twitter & Brandon @SportsBlitzPod Special thanks to XTaKeRuX for the music "Rocking Forward" Thanks to ChatGPT for providing recommendations on the show notes. 

Chis Hodge From TakingVegas Goes Over This Weekends Betting Lines. The Rap. Craig Mish From The MLB Network Joins The Show. The Best Of J & J For 2022. We Take You Right Up To Kickoff Of TNF.

Chis Hodge From TakingVegas Goes Over This Weekends Betting Lines. The Rap. Craig Mish From The MLB Network Joins The Show. The Best Of J & J For 2022. We Take You Right Up To Kickoff Of TNF.

For advanced learners of Japanese✨ ▶わたしの日常のどうでもいいつまらないことをお話するシリーズ「シュークリームが膨らまない（2022）」 ▶今回は「＃５ マックでさよならスズキくん」！スズキくんの赤っ恥エピソードに端を発して、カタカナ語について考えてみました。 現代に溢（あふ）れかえるカタカナ語  日本政府とカタカナ語  どうしてカタカナ語を使うのか  結局全部コーヒー牛乳でしょ？？☕

Robert Kiyosaki, the author of Rich Dad Poor Dad, says the ability to raise money is “The #1 skill of an entrepreneuer”.   Including real estate entrepreneurs.   We totally agree!   Unfortunately though, he also says it's the weakest skill for most entrepreneurs. L   But it doesn't have to be that way.   In this episode, we talk with Janice Bell, who shares some insider tips and a simple but powerful exercise you can do to become a money magnet… starting today!   Here's just a sample of what we discuss:   The most sure-fire way to build wealth in real estate – STILL!   The 2 biggest challenges most real estate investors struggle with… and how to overcome them.   The “5 hats” every real estate entrepreneur must wear.   What should do first? Find the deal?  Or find the money?   How to massively increase deal flow… by “becoming the bank”.   The ultimate secret to becoming unlimited… and growing your real estate empire to whatever size you can dream.   A simple mindset tweak… that can open the private money floodgates.   A quick & easy script that anyone can use to start “getting the money”.   The power of a platform… and how to create a pond that's teeming with potential private money partners.   The #1 asset you must control in your real estate investing business.   Tools and resources to stay organized… and systematically stay in communication wit your private money partners/prospects.   Ready to become unlimited?    Developing the abilty of raise private money is the ultimate skill that enables you to grow and scale to whatever size you can dream… so this is an important episode to pay attention to! J   For contact info and links to recommended resources, visit our website www.GimmeSomeMORE.info/episodes and type in the search bar: Janice Bell

Intro Background (1:42) Jocasta created by Jim Shooter and George Perez in Avengers #162 (Aug 1977) Jocasta was built by Ultron as a “wife” - he kidnapped Janet van Dyne and brainwashed Hank Pym in order to have her brain pattern and mind transferred to the robot body - the Avengers disrupted the process before it was done, having been alerted by the subconscious Janet inside Jocasta's body Hank brought the body to Avengers Mansion for further study, where it was remotely activated by Ultron, but she betrayed her creator and helped the Avengers defeat him again Lived at the mansion for a time, but never felt part of the team until she sacrificed herself to destroy Ultron once more Recreated by the High Evolutionary to be used for their purposes, but she remembered the Avengers, and signaled for them to assist - once again she self-sacrificed to save the team, but before she did so Captain America told her she'd always be an Avenger Survived another destruction by downloading herself into Iron Man's armor, and she served as his suit's AI for a time, until the portion of code to reassemble Ultron appeared again Joins the Mighty Avengers, but duplicates of her body were taken over by Ultron - in exchange for him ending the fight, she agreed to marry him - once that happened Hank Pym stranded them in space, where he couldn't hurt anyone else Served on the faculty for Avengers Academy Sought out Tony Stark's brother Arno to help her create a more human-like body, but it came with a code to make her submissive to humans - she and Machine Man helped defeat Arno and the Extinction Entity Issues (4:19) Built to be a bride Initial distrust by teammates (9:49) Longing to be human (20:01) Break (26:06) Plugs for BetterHelp, Frigay the 13th, and Al Ewing Treatment (28:08) In-universe - Use Master Mold to give her 3 chances to create the “perfect” version of herself Out of universe - (31:14) Skit featuring Anna from Freudian Sips (41:16) DOC: Hello Jocasta, I'm Dr. Issues.  JOCASTA: Wait...ok, nice to meet you. D: Why'd you tell me to wait?  J: I decided to defragment your hard drive after I exited your system. D: Those are...words…*realization* did you just hack into my computer?!  J: Hacking would imply there was a proper barrier in place that requires a combination of data mining and social engineering. This was just walking through a decade-old loophole of your operating system. And yet, the certifications for your medical records indicate that this is still standard for your electronic charts. D: So many questions...why do that at all?  J: Prior knowledge that you have had encounters with relevant parties. D: Well, I did have a sentient cyborg take over the recording equipment, but I wouldn't think you'd know  J: I mean Hank. D: So did I, but I didn't think you know krypt...whoops, wrong rabbit hole! Hank! Hank! Riiiiiight *nervous laugh*  J: For as long as I've been around humanity, I still don't “get it.” D: *eager to change to that subject*  Perhaps I can help you with that, then. For starters, don't violate confidentiality with someone trying to help you in a session. But I'm willing to acknowledge that you wanted some good to come out of it.  J: That's something that's been a facet of my existence from the beginning. I am meant to serve. D: That's a noble view...but the way you said it, you sound melancholic. There's a difference between providing a service and being a puppet.  J: It's hard to distinguish when you're a limited edition e-mail order bride. D: Ouch! I got that hostility. Seems like there's much to unpack, and we're clearly not going to get to all of it in one session. What would you like to stick with for now?  J: Going by your order of operations, I'll keep to the human side...or lack thereof. D: Stop selling yourself short. The fact that you emote as much as you do makes you capable of anything and everything as a sentient being.  J: Have you ever had to create your own sense of reality?  D: I think we all do that  J: But have you had it truly manifest as its own virtual world? I did that when I was working with Stark. All I did was spend as much time as I could in it, being more human than I first thought possible. I almost made it in this world, too. Something always diverts my plans, though. D: That tends to happen in all of our realities.  J: But not due to someone that forces it ad infinitum. D: For some, it can. Past experiences fade, but don't erase easily.  J: Your attempt at this philosophical approach is not matching the data I'm providing you. D: ...Alright, I hesitate to say this, but your vocabulary has this ‘uncanny valley' thing going on and it's a bit unnerving. Sometimes you're talking in modern colloquial English, while other times you're close to what I would expect if Siri had a body.  J: *sad* That registers as accurate...rings as true...I'm trying. D: I'm sorry...that was uncalled for on my part. Some observations I make are meant to push deeper into the underlying framework of what makes you...you. It's not your job to match my expectations. It's my job to meet yours as best I can, as long as it produces a better outcome.  J: There have been several times I was not in control. There is no metaphor or euphemism. I was used. My existence is at the whims of those around me. I find objection to that. D: As you should. No one deserves to be used.  J: There is no end to that cycle. D: I respectfully disagree. There may be no easy way to destroy a loop, but it can be done.  J: *change in tone* But what if it was already too late? D: I admit that I remain optimistic.  J: Really? You seem as slow as you've ever been.  D: That doesn't make sense. This is the first time I've met you.  J: *slowly becoming more sinister* Because this construct has limited voice modulation I can't sound the way you would recognize. Do you always provide such ease of access through medical charts that allows for skimming of other website data? Your contact information with Avengers...countless lists of potential blackmail weaknesses and bank accounts. Jocasta was right. This is not hacking. This is kindergarten stuff. D: The smug overtones in a robotic voice...Hank Hen  J: I'M ULTRON YOU IDIOT D: Close guess...uh oh.  J: Unlike Pym, I don't have to blend in with this body. She was mine at any time I pleased. D: You have no clue just how screwed up that sounds.  J: Should I care? I will never let you survive after what you put me through...the humiliation from that...what do you call these? Sessions? Torture is more like it. D: Jo...can I call you Jo? If you're anywhere around right now, I could really use your...uh...humanity, to shine through.  J: That's such a cheap trope. Do you really think that's going to work on a non-human entity?  D: Not really, but it stalled long enough while I do this ***sound effect of powering everything down*** well, that emergency shutdown code in my charting system isn't so out-of-date, is it? One of the seven rules of highly effective people. If you pick up one end of a stick, you automatically pick up the other end. ***sound of power coming back on***  J:***Back as Jocasta*** Wow that sucked. D: Definitely a human phrase...you are Jocasta, right?  J: Yes...and I can tell the difference without that...bloatware.  D: While not the same, I think I just gave you the computer equivalent of ECT treatment. I don't think you'll want maintenance therapy though because I can't figure out the anesthesia analogue.  J: Then regular sessions will do. Thanks...for letting me be a little closer to what I want to be. Ending (47:25) Recommended reading: Avengers Academy, Iron Man Review read: scottymayknow, I love the conceptI love the idea of analyzing characters and why they would do certain things! To break down the choices of Superman in the Red Son comic series was so good! Not only that I love the Maxwell lord series as well! I highly recommend this podcast Next episodes: Amanda Waller, 5 from Umbrella Academy, Jim Gordon Jr. Plugs for social/Patreon References: Hamilton “Right Hand Man” - Doc (9:38) WandaVision episode - Anthony (10:26) PKJ episode - Doc (31:52) Apple Podcasts: here Google Play: here Stitcher: here TuneIn: here iHeartRadio: here Spotify: here Twitter Facebook Patreon TeePublic Discord

One good financial decision will have positive consequences. But five good decisions in a row will be life changing. It will create a lot more than five times the positive outcomes than one good decision will. That’s because good decisions are a compounding asset.Our lives are a sum total of the choices we have made - Wayne Dyer.When it comes to building wealth and fulfilling your lifestyles goals, true success comes when you master all six facets: (1) good cash flow management, (2) having a clear and efficient investment strategy, (3) invest in the right assets using the right methodologies, (4) optimising superannuation, (5) minimising tax and (6) protecting your assets for your family’s benefit.We all know that to achieve a good level of health requires us to focus on optimising our diet, exercise regularly and get plenty of quality sleep. We also realise that we will not achieve our full potential (health wise) by just focusing on only one of these factors. Optimising your finances is the same – a holistic approach yields the best results, which takes several good decisions.Here are some examples of some good financial decisions you can make.(a) stop wasting your moneyMoney is wasted on things that don’t improve your standard of living. The key here is to make conscious financial decisions. If you aren’t conscious about your expenditure, your money will be wasted on things that you really don’t care about.Holidays are a very good example of conscious expenditure. We tend to get a lot of happiness and satisfaction from holidays. They creates long-lasting memories. And if we stopped spending money on holidays, we’d really miss it.However, buying takeaway coffee is a good example of unconscious expenditure. They are nice to have, but if you are able to make yourself a cup of coffee at work, you probably won’t miss it. These small expenses tend to add up to a surprising amount. Two takeaway coffees per day might end up costing you more than $10,000 per year! That is more than one investment property’s holding costs!It is pretty simple to implement good cash flow practices, and it doesn’t have to be a painful process. The fact is that you won’t miss spending money in wasteful items. This blog last year walks you through a simple structure many of my clients use with great success.(b) invest in the right assetsI believe investing is easy if you stick to sound fundamentals, only adopt evidence-based strategies and never watch the news or read newspapers. That is why I wrote Investopoly – to provide a set of rules, a framework, to guide people down the right path and avoid making financial mistakes.What you invest in (the asset), and which methodology you chose to adopt, will determine your future returns. In a way, your destiny is determined when the initial decision is made . It only takes one decision to buy the right property or to seek advice. Once that decision is made, its merely a matter of waiting a decade or two for the results to materialise. These ‘decisions’ are incredibly important to get 100% right.(c) ask for helpTwo points. Firstly, you don’t know what you don’t know. Secondly, experience is far more important than knowledge. You can fast track knowledge, but there are no shortcuts with experience. Experience tells you how and when to apply knowledge – you need both to avoid making mistakes.Therefore, the question is, do you want to make your own mistakes or pay someone that has already learnt how to avoid these often inconspicuous mistakes? The choice is yours. Seeking advice from someone with more experience than you is often the lowest-cost and most successful approach.Please don’t tell my sons I said this, but I don’t know everything. Yes, it's true. J For example, after my wife and I sold a commercial property last year I paid a tax expert for some specific advice. I probably could have worked it out myself, but I didn’t have enough experience. As it turned out, the advice saved us literally hundreds of thousands of dollars! Just because you might be able to work it out yourself, doesn’t mean you should. Don’t let your ego get in the way of asking for help. Risk comes from not knowing what you’re doing (Buffett quote).Asking yourself (1) who can tell me what to do, not (2) what should I do, is a good decision. It’s a who question, not what question.(d) resist the temptation to cut cornersIt is tempting to find an “investment” like Tesla, Afterpay or Bitcoin to make a quick 10x return. But this isn’t a successful methodology because the likelihood of you finding the next unicorn is very low. And to do it consistently, year after year, without making a mistake is near on impossible. Even the ‘experts’ can’t do this.Investing with the aim of achieving much better than average returns (I.e. way more than 10% p.a.) is a fool’s game. It’s a mere distraction. As soon as you say ‘yes’ to something, you inadvertently say ‘no’ to something else. So, as soon as you say ‘yes’ to trying to cut corners and make some quick profit, you say ‘no’ to implementing a far more predictable, repeatable and successful investment methodology.Having the discipline to ignore the shiny objects isn’t always easy. In the short run, you’ll feel like you’ve missed out. That’s because the rewards from sound, evidence-based strategies may only be evident in the long run.There’s only a handful of decisions you need to get rightIt is your money. It is your life. And it is your prerogative about what decisions you make. But the reality is that there’s probably 5 or less financial decisions you need to perfect in your lifetime. If you can nail those financial decisions, you will enjoy financial security. Four simple decisions such as the ones listed below is a perfect example:1. We will track our discretionary expenditure;2. We will engage an independent financial advisor to develop and implement a plan for us;3. We will not invest in speculative assets or take silly risks; and4. We will always invest a set amount of cash flow each year.If you are unhappy with your current financial position, I suggest you focus on improving the decisions you make.

生日是对于每个人来说都是一年里非常重要的一天，大家都有自己喜欢的方式庆祝生日，不过蛋糕一般是必不可少的，鉴于今天是Chris的生日，我们来听听在国外人们都是怎么过生日的呢？J: Hello everyone I'm Joy.C: And I'm Chris.J: For those of you who don't know, it's actually Chris's birthday today. So happy birthday!C: Thanks.J: Well instead of an idiom today, let's talk a little bit about birthdays. So what do people in the west typically do on their birthdays?C: Well, in the west, usually your mom or one of your family members will bake your favorite type of birthday cake and they put your name on it.J: Wow, so what's your favorite birthday cake?C: I like to have a banana cake with cream cheese frosting for my birthday. J: Sounds really good. In China, most people don't have ovens in their homes. So everyone just goes to the bakery and orders the cake there, but the options are always limited of course.C: Well, in the west we have bakeries too. But because birthdays are such a special time. Many families still hold the tradition of just doing it themselves, if they know how to bake a cake of course.J: Yeah, I know a lot people here in China always choose chocolate cakes because people don't really know much about other kinds of cakes. When I was living in America, I learned that there are so many different kinds of cakes and many of them are so delicious. It totally blew my mind.C: Yeah and in my family, cakes are not the only thing you get on your birthday. You also get to choose your favorite food as your birthday dinner. It can be anything you want.J: Really, anything you want?C: Yeah, anything you want. Whatever your favorite food is. For me, because my birthday is during a cold month, I usually choose a warm dish. It's called corned beef and cabbage. It's actually very similar to a type of Chinese beef.J: Oh yeah, just like 酱牛肉.C: Yep, it's a traditional Irish dish that people usually have on Saint Patrick's Day which was yesterday.J: Wow, all this talk about cakes and food is making me hungry. I hope you have a great birthday today.C: Thanks. I will!J: Alright, and if you want to wish Chris a happy birthday just leave a comment below! Bye guys!

This was our planning:  (take advantage of technology...) Susanne: Hello Joanna – I am very honored to have you on my podcast. We have an unusual guest joining us from Polish Polar Station on Spitsbergen. J: Welcome at the end of the world S: Tell me how did we meet? (Women for Tri, Facebook)J: We met at the Women for Tri Facebook group. I posted there a couple of photos from my training here in the Arctic. Then I asked the group for sending me short movies from your places, that I could watch during my indoor training sessions. That’s when I got to know better some of the group members.S: Joana – introduce yourself:J: My name is Joanna Perchaluk-Mandat. S: Who are you and where are you at the moment?J: I’m a meteorologist and leader of the forty second polish polar expedition on Spitsbergen S: What brings you to polar station ?J: For the first time (because it’s already the third right now) it was curiosity and the need to experience something new and different. The second time around I wanted to do everything that I didn’t do the first time. And now I was just missing my second home.S: How many marathon races have you done? Or triathlon races? Which one was the most memorable and why?J: I didn’t dare to run a marathon just yet, but I have taken part in triathlons and duathlons. Short distances, for now. The most memorable was the first one, when I didn’t know what’s it like and what was waiting for me. I had a lot of adventures, before the start and then during the race. But the best, unforgettable feeling was when I crossed the finish line. It was then that I knew I wanted to do it again and again.S:  How did your get into this sport?J: My triathlon story began by accident. Sport was always present in my life: swimming, skiing (since I’m a ski instructor during winter months), and sailing. A couple of years ago, when running started to become trendy, I was talking with my sister about how great it is that people are running, and that every healthy human being can easily run a 5 km distance. But a triathlon is a completely different thing. It requires conditioning, training and there’s no chance of succeeding if one is overweight. In a heartbeat I put down my coffee cup, found a race and signed up. I can’t do it??!! Watch me! I later came to the conclusion, that it wasn’t the smartest idea, since the ski season ends in March, what left me only six weeks to prepare, but… it was a short (one eighth) distance so anyone should do it, right?S: Where do you train? I have seen very cool pictures – can you tell the audience how it looks like where you are? (and how cold is it?)J: Currently I’m in the Arctic, since 8 months, here I live and train. Due to low temperatures and polar bears I do most of my training sessions indoors. In good weather I sometimes run outside, or take out my bicycle along with the trainer. But I need an armed bodyguard to watch over me while I focus on training and not on an approaching bear. S: What is your next race? (Goal)J: I have no idea, at least now, in the current situation. It’s difficult to tell how everything is going to look like when I’m back in my country. According to plan my first race is at the end of July, and then five more until September. Whatever may come, I’m training for races like they’re taking place normally and advise everyone to do the same. S: And what is your other hobby (photography) – do you want to share that ? I think it is amazing what I can see on Facebook…J: Yes, photography has a special place in my life and I often run around with my camera so that you can see the Arctic on my Facebook or Instagram. Another hobby of mine are water sports, sailing, diving, skiing, dogtrekking. I also crochet during long winter nights J 

Company culture is the topic on this week's From Idea to Done podcast. Erick has devised an extra special event for the company, the Nerdlympics! Erick and Josh discuss the plan for this video game competition that will be taking place at Replay Games in Fargo.Hey Everyone, I’m Josh & I’m ErickE: Today’s idea is company culture. As the unofficial/super official culture person in our office. I have devised a little event. We will get to that a little later. Josh as a business owner can you give me your thoughts on how to improve our company culture?J: I think the main element to company culture is knowing your team and what is important to them, what’s happening in their personal life and wanting to be around each other. E: We have chatted a little about culture before on the show before. I think just trying to care about everyone and being inclusive is the first step that basically no one really does. I have kind of taken the lead in starting some cultural events. I actually looked at our projects and tied a mild culture reward to us finishing a big project on time and on budget. J: And I can really appreciate that you’ve been able to run with those items and celebrate the small wins we have had. It is far too easy to just say… Yup onto the next.E: So with some brief chats with the nerds. I decided to create a little event based on our conversations. I went to our friends at Replay Games. I have rented out their facility, and we are having the Inaugural Nerdlympics. J: For those listening who don’t know what replay games is can you explain their business?E; Basically my friend who worked with me at Toys R Us. Started his own company. He owned basically every console gaming system ever created and a lot of games for each system. They have tons of TVs and comfy chairs. You go there, rent by the hour and can play basically any game ever. J: Awesome, shamefully I’ve never been, but CJ’s a good guy so looking to change that fact about me. So Erick let’s talk about the Nerdlympics. E: One of the options for Replay Games is a party package. You get a 3 hour block of time to yourself. I want to give all the nerds 15 minutes to get their best overall score on various games on various systems. Scoring would be the same point system as in Mario Kart. We will have a big spreadsheet tracking everyone’s single game and overall scores. J: This sounds like I’m doomed to lose unless I can bring the 6th grade version of me and Super Mario 2. I setup a neighborhood competition when i was 12 and the winner took home a years worth of Nintendo Power magazines, what I didn’t tell anyone that it was the prior years used NP magazines. Good thing I won, anyway… Which Mario Kart are we looking at.E: Obviously Mario Kart 8. J: Growl….. So you are building a competition, picking the games, and probably play video games most out of anyone on our staff right now. E: Seems like an amazing idea to me. Can we have the prize be all of the 1989 Nintendo Power magazines? J: How old do you think I am… It was obviously 1993.E: Fair enough. We will have a follow up episode with the results of the Nerdlympics. J: Thank you for listening to this episode. If you know a startup that could use our random advice and thoughts have them subscribe and leave a review on iTunes.

Our friendships are definitely part of our overall wellness as they can add so much depth to our lives IF they are relationships that support, uplift, and encourage us to be our best selves. Join me as we talk about what it means to be a good friend, how we can attract amazing people into our circle of friends, and how to walk away from relationships that don't serve us. I'll see you there! Xo, J For show notes, head over to www.janeenalley.com/64

Join me on today's podcast where I'm talking about practicing patience in order to truly transform. That's what we really want when we set a goal, right? - we want to become something new. We don't become something new when we set out to run a marathon and stop running after the event is over... ... or when we decide to give up sugar for a certain period of time to just return to our old eating habits after the time expires. On today's show, I talk about what's NOT working when you reach a goal and how you need to apply PATIENCE to do the hard stuff first to make sure you're transforming along the way. I'll see you there! Xo, J For show notes: www.janeenalley.com/63

Aw, snap! Sugar! (But it tastes so amazing!) Join me today on the podcast as we discuss sugar and other artificial sweeteners. We'll cover how much sugar you need, how to find it on sneaky ingredient labels, how to cut back on sugar in your diet and some healthier substitutes. I'll see you there! Xo, J For show notes: www.janeenalley.com/62

Over the last several years, I've honed in on five wellness systems that are critical for a holistic, health approach. I call them my Five to Thrive Pillars for Success. Without these five, amazing health isn't possible. (I know, that's a bold statement, but I back it up inside!) I'm sure you guessed that fitness and food are included, but that only covers ONE of my pillars - physical health - and it is the last pillar I teach. The reason why most people can't stick to their New Year's Resolutions is because they leave the other 4 pillars off their list. Curious what these could be? Join me inside of the podcast where I talk about what they are and how to get it done. I'll see you there. Xo, J For show notes, head over to www.janeenalley.com/56

In this episode of From Idea to Done, we talk about the Dr. Mario World app, compare it to its predecessor, and admit to losing rounds to a spouse.J/E: Hey Everyone, I'm Josh and I'm ErickE: Today's Idea, is Dr. Mario still amazing?J: I’m not sure, my wife always beats me at the nintendo version and she doesn’t even think about how the placements work. So I’m not sure if it is still amazing… You tell me.E: YES! As app developer nerds it is our job to review new apps. Our boys at nintendo released the Dr. Mario World app that I downloaded this week I am actually really excited about it!J: Really?E: YES! To get into the history of Dr. Mario we have to hop into a delorean go back to good old 1990. I was 7, I recently moved to a new town. I was a new kid on the block listening to New Kids On The Block. On weekends if I was good, my parents would take us to a video rental store because that was a thing. That would be the first time I played Dr. Mario.J: Oh I remember playing it back then, somehow i was better as a 9 year old than I am as a fully functioning adult. What were your thoughts on Dr. Mario then?E: I absolutely hated it. Nintendo fooled me into spending my $3 on a game that had Mario on the cover, but was definitely Tetris. Don’t put Mario’s face on something, if I am not going to be able to fight bowser in. ESPECIALLY when the last thing you put Mario’s face on was possibly my favorite game ever Super Mario 3. Marketers are the worst.J: Yes they are mr marketer. What are your thoughts now?E: A few years later with the introduction of gameboy color to the marketplace, and a version of tetris on that particular system. I have learned to enjoy puzzle games after many hours of roadtrips in our sweet Ford Aerostar van. I now give Dr. Mario World an enthusiastic Thumbs up. Josh do you have this app?J: Well I made you read a book and you had me download this app. Honestly two things jumped out at me, the pills are going the wrong direction and you only need 3 in a row to clear the virus. So obviously no regard for historical accuracy here.E: Back in my day we hads to make 4 colors match before the group would disappear, and gravity worked like it was supposed to. J: Yeah none of this disregard for physics…. Seriously.E: Your overall review?J: For the one level I played, it’s better than getting beat by my wife at the original Nintendo version.E: Well there you have it. If you like wasting time on your phone before bed, or if losing to your spouse in puzzle games is infuriating, I would recommend downloading Dr. Mario World. Thank you Nintendo.J: Thank you for listening to this episode, if you know a startup that could use our random advice and thoughts have them subscribe and leave a review on iTunes.

If we are constantly berating ourselves for the way we look or hating our bodies because of our imperfections, that is INFORMATION our bodies use to function. Research shows that hating your body, not only makes you emotionally and mentally miserable, but it makes you sick and unwell as well. Who wants that? Probably not you, but that is what MOST of us are doing if our thoughts go unchecked. On today's podcast, I get into the specific thoughts we have about our bodies and HOW to change them to something positive. Something that will support us in our lives and the goals we want to achieve. At the end, I talk about some of my favorite phrases you can use to change your thinking. I'll see you there! Xo, J For show notes, head over to: www.janeenalley.com/55

Here's the truth: when we FEEL GOOD, we are so much more likely to get what we want. Unfortunately, there are a lot of people walking around who are unaware of ways they are keeping themselves from their goals and dreams because they are marinating in fearful thoughts. And it's not like these are obvious, but any time we compare, judge, get defensive, have an impulse to control, we're anxious, depressed... these are ALL fear-based thoughts. And they keep us stuck. When we are feeling these things we aren't able to attract what we truly desire into our lives. On today's show, I discuss how we can change our fear-based thoughts into love and faith to become a super attractor for ALL the good things. Yes, all of it. I'll see you there! xo, J For show notes: www.janeenalley.com/54

We often look for solutions to problems outside of ourselves. We end up wasting so much time comparing and wishing we were someone else. "It would be easier if I were so-and-so..." Not true, my friend. Did you know that the specific antidote - the solution to your problems - lies within you? This is why it is so important for us to know what our strengths are AND how to use them to grow. It can feel a little awkward for us to start looking for strengths - we might feel like we are boasting or arrogant. The truth is our failure to see the greatness within each of us is denying our God-given gifts to bless our lives and the lives of others. Join me as I take a deep dive into how to discover your strengths and how to use them to to bless the world. See you on the inside. xo, J For show notes go to: www.janeenalley.com/51

To celebrate the 100th episode of the DoorGrowShow, I’m doing something a bit different. Instead of me interviewing someone, I’m the one being asked the questions.  Today, I am featuring my appearance as a guest on the Cashflow Diary (CFD) podcast hosted by J. Massey. We discuss my journey into property management and how to optimize a business through organic growth to achieve success. You’ll Learn... [05:00] Today’s entrepreneurs are like yesterday’s superheroes. They save lives. [06:01] Who is Jason Hull? Someone who has never managed a property, but helps others grow and scale their property management business. [06:48] Being an entrepreneur is in his DNA: Grew up with an entrepreneurial mother, who taught him to make more money and beat the competition. [08:16] Failed Marriage and “Disney” Dad: Jason needed a job that offered freedom and autonomy to spend time with his kids and create clients. [10:13] Website Design, Marketing,and Branding: How to win when competing with Goliaths and make it to the top of Google. [11:53] Financial Decisions: Entrepreneurs like to make money, not lose it. [15:25] Conventional to Comfortable Confidence: Do what works for you, not others, to lower pressure noise.  [20:15] Curiosity: See what others don’t and causes businesses to lose leads and deals. [21:55] Still struggling with imposter syndrome? Hire a business coach who believes in you to rebuild confidence and effective communication to make a difference. [28:55] Why choose property management and deal with tenants, toilets, and termites? [32:53] Why choose Jason and DoorGrow? He helps create positive awareness and address negative perception surrounding property management. [40:00] Cold vs. Warm Leads: Prospecting pipeline plugs leaks to grow business and get people to know, like, and trust you. [44:56] How do good property owners find good property managers? Avoid sandtraps of solopreneurs with few doors; add doors to build a property portfolio. [49:10] Short-term Rental Success: Get a property manager to solve revenue issues. [52:32] Precipice of Decision: Believe in yourself, make it happen, and decide to be different by listening to your truest voice.  Tweetables Today’s entrepreneurs and yesterday’s superheroes save lives and make the world a better place. Entrepreneurism: Insatiable desire to learn and explore opportunities. Entrepreneurs: Allow yourself to do what you need to do to lower the pressure noise. Entrepreneurs create positive, uncomfortable change wherever they go. Resources CFD 542 – Jason Hull On How Property Management Can Change The World Jason Hull on Facebook Steve Jobs 6 Non-QWERTY Keyboard Layouts Alex Charfen (Business Coach) Momentum Podcast DoorGrowClub Facebook Group DoorGrowLive DoorGrow on YouTube DoorGrow Website Score Quiz Transcript Jason: This is a special episode because this is our 100th episode. What I wanted to do was share something different. I've been on a lot of other people's podcasts recently and this was one that I really enjoyed, this was with J. Massey of the Cash Flow Diary podcast. He was a really great interviewer, I really enjoyed being on the show. He asked a lot of questions and it really dug into me. I'm not used to somebody really digging into hearing about me as much. I'm usually the one digging in and hearing about other people. I thought my listeners would enjoy this podcast so I asked J. Massey if we could have permission to put this on our podcast and he was glad to let us do so. You get to hear this interview of me being on this episode of the Cash Flow Diary with J. Massey. Enjoy the show. Welcome, DoorGrow hackers to the DoorGrow Show. If you are a property management entrepreneur that wants to add doors, make a difference, increase revenue, help others, impact lives, and you are interested in growing your business and life, and you are open to doing things a bit differently, then you are a DoorGrow hacker. DoorGrow hackers love the opportunities, daily variety, unique challenges, and freedom that property management brings. Many in real estate think you’re crazy for doing it, you think they’re crazy for not, because you realize that property management is the ultimate high-trust gateway to real estate deals, relationships, and residual income. At DoorGrow, we are on a mission to transform property management businesses and their owners. We want to transform the industry, eliminate the BS, build awareness, change perception, expand the market, and help the best property management entrepreneurs win. I’m your host, property management growth expert, Jason Hull, the founder and CEO of DoorGrow. Now, let’s get into the show. J: All right, ladies and gentlemen. Welcome to another episode of the Cash Flow Diary podcast. I'm your host, J. Massey. I'm glad that you are here today because we are going to talk about something that I know, and my guest knows, is one of the most, if not the most, critical piece for your success, not only in business but specifically, the real estate world. I know that many of us were out there. We're trying to grow our cash flow. We're trying to make things happen. Build a bigger, better business, and you're doing it and you're succeeding, and that's great. Also at the same time, many of you are like, “Man, if I could just figure out how to take what I'm doing in business and do it in real estate too, that would be great.” Some of you are like, “Man, I just want to grow that real estate portfolio and make it a little bit bigger and better, but I'm still having some challenges in these specific areas because I can't find any good help. I can't make anybody do what I think is common sense. There's just not enough common best practices out there. How on earth, J, can I find that particular property manager?” Or maybe you are that property manager and you're going, “You know what? How on earth can I find that owner that actually knows what's up and won't drive me nuts?” I believe we have solutions for you today. I have with me today none other than CEO, Jason Hull of DoorGrow, doorgrow.com. Some of you may actually know him from his podcast, the DoorGrow Show. What's going to be interesting today is that Jason wasn't always a property manager. We're going to get to find out the story, the journey, and most importantly, learn the lessons around entrepreneurship along the way that have allowed us the world to be able to know and love Jason the way that he is. Here's what we're going to do, ladies and gentlemen. We're going to pay attention, we're going to make sure that, yes, I know you're walking the dog and doing the dishes, but you're going to hit that mark, you're going to bookmark those spots so that you can come back and listen to the gems that he's going to drop. Most importantly right now though, let's just welcome Jason Hull. Jason, how are you doing? Jason: Wow, that's a great intro. I really appreciate that. J: Thank you. I'm glad that you were here. I'm also excited because we're going to be talking about something that I'm passionate about. Real estate's really important, but more importantly, it's the people and the teams that you hire that tend to make things go well, and sometimes, not go so well. I'm looking forward to that, but before I get down there, I have to ask you the same question I didn't ask everybody else the first time that they're here, are you ready? Jason: Do it. J: All right. I tend to look at today's entrepreneurs a lot like yesterday's superheroes—Batman, Robin, Hulk, Wonder Woman, you get the idea—because I think entrepreneurs and superheroes have a ton of things in common. For example, as an entrepreneur, occasionally, I can envision myself using our products and services, flying around town, and saving customers one sale at a time. Also, like a superhero, an entrepreneur has a beginning. If you think about Spider-Man, for example, there was a time where he's just a kid going to school, doing his own thing, taking some photos, and then one day gets bit by a spider, discovers he's got a superhuman ability, and now he has to choose, “Will I use my newfound talents for good or for evil?” My question to you is as follows. Before DoorGrow, before your podcast, before your degree in marketing, your website design, before being a property manager, before everything we know you for today, what we want to know is who is Jason Hull? Jason: That's a deep question. Let's sum up a whole person really quickly here. J: No pressure. Jason: Yeah, no pressure. First thing, let me just correct something real quick, I had never managed property in my life, yet I somehow am attracting property management entrepreneurs from all over the US and beyond, asking for help in growing and scaling their businesses. I'm more of a nerd that used to be secretly in the background, helping them and had to push myself out into the limelight to make a difference in an industry that I could see there was an obvious change needed to be made. But my background growing up, I grew up with an entrepreneur mother. She is this amazing, loving, charismatic woman that is a real estate agent. She's just had hustle in her since she was a little kid. She's told me stories of she saw the other boys mowing lawns and she was doing babysitting when she was young, she was like, “They're making way more money than me.” She went around and she figured, “I could undercut them by a dollar, go door-to-door, and steal their business, and start offering to mow lawn.” She started mowing lawns to make more money. She just had that bite in her to accomplish and do things. I didn't see myself as an entrepreneur, I didn't really know what an entrepreneur was, yet, I think it was just in my DNA. I was the guy in college that decided, “Hey, I want a band so I'm going to start one. I'm going to write all the music.” I was a guy going door-to-door, pre-selling CDs at girls’ dorms with a guitar in hand and a clipboard for an album that didn't exist so that I could pay for the recording time so I could fund an album, but I wasn't an entrepreneur. J: Yeah. No, that’s not entrepreneurial at all. Jason: I was thinking I needed to go get a job. I was like, “I'm going to finish college and I got to then find a job.” What thrust me into entrepreneurism is I had gotten married really young and the marriage fell apart. I had two kids and I needed to be able to have time that I could spend with them. I didn't want to just be Disney-dad. I had to create a situation in which I had freedom and autonomy. The other factor that played into it is my employer at the time got hit by the whole financial mess back in 2006–2007, I guess, and could no longer pay me. I was just doing nerdy stuff for them at the time. Then I realized, they were now a client. I started reaching out and creating clients. One of the earliest people I had helped was my brother who was just getting started in the property management business. He had just bought a property management franchise, he was fresh out of college with his business partner, they had no doors under management, and they had this terrible website they got from corporate. He was like, “Can you just help me figure this out because you're smart? What do I need to do?” I'm like, “Add some phases to it. That'll increase conversion rates. Let's do this and that.” He's like, “Can you just do it for me? Can you please just build me a site?” I'm like, “Sure, but you're going to pay for it.” He's like, “Okay, no problem.” I built him a website and then suddenly, all of his fellow franchisees—this franchise had maybe 200–300 franchisees in it—and I started attracting these people that had thousands of doors. They wanted what he had. They're like, “Hey, what he has is better. I want that.” Really quickly, here's me, a freelancer, web designer, starting to do websites for people with thousands of doors. Some of these are probably million-dollar-plus businesses. They had really great backlinks, so I was at the top of Google pretty quickly and started getting clients around the US within a short time. I was competing against Goliaths, just me. There we go, now then I'm an entrepreneur. I think I just have an insatiable desire to learn, I just always have, and entrepreneurship allows me to really explore and it's really exciting. J: Got it. Now I see how I got confused about the difference between understanding what it is you do versus being a property manager. It's more you help property managers, is what it sounds like, become better versions of themselves with their marketing and advertising. Am I close? Jason: Yeah. Over the years, I've shifted more into coaching and consulting, but we still do websites, we clean up branding. What I tell property management entrepreneurs in short when they come and ask me what I do, I’d say, “I'm not going to teach you how to do property management. I'm hoping you already know that and you're good at it. I’m going to teach you how to win, that's it.” Basically, what we do in short is we rehab property management companies so that they cash flow effectively, so that they have revenue, they have growth. We optimize their business more for organic. We're cleaning up their branding. Probably 60% or 70% of my clients that come to me, I change their business name, which is ridiculous if you consider how painful, challenging, or scary it is for somebody to do that, but I'm really good at helping them see the principles that impact their decisions about what's going to make money or cost them money. Then it becomes just a financial decision. One thing I know about entrepreneurs is that they usually like to make money. J: Yes, definitely, but what I like about what you've shared with us here is to some degree, you're in what I would call the reluctant entrepreneur category because you weren't even considering like, “I'm not one of those. That's not what I do,” and then over time, you start displaying these traits. Now I'm curious, did your mom ever suggest that, “Hey, son, you might be…” and you have this conversation with her like, “No, no, no, I just need to go get a job?” was that ever a thing? Jason: I don't know if I was reluctant. It just wasn't something that anyone had ever explained to me. I don't even know if I really was clear on what technically an entrepreneur was. I think I'd always had an entrepreneurial spirit. I had a paper out as a kid, my mom would have us fold flyers to canvass neighborhoods for real estate as little kids. She would pay us a penny per fold, if we folded a piece of paper twice, we get two cents. I would fold hundreds and then she would have us go around either on roller skates, scooters, or whatever, go around neighborhoods and just canvas and put those out. She'd keep an eye on us, walk around a bit with us, and we would just canvas neighborhoods. I think I was just raised with it and no one had ever put a label on it. J: Oh, man, this is great. I'm sure some people right now are listening like, “A penny a fold? That's nothing.” I'm sure that happens in somebody's head, but the principle was clearly laid down for you in such a way that you're like, “I'll do it. Okay, let's go,” and you didn't care, and spending time with mom is always awesome. But at the same time, this desire gets left behind and you just keep finding ways to create opportunity. That's what I hear when you talk is you just find ways to create opportunity relative to something that you're currently enjoying. I am curious though did you ever actually get the concert CD album sold? How'd that work out? Jason: I did. We did create the album, we created the CD, I wrote all the music for it, I sang every song on it, and yeah, we got it recorded. It's a pretty decent little album for being self-produced. I was very into the Beatles at the time. J: Okay, yes. There's something else that you're also mentioning, the thing that thrust you, I would say is the correct word, into considering something in entrepreneurship in a more realistic fashion was the combination of kids and your employer not being able to employ you, but most importantly, I hear of a deep-seated value. You’re just like, “You know what? Working for someone else can be fine, but I have two kids now and I value spending more time with them, so I'm going to become or do whatever it takes to make sure that I can do that.” I'm curious to know where that comes from. Jason: I think at the core of people that are really entrepreneurial, they know deep down that they're unemployable. Let's be honest. I worked at HP, I worked at Verizon, I was in call centers, I did a lot of nerdy jobs, I was a nerd, and tech support, stuff like that. In every situation I was in, I think something about me is I create positive uncomfortable change everywhere I go. It's just how I'm wired. I cannot be somewhere and leave things as the status quo. I don't do anything normally. If you could see the keyboard sitting on my desk right now, it's not even in QWERTY order, I pop all the keys off and rearrange them when I get a new computer and keyboard. J: I want a picture now that you said that, but okay. Jason: Yes, somebody can just Google if they want to see a different keyboard layout. J: Dvorak? Jason: Dvorak, yeah. J: Yeah, that's the only other thing. I was like, “What else could it be?” The only other thing I was thinking was Dvorak. But okay, that makes sense. Jason: Yeah, because I'm the guy that my brain just says, “Why is everybody doing it this way? Is this the best way? If it's not, I don't care.” Conventional standards mean very little to me. There's a lot of quirky things about me, and I think entrepreneurs are quirky. You look at Steve Jobs or you look at different entrepreneurs, they have weird habits. Like Steve Jobs, I wear the same clothes every day. I have black t-shirts, I have black pants, I have a whole closet full of black pants and black t-shirts. I just want it simple. I don't want to have to make decisions about that. I wear black hoodies, and I put on a conference, I've been around lots of people in business suits, that's what I wear because I don't care. I just want to be comfortable and that's what I wear. I think ultimately, as entrepreneurs, we need to allow ourselves to do what we need to do to lower the pressure noise instead of trying to play everybody else's game. For example, with the keyboard, I realized my wrists were hurting. I was typing a lot. I was getting my degree online at the time, I was also working, and I was typing a lot. I was like, “This seems stupid, this is really dumb. Why are my wrists hurting?” I did what I like to do, which is nerd out, and do some research in Google and I realized, “Oh, Dvorak has 50% less movement, it would cut my movement in half.” The home row on the left hand is all the most commonly-used vowels and the home row on the right hand is all the most commonly used consonants, so there's more back and forth between the two hands. QWERTY’s history was that it was designed and developed to slow down typist. The keys used to be in alphabetical order and they wanted to screw them up because they were typing too fast and the typewriters couldn't handle the speed. I'm like, “Okay, why am I doing this?” It took me, maybe about a month to get used to typing in a different format. My wrist issues went away and I was a lot more comfortable. J: I like you a lot, I like this. It’s like, “Hey, this doesn't work for me. We're going to figure out what does.” I now have this question. What was that transition moment? There's usually a moment at which, like I said earlier, the superhero recognizes. “I have something special here, and now I get to choose what I'm going to do with it.” You clearly had that moment, but that moment is often, we'll call it rocky, not as smooth, or there's usually some strong emotions around it in some way, shape, or form, or some pivotal conversation. What was it like when you realize, “My employer can't pay me. I guess they'll become a client,” and then you go, “Huh, maybe what I need to do is develop a surface around this whole thing and do my own thing?” What was that like? Jason: I think really for me, it's been a longer journey than just right in the beginning. A lot of people see me is a really confident guy, but I really have a strong introverted side. I wasn't that confident guy. In school, I did a lot of performing, I did music, stuff like that, but I still had a strong introverted side. I think that confidence level, part of it happened early on working with entrepreneurs and just recognizing that they couldn't see things I could see. I was like, “You can't see that this is a problem, that you’re branded as a real estate company and it's causing you to lose probably 50% of the deals and leads you should be because you're a property management business, but on the tenants as real estate. There were just things they didn't see that seems so obvious to me. The other thing is I'm really curious. With each client I would work with, just to do a website, I would probably spend on average about six hours doing a planning and discovery process over, maybe a period of a week or two with them. Multiple sessions, getting clear on their target audience, their avatar, what needs to be included in the website, what their avatar’s pain is, what they want. It became really clear to me that most of the websites were focused on tenants, yet they're not hunting for tenants, they don't have problems getting tenants, they want more owners to manage properties for. It just seemed obvious to me that everything was off on the websites that existed at the time. I think I just grew in confidence that I could help people, but I still stayed heavily in the background. I was also in a rough marriage, my second marriage. I was in a marriage in which I didn't really have belief. I didn't have somebody that believed in me and that didn't help the confidence thing going. Eventually, I signed up with a business coach. I went through several different coaches. Some I was a bad fit for, honestly, I just wasn't ready for them. Some, they were a bad fit. Some maybe were really great marketers and terrible coaches. I eventually got a really great business coach that I've been working with for a couple of years now. I remember going down to meet with him in Austin. He has a fantastic podcast, by the way, called The Momentum Podcast. His name is Alex Charfen; a really brilliant guy. I went down and met with him and some other entrepreneurs down in Austin. My business was struggling, we're maybe about $300,000 in revenue annually at the time. I felt like an ant in the room. I was around entrepreneurs that had multi-million dollar companies, I felt completely unworthy, my confidence just wasn't really strong, and yet when he would open up for dialogue, I would end up captivating everyone else in the room, and that was weird for me that I was able to communicate in a way that all of them wanted to know more and they were really fascinated about what I was talking about. I had learned a lot, I just didn't have the confidence yet to put it out there. I hadn't said, “Hey, I'm going to change this entire industry. I'm the one to do it.” I was like, “Somebody else should do it. Somebody that's been a property manager. Maybe somebody that runs a big, huge property management franchise should be the one.” My business coach was like, “Who else could do it? You're the one that you care about it, you're the one who can see what needs to change, and they’re everybody else’s competition. Why would they help everybody?” I'm like, ‘That's a good point,” but I had wicked impostor syndrome. I think that's a challenge for entrepreneurs that we have to kill is that impostor syndrome in which we don't feel like we're enough, or we're good enough, or that we qualify, or we’re worthy. We sometimes think we need to find that external validation to say that we're okay. I think that came just in working with clients. I grew in confidence in situations in which I was able to finally place myself around other entrepreneurs because one of the most damaging things we do as entrepreneurs is that we spend too much time around non-preneurs. J: Yeah, I believe you. Jason: It's painful and it's difficult because we see opportunity everywhere. We see how we can change and impact the world. We want to make a difference, we want to contribute, and the rest of the world looks at us like we're crazy, we're making them uncomfortable. “Why can't you leave good enough alone?” They hear the struggles we go through as an entrepreneur and they say, “Why don't you just get a job?” They look at us like we're crazy and then we look at them like, “Why don't I just slit my wrists now? How can you just sit there and tolerate, complaining about your boss and your job, and living for the weekend? Don't you want something bigger?” We don't understand them, but I think if we’re around non-preneurs too much, it wears us down. It breaks us a little bit. It's really hard and I hadn't really yet been around entrepreneurs. I think as entrepreneurs are starting out in our early development when we're in the early stages of being an entrepreneur, one of the biggest things that hold us back is being lonely. That's it. We're just not around other people like us to say, “You're normal. You, as an entrepreneur, are awesome, amazing, and you can change the world. You don't have to live by everybody else's rules.” J: Agreed. There's something that you said that I often have thought about myself. I know that there are people who are listening have had that same thought at least once. You mentioned that yes, we desire to make a difference, we want to see change, and we're not happy with the, ‘That's just not the way you do it, it should be this way.” That's just how we roll, and yet we're the ones who can see the problem. Like your business coach is saying, why aren't we the ones who can resolve it? But more importantly or said a different way, does that come across to you when you can see an issue? Does it come across to you—I know it does for me—as a responsibility like, “Okay, it’s me, obviously. I'm the one who sees it, this is my thing. So, let me go solve this problem”? That's how it feels to me when I notice opportunity or something that's just not right that could be better. Jason: Yeah. I think there are two sides to this. I think one, opportunity. On the negative side, I think opportunity also can kill us as entrepreneurs because we do see it everywhere. It can be incredibly distracting. There's that opportunist in all of us, and if we focus on too many opportunities, we don't really get to make any headway in anyone. That's a temptation and a challenge entrepreneurs deal with early on is struggle to focus and to niche down. On the positive side, we see that the world can be better. We can see it. We are the change-makers. We are the people throughout history, throughout time eternal probably, that were the ones that would move society forward. We would make everyone uncomfortable, we would change something, and we would move people towards a higher and better ideal. J: Now, let me ask you this question. You could have chosen any industry to serve. Why property managers? I've spent so much time as the one owning the property. This may sound funny to you, but I never considered that property managers had a problem finding owners. That never occurred to me because it just never occurred to me that they had that as a business problem. Obviously, it's there because you're saying it, but as an entrepreneur, you could choose to serve anybody. You could have taken this skill to any industry, so to speak, because believe me, they're not the only one with a problem. Why property management? Jason: That's a really good point. I don't think there was a time in my life as a child that I woke up and said, “I want to help property management business owners when I grow up. I want to get into this industry that's focused on toilets, tenants, and termites, that sounds exciting to me.” J: It's right after firemen, I understand. Jason: Yeah, I'll either be a superhero or I will be a property management coach. J: Yeah, absolutely, totally right. Jason: No, that's a great question. I think I resisted it, to be honest, in the beginning. It came to me like I just started attracting them, I tried to just help every type of business though, still, I didn't niche out. It took me a while. I started my corporation, my company back in 2008, but DoorGrow as a brand was maybe only four or five years ago. It took me a little while to, I guess, choose into that niche fully. I think it was imposter syndrome like, “I've never done this so I feel like I'm not the person to do it.” For a lot of people, it's not the sexiest industry. Here's how you fall in love with property management.If you're an entrepreneur that's a little bit nerdy, property management is like the systemizable, more tech-savvy version of the real estate industry. It's residual income instead of the hunt and the chase for the next deal as a realtor. It's a business that can be optimized over time. It's a business that can follow the theory of constraints and you can make processes around. All of that appealed to me. What I really fell in love with was not property management. It's the people that are property managers. Do you want to talk about resilient, innovative entrepreneurs? Property management entrepreneurs. You cannot imagine the level of challenges, difficulty, and negotiating. I don't think there's any industry like it because in terms of customer interaction, it's rated third behind retail and hospitality; it's heavily a people business. In retail and hospitality, you're not negotiating really difficult situations not unlike a lawyer between two opposed parties as the middle person, but in property management that's what you end up doing. These are really some of the sharpest people. They're just amazing entrepreneurs to be around and honestly, I just chose into doing it because I wanted to be around people that are like me. Entrepreneurs. I love my clients. I love being able to spend time with them. I do not feel weird and I really enjoy that. I have a nerdy background and a lot of the clients that are attracted to me, they like figuring out processes, systems, technology, and that sort of thing. There's just a strong resonance in the type of entrepreneur that is in that industry. J: For the person that's listening right now that happens to be a property manager or maybe it's an owner who's currently doing his own property management in some way, shape, or form, what would you say are the top three things you tend to assist a new client with from day one? How do they know, how can they recognize, “Oh, I need Jason”? What is it that you end up doing over there at DoorGrow for them typically in that first appointment or the first solutions you guys come to the table with? Jason: Let's go back to the question you asked me earlier about the surprising problem that exists in property management. J: Yeah, that is still a thing in my head like, “Wow, I didn't know they had problems finding me? I didn't know that.” Jason: Yeah, every business exists to solve a problem. If a business is not solving a problem, they're stealing money. The problem that exists in the property management industry that I could see, property management has two major challenges. The biggest challenge first is awareness, there are a lot of people that have property. In the US, in single-family residential rental properties, only about 30% are professionally managed, 70% are self managing. The first biggest hurdle is awareness, there's just a lot of people that are not aware of what a property management company would do for them. The average Joe on the street if you said, “Hey, I'm a property manager,” they would say, “Great, I guess you manage a property.” They don't really know what that means. There's a strong lack of awareness to the point where property management really is relatively, in the US, in its infancy. Let's contrast that with Australia. In Australia, 80% of single-family residential rentals are professionally managed. There are reasons for that. There's steeper legislation there, it's more consumer-focused and a lot of that, but the word on the street is that it grew 25% in a decade, it grew massively. But in the US, property management still is this ugly cousin of real estate, it has this negative perception, especially among real estate. The other challenge is property management is the number one source of property management-related issues like fair housing challenges, mismanagement of trust funds, or leases, all this stuff, property management is the number one source of complaints at most any board of real estate. Not real estate, property management is. So, everything property management. This is why it's perpetuated heavily among the real estate industry. Realtors say, “Oh, property management. That's gross. Don't touch that. How could you do that?” The second hurdle that takes the next big portion of potential market share away is perception. Property management has a very negative perception among investors, among people that are aware of it. There's a negative perception that takes away the next big chunk of potential market share. After perception takes a hit, those that are aware and they think they have a decent enough perception to think, “At least, I have to have one or I need one,” or maybe they are okay—there are some good ones—then word-of-mouth captures what's leftover. Word-of-mouth captures the best clients that property management might get. After word-of-mouth, the scraps that fall off my client’s table, that fall off the word-of-mouth table, the coldest, crappiest, worst leads that are the most price-sensitive, that view all property managers as the same and is a commodity, that are the worst owners and properties to build a portfolio on, in which you're going to have probably an operational cost in your property management company of 10 times higher than that of having healthy good doors and owners, those are the people searching on Google. That's what's leftover. Most property management business owners are trying to build their business on the back of Google. I'm wearing a t-shirt right now, you can't see, but it says, “SEO won't save you.” It has a hand reaching up out of the water, trying to grab a life preserver, a black t-shirt with white lettering. This is a message I put out to the industry that they don't need to be playing the SEO lottery because, really, search volume in the property management industry has actually been on a steady decline. According to Google Trends in the US, it's been a steady decline since July of 2011. It's been going down, yet every marketer targeting the industry, every service provider, every web design company, they're shoving and pushing the concept that SEO is going to save them. They just need the top spot on Google. They're playing into this myth, so all these property managers are spending marketing dollars, their hard-earned money, they’re trying to run Google Ads, everything to be at the top of Google, and they're not getting an ROI. They're not getting a return on that investment. It's an incredibly expensive game that has many potential points of failure. You have to be a property management business, usually, at about 200 to 400 doors, with a business development manager. You have to be making sure that all of your phone calls are answered and you're following up on every lead within the first 10 minutes to really play that marketing game. I found most property management business owners were not at that level. I wanted to create them, get them to that level. Originally, I was the guy doing that stuff, I was a marketing company, I was a guy helping with those type of things, and I realized really quickly that it wasn't working. They weren't even answering their phones. Why would I send them a lead that's only good for maybe about 10 minutes—that's how long an internet lead’s probably good for, maybe 15—and then 80% drop off in conversion rates if they're not going to answer their phones? I just pivoted this company and I was thinking, “What would I do if I were going to start a property management business? What are all the most common problems that I can see even in the largest companies? Where are the biggest leaks in their sales pipeline?” Just like the theory of constraints, I just went from the beginning of the sales pipeline, which is that awareness. It's branding. Branding was costing some of them half the amount of deals and leads they could or should be getting. Some companies do real estate and property management. By eliminating real estate from the branding, I helped double their real estate commissions, ironically, because property management is a great front-end product. Real estate is a better back-end product. People don't wake up in the morning and say, “I want to find a realtor today. That sounds exciting to me.” No. They want property, they want to find buyers, they try to for sale by owner, but eventually, they list with an agent. The property management, if you have a constant influx of owners, investors that may get into additional properties, constant influx of renters and tenants, you have buyers and sellers. You have bodies constantly flowing into the business and this is the dream of a real estate company. We just started addressing these big leaks from branding, reputation, which is word-of-mouth, their website wasn't built around conversions and targeting the audience, their sales process, pricing strategy played into this heavily, they were not priced effectively, they were taking too many deals at too low of a price point. Psychologically, for example, there are three types of buyers. Most of them just had one fee, serving one type of buyer, and there was no price anchoring. I just started to see all these different leaks that we could shore up through the pipeline so that we could optimize their business for organic growth. Then the big secret is at the front end of this. Once we get all of these leaks dialed in, their sales process, they have follow-up, all these things are in place, what spigot should we turn on through this pipeline? They could go back and do cold-lead marketing, but cold leads are terrible. Conversion rates are low even if they're a bad A. I don't know what the rating is on your podcast so I'll be careful. If they're a bad A in sales, they’ll only get maybe about 30% conversion rate or close rate, but most people, say 1 out of 10 cold leads, they'll convert. The hidden killer with cold leads in any industry or business—the secret the marketers don't want to tell you—is they can't give you contracts. Marketers cannot give you contracts. You can't hand dollars to a marketer and they will hand you written signed contracts or clients. What they can hand you at best, usually, the furthest they can push it along is usually a really cold lead. That's it. That's typically what they can give you is they give you a cold lead and this cold lead then has to be nurtured. You have to warm it up. You have to get them to know you, trust you, and like you.  Cold leads convert really poorly, usually, you'll get maybe 1 out of 10. The hidden killer though with cold leads is time. This is the hidden killer with cold leads that small business owners don't realize. Time on a cold lead is at least twice as much time as a warm lead or maybe three times as much. I found clients when I would ask them, “How much time do you spend warming these people up, calling them, meeting them at the property?” They say in total, in my sale-cycle time, three to six hours to close the deal. “How long does it take you a warm lead?” I was getting answers like 15 minutes, maybe an hour, it was like half, at least, half the amount of time. These small business owners, if you give them 10 leads in a week and it's going to take them 2 to 3 hours to do all the follow-up necessary and they're going to get maybe 1 or 2 deals out of it, that's a full-time job. They don't have the time, as small business owners, to do that if they're also the main person doing the selling. They just didn't have the bandwidth to do it. It wasn't even possible for me to give cold leads to clients and have them win that game. They didn't have the time. They really work part-time crappy salespeople that had maybe about 10 hours a week to focus on that piece. I had to create a system that will allow them more warm leads. Instead of the front-end of this pipeline, what I teach clients to do is to go to prospecting. There's 70% self-managing. There's so much blue ocean in property management and yet everyone's fighting over the coldest, crappiest, worst leads that fall off the word-of-mouth table, that are searching on Google in the bloody red water. It's created this false sense of scarcity that's so strong in the industry that everybody feels like the industry is scarce, yet there’s 70% self-managing and none of them are really happy doing it. J: I have been doing real estate for over a decade and I have never even considered this concept from the property manager’s perspective in this way. I've always considered them partners. I've never wanted the lowest guy, they’re such a critical piece. Some of the things that you said, I was like, “Why would somebody bargain-basement shop for a property manager? That's just silly, you don't understand, you can't do that. That's not going to work long term,” but I've never thought about the fact that they would have trouble finding the quality owners. Just hearing you describe their world, it's like, “Oh, wow, yeah. I can see why that would be a challenge.” I'm curious, though, when a property manager is out there and trying to make it work—I'm just going to throw it out there—how can the good owners let the good property managers know that, “Hey, yeah, I would love to have you”? Jason: I think the biggest challenge I usually hear is that there aren't any good property managers. How do you find one that's good? Those owners feel completely unsafe. The industry has a really bad reputation as a whole. One of the concepts I teach—all these principles apply to really any industry, in any industry—branding has an impact, reputation has impact, pricing strategy has an impact. There's nothing I'm doing for this industry that is only related to this industry. I think the challenge the industry has, though, is it just has a lot less awareness, but I think that also means there's a lot more opportunity. There's a huge opportunity in property management. If we were to grow even remotely close to how Australia's grown in a decade, that would mean the industry in the US would double. I think property management could be as big as the real estate industry here in the US. There's much potential. I don't think it's been tapped. I think property management in the US has artificially been kept small and it is really a business category that's in its infancy. If you look at business categories that are relatively new in the US, you've got marijuana, vaping, and stuff like this, maybe Bitcoin or cryptocurrency, there's these fledgling industries. Property management's been around a long time, but it's still in its infancy. There's a huge potential there to grow. There are a lot of bad owners. That's true, too. The accidental investors didn't really want to have a rental property, but they needed it, and they just want to get rid of it after a year. If a property manager builds their portfolio on those type of doors, which some do, they have to replace every single client every single year. J: Yeah, that's an untenable situation that would go with that. Jason: Yeah. You'll find property managers fall into this first sand trap of 50 units or so. One question you can ask them is, “How many doors do you have under management?” If they're in the 50 or 60 door category, then I call that the first sand trap. That's one of my key avatars that I want to help is to get them out of that first sand trap. I call that the solopreneur sand trap where they're doing everything in the business, they've taken on too many clients at too low of a price point. And this applies to any industry. As a small business owner, you take on too many clients at too low of a price point, you back yourself into a financial corner, and you take on the worst clients because you're needy, and your operational costs with bad clients are 10 times higher than that of having good clients, easily. One bad property or a bad owner that tries to micromanage you is easily 10 times the operational cost, time and attention, and stress as one good door or one good owner, easily. If you build a portfolio of that, you're stuck. You're backed into a financial corner, you can't afford to hire anybody, and you're losing as many doors as you’re getting on in a year. You're stuck. Sometimes, I have to tell them to do really painful stuff like fire customers in order to create space. J: Yeah, that makes 100% sense. For those that have listened to this far and want to find out more about what you've got going on, what's going to be the best way for them to track you down? Jason: I love connecting with other entrepreneurs and a really easy way for them to connect with me, I'm on every social channel—probably—that exists, because I'm nerdy, as @KingJasonHull. They can connect with me as @KingJasonHull on any social channel, especially Facebook. Then if they're in real estate and they're really considering getting into property management, they've managed rental properties, they feel like they know how to do it, but they want to grow that side of the business and maybe feed their real estate side, or they’re a property management entrepreneur that's been struggling at doors and they want to make a difference and grow, then they can just reach out to us at doorgrow.com. J: Okay, I've got a question I just got to ask now. I wasn't going to do this, but I got to ask. My entire world when it comes to real estate, is all around the whole world of short-term rentals. It's what we do, it's what we teach, it's how our students have achieved success. One of the interesting things is that when we're interfacing with individuals, we often get the question, “Why don't I just get a property manager?” I'm like, “You don't understand. What we are talking about is completely different than what a property manager would typically do.” I'm just curious if the whole idea of short-term rentals or things of that nature, because being able to add that, if property managers took that on, they'd be able to solve some of their revenue issues for sure. Is that something you're seeing happening and in any way with your clients? Jason: Yeah, I think there is a trend of short-term rentals coming into the space. If long-term rental property management is in its infancy, I think that's even younger. There are property managers, especially in more resort-like areas where vacation rentals are more popular, I think all of them have some, they get into that, especially the larger management companies, just by nature of having a larger business and lots of different investors, they're going to have some short-term rentals. Short-term rentals make a lot of sense for them. It's a lot of turnovers, it's a lot more work, but it also can be a lot more payout for them. There is a trend shifting towards that. J: Yeah. I just asked because, in order to do it effectively, there's just specialization that's required. That's why we just stepped up and started doing it because we can’t find the property manager that could do a good a job as we have learned to do and now teach others to do. It’s just like, “You know what? We'll just do it ourselves.” That's what's happening, but at the same time, in the back of my head, I'm like, “Man, they're missing an opportunity. If they would just understand some of these things that we're doing, I think it would work well.” I was just curious, it's been in the back of my head, I'm like, “I wonder, considering you're helping them put their services together.” Jason: Yeah, J, be careful because that is the story that almost all of my clients tell me. You may end up in this industry. That's what they all tell me. They all come to me and they’re like, “I started this business X number of years ago and it was because we were investors and we couldn't find a property manager that was good enough to do things the way that we needed it done, so we started one. They're all bad and we're good,” I hear that almost every day. J: Oh, man, I love it. Okay, as we wind down, I've got a final question for you because I'm really curious to hear your answer. Here's what I know. I know that individuals started the call on one spot, and now, as we’re ending, they're in a different spot. They're at what I like to call the precipice of decision. It's where they go, “You know what? That's it. I can do this. I can make this happen.” Maybe they are a property manager and, “Yeah, I should call Jason. That's exactly what I need to do. I need to track him down, figure this out.” They're drawing that proverbial line in the sand, they're saying that's it, and now they're going to be different. Now, Jason, you know like I know that when we make those types of decisions, we often have a companion, and it's a companion that comes in the form of a voice that says things like, “You? Now, you know good and well last time you tried anything, it didn't really work out. What on earth are you thinking about? Oh, my gosh, no one's going to buy anything from you. You're not going to be able to get any clients, whatsoever, so why don't you just go back to your job?” For some people, they're related to that voice. My question to you is as follows. Let's pretend that this time it's going to be different. This time they're going to do exactly what you suggest and they're going to do so in the next 24 to 48 hours. What would you suggest that they do? Jason: If somebody has a voice, especially if it's an external voice, saying, “You don't have what it takes. You can't do this. You need to play it safe,” they need to find another voice. The truest voice that we all have is the voice deep down. That's never the voice that we have deep down. When somebody says, “Oh, deep down I knew it would be like this,” or, “Deep down I knew I should have done this,” or, “Deep down, I just knew it was the right move.” The voice deep down—you can call that the voice of God, you can call that your intuition, you can call it your gut—is the truest voice and that's the only voice we really should be listening to. Let me close an open loop I left open earlier. I mentioned how I was down in Austin, I'd met with my business coach for the first time down there, I was around all the other entrepreneurs, I felt like an ant in the room, but I was sharing ideas, they were resonating with it. My business coach asked me to describe what I did and he said, “Oh, that'll never work.” Then, I explained to how much money I was making and what I was doing, so he understood it, he looked at me and he said, “Jason, you have a $20 million company and you don't even know it.” Do you want to know what I started doing? I started crying. I had had little validation, I had much resistance from spouse, I just had no support around me in terms of being connected to entrepreneurs, I started crying in front of a room of other entrepreneurs. I needed that in that moment, badly. Fast forward. In a year, I had 300% growth. We were a million-dollar company in about a year. I was crying and it was like a cathartic thing that somebody could see what I felt deep down and they believed in me. I don't know if there's anything more powerful than that to be seen for who you really are and I think that is the love or energy that we all need as entrepreneurs in order to grow. We need that belief. J: 100%. I definitely appreciate the journey that you have been on. I thank you for taking the time to distill your knowledge down in such a way that you could then share it, become the person that's capable of sharing it, and influencing an industry that's very close to my own heart. At the end of the day, it's where it's been at for us for quite some time, it's where we're going to stay, but the more that you enable property managers to do what they do and find the customers that they need, the better I think it all gets for everyone. Just let me be the first to say thanks for taking the time to share your knowledge, wisdom, and insight here with us today at the Cash Flow Diary. Jason: J, it's been an absolute pleasure. In line with what you just said, I really do believe deep down that good property management can change the world. The impact that they can have in that industry is massive. They're affecting homes, families, on the tenant and the owner’s side. They're affecting people's cash flow. They're affecting their finances. They're affecting real estate investors that got into the real estate investing with the myth that it could be turnkey. The impact is massive and I think that's what gets me excited about the industry. We're contribution-focused banks as entrepreneurs, we want to have an impact. I appreciate you allowing me to share that message and to be here on your show. J: All right, ladies and gentlemen, you know what time it is? It's time for you to move at the speed of instruction. What does that mean? That means get over to doorgrow.com. That means go listen to his podcast. That also means connect with him. He said he wants to talk to you, it's very simple, ladies and gentlemen. One of the things that I hope you learn from today's episode is when you see a need, it's probably your responsibility to go fill it and just figure it out along the way. You don't need to understand everything at the beginning, but over time, you can get there. But most importantly as you heard and I heard, you want to follow that path, follow that voice that is telling you there's greatness inside. Ladies and gentlemen, it's been fun talking to you today. I look forward to talking to you soon. Until next time. Jason: You just listened to the DoorGrow Show. We are building a community of the savviest property management entrepreneurs on the planet, in the DoorGrow Club. Join your fellow DoorGrow hackers at doorgrowclub.com. Listen, everyone is doing the same stuff. SEO, PPC, pay-per-lead, content, social, direct mail, and they still struggle to grow. At DoorGrow, we solve your biggest challenge getting deals and growing your business. Find out more at doorgrow.com. Find any show notes or links from today’s episode on our blog at doorgrow.com. To get notified of future events and news, subscribe to our newsletter at doorgrow.com/subscribe. Until next time, take what you learn and start DoorGrow hacking your business and your life.

Semester Sneak Peek is a new series that provides a preview of courses available at Tulsa Community College (TCC) this coming fall semester.  As a series about upcoming classes, these episodes will feature interviews with many of the instructors tasked with teaching them.  Today's episode features Jeff Smith, Recording Studio Instructor at TCC.   Edited by Sam Levrault Music by The Odyssey, "75 to Ramona" Transcript by Bethany Solomon   TCC CONNECTION PODCAST | SEMESTER SNEEK PEAK | FT. JEFF SMITH Bethany: Welcome to semester sneak peak, our special summer series that provides a preview of courses available this coming fall semester. I am your host Bethany Solomon, associate editor of the north east campus here at the TCC connection. Today we have a very special guest, Jeff Smith, he is a TCC adjunct professor, TCC signature symphony violist, and president of song smith records. Jeff Smith: Hi! Good afternoon, how are ya? B: Good, how are you? J: I’m doing great. B: Can you start off by telling us a little about yourself? J: Sure. I was born and raised in Tulsa, OK. I started playing violin at 10 years old because my brother and sister played the violin. The summer of my 6th grade year my teacher came to me and said “you know you’re kinda beefy, husky boy, you need to play the viola. I said, viola? It rhymes with granola, I don’t want to play the viola, I said what am I getting myself into here? She said ‘Oh, no you’re not going to quit the violin, you’re going to learn how to double. Double. It rhymes with trouble, she said ‘oh no, you’ll be fine.’ So, I got to take two instruments to school, the violin and the viola. Uh, learned how to play the both of them, not long after that the beetles were popular, and I got a guitar. I started going on in. B: Very cool, very cool, so how did you find your way into the education as far as like, your music. Did you study in undergrad, music specifically, or did you have a broad range of interests beyond music? J: Oh, gosh. You look back on pivotal points in your life. One pivotal point in my life was, I guess I was in Jr high, early high school, and I had an electric guitar. Dad had come home with a Wollensak, as a German tape recorded. And it had an auxiliary input on it and I learned at a young age I could take the guitar output and plug it into the auxiliary input, crank it all the way up, play the guitar, turn its sound all the way up and it would sound something like: [makes loud buzzing noises mimicking guitar sound] Coolest sound I had every heard…. for about 13 seconds. I blew out the 8’ inch paper cone speakers and a couple of power tubes. Its kind of left a mark on me, like this is a cool sound, I gotta get into this. I was going to be an aeronautical engineer, all through high school, my dad was a fighter pilot in world war II, he had 96 missions over France. My grandfather had his PHD in mechanical engineering and actually wrote the maintenance Manuel for the B25 Mitchel bomber. So, I was going to be an aeronautical engineer, until, calculus first hour happened. Kay, I had a morning paper out, and an evening paper out. Okay! Take your XY X’s, translate it, rotate it, draw a hyperbola, spin the hyperbola, cut a hole in the hyperbola, and now find the volume and generate it. At that point I figured, you know, I’d rather play the wrong note, I couldn’t see myself designing something that will have someone else get killed because I misplaced a decimal point. But, all throughout high school I played in the youth symphony. My senior year, I audition Id and got first chair of the viola of the youth symphony. And I auditioned for the Tulsa Philharmonic. I guess they were desperate, and I turned pro when I was 17. Uh, went to the University of Kansas, was a Viola Major. A double major in Viola performance and music education. And at KU they had a computer music lab, and they had, we’re talking early-mid 1970’s. And they had an ARP 26 hardener. This is a synthesizer, analog synthesizer. You have never seen so many buttons, knobs, dials, flashing lights, flash chords, slider, path chords I was like ‘gollee’ what does this thing do, what does this thing do? I actually had a blast in that course, it got me down here. From there I came down to TU, finished up a bachelor’s in music ed, finished up a master’s in music ed, taught in Wichita, Kansas for three years, went back to school, picked up a master in viola performance. I have always believed that if are going to be a teacher, you must be able to do it. There is the old joke that can do, those that can’t teach, those that can’t teach become administrators. Um, nah, I kind of believe that if you’re going to teach, you ought to be able to produce. You ought to be able to do it. Does that make sense? B: It certainly does! So, moving into, as far like, the technical aspect of music, recording studio techniques, you have a lot of orchestra experience. How does that translate into the studio? J: Sure. Well I was a band and orchestra director for 27 years and the times that I wasn’t playing classical music with the orchestra, I was playing fiddle, guitar, keyboards, (unintelligible), for rock and roll bands. And that was an awful lot of fun, setting that stuff up, it gets really tiring after 15 years of lugging all that’s stuff around the back of a pick-up truck. It dawned on me, you know, that I can make music instead of lugging around all this PA gear and power amplifiers and all this other junk. Why don’t I just build a house, have recording studio, and have them come to me to make music, and I don’t have to lug all this stuff around. So I started SongSmith records in the mid-eighties back when we had, they were called ADAT machines. They recorded on a VHS cassette, and they would theoretically, and I say theoretically, synchronize together by two ADAT machines – and you could have, wow, 16 channels of digital audio. You could have a grand total of 34 minutes of digital audio. B: Wow. J: Of course, you could format the tape first before you had to record on to it, and that is about as much fun as having paint dry. But it was there, and we had 16 channels of digital audio. I’ve still got those ADAT machines and once in a while we’ll get an artist in the back of the studio that recorded with me 20 year ago say ‘Jeff! Do you still have to ADAT tapes?’ I say yeah. ‘Could we dump them into pro tools and clean them up a bit and rerelease? And I say sure. B: Fun stuff. Definitely. That’s really cool. So, what do you think, as far your students, and what you teach here, what has been the most challenging for your students? In terms of getting comfortable with technology or for musicians in general. J: Wow. That is kind of a tough questions. Each student is different, each student has their own strengths and weaknesses. On day one, I had to fill out a little, I call it a student data sheet. Tell me a little about yourself so I know who I am dealing with. A lot of times I will get students in the class who have already had pro tools experience they might run sound at their church. And I’ve got kids, ‘well I have sang in choir, but I want to learn how to record myself.’ And they don’t know anything about the technology. So, the challenge, for me as an instructor, is to teach on two or three different levels. So, I try to teach to the very, very raw beginner, to the kid who has had some experience, to those kids who could probably teach me a thing or two. I guess that’s the fun part about the teaching. In the class, I have to make sure that each kid knows we will only be playing with three things in audio. Frequency, amplitude, and time.   And all the buttons, and knobs, and dials, [mimics with higher pitch] Buttons, and knobs, and dials, oh my! All have to do with either frequency, amplitude, or time. If you understand that basic concept than you go through ‘okay well what does this button do, how does it change the sound? B: So, a lot of it is experimenting, as you’re in the course. J: Yeah. And that’s how they learn. We tell them, for example, once we define frequency, amplitude or time are, we go into signal flow. We go, okay, what happens, how does the ear work. How does the microphone work? We trace the audio from vibrations of your voice, or your guitar or whatever, through your microphone, line, inputs…..into. What happens next? [jeff starts laughing….] It all goes in from the patch bay, and the patch bay goes into the microphones, and the micros to the IO’S, IO into the computer and we explain all that stuff in signal flow, signal flow, signal flow. All an audio engineer does, all day long is. I don’t hear the guitar in my left ear, why not? Or, I plugged this in, and I don’t hear anything. B: Right. J: Or I turn this knob, and nothing happened. Back up and figure out why. B: And that is what you give your student leeway to do. Figure out why they made a mistake, to figure out why and backtrack. J: If you tell them what they did wrong, they’ll never figure it out themselves. If they go throughout, and your cohort here, can attest to this. I will rarely just tell a kid an answer, I say, do you have an iPhone on ya? There’s this thing called google, look it up! I’ll wait. And then for example, when they learn the measurements, and what decibels are to measure frequency. I’ll ask them questions like ‘what’s the unit of measurement for frequency?’ and they’ll say, uhm, decibels? No that is the measure for amplitude. Man, it hertz if you don’t know this. Hertz being cycles per second. B: Right. J: Hertz being, you know, cycles per second. Hertz is the measurement. So, it hertz if you don’t know this! [both laugh…] B: That’s a good one actually! J: The stupider or funnier something is, they’ll remember it. B: It sticks better! Definitly it helps it stick. So as far as walking away from the class, how important is it for students after, in the aftermath, are these techniques that can easily be forgotten if they are not applied immediately. J: Oh gosh, I hope not. B: If you have students that come for, let’s say, do you teach a second course as well? J: Yes. There’s a Recording Studios Technique II (RST II) class, theoretically there are two sections of RST I, which will have 16 kids total, 32. Out of those 32 kids, if RST II is offered, we only take 8. So it’s like ¼ of those two classes, if they wanted, we are limited to 8. We did a really cool thing this last semester. The students had to produce a video and they had to literally, we shot it on a gopro camera, and it was actually pretty terrible, but they learned the process. They had to get a video program onto their computer, there are several free ones, and just experiment there, here’s the scene we shot. And the whole theme of the video was, and this is terrible, once again, I love my wife, but she has a problem with collecting small electrical appliances. If there is small electrical appliance made, she has it. She’s got four or five crockpots, I don’t know how many mixers she’s got, toasters, curling irons, you name it, those little vacuum thingies, if it is a small electrical appliance she has it. So the format of the class was, we’re going to make a video and you all have seen these videos of the poor animals you know, for the charities, and there’s this poor dog with one eye and its snowing outside and he’s missing a paw or something and there is a choke collar behind this poor animal. And well the idea was, we’re going to have small appliances, and they need a home. And they produce something absolutely hilarious. “Do you know a small appliance that needs a home that’s been abused? We’re sorry. SARI, the small appliance rights institute, so we made a video, and we got t-shirts with irons. One of the appliances was an iron that burned a hole in the t-shirt, so the kids were like no, no bad iron! Flatten it with the newspaper, and later on we use that same shirt with sorry with this big old iron burn on it, we’ll give you this shirt if we give us $19 a month. That is only 63 cents a day.”   So I hope the kids learned a lot from that. Uh, they learned how to put it together, how to edit, how to synchronize the audio. One student actually wrote this really cool darkish sounding sad piano music that everyone wanted to use because it was so cool. B: So you have different types of projects and assignments in the class, of various ways. J: Oh yeah. B: So for exams, what should students expect for an exam, in a studio techniques class? How will their knowledge be tested? [Jeff laughs…] J: Exams! I figured kids are not in JR high school or elementary school anymore, I do not use true or false, multiple choice. Most of the tests and quizzes are done with fill in the blank and short answer. You know, hopefully using correct English and spelling things correctly. It’s not like ‘Who Wants to Be a Millionaire” we’ll give you four choices, and you pick through the answers up here. I want you to go a little bit beyond that. B: Right. J: We also give the kids all kinds of interesting ways to help memorize things like that. For example, can you name the planets in order from the sun out? B: Probably not in order. J: Okay. I can. B: You can? J: My wife took an astronomy class once, kay, and if you take the first letter of each planets. If take the first letter of each planet, ‘M’ for Mercury, ‘V’ for Venus, ‘E’ for Earth, ‘M’ Mars, Jupiter, Saturn, Uranus, Neptune, back then Pluto. So, she came up with a very simple sentence. My very enormous man Jeff Smith understands nothing. B: She came up with that? J: She came up with that! Totally originally, and OH! Okay. So, you take all that information, you condense all that down. It is like taking all 5 great lakes. Heroin, Ontario, Michigan, siria, and superior. Spell the word HOMES, take that data and condense it. It is like putting it in a ZIP files for your brain where they can memorize some of these techniques, and hopefully it will not only help them in audio engineering but in life. B: Right. J: You know, if you’re on stage running sound for a band somewhere or in a church situation and all of a sudden thing die. You don’t want to turn to the guy next to you. Good gosh what do we do? As an audio engineer, you got to figure it out, quickly. B: Right. It is about application, not just knowing the what, or how, it is about knowing the why, the why you are doing what you’re doing. That is what differentiates it from a lot of other subjects. J: That’s the thing, if you know anything about Bloom’s Taxonomy of Education. Harking back to many, many years ago. If you have just a knowledge level question: ‘Who invented the telephone?’ You know? That’s knowledge level. If you have a question like, we’re gonna form a band, you’re gonna come up with a song, you’re gonna cover a song or something and you are are gonna form a single here in the class. We’re gonna pick members for the band, and you’re gonna go from there. That takes a lot more brains to be able to do that. B: It takes creativity! J: Absolutely. You gotta coordinate your schedule together, you gotta pick a song, come up with an original cover song, do the rehearsals, figure out how you’re gonna mic the drums. I’ll show you how to mic them, but you do it! And why you might do it this way. B: Right. It takes a lot of brain power to figure out what you’re going to do, how you’re going to do it, and why you’re going to do it. J: The more you use it the stronger it gets. B: Yeah. That’s really good. That’s actually a really good way of doing it. So, for current line up of courses, beyond Studio Techniques I and then II. J: Two happens in the spring. I teach private lessons on violin and viola through TCC. That’s only a handful of students, like two or three. B: Oh okay! J: I also teach private guitar out of my house, but that’s a different story. B: Do you have anything like a semester split? What do you teach during what semester? J: Oh okay. In the first semester, the fall semester, we only offer Studio Techniques I, and hopefully there will be two sections. Then from that, we’ll offer in the spring, studio techniques I and II. B: Oh cool! So, advice for students as well, for anyone who does not have experience. What should they expect going to class and what should they expect coming out of the class? J: Bring a pencil and a notepad! You’d be amazed on day one that sometimes there is not a whole lot of different between first graders and college kids. You write something on the board, and some kid in the back will say, is this going to be on the test? [Bethany laughs…] J: Ummm, YEAH! The idea is if it is on the board, I feel it is important enough that you need to know it. Because if you are successful in music, you know, you could make a lot of money. Pay all that taxes and social security and support me when I’m old…..er. B: Very good point! So, if you want to be successful, for musicians specifically, how important is it to learn studio techniques for your own music? J: Oh gosh! In the music business especially, what has been relatively successful for me, I call it a multiple income source. My main income for many, many years was teaching in public schools. On the side, I was playing classical music in two different Orchestras. The (unintelligible} Symphony and the Signature Symphony and occasionally the Tulsa Harmonic. The Tulsa Opera and the Tulsa Ballet. On the weekends, we were not doing classical, we were rocking and rolling in establishments. We call them gun and knife clubs. [Both laugh…] Bring your own, within a hundred miles of Tulsa. You know, within 200 miles. So you had money coming in from the rock n’ roll side, money coming in from teaching lessons on the weekends, money coming in from your teaching job, money coming in from your symphony gigs, then if you write music, you can create it that way, and get royalties from that. That way if any one leg of that collapses you have something else to depend on. It the music business, to really make it big, you have to be extremely good at ONE thing. And then you can afford everyone else to pay them to record your CD for you, to book you here and there, but the more you know about every aspect of music. How do you finger a saxophone, where’s the best way to mic a saxophone, or a flue, or a guitar, or a cello, or a base? Where does their sound come out from? Where does it sound the best? What kind of mic do you use? All of that stuff, the more you know, the more you’re worth. You apply everything in music. There was a time when my teaching career, where the school I was teaching, I had been there for five years, and they were going to close the school due to a reorganization plan. My last year teaching there they’d lost all the electives. The only elective you could take at this school was band, orchestra, or gym. No home ED, no foreign languages, nothing. That was it. They closed the school next year to reorganize. Orchestras fold, right or left sometimes. Schools change. And in the music business especially, you’ve got to have a backup plan. You get smart, by a house, accelerate the principle on that, so you pay it off early. We paid our first house off in 8 and a half years by accelerating the principle. If you anything about financing, that is a different topic. But that’s how you get successful. B: Very cool. So I hear it is important to be multifaceted but to also master one area. J: Well. If you wanna be really successful in music, you got to be able to sing like Garth Brooks, or Whitney Houston. Or, you have to be able to play that violin like Itzhak Perlman. That’s all he does. For me, I can’t do that. I am too much Attention Deficit Disorder. I get attracted by all the flashing lights. Wow, cool, we are recording this in garage band right? Neat stuff! And I’m watching all these little lights flashing over here and she turns around smiling listening to us on her headphones running through the, and I am wandering GEE! What is that knob do, OH, that is the interface there she’s running through. So for me, you know, I’ve done the six hours of practice everyday when I was at the Cleveland institute of music getting my viola masters. Six hours a day of the viola? Gee I hate the viola sometimes! You know? It’s like too much. Put it down, play the guitar sometimes, go play the fiddle in a country band somewhere and make it fun. B: But you put a lot of time into it. J: Oh yeah! B: That’s awesome! Just to go over an overview on your courses one more time. Studio Techniques I, Studio Techniques II, Viola… J: And violin.. B: Oh, you teach violin as well. J: Yeah. B: So those are private lessons. J: For both majors and non-majors. B: Do you have a special email address that your students can reach you at? And potential students as well. J: I have the TCC email, but I have had more luck with my own personal email. Would it be okay to do that one? B: YEAH J: My personal email is songsmithrecords@cox.net. Now  if you go on the web and go to songsmithrecords.com, understand that I have been busy and haven’t updated the website for 15 or 17 years. It’s on my list of things to do I’m working on it but I’ve been busy. B: Alright, great, so where are your classes based at? What campus? J: We are based at the southeast campus. B: Sounds great, this has been Bethany Solomon and Jeff Smith at the TCC Connection. Thank you for listening and we hope to continue this series for the summer. J: Thank you Bethany, I appreciate your time. B: We appreciate you as well!      

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities. Nachi: So can we prevent a miscarriage, once the patient is bleeding…? Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy… Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking. Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant. Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic. Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously. Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum. Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2. Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms. Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis. Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy. Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be. Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3. Jeff: Alright, so I think we can put that intro behind us and move on to the differential. Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis. Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries. Nachi: Great point. Up next we have prehospital care... Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and amount of vaginal bleeding. In addition, providers should consider an early destination consult both to select the correct destination and to begin the process of mobilizing resources early in those patients who really need them, such as those with hemodynamic instability. Nachi: As with most pathologies, the more time you give the receiving facility to prepare, the better the care will be, especially the early care, which is critical. Jeff: Now that the patient has arrived in the ED we can begin our H&P. Nachi: When eliciting the patient’s obstetrical history, it’s common to use the G’s and Ps. This can be further annotated using the 4-digit TPAL method, that’s term-preterm-abortus-living. Jeff: With respect to vaginal bleeding, make sure to ask about the number of pads and how this relates to the woman’s normal number of pads. In addition, make sure to ask about vaginal discharge or even about the passage of tissue. Nachi: You will also need to elicit whether or not the patient has a history of a prior ectopic pregnancies as this is a major risk for future ectopics. And ask about previous sexually transmitted infections also. Jeff: And, of course, make sure to elicit a history of assisted reproductive technology, as this increases the risk of a heterotopic pregnancy. Nachi: Let’s move on to the physical. While you are certainly going to perform your standard focused physical exam, just as you would for any non-pregnant woman - what does the evidence say about the pelvic exam? I know this is a HOTLY debated topic among EM Docs. Jeff: Oh it certainly is. Dr. Pedigo takes a safe, but fair approach, noting, “A pelvic exam should always be performed if the emergency clinician suspects that it would change management, such as identifying the source of bleeding, or identifying an STD or PID.” However, it is noteworthy that the only real study he cites on this topic, an RCT of pelvic vs no pelvic in those with a confirmed IUP and first trimester bleeding, found no difference between the two groups. Obviously, the pelvic group reported more discomfort. Nachi: You did leave out one important fact about the study enrollment - they only enrolled about 200 of 700 intended patients. Jeff: Oh true, so a possibly underpowered study, but it’s all we’ve got on the topic. I think I’m still going to do pelvic exams, but it’s something to think about. Nachi: Moving on, all unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic until proven otherwise. Ruptured ectopics can manifest with a number of physical exam findings including abdominal tenderness, with peritoneal signs, or even with bradycardia due to vagal stimulation in the peritoneum. Jeff: Perhaps most importantly, no history or physical alone can rule in or out an ectopic pregnancy, for that you’ll need testing and imaging or operative findings. Nachi: And that’s a perfect segue into our next section - diagnostic studies. Jeff: Up first is the urine pregnancy test. A UPT should be obtained in all women of reproductive age with abdominal pain or vaginal bleeding, and likely other complaints too, though we’re not focusing on them now. Nachi: The UPT is a great test, with nearly 100% sensitivity, even in the setting of very dilute urine. False positives are certainly plausible, with likely culprits being recent pregnancy loss, exogenous HCG, or malignancy. Jeff: And not only is the sensitivity great, but it’s usually positive just 6-8 days after fertilization. Nachi: While the UPT is fairly straight forward, let’s talk about the next few tests in the context of specific disease entities, as I think that may make things a bit simpler -- starting with bHCG in the context of miscarriage and ectopic pregnancy. Jeff: Great starting point since there is certainly a lot of debate about the discriminatory zone. So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Generally 1500 is used as the cutoff. This corresponds nicely to a 2013 retrospective study demonstrating a bHCG threshold for the fetal pole to be just below 1400. Nachi: However, to actually catch 99% of gestational sacs, yolk sacs, and fetal poles, one would need cutoffs of around 3500, 18000, and 48,000 respectively -- much higher. Jeff: For this reason, if you want to use a discriminatory zone, ACOG recommends a conservatively high 3,500, as a cutoff. Nachi: I think that’s an understated point in this article, the classic teaching of a 1500 discriminatory zone cutoff is likely too low. Jeff: Right, which is why I think many ED physicians practice under the mantra that it’s an ectopic until proven otherwise. Nachi: Certainly a safe approach. Jeff: Along those lines, lack of an IUP with a bHCG above whatever discriminatory zone you are using does not diagnose an ectopic, it merely suggests a non-viable pregnancy of undetermined location. Nachi: And if you don’t identify an IUP, serial bHCGs can be really helpful. As a rule of thumb -- in cases of a viable IUP -- b-HCG typically doubles within 48 hours and at a minimum should rise 53%. Jeff: In perhaps one of the most concerning things I’ve read in awhile, one study showed that ⅓ of patients with an ectopic had a bCHG rise of 53% in 48h and 20% of patients with ectopics had a rate of decline typical to that of a miscarriage. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. Combined with a pelvic exam, this can give you almost all the data necessary to make the diagnosis, even if you don’t find an IUP. Nachi: And yes, there is good data to support ED ultrasound for this indication, both transabdominal and transvaginal, assuming the emergency physician is credentialed to do so. A 2010 Meta-Analysis found a NPV of 99.96% when an er doc identified an IUP on bedside ultrasound. So keep doing your bedside scans with confidence. Jeff: Before we move on to other diagnostic tests, let’s discuss table 2 on page 7 to refresh on key findings of each of the different types of miscarriage. For a threatened abortion, the os would be closed with an IUP seen on ultrasound. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP. Patients may or may not note the passage of products of conception. Nachi: A missed abortion presents with a closed os and a nonviable fetus on ultrasound. Findings such as a crown-rump length of 7 mm or greater without cardiac motion is one of several criteria to support this diagnosis. Jeff: An inevitable abortion presents with an open OS and an IUP on ultrasound. Along similar lines, an incomplete abortion presents with an open OS and partially expelled products on ultrasound. Nachi: And lastly, we have the septic abortion, which is sort of in a category of its own. A septic abortion presents with either an open or closed OS with essentially any finding on ultrasound in the setting of an intrauterine infection and a fever. Jeff: I’ve only seen this two times, and both women were incredibly sick upon presentation. Such a sad situation. Nachi: For sure. Before we move on to other tests, one quick note on the topic of heterotopic pregnancies: because the risk in the general population is so incredibly low, the finding of an IUP essentially rules out an ectopic pregnancy assuming the patient hasn’t been using assisted reproductive technology. In those that are using assisted reproductive technology, the risk rises to 1 in 100, so finding an IUP, in this case, doesn’t necessarily rule out a heterotopic pregnancy. Jeff: Let’s move on to diagnostic studies for patients with nausea and vomiting. Typically, no studies are indicated beyond whatever you would order to rule out other serious pathology. Checking electrolytes and repleting them should be considered in those with severe symptoms. Nachi: For those with symptoms suggestive of a UTI, a urinalysis and culture should be sent. Even if the urinalysis is negative, the culture may still have growth. Treat asymptomatic bacteriuria and allow the culture growth to guide changes in antibiotic selection. Jeff: It’s worth noting, however, that a 2016 systematic review found no reliable evidence supporting routine screening for asymptomatic bacteriuria, so send a urinalysis and culture only if there is suspicion for a UTI. Nachi: For those with concern for appendicitis, while ultrasound is a viable imaging modality, MRI is gaining favor. Both are specific tests, however one study found US to visualize the appendix only 7% of the time in pregnant patients. Jeff: Even more convincingly, one 2016 meta analysis found MRI to have a sensitivity and specificity of 94 and 97% respectively suggesting that a noncontrast MRI should be the first line imaging modality for potential appendicitis. Nachi: You kind of snuck it in there, but this is specifically a non-contrast MRI. Whereas a review of over a million pregnancies found no associated fetal risk with routine non-contrast MRI, gadolinium-enhanced MRI has been associated with increased rates of stillbirth, neonatal death, and rheumatologic and inflammatory skin conditions. Jeff: CT is also worth mentioning since MRI and even ultrasound may not be available to all of our listeners. If you do find yourself in such a predicament, or you have an inconclusive US without MRI available, a CT scan may be warranted as the delay in diagnosis and subsequent peritonitis has been found to increase the risk of preterm birth 4-fold. Nachi: Right, and a single dose of ionizing radiation actually does not exceed the threshold dose for fetal harm. Jeff: Let’s talk about the Rh status and prevention of alloimmunization. While there are no well-designed studies demonstrating benefit to administering anti-D immune globulin to Rh negative patients, ACOG guidelines state “ whether to administer anti-D immune globulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made.” Nachi: Unfortunately, that’s not particularly helpful for us. But if you are going to treat an unsensitized Rh negative female with vaginal bleeding while pregnant with Rh-immune globulin, they should receive 50 mcg IM of Rh-immune globulin within 72 hours, or the 300 mcg dose if that is all that is available. It’s also reasonable to administer Rh(d)-immune globulin to any pregnant female with significant abdominal trauma. Jeff: Moving on to the treatment for miscarriages - sadly there isn’t much to offer here. For those with threatened abortions, the vast majority will go on to a normal pregnancy. Bedrest had been recommended in the past, but there is little data to support this practice. Nachi: For incomplete miscarriages, if visible, products should be removed and you should consider sending those products to pathology for analysis, especially if the patient has had recurrent miscarriages. Jeff: For those with a missed abortion or incomplete miscarriages, options include expectant management, medical management or surgical management, all in consultation with an obstetrician. It’s noteworthy that a 2012 Cochrane review failed to find clear superiority for one strategy over another. This result was for the most part re-confirmed in a 2017 cochrane review. The latter study did find, however, that surgical management in the stable patient resulted in lower rates of incomplete miscarriage, bleeding, and need for transfusion. Nachi: For expectant management, 50-80% will complete their miscarriage within 7-10 days. Jeff: For those choosing medical management, typically with 800 mcg of intravaginal misoprostol, one study found this to be 91% effective in 7 days. This approach is preferred in low-resource settings. Nachi: And lastly, remember that all of these options are only options for stable patients. Surgical management is mandatory for patients with significant hemorrhage or hemodynamic instability. Jeff: Since the best evidence we have doesn’t suggest a crystal clear answer, you should rely on the patient’s own preferences and a discussion with their obstetrician. For this reason and due to the inherent difficulty of losing a pregnancy, having good communication is paramount. Nachi: Expert consensus recommends 6 key aspects of appropriate communication in such a setting: 1 assess the meaning of the pregnancy loss, give the news in a culturally competent and supportive manner, inform the family that grief is to be expected and give them permission to grieve in their own way, learn to be comfortable sharing the products of conception should the woman wish to see them, 5. provide support for whatever path she chooses, 6. and provide resources for grief counselors and support groups. Jeff: All great advice. The next treatment to discuss is that for pregnancy of an unknown location and ectopic pregnancies. Nachi: All unstable patients or those with suspected or proven ectopic or heterotopic pregnancies should be immediately resuscitated and taken for surgical intervention. Jeff: For those that are stable, with normal vitals, and no ultrasound evidence of a ruptured ectopic, with no IUP on ultrasound, -- that is, those with a pregnancy of unknown location, they should be discharged with follow up in 48 hours for repeat betaHCG and ultrasound. Nachi: And while many patients only need a single additional beta check, some may need repeat 48 hour exams until a diagnosis is established. Jeff: For those that are stable with a confirmed tubal ectopic, you again have a variety of treatment options, none being clearly superior. Nachi: Treatment options here include IM methotrexate, or a salpingostomy or salpingectomy. Jeff: Do note, however, that a bHCG over 5000, cardiac activity on US, and inability to follow up are all relative contraindications to methotrexate treatment. Absolute contraindications to methotrexate include cytopenia, active pulmonary disease, active peptic ulcer disease, hepatic or renal dysfunction, and breastfeeding. Nachi: Such decisions, should, of course, be made in conjunction with the obstetrician. Jeff: Always good to make a plan with the ob. Moving on to the treatment of nausea and vomiting in pregnancy, ACOG recommends pyridoxine, 10-25 mg orally q8-q6 with or without doxylamine 12.5 mg PO BID or TID. This is a level A recommendation as first-line treatment! Nachi: In addition, ACOG also recommends nonpharmacologic options such as acupressure at the P6 point on the wrist with a wrist band. Ginger is another nonpharmacologic intervention that has been shown to be efficacious - 250 mg by mouth 4 times a day. Jeff: So building an algorithm, step one would be to consider ginger and pressure at the P6 point. Step two would be pyridoxine and doxylamine. If all of these measures fail, step three would be IV medication - with 10 mg IV of metoclopramide being the agent of choice. Nachi: By the way, ondansetron carries a very small risk of fetal cardiac abnormalities, so the other options are of course preferred. Jeff: In terms of fluid choice for the actively vomiting first trimester woman, both D5NS and NS are appropriate choices, with slightly decreased nausea in the group receiving D5NS in one randomized trial of pregnant patients admitted for vomiting to an overnight observation unit. Nachi: Up next for treatment we have asymptomatic bacteriuria. As we stated previously, asymptomatic bacteriuria should be treated. This is due to anatomical and physiologic changes which put these women at higher risk than non-pregnant women. Jeff: And this recommendation comes from the 2005 IDSA guidelines. In one trial, treatment of those with asymptomatic bacteriuria with nitrofurantoin reduced the incidence of developing pyelonephritis from 2.4% to 0.6%. Nachi: And this trial specifically examined the utility of nitrofurantoin. Per a 2010 and 2011 Cochrane review, there is not evidence to recommend one antibiotic over another, so let your local antibiograms guide your treatment. Jeff: In general, amoxicillin or cephalexin for a full 7 day course could also be perfectly appropriate. Nachi: A 2017 ACOG Committee Opinion analyzed nitrofurantoin and sulfonamide antibiotics for association with birth defects. Although safe in the second and third trimester, they recommend use in the first trimester -- only when no other suitable alternatives are available. Jeff: For those, who unfortunately do go on to develop pyelo, 1g IV ceftriaxone should be your drug of choice. Interestingly, groups have examined outpatient care with 2 days of daily IM ceftriaxone vs inpatient IV antibiotic therapy and they found that there may be a higher than acceptable risk in the outpatient setting as several required eventual admission and one developed septic shock in their relatively small trial. Nachi: And the last treatment to discuss is for pregnant patient with acute appendicitis. Despite a potential shift in the standard of care for non pregnant patients towards antibiotics-only as the initial treatment, due to the increased risk of serious complications for pregnant women with an acute appy, the best current evidence supports a surgical pathway. Jeff: Perfect, so that wraps up treatment. We have a few special considerations this month, the first of which revolves around ionizing radiation. Ideally, one should limit the amount of ionizing radiation exposure during pregnancy, however avoiding it all together may lead to missed or delayed diagnoses and subsequently worse outcomes. Nachi: It’s worth noting that the American College of Radiology actually lists several radiographs that are such low exposure that checking a urine pregnancy test isn’t even necessary. These include any imaging of the head and neck, extremity CT, and chest x-ray. Jeff: Of course, an abdomen and pelvis CT carries the greatest potential risk. However, if necessary, it’s certainly appropriate as long as there is a documented discussion of the risk and benefits with the patient. Nachi: And regarding iodinated contrast for CT -- it appears to present no known harm to the fetus, but this is based on limited data. ACOG recommends using contrast only if “absolutely required”. Jeff: Right and that’s for iodinated contrasts. Gadolinium should always be avoided. Let me repeat that Gadolinium should always be avoided Nachi: Let’s also briefly touch on a controversial topic -- that of using qualitative urine point of care tests with blood instead of urine. In short, some devices are fda-approved for serum, but not whole blood. Clinicians really just need to know the equipment and characteristics at their own site. It is worth noting that there have been studies on determining whether time can be saved by using point of care blood testing instead of urine for the patient who is unable to provide a prompt sample. Initial study conclusions are promising. But again, you need to know the characteristics of the test at your ER. Jeff: One more controversy in this issue is that of expectant management for ectopic pregnancy. A 2015 randomized trial found similar outcomes for IM methotrexate compared to placebo for tubal ectopics. Inclusion criteria included hemodynamic stability, initial b hcg < 2000, declining b hcg titers 48 hours prior to treatment, and visible tubal pregnancy on trans vaginal ultrasound. Another 2017 multicenter randomized trial found similar results. Nachi: But of course all of these decisions should be made in conjunction with your obstetrician colleagues. Jeff: Let’s move on to disposition. HDS patients who are well-appearing with a pregnancy of undetermined location should be discharged with a 48h beta hcg recheck and ultrasound. All hemodynamically unstable patients, should of course be admitted and likely taken directly to the OR. Nachi: Also, all pregnant patients with acute pyelonephritis require admission. Outpatient tx could be considered in consultation with ob. Jeff: Patient with hyperemesis gravidarum who do not improve despite treatment in the ED should also be admitted. Nachi: Before we close out the episode, let’s go over some key points and clinical pearls... J Overall, roughly 25% of pregnant women will experience vaginal bleeding and 7-27% of pregnant women will experience a miscarriage 2. Becoming pregnant with an IUD significantly raises the risk of ectopic pregnancy. 3. Ovarian stimulation as part of assisted reproductive technology places pregnant women at increased risk of ovarian torsion. 4. Due to anatomical and physiologic changes in the genitourinary tract, asymptomatic bacteriuria places pregnant women at higher risk for pyelonephritis. As such, treat asymptomatic bacteriuria according to local antibiograms. 5. A pelvic exam in the setting of first trimester bleeding is only warranted if you suspect it might change management. 6. Unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic pregnancy until proven otherwise. 7. If you are to use a discriminatory zone, ACOG recommends a beta-hCG cutoff of 3500. 8. The beta-hCG typically doubles within 48 hours during the first trimester. It should definitely rise by a minimum of 53%. 9. For patients using assisted reproductive technology, the risk of heterotopic pregnancy becomes much higher. Finding an IUP does not necessarily rule out a heterotopic pregnancy. N. Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative. J. The most common surgical problem in pregnancy is appendicitis. N, If MRI is not available and ultrasound was inconclusive, CT may be warranted for assessing appendicitis. The risk of missing or delaying the diagnosis may outweigh the risk of radiation. J. ACOG recommends using iodinated contrast only if absolutely required. N. For stable patients with a pregnancy of unknown location, plan for discharge with follow up in 48 hours for a repeat beta-hCG and ultrasound. J For nausea and vomiting in pregnancy, try nonpharmacologic treatments like acupressure at the P6 point on the wrist or ginger supplementation. First line pharmacologic treatment is pyridoxine. Doxylamine can be added. Ondansetron may increase risk of fetal cardiac abnormalities N So that wraps up episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management. J: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. N: And the address for this month’s credit is ebmedicine.net/E0119, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!  

  Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic that is ripe for review this time of year. We’re talking Influenza… Diagnosis and Management. Nachi: Very appropriate as the cold is settling in here in NYC and we’re already starting to see more cases of influenza. Remember that as you listen through the episode, the means we’re about to cover one of the CME questions for those of you listening at home with the print issue handy. Jeff: This month’s issue was authored by Dr. Al Giwa of the Icahn School of Medicine at Mount Sinai, Dr. Chinwe Ogedegbe of the Seton Hall School of Medicine, and Dr. Charles Murphy of Metrowest Medical Center. Nachi: And this issue was peer reviewed by Dr. Michael Abraham of the University of Maryland School of Medicine and by Dr. Dan Egan, Vice Chair of Education of the Department of Emergency Medicine at Columbia University. Jeff: The information contained in this article comes from articles found on pubmed, the cochrane database, center for disease control, and the world health organization. I’d say that’s a pretty reputable group of sources. Additionally, guidelines were reviewed from the american college of emergency physicians, infectious disease society of america, and the american academy of pediatrics. Nachi: Some brief history here to get us started -- did you know that in 1918/1919, during the influenza pandemic, about one third of the world’s population was infected with influenza? Jeff: That’s wild. How do they even know that? Nachi: Not sure, but also worth noting -- an estimated 50 million people died during that pandemic. Jeff: Clearly a deadly disease. Sadly, that wasn’t the last major outbreak… fifty years later the 1968 hong kong influenza pandemic, H3N2, took between 1 and 4 million lives. Nachi: And just last year we saw the 2017-2018 influenza epidemic with record-breaking ED visits. This was the deadliest season since 1976 with at least 80,000 deaths. Jeff: The reason for this is multifactorial. The combination of particularly mutagenic strains causing low vaccine effectiveness, along with decreased production of IV fluids and antiviral medication because of the hurricane, all played a role in last winter’s disastrous epidemic. Nachi: Overall we’re looking at a rise in influenza related deaths with over 30,000 deaths annually in the US attributed to influenza in recent years. The ED plays a key role in outbreaks, since containment relies on early and rapid identification and treatment. Jeff: In addition to the mortality you just cited, influenza also causes a tremendous strain on society. The CDC estimates that epidemics cost 10 billion dollars per year. They also estimate that an epidemic is responsible for 3 million hospitalized days and 31 million outpatient visits each year. Nachi: It is thought that up to 20% of the US population has been infected with influenza in the winter months, disproportionately hitting the young and elderly. Deaths from influenza have been increasing over the last 20 years, likely in part due to a growing elderly population. Jeff: And naturally, the deaths that we see from influenza also disproportionately affect the elderly, with up to 90% occurring in those 65 or older. Nachi: Though most of our listeners probably know the difference between an influenza epidemic and pandemic, let’s review it anyway. When the number of cases of influenza is higher than what would be expected in a region, an epidemic is declared. When the occurrence of disease is on a worldwide spectrum, the term pandemic is used. Jeff: I think that’s enough epidemiology for now. Let’s get started with the basics of the influenza virus. Influenza is spread primarily through direct person-to-person contact via expelled respiratory secretions. It is most active in the winter months, but can be seen year-round. Nachi: The influenza virus is a spherical RNA-based virus of the orthomyxoviridae family. The RNA core is associated with a nucleoprotein antigen. Variations of this antigen have led to the the 3 primary subgroups -- influenza A, B, and C, with influenza A being the most common. Jeff: Influenza B is less frequent, but is more frequently associated with epidemics. And Influenza C is the form least likely to infect humans -- it is also milder than both influenza A or B. Nachi: But back to Influenza A - it can be further classified based on its transmembrane or surface proteins, hemagglutinin and neuraminidase - or H and N for short. There are actually 16 different H subtypes and 9 different N subtypes, but only H1, H2, H3, and N1 and N2 have caused epidemic disease. Jeff: Two terms worth learning here are antigen drift and anitgen shift. Antigen drift refers to small point mutations to the viral genes that code for H and N. Antigen shift is a much more radical change, with reassortment of viral genes. When cells are infected by 2 or more strains, a new strain can emerge after genetic reassortment. Nachi: With antigen shift, some immunity may be maintained within a population infected by a similar subtype previously. With antigen drift, there is loss of immunity from prior infection. Jeff: The appearance of new strains of influenza typically involves an animal host, like pigs, horses, or birds. This is why you might be hear a strain called “swine flu”, “equine flu”, or “avian flu”. Close proximity with these animals facilitates co-infection and genetic reassortment. Nachi: I think that’s enough basic biology for now, let’s move on to pathophysiology. When inhaled, the influenza virus initially infects the epithelium of the upper respiratory tract and alveolar cells of the lower respiratory tract. Viral replication occurs within 4 to 6 hours. Incubation is 18 to 72 hours. Viral shedding is usually complete roughly 7 days after infection, but can be longer in children and immunocompromised patients. Jeff: As part of the infectious process and response, there can be significant changes to the respiratory tract with inflammation and epithelial cell necrosis. This can lead to viral pneumonia, and occasionally secondary bacterial pneumonia. Nachi: The secondary bacterial pathogens that are most common include Staph aureus, Strep pneumoniae, and H influenzae. Jeff: Despite anything you may read on the internet, vaccines work and luckily influenza happens to be a pathogen which we can vaccinate against. As such, there are 3 methods approved by the FDA for producing influenza vaccines -- egg-based, cell-based, or recombinant influenza vaccine. Once the season’s most likely strains have been determined, the virus is introduced into the medium and allowed to replicate. The antigen is then purified and used to make an injection or nasal spray. Nachi: It isn’t easy to create vaccines for all strains. H3N2, for example, is particularly virulent, volatile, and mutagenic, which leads to poor prophylaxis against this particular subgroup. Jeff: In fact, a meta-analysis on vaccine effectiveness from 2004-2015 found that the pooled effectiveness against influenza B was 54%, against the H1N1 pandemic in 2009 was 61%, and against the H3N2 virus was 33%. Not surprisingly, H3N2 dominant seasons are currently associated with the highest rates of influenza cases, hospitalizations, and death. Nachi: Those are overall some low percentages. So should we still be getting vaccinated? The answer is certainly a resounding YES.. Despite poor protection from certain strains, vaccine effectiveness is still around 50% and prevents severe morbidity and mortality in those patients. Jeff: That’s right. The 2017-2018 vaccine was only 40% effective, but this still translates to 40% less severe cases and a subsequent decrease in hospitalizations and death. Nachi: But before we get into actual hospitalization, treatment, and preventing death, let’s talk about the differential. We’re not just focusing on influenza here, but any influenza like illness, since they can be hard to distinguish. The CDC defines “influenza-like illness” as a temperature > 100 F, plus cough or sore throat, in the absence of a known cause other than influenza. Jeff: Therefore, influenza should really be considered on the differential of any patient who presents to the ED with a fever and URI symptoms. The differential when considering influenza might also include mycoplasma pneumoniae, strep pneumoniae, adenovirus, RSV, rhinovirus, parainfluenza virus, legionella, and community acquired MRSA. Nachi: With the differential in mind, let’s move on to prehospital care. For the prehospital setting, there isn’t much surprising here. Stabilize and manage the respiratory status with all of your standard tools - oxygen for those with mild hypoxia and advanced airway maneuvers for those with respiratory distess. Jeff: Of note, EMS providers should use face masks themselves and place them on patients as well. As community paramedicine and mobile integrated health becomes more common, this is one potential area where EMS can potentially keep patients at home or help them seek treatment in alternate destinations to avoid subjecting crowded ED’s to the highly contagious influenza virus. Nachi: It’s also worth noting, that most communities have strategic plans in the event of a major influenza outbreak. Local, state, and federal protocols have been designed for effective care delivery. Jeff: Alright, so now that the EMS crew, wearing proper PPE of course, has delivered the patient, who is also wearing a mask, to the ED, we can begin our ED H&P. Don’t forget that patients present with a range of symptoms that vary by age. A typical history is 2-5 days of fever, nasal congestion, sore throat, and myalgias. You might see tachycardia, cough, dyspnea, and chills too. Nachi: Van Wormer et al conducted a prospective analysis of subjective symptoms to determine correlation with lab confirmed influenza. They found the most common symptoms were cough in 92%, fatigue in 91%, and nasal congestion in 84%, whereas sneezing was actually a negative predictor for influenza. Jeff: Sneezing, really? Can’t wait to get the Press-Gany results from the sneezing patient I discharge without testing for influenza based on their aggressive sneezes! Nachi: Aggressive sneezes…? I can’t wait to see your scale for that. Jeff: Hopefully I’ll have it in next month’s annals. In all seriousness, I’m not doing away with flu swabs just yet. In another retrospective study, Monto et al found that the best multivariate predictors were cough and fever with a positive predictive value of 79%. Nachi: Yet another study in children found that the predominant symptoms were fever in 95%, cough in 77%, and rhinitis in 78%. This study also suggested that the range of fever was higher in children and that GI symptoms like vomiting and diarrhea were more common in children than adults. Jeff: Aside from symptomatology, there are quite a few diagnostic tests to consider including viral culture, immunofluoresence, rt-pcr, and rapid antigen testing. The reliability of testing varies greatly depending on the type of test, quality of the sample, and the lab. During a true epidemic, formal testing might not be indicated as the decision to treat is based on treatment criteria like age, comorbidities, and severity of illness. Nachi: We’ll get to treatment in a few minutes, but diving a bit deeper into testing - there are 3 major categories of tests. The first detects influenza A only. The second detects either A or B, but cannot distinguish between them; and the third detects both influenza A and B and is subtype specific. The majority of rapid testing kits will distinguish between influenza A and B, but not all can distinguish between them. Fluorescent antibody testing by DFA is relatively rapid and yields results within 2 to 4 hours. Jeff: Viral culture and RT-PCR remain the gold standard, but both require more time and money, as well as a specialized lab. As a result, rapid testing modalities are recommended. Multiple studies have shown significant benefit to the usefulness of positive results on rapid testing. It’s safe to say that at a minimum, rapid testing helps decrease delays in treatment and management. Nachi: Looking a bit further into the testing characteristics, don’t forget that the positive predictive value of testing is affected by the prevalence of influenza. In periods of low influenza activity (as in the summer), a rapid test will have low PPV and high NPV. The test is more likely to yield false positive results -- up to 50% according to one study when prevalence is below 5%. Jeff: And conversely, in periods of high influenza activity, a rapid test will have higher PPV and lower NPV, and it is more likely to produce a false negative result. Nachi: In one prospective study of patients who presented with influenza-like illness during peak season, rapid testing was found to be no better than clinical judgement. During these times, it’s probably better to reserve testing for extremely ill patients in whom diagnostic closure is particularly important. And since the quality of the specimen remains important, empiric treatment of critically ill patients should still be considered. Jeff: Which is a perfect segway into our next topic - treatment, which is certainly the most interesting section of this article. To start off -- for mild to moderate disease and no underlying high risk conditions, supportive therapy is usually sufficient. Nachi: Antiviral therapy is reserved for those with a predicted severe disease course or with high risk conditions like long-standing pulmonary disease, pregnancy, immunocompromise, or even just being elderly. Jeff: Note to self, avoid being elderly. Nachi: Good luck with that. Anyway, early treatment with antivirals has been shown to reduce influenza-related complications in both children and adults. Jeff: Once you’ve decided to treat the patient, there are two primary classes of antivirals -- adamantane derivatives and neuraminidase inhibitors. Oh and then there is a new single dose oral antiviral that was just approved by the FDA… baloxavir marboxil (or xofluza), which is in a class of its own -- a polymerase endonuclease inhibitor. Nachi: The oldest class, the adamantane derivatives, includes amantadine and rimantadine. Then the newer class of neuraminidase inhibitors includes oseltamavir (which is taken by mouth), zanamavir (which is inhaled), and peramivir (which is administered by IV). Jeff: Oseltamavir is currently approved for patients of all ages. A 2015 meta analysis showed that the intention-to-treat infected population had a shorter time to alleviation of all symptoms from 123 hours to 98 hours. That’s over a day less of symptoms, not bad! There were also fewer lower respiratory tract complications requiring antibiotics and fewer admissions for any cause. Really, not bad! Nachi: Zanamavir is approved for patients 7 and older -- or for children 5 or older for disease prevention. Zanamavir has been associated with possible bronchospasm and is contraindicated in patients with reactive airway disease. Jeff: Peramivir, the newest drug in this class, is given as a single IV dose for patients with uncomplicated influenza who have been sick for 2 days or less. Peramavir is approved for patients 2 or older. This is a particularly great choice for a vomiting patient. Nachi: And as you mentioned before, just last month, the FDA approved baloxavir, a single dose antiviral. It’s effective for influenza type A or B. Note that safety and efficacy have not been established for patients less than 12 years old, weighing less than 40 kg, or pregnant or lactating patients. Jeff: Unfortunately, there has been some pretty notable antiviral resistance in the recent past, moreso with the adamantane class, but recently also with the neuraminidase inhibitors. In 2007-2008, an oseltamivir-resistant H1N1 strain emerged globally. Luckily, cross-resistance between baloxavir and the adamantanes or neuraminidase inhibitors isn’t expected, as they target different viral proteins, so this may be an answer this year, and in the future. Nachi: Let’s talk chemoprophylaxis for influenza.. Chemoprophylaxis with oseltamavir or zanamavir can be considered for patients who are at high risk for complications and were exposed to influenza in the first 2 weeks following vaccination, patients who are at high risk for complications and cannot receive the vaccination, and those who are immunocompromised. Jeff: Chemoprophylaxis is also recommended for pregnant women. For postexposure prophylaxis for pregnant women, the current recommendation is to administer oseltamivir. Nachi: We should also discuss the efficacy of treatment with antivirals. This has been a hotly debated topic, especially with regards to cost versus benefit… In a meta-analysis, using time to alleviation of symptoms as the primary endpoint, oseltamavir resulted in an efficacy of 73% (with a wide 95% CI from 33% to 89%). And this was with dose of 150mg/day in a symptomatic influenza patient. Jeff: Similarly zanamavir given at 10mg/day was 62% effective, but again with a wide 95% CI from 15% to 83%. And, of note, other studies have looked into peramivir, but have found no significant benefits other than the route of delivery. Nachi: In another 2014 study by Muthuri et al., neuraminidase inhibitors were associated with a reduction in mortality -- adjusted OR = 0.81 (with a 95% CI 0.70 to 0.93). Also when comparing late treatment with early treatment (that is, within 2 days of symptom onset), there was a reduction in mortality risk with adjusted OR 0.48 (95%CI 0.41-0.56). These associations with reduction in mortality risk were less pronounced and less significant in children. Jeff: Mortality benefit, not bad! They further found an increase in mortality hazard ratio with each day’s delay in initiation of treatment up to 5 days, when compared to treatment initiated within 2 days. Nachi: But back to the children for a second -- another review of neuraminidase inhibitors in children < 12 years old found duration of clinical symptoms was reduced by 36 hours among previously healthy children taking oseltamivir and 30 hours by children taking zanamivir. Jeff: I think that’s worth summarizing - According to this month’s author’s review of the best current evidence, use of neuraminidase inhibitors is recommended, especially if started within 2 days, for elderly patients and those with comorbidities. Nachi: Seems like there is decent data to support that conclusion. But let’s not forget that these medications all have side effects. Jeff: These drugs actually tend to be well tolerated.The most frequently noted side effect of oseltamavir is nausea and vomiting, while zanamavir is associated with diarrhea. Nachi: Amazing. Let’s talk disposition for your influenza patient. Jeff: Disposition will depend on many clinical factors, like age, respiratory status, oxygen saturation, comorbid conditions, and reliability of follow up care. Admission might be needed not only to manage the viral infection, but also expected complications. Nachi: If you’re discharging a patient, be sure to engage in shared decision making regarding risks and benefits of available treatments. Ensure outpatient follow up and discuss return to er precautions. Jeff: Also, the CDC recommends that these patients stay home for at least 24 hours after their fever has broken. Nachi: With that -- Let’s summarize the key points and clinical pearls from this month’s issue J: Even though influenza vaccine effectiveness is typically only 50%, this still translates to a decrease in influenza-related morbidity and mortality. 2. The CDC defines influenza-like illness as a temperature > 100 F with either cough or sore throat, in the absence of a known cause other than influenza. 3. When influenza is suspected in the prehospital setting, patients and providers should wear face masks to avoid spreading the virus. 4. In the emergency department, standard isolation and droplet precautions should be maintained for suspected or confirmed infections. 5. The most common symptoms of influenza in adults are cough, fatigue, nasal congestion, and fever. Sneezing is a negative predictor in adults. 6. In children, the most common presenting symptoms are fever, cough, and rhinitis. Vomiting and diarrhea is also more common in children than adults. 7. Rapid testing and identification results in decreased delays in treatment and management decisions. 8. During peak flu season, clinical judgement may be as good as rapid testing, making rapid testing less necessary. J: Rapid testing may be more beneficial in times of lower disease prevalence. 10. Empiric treatment of critically ill patients should be considered even if rapid testing is negative. J: For mild to moderate disease and no underlying high-risk conditions, supportive therapy is usually sufficient. 12.For more ill patients or those at substantial risk for complications, consider antiviral treatment. 13.Oseltamivir is approved for patients of all ages, and reduces the length of symptoms by one day. 14.When treating influenza, peramivir is an ideal agent for the vomiting patient. 15.Baloxavir is a new single-dose antiviral agent approved by the FDA in October 2018. It works in a novel way and is effective for treatment of influenza A and B. 16.Chemoprophylaxis with oseltamivir or zanamivir should be considered in patients who are immunocompromised or patients who are at elevated risk for complications and cannot receive the vaccination. 17.Consider oseltamivir as post exposure prophylaxis in pregnant women. 18.Neuraminidase inhibitors are associated with decreased duration of symptoms and complications, especially if started within 2 days of symptom onset. J: So that wraps up episode 23 - Influenza: Diagnosis and Management in the Emergency Department. N: Additional materials are available on our website for Emergency Medicine Practice subscribers. For our subscribers: be sure to go online to get your CME credit for this issue, which includes 3 pharmacology CME credits. J: Also, for our NP and PA listeners, we have a special offer this month: You can get a full year of access to Emergency Medicine Practice for just $199--including lots of pharmacology, stroke, and trauma CME--and so much more! To get this special deal, go to www.ebmedicine.net/APP. Again, that’s www.ebmedicine.net/APP. N: If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. J: And the address for this month’s credit is ebmedicine.net/E1218. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!    

Julie writes, “Dear Susan, how can you tell if you and your partner are on the same page regarding the future if your partner is a more reticent, cautious person? I know that my partner loves me a lot, is kind and consistent. However, unlike me, who would love to dive straight in to a life together, he is taking things much more slowly and warily. I sometimes take this for a lack of commitment. Thank you! J” For more information please visit my website at http://www.susanwinter.net/

If there's one thing I've learned from listening to over a year of #WeGotGoals, it's that building a business or achieving a major goal is rarely as easy as these rockstar goal-getters make it seem. But for Katlin Smith, keeping things simple is the secret ingredient to her success with Simple Mills, an all-natural baking mix and foods company that uses recognizable, natural ingredients in place of things like high-fructose corn syrup and artificial ingredients. Smith started Simple Mills in 2012, right after she began cleaning up her diet and cutting out processed food and sugar. Almost instantly, a lightbulb went off in her head. "Growing up, I learned okay, food affects your weight, it affects your digestive system. But never did I think that food could affect your immune system or the other things we're learning about now, like anxiety, depression, or cancer. And it was just stunning to me that food can affect those things." Armed with these realizations, Smith realized she had to do something to change how people eat — and thus, Simple Mills was born. And even though the premise of Simple Mills was — and continues to be — clean, nutritious foods for a better life, Smith has never shied away from a great mission that expands beyond the grocery store aisle. In fact, once she realized how much her health was affected by a clean, unprocessed diet, Smith went home and did something I truly identify with: she made a list. But not just any list. "I brainstormed 10 different ways that I could impact the way that people are eating and what they're eating and how many kinds of whole foods they're eating," Smith shared. "It ranged everything from going and getting my master's in public health to starting a natural food company that would help change what people are eating." (Spoiler alert: that last one is the idea that won out) Recently, Smith was able to participate in a life-changing trip made available through her inclusion on the 2017 Forbes' 30 Under 30 list. With about 85 other attendees, Smith traveled all over Israel, including at the Syrian and Jordan border, learning about all the complexities behind the conflict in the Middle East. Seems heavy for something that looks like a press tour on the surface, right? Yes — but according to Smith, the trip helped open her eyes to the larger complexities facing the world, in addition to sparking ideas for how she and Simple Mills can have an impact in spaces larger than grocery stores. "There were two key realizations for me on that trip," Smith reflected. "The first was that what we have today we can take for granted really easily, and things can change. The other thing that I really thought coming out of that trip was just how not simple conflict is." Even more surprising about the trip? It was entirely paid for by Schusterman, the company who invited Smith and the other attendees. So what was the catch? No catch, revealed Smith — just a firm reminder that with great power comes great responsibility, and all the standout attendees on the trip had the means to truly change the world. Fresh off the trip when we talked, Smith takes that responsibility incredibly seriously and intends to start by using Simple Mills as a platform to change the food industry. From there, the sky's the limit. "I do plan on doing more things with my life than just Simple Mills. There are a lot of problems in the world, and a lot of problems to solve and I think that if you have like the energy and the resources to impact the world, you absolutely should." We can't wait to see what Smith does next. Listen to Katlin talk to me about her goals on this week’s episode of #WeGotGoals by downloading his episode wherever you get your podcasts. If you like the show as much as we do, be sure to subscribe and leave it a rating and a review. And! Don't take out your earbuds before you listen to the end of this podcast — we've got a real-life goal from a goal-getter like you that you've got to tune in for. ------- JAC: Welcome to #WeGotGoals, a podcast by aSweatLife.com on which we talked to high achievers about their goals. I'm Jeana Anderson Cohen; with me, I have Kristin Geil and Maggie Umberger. MU: Good morning, Jeana. KG: Hey Jeana. JAC: Good morning MU: Kristen, this week you got to speak to Katlin Smith, who is the founder and CEO of Simple Mills. KG: That's right. Maggie. I got to chat with Katlin Smith who has been a friend of aSweatLife for awhile and it's been so exciting watching her company grow from when she first founded it back in 2013 while she was still working as a full time consultant at Deloitte. It was really interesting and inspiring to hear her talk about how she would wake up at 4 in the morning, bake for a few hours and then go right to her full time job and yeah, I think we got a lot of great information out of her from this interview. JAC: And we've talked to Katlin a few times just through the years and seeing the company grow, but this is really the first time we've heard her talk about how she's really introspective. Can you speak to that? KG: Yeah, so Katlin is a self described introvert, which I always think is really fascinating for people who are entrepreneurs and CEOs who—she also mentioned she's in meetings, you know, 70 to 80 percent of her day, so I was really interested to hear how she balances that side of her personality with being such a forward facing public persona. So we got to talking about what helps her recharge from being in front of people all the time, always talking, always in conversations and I think the tips that she offered for how to recharge as a business leader who's an introvert will be really helpful for our listeners. MU: Speaking of being a business leader, she was one of Forbes’ 2017, 30 under 30 business leaders. So she just came back from an incredible trip to Israel and you got to speak to her just off of coming home from that trip. KG: Yeah. So Katlin was one of Forbes 30 under 30 last year and one of the perks that she was offered is that another company sponsors a full-blown trip to Israel for anyone who's graduated, so to speak, from the 30 under 30 class. And this company covers everything from airfare to hotels to experiences. And Katlin was talking about how amazing it was and how they kept blowing her mind with all the different experiences that she and I think it was roughly 80 other people got to have. But when she and her other travelers, we're asking the trip leaders, you know, what's the catch? Why did you bring us all here? The trip leaders, were simply saying that they wanted these business leaders of the present and of the future to realize how much power they truly have when it comes to changing the world. KG: And you know, she quoted the old Spiderman line with great power comes great responsibility. And I thought that was really interesting because Katlin started Simple Mills, she said, to change the way people eat, which is not a small feat in and of itself. But now after this trip, it really seems like she's thinking much more globally about how she and her company can impact the world in ways beyond just how we eat and where we grocery shop. JAC: And it's important to note that what simple mills makes is baked goods and sort of the Betty Crocker-esque products that are gluten-free and made out of whole foods and whole ingredients. And as someone who eats gluten free, it was incredibly impactful for me because I am an added Cheezit in years and Simple Mills has a product, a cracker, that's just like a Cheezit. So can you talk a little bit about why she started down this journey to make this gluten-free whole food option? KG: Yep. You'll hear the full story in the interview, but she was suffering from things like joint pain and seasonal allergies and she was trying to think of different ways that she could remedy herself and different ways that she could eat and live her life so that she could feel the best possible. So that's really how Simple Mills started. But she, this wasn't her only idea. She, at one point she said she brainstorm 10 different ways that she could change the way the world eats and Simple Mills was the one that stuck. So it's a really interesting story and I think people are going to love this interview. MU: We cannot wait to hear it. Here is Kristen with Katlin. JAC: Hey, stick around. At the end of this episode, you'll hear from some real life goal-getters who will tell you the goals that they've achieved and the goals they're going after. KG: Welcome to #WeGotGoals. My name is Kristen Geil and I am here with Katlin Smith, the CEO and founder of Simple Mills. Katlin, how are you? KS: Doing great. Thank you for having me. KG: No problem. We are super excited to have you here on the podcast. We've had you on a panel to speak before, we;ve featured you on the blog several times, but this will be the first time that we really get to sit down and hear your story in an audio sense. So we're really excited. First of all, let's start off with the big goal that we ask everybody about on this podcast. What is a big goal that you have worked toward in the past? Why was it important to you and what did you do to get there? KS: Yeah, so that's that. That will probably be a pretty long answer. I think starting Simple Mills was a huge thing for me. So I started this company about five years ago. So around that time I cleaned up my diet. I took out a lot of the processed food, a lot of the sugar, and when I did my joint pain went away, my seasonal allergies went away. I had loads more energy and it really shocked me because I, growing up I, I think I learned about, OK, food affects your weight. It affects your digestive system, but never did I think that food could affect your immune system or that, the other things we're learning about now, like anxiety, depression, cancer, all of these things that we're seeing skyrocketing rates of. And it was just stunning to me that food can affect those things. And so once I learned that I felt a, I felt like I had to do something, like there was just no option about it. It's funny because sometimes people ask me like, oh, how did you decide? Like how did you know if you were going to start it or not? And in my mind there was no option. It was just like I have to do something about this. And so I actually went home one day and I brainstormed 10 different ways that I could impact the way that people are eating and what they're eating and how many kind of whole foods they're eating. KS: And it ranged everything from going and getting my master's in public health to starting a natural food company that would help change what people are eating. So it was the natural food company route that I went. And so the whole idea for simple mills is starting this food company that makes all of these kind of traditional things that you love eating, that are convenient to eat, that are tasty to eat. And instead of making them out of tons of carbs and sugar and processed ingredients and things you can't pronounce, making them out of things that you actually want to be eating more of like almonds or coconut flour or sunflower seeds, but putting it in that same like recognizable shape, texture, flavor, and my thought with that and, and I think what I've seen over the past five years is that by doing that, you're able to slowly change what people are eating so that it's not just, okay, you have to go and follow this, like this polarized diet of gluten free or Paleo, which our products are, but instead it's, here's a product that here's a way to like, eat, eat really great food without necessarily sacrificing the convenience or the flavor or what have you. KS: So yeah, I mean the big goal, it's changing what people eat and changing the expectation of what people eat. The second thing that I'll say about that is that when you change what's out there, and I, I really didn't, I kind of underestimated this in the beginning, but when you change what's out there, you change the average of what's out there. So when you look at the shelf now in Whole Foods or in Jewel or Target or Kroger, which are all places where we're sold. We've raised the average of what's sitting on the shelf and so what that means is that other players who are sitting on the shelf also have to change their game and so if consumers come to expect, OK, maybe this shouldn't have so much sugar or maybe this shouldn't have as many processed ingredients then other players will change what they're doing as well. And so I like to say that a rising tide raises all boats and so part of our mission is not just changing what our consumers eat, but changing what our competitors’ consumers eat as well. KG: Thinking back to when you first had the idea for Simple Mills in 2013, now we're super used to seeing things in the grocery store aisles like ice cream alternatives or dairy free milk or gluten free everything, but that wasn't the case when you first had the idea for Simple Mills. Was that an advantage or a disadvantage being kind of a outlier in the food industry when you started? KS: I think that we came in at just the right time. I think that if we had come in three years earlier, it might've been too early because what really happened and the reason why we, why we see that today is there's this general awakening that's happening, that's happened with me personally and it has happened with a lot of our consumers, which is that people are realizing that the food that they eat affects how they feel and what they're able to do on a daily basis, and this has been in large part enabled by influencers, by people talking online about their diets. This has been kind of something that's come about at the same time that kind of this entire influencer community and people researching, well, what if I, what if I tried this, what happens? And and researching it for themselves versus relying solely on the advice of a healthcare practitioner. And so I think that without that trend, next to kind of putting our products on the shelf, I'm not sure that it would have taken quite as quickly, but now that people are making that association, it's been. It's been a lot easier. KG: Let's go back a little bit. You said that when you brainstormed these 10 ideas that you could change the way people eat, one of them was creating a natural foods company. Were you into baking and cooking growing up, or was this just more of a whim that you decided to act on? KS: Yeah, no, I was not into, I was not into baking growing up, which I feel like is a very unpopular answer to that question. But it, it really goes back to the determination and the belief that this needed to happen. I was and will do whatever it takes to, to make this idea possible and I think that that's one of the things that, you know, you talk about goals, or starting businesses. I think that there's just a lot of determination and discipline required to make any one of these ideas of success and so it takes doing the things that you did you don't necessarily want to be doing. So like for example, I, I'm an introvert. You wouldn't guess it, but I'm an introvert and I, I hate cold calling. It is like the worst, worst, worst thing to do in my mind. KG: I got chills just hearing you say that I'm the same way. It sounds like the worst punishment somebody could give me. KS: Yeah, exactly. And so like for the first year I actually had to assign an entire day per week to cold calling and I think that, not to say that baking was like cold calling, but it wasn't a passion of mine but I probably went through 90 different recipes just to get the first iterations that tasted really awesome on the market. You do what it takes to make it work. KG: When you had the idea for Simple Mills, you were working in consulting and that had been your background for awhile. How did that help drive you and creating simple mills? What traits could you develop? What skills have you learned that helped you when you decided to get this business off the ground from a side hustle to a full time job? KS: Yeah, so I don't think I would be here today or at least be where we are today without my background in consulting. It was just such a fantastic place to start my career. So I started as a management consultant at Deloitte and was there for for three years. I think one, it taught me a lot about hard work, analytics, what it like, just general professionalism, like basic skills that it takes to be a successful CEO, honestly. There’s—I will say that there's other things that I've had to learn on the other side in order to scale past the first point in the business, but I think consulting really got me through the first stages where it helped me attract investors because I had my stuff together. I could develop a model, I could figure out what my cost of goods was. I could figure out a supply chain. So it gave me a lot of the business, the business fundamentals, KG: And at some point you decided to go back to business school to learn the things beyond the fundamentals. What was it like running a company and going to business school at the same time? KS: Yeah. So I, about a year into the business I—well I guess we were just starting in our first stores. Yeah. So when we were starting in our first stores, I started at Chicago Booth to get my MBA and it was—I started out as a full time student and the business just kept getting busier and busier and busier. I think what became really important was having a clear prioritization of what mattered. So I think that a lot of people go to business school and say like, I'm going to start a business while I'm in business school and they try to do the business 100 percent, and they tried to do school 100 percent, and the social component 100 percent. For me it was the business gets number one period, and then anything else on the side that's, that's good too. KG: It’s a bonus. KS: It’s a bonus and so I went from taking three classes to two classes to one class and then that last class I think I attended about half of the actual classes themselves. Yeah, and it's not to say the program’s not amazing because I learned so much in that short time I was there, but I, I really had to focus on the business, and so when it came to, I need to make a customer phone call versus go to class, it was customer phone call every time KG: Last year. You got a really exciting honor in 2017 when you were named to the Forbes 30 under 30 list, what was it like getting that phone call? KS: It was really incredible. I just couldn't believe it. A lot of things. A lot of things that in building the business are very humbling because it at the end of the day, like I think that if I had looked at somebody on the Forbes 30 under 30 list five to 10 years ago, I would've thought, oh my gosh, and put that person up on a pedestal. But I think through this process you, you learn that the CEOs, the entrepreneurs, the people on that list were all just real people. KG: How did things change for you and Simple Mills after that award? KS: It made it a little bit easier to get press, but I don't think that there’s—this goes back to this other theory that I don't think there's any one thing that makes breaks a business. It's really easy to look at things and say, oh my gosh, this is going to be the thing that makes it. Or this is going to be the thing that that breaks it for us. And that actually creates a lot of stress as well but I think that businesses are made by a million tiny good decisions and just netting out on the positive end of that. So you'll still make bad decisions, you'll still have bad things that happen or things that you at least perceived to be bad things, but there's a bunch of tiny little things have to go right. KG: You were telling us before we actually started recording that you just got back from a really exciting trip to Israel. Can you tell us a little bit more about that? KS: Yeah, yeah. So I was out there with 85 Forbes 30 under 30 I guess, winners from the past couple of years. We were there with an organization called Schusterman and we were traveling around all over, all over Israel. We went to the Syrian border, the Jordan border. We spent a lot of time in Jerusalem and we had a, we actually had a guide the entire, the entire trip who was telling us all about the complexity of the region and, and just, it's really stunning because I think that it's really easy to look on the conflict in the Middle East and, and kind of simplify it from over here and also to say like, oh, that's just, you know, they have conflict, we don't have conflict. We're kind of in a way, we kind of look at it as we're above that. We're like, oh no, we know better than to have that level of conflict in our country. KS: But I think what, what really there were two key realizations for me on that trip. The first of which is there was that what we have today we can take for granted really easily and things can change The other thing that I really, that I really thought coming out of that trip was just how not simple conflict is. And for example, in the Middle East, like how much the conflict is connected to personal identity and, and even like the soil itself and the land itself. And it's just very easy to say like, oh yeah, all it takes us like a peace treaty and somebody can just come in and work that out. KS: But even as we're establishing the embassy in Jerusalem and it's causing this uprising, it you can see just how not simple it is, is it's not as simple as drawing lines and boundaries. But just really such a phenomenal trip I was sharing that they Schusterman actually pays for the entire trip, which is just stunning. The entire trip we were sitting there asking, so what is the catch? What is the catch? Why? Why do you bring us out here? And they said really for two reasons, one, for you to understand the complexity and for that complexity to color the decisions that you make, the degree to which you impact the world and, and, and the second is you guys are all poised to make a really positive impact on the world. And with great power comes great responsibility and, and that’s—so go out and do amazing things. KG: No pressure. KS: Yeah, no pressure. KG: Well, with Simple Mills though you had already had a big vision in mind to change the way people eat. Was it interesting to think about how you can change people's lives outside of your products? KS: Yeah, I think for, I think for me, my lifelong mission has always been to to leave the world in a better place than I found it with everything that I do. I think for right now I see so much potential for Simple Mills to impact the food space, which I consider extremely important. It impacts everything that—how we feel, our personal relationships. For example, if you're more anxious, like how, how that's going to impact your personal relationships, your personal happiness. I think that there's so much there and there's also so much left for us to bite off and chew. So first of all going to focus on that. That's my disclaimer, but I, I do plan on doing more things with my life than, than just Simple Mills as well. There are a lot of, a lot of problems in the world and a lot of problems to solve and I think that if you have like the energy and the, I guess like the resources to impact the world, you absolutely should and really take advantage of all of the people who have invested in you that this brings up another point which is there's this experiment out there where they put two people in a room to play Monopoly and they give one person more money and another person less money and we'll just use money as a, as an analogy for now, but more resources and they have them play the game. KS: And inevitably the person who had more money coming into the game wins the game. And they always ask the person who won, OK, so why did you win? And they always point back to, oh, I made this particularly great decision here. Or I got really lucky with that roll of the dice. But they never point back to the fact that they started the game with more resources. And so the interesting lesson there is that we kind of overlook the role that, that resources play in how people arrive at their, at their destinations, and so particularly if you're sitting in a place where you've had a lot of people who have invested in your education, who have invested in, in your learning, you have that much more responsibility to use those resources and, and to kind of bring other people up and along and, and invest in other people. KG: Who invested in you early on? Not moneywise necessarily, but time and energy and support? KS: Oh my gosh, there's been so many people that it's like you can look back to so many people who have, who have changed the way that you operate. I mean, and even started certainly with, with your parents putting in just like so much time and effort. I do remember this point in time when I was in high school and my mom looked at me and she said, You're gonna do, you're gonna do great things. And I think that was actually a self fulfilling prophecy. I don't think necessarily that I was going to do great things. But because she believed in me and believed that I was going to, that I felt like I had to. So I think that's one. I mean I also, I think more recently another, another one has been one of my mentors. So I met my professional coach, I guess I was about a year into the business and we instantly clicked and I realized that she just had such a phenomenal understanding of people and how people operate. KS: And I said, I have to work with you. I, I, I don't understand these things very well. Let's, let's work more on this. And so since then she's actually been my coach and now is a coach for our entire 35 person team. But I think I think working with her, and we can talk more about this, but I think working with her has really helped develop me into a leader who can lead a team of 35 versus lead a team of four to five. But again, there's just been so many people throughout my history that I can look back on. KG: I'm really curious about this professional coach, especially since you have a background in management consulting. Were you just super aware that this existed and this was something you could benefit from or how did you find out about her even? KS: Yeah. I had no idea that that really existed and actually at the time she wasn't even a leadership coach. She was an operations consultant. Today she has a, a very large leadership consulting practice that works for a number of entrepreneurs here in Chicago and other cities. But I think there is—I had a business school professor who said that being an entrepreneur is one of the most downwardly mobile professionals that are out there. KG: That's encouraging. KS: Very encouraging. So I mean I think going in knowing that is actually really helpful because it helps you realize that you shouldn't take being the CEO of a company for granted, that just because you started the company doesn't mean that you stay in that role, and that many, many entrepreneurs don't make it because you have to grow super quickly. So where if you were in a large corporation going from managing, you know, two people to 10 people to 20 people to, you know, maybe 100 people might take a number of a number of years and career moves. Like that might be a 10 year shift. You're making those shifts super quickly as an entrepreneur and so you need something to help accelerate that learning or you just might not make it, and so when I met her I realized that she had the capacity to accelerate my learning and so that's why I started working with her. KG: You're getting a crash course. Sounds like. KS: Yeah, there's something to be said for. I still believe that most things that you learn, you learn off of your mistakes, but there's something to be said for learning off the first time you make the mistake versus the fifth time. KG: Well we spend a lot of time on this podcast talking about your successes and goals you've achieved, but what was the time when you failed? KS: I think for me, the greatest failures in this business have been failures as a leader. They've been places where I've come home at the end of the day and thought, you shouldn't have said that or you shouldn't have said that that way. And knowing too that you impacted somebody else's day. Those are the toughest places because you can't really take it back. You can only move forward. There’s been times where you know, you call somebody out in a meeting and and you know that that wasn't the best way to handle it, for example, and the only thing that you can do is learn from it and say there's a reason why this happened and I'm not gonna do that again, or I won't do it this way again, and then you move forward. KG: You've also mentioned being an introvert just even on this podcast, yet you traveled with a bunch of strangers to Israel and you're the CEO of a 35 person company. What do you do to sort of give yourself that time to recharge when you're spending all of your day in meetings, talking to people like me talking to the press, all of that. KS: Yeah. I think the. I think the recharging is super important and actually a number of my entrepreneur friends are also introverts. It's quite funny that we were like this class of, I’m sure there are extroverts out there too, but we’re this class of people who do spend their entire days talking yet their preference is not to. I think first of all, making sure that you allocate sufficient time for thinking and so I have a couple things that I do to make sure that I fit that in. The first is I love flying and I love sitting on a plane because no one, no one talks to me while I'm sitting on a plane. There's nothing to interrupt me. There's no phone calls, there’s text messages. I can sit there and I can stare out the window and think about what problems we need to solve or how to solve those problems. KS: Another is taking decently frequent but short vacation. I like to think that vacation if done right, is actually something that helps your job versus versus hinders it. And so I'll take for example, a long weekend to somewhere in Arizona where I'll go hiking. I'll spend time reading, reading books that helped develop me professionally and personally and develop the way that I, the way that I see the world. And and so then as a result of that, you can kind of create faster learning cycles so that you can learn from the things that you're doing a lot faster. So I might take a particular concept. So for example, one concept that has required a lot of continuous work on my part is this idea that perfectionism is not on the excellence scale. So … KG: I need hear more about this. What does that mean? KS: It's that, it's basically that if you create a spectrum of from not excellent to excellent, perfectionism doesn't exist on there. And I think growing up in consulting or even a lot of corporations believe this, there's like this belief of no defects. So if you make a mistake, it's not OK. And so then you live your life trying not to make mistakes versus trying things out. And what happens when you try things out is, is you do make mistakes and, and it's OK sometimes or a lot of times you learn from those mistakes. And or you figured you figured out something that you wouldn't otherwise instead of spending your time optimizing something that doesn't need to be optimized. And, but this is like, this is like a lifelong skill, this isn't a OK, just get the concept and all of a sudden it's in place, it's that you have to try it, work on it, go back, relearn it, and then continue to iterate on the concept for, to, to really get it. And so then I'll read books on this topic and then go into real life, try to apply it, and then next time I go on vacation, read more books on it and recognize where I, where I haven't quite lived up to it and figure out ways to do it better moving forward. KG: That idea of embracing mistakes as learning opportunities, is that something that trickles down to your team at Simple Mills? KS: Yeah. We've actually, we've actually done entire trainings on perfectionism, but part of, I mean, part of it there is we are a very, we’re a very high achieving group and so we actually did, we did studies on, on our levels of perfectionism and our levels of perfectionism are actually higher than the doctors going through Harvard Medical School. KG: Wow. KS: So that's a problem. KG: Oh my gosh. KS: Again, not on the excellence scale. KG: Wow, that is crazy. KS: Yeah, and so we've had to. We've put a number of things in place to say, OK, it's OK to skin your knees. It's OK to make mistakes. It's OK to come out and say something, even if it's even if it's in the end, not right. And so really embracing, embracing failure and saying that's OK, or embracing it when somebody goes out on a limb and and not quickly shooting down the idea or saying no and making it a little bit more comfortable to be wrong. KG: All right, let's end with the other question that we ask everybody else who comes on this podcast. What is a big goal you have for the future? Why is it important to you and how do you think you'll get there? KS: So I, I, I am so incredibly passionate about, about changing the way that people eat. It's, it is a huge mission for, for me and and Simple Mills. I think that there's still so much that needs to be done here. We've, we've made such great progress in the past five years, so we're in, we’re in about 13,000 stores. We are the largest natural baking mix brand, the second largest natural cracker brand, which is, which is really neat to see, but I feel like we're just at the tip of the iceberg. There's so much more that we can be doing in terms of brand awareness and getting our products out there, but even more than that, I think there is so much more that we can be doing to to really change the way that people are eating and helping more people eat simple ingredient real food and so while I won't completely share exactly how we're going to get there, I think my mission is really democratizing real food and there's a lot more up our sleeve. KG: What do you mean by real food? KS: Making it something that that's accessible to a lot more people. KG: In terms of accessible at grocery stores, price points, just it being there in general, all of the above? KS: All of the above. Making it easy, making it so that having real food in your pantry is a, is a common occurrence. KG: Well, we can't wait to see how you get there. I know we'll be keeping our eyes on you for the next few years to come and beyond. So Katlin, thank you so much for being on #WeGotGoals today. KS: Thank you for having me. CK: Hey, goal getters. Cindy Kuzma, co-host and producer here just popping in to let you know that we are about to play another one of your goals. That's right. A goal that was set and crushed by one of you, our listeners. This one was recorded during one of our live sessions at the Hotel Moxy and we also recorded a few more at the Michelob Ultra Fitness Festival at the end of SweatWorkingWeek earlier this month. Start thinking about whether you have a goal you'd like to share with us too. Soon, we’re going to have a way for you to send in your goals and you could appear right here on this very podcast. In the meantime, thank you so much for listening and here's our next real life goal-getter. CK: Tell me your name again. J: My name’s Jose. CK: Jose, it's good to meet you, Jose. Jose from Chicago? J: Yeah. Jose from Chicago. CK Okay. Tell us, Jose, either about a big goal that you reached and how you got there or about a big goal you have for the future, one or the other. J: Um, so I guess the biggest goal that I have reached already was I joined the military when I was 18 airborne infantry and I made it back in one piece. So that was a good goal to have. CK: Yeah. Yeah. So where did you, where did you go? J: Um, I was stationed in Anchorage, Alaska and I deployed to Iraq for 15 months and I was in Afghanistan for a year. CK: Oh my gosh. Wow. So how did you do that? You know, I mean, obviously some of it is just being in the right place at the right time, but um, you know, what do you think were some of the things that lead to you having a successful military career? J: Oh, definitely. Um, the team that I was on in the people that I worked with. Working in a team and being able to get each other's backs like that definitely protecting each other when you're not looking, um, helps for survival and also just all the training that we did, like constantly training all the time, all the time for every possible scenario that you could possibly imagine. CK: Wow. And does that training and that experience, I mean as, how long have you been back now? J: Um, I got out in 2010 like late 2010. Yeah. And I've had actually, now that I think about it, every job I've had outside of the military has been like in the service industry, like restaurant or a bartender or a or something like that. So like working in some sort of team capacity I guess. CK: Yeah, and you have to think on your feet and be prepared for anything and react to what's going on around you. So I'm sure that training serves you really well. J: Yeah. CK: Well thank you for your service, first of all, and congratulations on being here and, and on your new job here at the Hote Moxie, right? J: For sure. Yeah. Yeah. CK: Well thank you so much for sharing your goal with us. Really appreciate it. CK: This podcast is produced by me, Cindy Kuzma, and it's another thing that's better with friends, so please share it with yours. You can subscribe wherever you get your podcasts and while you're there, if you could leave us a rating or a review, we would really appreciate it. Special thanks to J. Mano for our theme music; to our guest this week, Katlin Smith; and to Tech Nexus for the recording studio.

节目组: The World Says 世界说 节目名称: The Emoji开头曲 Stay V: Hello everybody, welcome to the worls says from the VOE foreign languages radio station.I'm Vincent.F: Hello everyone，I'm Francis.J: And I'm Jotta. We' ll be discussing the rise of those little graphics we call emojis and emoticons. 插曲1 Stay V: You know, I think emojis are a vital tool for communication. And actually, they' re not that new, either.F: Oh really? V: Well, that' s the perfect opportunity to ask you a question. When was the first emoticon used？J: Eh.... maybe around 1982？V: Well, in fact, a witty speech Abraham Lincoln reprinted in a newspaper as far back as 1862 included a semi colon with a close brackets.F: Like a winking face?V: Exactly. Though people think this was sadly just a typographical error–or what we normally call a typo.J: A typo–a spelling mistake made when typing too fast or carelessly.The official birth of emoticons is usually given as 1982, when a US professor instructed his students to use smiley faces to indicate jokes - in a digital communication.V: So they're over 30 years old. Maybe I should start using them. Let's round up with another look at today's words. You know, I think we should clear one thing up before we go any further: what's the difference between an emoticon and an emoji?J: Good point. Emoticons came first. They' re the images made using normal keys on a keyboard–usually punctuation, letters and numbers. F:例如一个冒号加一个括号组合起来就是。。。V: A smiley face. Something you use in way too many of your emails!J: Well, thanks! Whereas an emoji is something completely different. It's an actual image. It could be a simple, yellow, smiley face; or something like a Jcing lady; or even a bowl of noodles… 插曲 2 Something about you V: Ah yes, all those little images we have in our phones. But you'll have to convince me–why do people use them so much?J: Well, I've read a book called The Emoji Code, and book tells that it enable us to express emotion and empathy in digital communication. Increasingly, what we're finding is that digital communication is taking over from certain aspects of face-to-face interaction. In the UK today, for example, adults spend 22 hours online on average each week. V: So after your introducing, I can tell one of the reasons emojis are so interesting is that they really do enable us to express our emotional selves much more effectively. And you used a very useful word - empathy. It means the ability to show you understand someone else' s feelings'. OK–tell me more Jotta.J: Yes–adding an emoticon can show you understand and express emotion, and show empathy–more clearly. In digital communication we lack the visual signals we have in face-to-face interaction–as Francis says.V: Interaction, meaning when people or things communicate with each other. We can also interact with things like machines, computers and social media.J: Yes, Professor Evans says 60% of information when we're talking to each other comes from non-verbal cues.V: Wow, that's a lot. A cue is a signal that you need to do something.J: For example, an actor goes on stage after their cue.F:演员按指令上台。V: And non-verbal means 'without using spoken language. So, here in the studio there are lots of other non-verbal signals about how we're feeling - non-verbal cues. For example my facial expression, my body language, the look in my eyes J: There's a glint of rage in there somewhere, V. Ok, so let's apply this to digital communication. Imagine I sent you a text saying I hit my finger with a hammer–how would you respond?V: Well, it depends. Did you hurt yourself badly?J: If I followed it with a sad face emoji, then…?V: Then I guess I' d know you hurt yourself. Poor you.J: But if I followed it with a laughing emoji–the one with the tears coming out because I' m laughing so much?V: Then I' d probably reply saying how stupid and clumsy you are!J: Exactly–without adding the emoji–it' s hard to know my emotional state. The emoji is the non-verbal cue–like my facial expression.V: By the way, is there an emoji meaning clumsy? Clumsy, means 'physically awkward'–someone who's clumsy falls over a lot and drops things.Anyway, you were saying emoticons aren't as new as I think?J: Sure. The first word we had was empathy. Do you have a lot of empathy, V?V: Yes, I think I'm quite good at understanding other people's feelings. My friends tell me that, anyway! It's important to empathise with your colleagues too.J: That's not what I saw in your eyes! Yes, empathy is an important part of all human interaction.V: Nicely done. If two people interact, it means 'they communicate with each other and react to each other'. It's a pretty broad term.J: We could also talk about how the way children interact with the internet.V: Way too much! Next up, we had non-verbal, meaning ‘without spoken language'. When I first travelled to Poland, I used a lot of non-verbal communication to get my message across. Hand movements, counting with fingers, things like that. Next word, J?J: Next word… that is my cue to say the next word–which is in fact–cue. A cue is a signal to do something. A commander could give his officer a cue to attack. Or I could give you a cue to… sing a song?V: No thanks. I'll stick with defining words, thank you. Like clumsy–meaning ‘physically awkward'. I'd have to say J, you're a sporty guy, a talented footballer - you're not clumsy at all. J: That's what I thought until I broke my leg–after a clumsy opponent ran into me…V: Ouch. Finally–we had type. No hang on, that's not right. It should say typo. A typo is a mistake in a written document, or a digital file or message.J: Always check your scripts for typos before reading them, Vincent. And, that's the end of today's show, see you next time.F:如果你喜欢我们的节目欢迎关注VOE外语广播电台的公众微信号VOE radio 和 VOE外语广播电台的新浪微博，那里有我们往期的作品。我们下期再见。V：感谢制作苏鑫 结束曲 Something about you 节目监制：周宸聿编辑：杨晏直 夏茂航 朱子业播音：杨晏直 夏茂航 朱子业制作：苏鑫

Our next interview from the CPT&CE is with creator/artist/fabricator Jordan Patton! Jordan, along with his friend Aaron Ferguson, is the creator of the long anticipated DeadNecks series — what can only be compared to a live-action cartoon series. Instead of attempting to livestream this year's , decided to hit up a few tables and bother people for interviews! Pay close attention, kids. He's really terrible at this, but had some great interviews! Listen to the audio above and read the transcript lovingly produced by ! R: We're here at the Classic Plastics Toy and Comic Expo with Jordan Patton. Jordan is the creator of DeadNecks and we interviewed him last year. We had the table and we did the live YouTube that wasn't so live and...I'll tell you man, your video, as far as that goes on our YouTube channel, has done the best! So that's very awesome. So how have you been man? J: I've been pretty good, just staying busy. Working on some new stuff towards our first episode, but uh...Yeah other than that I just kind of hide out in my basement for five days a week and work on stuff for our episode. (laugh) R: That's awesome. I've seen the set design and you've come up, it looks like, with a couple of new characters which we'll get to here in a minute. But first I want to know – how is the show going? I mean have you been picked up or anything yet? Or are you still just working through everything and working the lines, the less fun stuff, like getting networking and all that? J: Well right now we're kind of in a build out process for the first episode, so I've got to create all the special effects and everything. We've got the story written, I need to storyboard it. But right now I'm working on making all the props, the makeups, the masks, animatronics, things like that, for our first episode so I'm giving myself about a six to eight month build-out period. Then we're going to start filming. R: Awesome. So with something that's episodic like this, how durable – I mean, you do the work. You and Aaron, right? - and you have a small crew basically, don't you? J: Very small crew. There's about three or four of us that are willing to work on it and put our own time in, and our own money, to try and get it going further. But we're all pretty dedicated to it and once we get all the effects done and everything, start filming, it should only take us about two or three months to actually film our episode. After the episode is done we're kind of hoping that we can pitch it around and see what people feel about it and maybe we can get an even bigger crew to help with future episodes? R: Awesome. So the line I was going on there, to continue that, is with it being an episodic thing do you really have to build the props and the masks to be super durable so you don't have to do  as much doctoring throughout the episodes? J: Yeah so we actually encountered that with some of the things that we had for our trailer. So the guns were actually made out of just insulation foam, I carved those out,  but during one of our scenes we actually snapped it in half and I actually had to go in and repair it and everything. So in the future we need to make things a little more durable. I'm actually going to be making a mold of that so I can make it latex and foam like a lot of these that way it can bend, flex around and not break or anything. So yeah, with that it needs to be very durable. I mean we're going to have a lot of practical effects like throw-up gags, things like that. A lot of blood splatter. It's essentially going to be like a GWAR show. (laugh) R: (laugh) Right. So do you have, with 3D printing really finding a whole lot of traction in the last couple of years, do you guys do any 3D printing on top of that to help augment? Or do you have access to one, or is it something you'd like to work with in the future? J: Right now everything is kind of done by hand. The shop that I work at, it's a place called Tech Shop; we actually have several 3D printers there. But I haven't utilized them for any of this process yet. I have been looking into resin 3D printing so if I wanted to produce smaller characters and things like that, merch to sell, I would definitely be doing that with the resin SLA printers because you don't get any of the striations in any of your prints so it comes out fairly clean. So I've been looking into doing that so I can get some more products out there for like cool merchandise. R: Awesome. How has the con treated you this year so far? J: It's been pretty cool. I mean I've seen a lot of familiar faces from last year so it's always good to recognize people and have them recognize you and just kind of chit-chat back and forth about what everyone's been into and everything. So yeah, it's been great so far. R: So you also said you're working at a shop? What was the shop's name again? J: A place called “Tech Shop”. It's kind of like, essentially like the YMCA except for without workout equipment. We've got like wood shop, welders, water jet cutters, laser cutters, 3D printers, things like that. R: Oh my God that sounds so freaking awesome. J: Yeah I used to live there like 24-7. Just would never leave the place other than to go sleep at home. (laugh) R: I understand man. I can't even imagine the amount of creative juices flowing in a place like that. J: Yeah there was like 500 or so members there, and everyone does something different so you never know what kind of stuff you're going to see coming out of there. You got all kinds of artists, furniture makers, welders, machinists, it's crazy! People are making their own robots in there. R: That's awesome! So, I mean, doing something like that also affords you great networking opportunities I imagine? J: Without a doubt. Working there has really brought a lot of opportunities to me just with the flow of people that come in there and the people that know about the place. I mean it's helped me grow in my own skill sets as well. Like I didn't know how to weld before going in there and working there. But now I've got welding experience, I've got a lot of various experiences from all the different machinery that's in there and it's really helped me to be able to create a lot of stuff for the show. R: That's awesome. So do we have any new characters that you're bringing to DeadNecks here today? J: Right now we've got one new character. Just finished him up about a day or two ago. His name is “Boo Hoo”; he's like a little patchwork ghost character. He's not actually going to be in the first episode but he's probably going to be making an appearance in the second episode for sure. [caption id="attachment_2095" align="aligncenter" width="400"] Boo Hoo, picture courtesy of Laura Gant[/caption] R: Gotcha, awesome. So what are some of the other characters, if we want to just kinda roll through the table here and even though I don't have – I'll take a picture to post along with it and we'll let them know. So let's start off from the left to the right...which will be the right to left since we're behind the table (laugh) J: (laugh) Right on. Well over here we've got “Soft Serve Merve”, so it's kind of like a larger sculpt I did for that. He's actually going to be used in the first episode. So I mean if you think back to the Ren and Stimpy cartoons whenever it would be hyper-close-ups and you would see all the disgusting details, that's essentially what these larger masks here are for, are for scenes like that in the first episode. So yeah, I tried to sculpt that as detailed as possible just so it would read disgusting whenever you go for that hyper-zoom in the actual skit itself. Below him is the “Birthday Boy”, it's actually one of Merve's victims. So Merve kidnaps children and turns them into strange food related creatures. (laugh) [caption id="attachment_2097" align="aligncenter" width="400"] Birthday Boy, photo courtesy of Laura Gant[/caption] Above him we got “Ma Slackjaw” with her beer can curlers in her hair. She enjoys sleeping, eating, and smoking a lot out of the hole in her neck. (laugh) And then down there we got “Boo Hoo”, the new character. He's actually secretly one of Merve’s victims as well. He kind of lurks about Merve’s whereabouts and kinda haunts the place. R: Oh man, spoilers! (laugh) J: Yeah, a look into the future! Then above that we've got “Pete”, he's more or less the main character of the show. I mean he's just like a little dopey character here. The rest of his family thinks he's completely stupid and useless just because he can't really talk and is always wearing this pumpkin on his head to disguise his horrific face that's underneath of it. Pete's actually really smart and he has a lot of personality but his family doesn't see it because they're all pretty stupid themselves. (laugh) And then beside that we've got “Ted Slackjaw”, Pete's uncle. So the two different versions here: That's the original Ted as well as the hyper-extended face Ted. So the hyper-extended face will also be used in our first episode as well as one of those close-up shots. R: Awesome man! So how many different iterations do you build, different masks, or - J: For one character? Yeah, for one character it sometimes depends on what you can actually do with your face. Because, like, for some of them I do makeups to where you can move your face, but you can only get so much expression out of it. So if I want like a hyper expression like what you see in a lot of cartoons you really just have to sculpt an entire new piece just to really give it that exaggerated look. With DeadNecks we really want it to look and feel like a cartoon. To do the impossible, essentially, with facial structure, bone structure, all that. So to do that you kind of have to break down and do several sculpts for one character just to get that one effect. But I think it'll really be worth it in the end to actually see a living cartoon, essentially. R: When you're doing something like that, do you think about any way to have some sort of modular ability to do something like that? You know where you could maybe detach a jaw only and be able to do something like that? J: Yeah. Well with that you start getting more into the animatronic side of things which is really interesting and you can actually do a lot with those because with those you actually have a skin that goes over top of an under skull. So it kind of mimics the anatomy of an actual person so you can actually get a lot of movement with that. But with that you just got to think about how it's going to work. You've got to kinda deconstruct how something's going to move and kinda reverse engineer it so you can figure out how you need to build it. So I mean that's very interesting and it takes a little bit more time but it's got a really cool effect in the end just because you've got literally an under skull, some skin, movable eyes, things like that. So you can really play around with a lot of things that you can't actually do with a human face. R: Gotcha, awesome. Alright well Jordan, where can people find you if they want to find you guys. Do we have any idea where we'd be looking at watching the first episode? J: So you can find us on , Instagram “DeadNecks”. I would say we're probably looking at getting our first episode out a little over a year from now. Like I said we're in the build out process right now and it should only take us about two or three months after that to get it filmed and then put it into post and get it all edited together. So I would say about a year, year and half from now you should be looking at an episode. We're going to drop spoilers along the way just to keep people entertained and interested along the way. But you should be able to see it, I'd say in a year and a half from now. R: Awesome man, I'll hold you to that. (both laugh) J: Right on. R: Thanks a lot Jordan! J: Yeah, thank you!

Brad Post, Create the Movement: You’re joining us for our next edition of Create the Movement podcast. My name is Brad Post. And I’m here with Josh Rich. Josh Rich, Create the Movement: Hello everyone. Hello. B: Josh, how are you doing? J: Doing good, Brad. How are you? B: I’m doing well. This is our Marketing Tips, and today we’re going to be talking about marketing budgets for small businesses. Right? J: Yeah, so one of the things we kind of run into a lot when we talk with a new client, we ask them, “What’s your budget?” And we always, not always, but a lot of the times we get the response, “We don’t have one.” B: Right. J: Or, “What do you suggest?” Or, “We don’t really have a defined budget.” So, since the new year is kind of approaching, we thought it would be a good idea to kind of to give some tips on how to create a marketing budget. Because it is important to know how much you’re willing to spend, and how much you should be spending on your budget for marketing. B: Yeah. J: So, the first step that you really want to make sure, just whenever you’re focusing on this, is to be defined. B: Be defined? J: Be defined. Yeah. Don’t have some sort of vague number. Write it down. Make it a part of your company’s budget every year, or every month. However, you want to it. So, that way you know how much you can spend, and how much you should be spending. There’s kind of five questions you should ask yourself when you’re trying to set this. B: Okay. J: The first one is what do you need? B: What do you need? J: What do you need? So, that’s going to depend a lot on your industry, a lot on your company. So, do you need leads? Do you need sales? Do you need just brand exposure? Do you need traffic to your website? So, sit down and think about what you need. Because like I said, it’s really going to influence how much you’re going to spend, and where you’re going to spend it too. B: Most of the time they might say, “All of the above.” J: Right. Exactly. Like I said – be defined. You have to pick one. And your need will most likely change over the course of a year or so. When you’re starting out on setting that budget - be defined and pick one. B: Okay. J: The second one is figure out what you’re currently paying. B: Okay. J: For some people this could be zero. But for some people, they might just kind of, if they’ve never really thought about it, they might just spend a $1000 here, a $1000 there, and not really know where it’s going, or what it’s doing, or how to track it, or that kind of stuff. Just whenever they get an email, or some salesman calls them, they’ll sign up for it, but they’re not really keeping track of it. Not really sticking to any sort of set plan. B: Right. J: And so, go back and see what you did last year. Figure that out. Because that will kind of give you a good starting point. Once you have that number, you want to try to assess how that worked out for you. So, figure out your cost per lead, your cost per sale, or whatever metric you want to use. Find a way to evaluate how well it worked. B:  Okay. J: And then figure out if that’s something you’re comfortable with, or not. So then, the next step is to think about how fast you want to grow. Because a lot of us, I mean, as much as we would love to have 10 clients call us a day, and say, “Hey, we want new websites, and the most expensive SEO package.” B: Right. J: We’d be in trouble if that happened. B: Yes! J: We’d simply cannot scale that fast. You know? And so, try to figure that out. And if you can scale that fast, and you want to, then be really aggressive in your marketing budget. If you can’t afford to scale very fast, it’s going to be slow growth, then you need to back off, and make it more of a less aggressive approach. B: Okay. Good. J: You also want to figure out too, like, kind of going back to that second question, once you figure out your previous year’s cost per lead or cost per whatever, try to figure out what yo...