POPULARITY
10 episodes with jeff as
4 episodes with jeff as
2 episodes with jeff as
Without question, the last several months have accelerated ecommerce adoption and drastically changed consumer behavior. The entire sales lifecycle from finding a prospect to closing the deal has been turned upside down. Now two key obstacles lie in the path of ecommerce leaders… The first is the more obvious, more discussed problem: How do you operationally and technically need to change to meet your customers' evolving needs? The second key obstacle is not as often addressed, but is equally as important: How do you then communicate to your customers that even in these changing times, you are equipped and ready to meet their new needs? The binding and laminating business doesn’t sound like it would be ripe with insights into answers to both of these questions, but Jeff McRitchie, the VP of eCommerce at Spiral, is here to prove that assumption wrong. Jeff has nearly two decades of experience in the ecommerce and digital space. Just last year, his own company, MyBinding.com, was acquired by Spiral, where he now helps lead ecommerce operations. On this episode of Up Next in Commerce, Jeff explains what it has been like merging his ecommerce business with a more traditional binding company. He shares some of the challenges he faced along the way, and what methods and strategies he’s leaned into to find success. Jeff also discusses tips for building out a winning SEO and content strategy, and how ecommerce is playing a larger role across the entire business, including in customer acquisition and content marketing. Main Takeaways: The Merge: When a primarily ecommerce company merges with a larger more traditional business, there are a lot of balls in the air to create a cohesive and efficient system. Most of the adjustments have to be made on the side of the acquiring company, which needs to learn how to compete in a digital marketplace. That means that education has to be a priority both internally and externally. Use Their Words: Every industry has jargon and industry-speak. It’s easy to fall into the trap of using that language throughout your platforms and channels. Instead, you have to meet customers where they are with their own language, and use the words and phrases they use. This will ensure that your customers feel like you are speaking directly to them and it also helps create more longtail SEO opportunities. Content For Now that Pays Off Later: Some of the most-viewed content you create might be consumed after a customer makes a purchase. On the surface, that might make it seem like content-creation is not a good customer acquisition strategy. On the contrary, it’s actually a critical long-term strategy in the sense that good, useful content is critical for brand awareness and building trust, which customers will remember when they need to buy in the future. For an in-depth look at this episode, check out the full transcript below. Quotes have been edited for clarity and length. --- Up Next in Commerce is brought to you by Salesforce Commerce Cloud. Respond quickly to changing customer needs with flexible Ecommerce connected to marketing, sales, and service. Deliver intelligent commerce experiences your customers can trust, across every channel. Together, we’re ready for what’s next in commerce. Learn more at salesforce.com/commerce --- Transcript: Stephanie: Welcome to another episode of Up Next In Commerce. This is your host, Stephanie Postles. Today on the show, we have Jeff McRitchie, the VP of Ecommerce at Spiral Binding, My Binding and Binding 101. Jeff welcome. Jeff: Thank you. Stephanie: Thanks for coming on the show. I was excited when I was looking through Spiral's background. It looked like you guys started in 1932. Is that right? Jeff: Yeah. I mean, we've been around for a long time. Stephanie: Yeah. I think that'll make for a really fun conversation because I'm sure that the company and you have seen a lot of transformation over the years, so that'll be fun to dive into later. Jeff: For sure. Stephanie: Tell me a bit about Spiral. What is it? How do I think about what you guys do? Jeff: So Spiral is really a company and we've built ourselves around helping people to bind presentations and proposals. We do a little bit of laminating. We do a little bit of other things, but really we focus a lot on binding. We sell the equipment and the supplies for people to be able to bind presentations, proposals, books and training materials. Those are probably the primary things that come out of it. Jeff: We're a niche player in the office products market is one way to think about it. We're an interesting a hybrid of a company because we sell a little bit in B2B, a lot in B2B, a lot in B2C or B2B to C sort of space. Then we also have some really interesting national account sort of business as well. Kind of a little bit of an evolving company, we're a manufacturer and a distributor at the same time. We have lots of different faces which presents some really cool challenges from the standpoint of being in a digital transformation or Ecommerce role. Stephanie: Okay cool. So how long have you been at the company for? Jeff: My story is interesting, actually I'm co founder of a company called My Binding about 17 years ago. Last year we sold to Spiral. I've been with Spiral for just over a year now in this sort of digital transformation role but with My Binding, which was more of a pure play Ecommerce space. We grew and we were the largest sort of binding Ecommerce player in the market. Then all of a sudden we joined forces essentially with Spiral, which was the largest sort of B2B player in the market. Now we're one force together going after the binding and laminating market. Stephanie: Oh, interesting. What was that process like where you had your own company, you guys were selling online and then joining a company that maybe wasn't doing as much of that. What was that process like when it came to incorporating your company into an existing older company? Jeff: There's definitely some upsides. Suddenly you have increased purchasing power, you have more access to talent and capital. Those were amazing things, but the integration side of things is tough. Jeff: I mean, you're trying to merge systems and figure out how everything works together and learn the language of a new company. Some of that stuff is not as easy as it should be, as well as trying to figure out where exactly are they on the landscape of digital transformation and how do you navigate that when... We were pretty much an Ecommerce or digital first organization. That wasn't really their background. Now we're figuring out how do we be both? That's a pretty big challenge actually. Stephanie: Yeah. That sounds really difficult. What does the customer journey look like for Spiral or what did it look like compared to My Binding? Jeff: I guess the best way to think about it would be that in a B2B, B2C sort of Ecommerce experience, we were really building our business around a large number of transactions with a large number of customers, essentially small transactions to a large number of customers. On the more traditional B2B model, the traditional side of the Spiral business would have been around a small number of transactions to really big customers. Which is pretty typical when you look at this idea of traditional B2B and more like an Ecommerce B2B sort of experience. At least a B2B, to C sort of experience. Jeff: That was the really interesting thing is that we were dealing with customers from all over the country that in almost every industry that you can imagine, but most of them were rather small and we are filling specific needs for those customers. That was fine. On the spiral side you were looking and saying, hey, they had deep relationships. Relationships that went back decades, in many cases, with organizations where they were the supplier of choice. They had complex contracts and all those kinds of things. That was never really part of the Ecommerce world. Trying to figure out how do you merge those two together to get the best of both. It's not easy, but it's really fun actually. Stephanie: Yeah. I can imagine it takes a lot of training for their existing customers who are used to those contracts and used to things being done a certain way. How are you maybe going about training the customers who are used to doing things the old way to be like, Hey, we actually can do this online usually. Jeff: Slowly. Stephanie: Any lessons there that someone can take away if they're going through the same thing right now within their org? Jeff: You don't have to do it all at once. Our approach is really to allow customers to interact with us the way they want to interact with us by giving them better options. Really the priorities for this past year have been to try to integrate systems and then upgrade our footprint so that we can allow the company to put its best foot forward. Really starting with the E-comm side and getting everybody on the same platform and then tied into the same systems. Jeff: Now we're actually probably just a couple of months away from launching our brand new B2B E-com experience for the traditional spiral customers. Essentially we have been allowing them to continue to exist and deal with the company in the way that they used to while improving the experience and then bringing the platform up for the entire organization. One of the things about especially B2B commerce is that it gets really complicated as you tie in lots and lots of systems and a lot of interesting rules. Jeff: Customers want to deal with you in the way that they want to deal with you. What we've found is that we have to build specific experiences for our different customer types. That's the approach that we've been taking. I think that's a good approach from the standpoint of, you're not trying to force everybody into the same sort of experience because not everybody wants to deal with it in the same way. As a large organization that sort of deals with these sort of different challenges, we have to answer questions, like, do you display pricing on the front end of your website or is it a login only experience? Jeff: What pricing do you show people or what price pricing do people get and how do you control that and how do you manage that and how do you make sure that that experience is personalized for individuals? Then there's the age old question, which is really challenging in an organization that has multi channels and that is, how do you deal with the channel conflict? Whose customer is that? I guess it depends on who you would ask because everybody thinks that the customer is theirs. Yet ultimately the customer needs to deal with the organization in a way that the customer feels the most comfortable, not in the way that the organization feels most comfortable. Stephanie: Yeah. That makes sense. What kind of legacy or what things did the legacy customers get hung up on the most when you guys are making this transition and trying to show them that a new platform's coming? Is there similar themes of things that they're like, oh, I don't feel comfortable with that, or, I don't want to move because of this? Jeff: I think when it comes to customers, most customers want technology. I mean, they become comfortable. I think that they don't want to lose functionality. That's been probably one of the hardest things is that even if that functionality wasn't the best, they become comfortable with it and they don't really want to lose that. Yes they do want a best in class experience. One of the hard things that we all have to deal with in Ecommerce right now is that the bar has been raised. Jeff: There are people who want more and more features in terms of their online shopping experience. What you find is that you need to be able to roll these things out, but you need to make sure that it doesn't make things harder on those customers, especially long time corporate customers. They are really dependent on these things working smoothly and easily. That's actually one of the hardest challenges in this process has been, okay, well, we've done a lot of cool things for customers over the years. One off, you build a feature on the website just for that one customer. Jeff: Well, trying to then redo that and not lose a substantial amount of functionality for specific customers, especially large customers that you have these really deep relationships with, that's pretty tough. Stephanie: I was actually going to ask that next, when you mentioned that you were personalizing the experience for certain customers to make them feel more comfortable or hearing what they want and trying to incorporate that into the platform, how do you go about picking out what things you should maybe personalize or give to the customer without going down a worm hole of having a personal experience for every customer? Jeff: Ultimately, we're taking an approach of first saying, what's the best in class experience that we could build. What are the things that are going to be the best for all of the customers and then looking and saying, "Hey, can we in our roadmap put in the flexibility to accommodate for these many things that customers have asked for?" Jeff: How could we build this in such a way that we can add that on or this on? I'm not sure that we always nail it just from the standpoint of... It's pretty tough to keep everybody happy. But we're taking the approach of, hey, we can make it substantially better for everybody. It may not be perfect, but it should be a dramatic enough improvement that they'll recognize that we have their best interest in mind. Stephanie: It seems like some of those requests might also fit other customers as well or it might be something where they're like, oh, I actually wanted that and never thought to ask. It could be helpful when it comes to product development on your side, like technology development. Jeff: Yeah, totally. We had a really good team that we used to build out stuff and we're able to iterate fairly quickly. That's the good news because sometimes we miss something and so... But as long as you can respond fairly quickly to a customer's need, it gives you an opportunity to serve them better and to communicate. But the other really important part of this is really getting the account managers and your sales people involved in this process so you get some really good feedback because one of the challenges that we face at least is that sometimes as the E-com department and on the technology side, you don't always get raw feedback. Jeff: Maybe the stuff you're hearing is from the people who are yelling the loudest, not necessarily from the people who are trying to help you. You're not necessarily hearing about the features that are going to make the biggest difference for most number of users. Stephanie: That makes sense. With this whole re-platforming and new tech stack that you're going to be launching what pieces of tech are you most excited about showing to the customer or bringing online that maybe wasn't there before? Jeff: For us it's really about an enhanced user experience. We kind of been a little bit on the old school side on the traditional B2B piece of it. This gives us the ability to provide a really much better experience end to end in terms of transacting with us. Some of the things that we're aiming for, that are harder than I was thinking they would be, would be real time freight quoting. When you're a B2B company and you've got a distribution network across the country, and you're trying to figure out how much that pallet is going to cost to go to this customer. You think, hey that should be super easy. That's like in the Ecommerce world, until you start to realize, well, it's really important that you get that right. You have to first know where all that's going to ship from. Jeff: One of the biggest things is a really deep integration with our ERP so we can understand where the inventory resides and then how much it weighs and the sizes and all those kinds of things so that we can do that on the fly. Because right now we do an add back type thing. We'll tell you what the freight is later. Customers don't like that. Especially not in the Ecommerce world. Getting that upfront, same with sales tax calculation. Right now, a lot of that's done on the backend and people want to know upfront. That means building a system that has management for resale certificates and all of those pieces. Jeff: I need to understand where are you exempted, where you not exempted and what are you exempt from and all of those kinds of things so that I can quote you and tell you what the sales tax is going to be upfront before you place your order. That's another piece of it that we're excited about. Requisition list is another one where people will have their own custom price list in the system where they can quickly order. We're building a system where they can upload an Excel file with all of their items that they want so they can do quick ordering and quick reordering. Jeff: I guess those would be a few of the systems. Like a quote management system to allow people to request pricing on items and then for us to respond to them live and track that inside of our system is another one that we're building. Those are all areas where we're saying, hey, this could really enhance the user's journey and make it a lot easier for them to do business with us. Stephanie: That's great. Yeah that sounds like some great changes. Have you had any customers trying out the platform as beta testers and have you seen any difference when it comes to average order value or anything? Jeff: We're not quite there yet. We finished design and we're in the midst of development at the moment. I would say that that's going to be one of those steps prior to launch. Will be first to have sort of sales associates and account managers jump into the platform and test it for themselves and then to really get especially key customers in the system testing, and then also giving us feedback. What do they love? What did they not like and how can we make it better for them? That's on the roadmap before launch to be able to say, "Hey is this better for you?" It's funny because on a traditional B2C Ecommerce launch, you'd be focusing so much on the front end. Jeff: Like, the My Account pages are taking just as much time for this site because that's where our customers are living. They want to use the search, but they really want to use the my account pages. They know what they want, and they need to be able to quickly reorder it. They need to be able to see their orders. They need to be able to have the ability to upload those requisition lists. It's a little bit of a twist but getting them, especially into those my account pages so that they can spend some serious time understanding their accounts and telling us what they like or what they don't like is going to be really important for the launch process. Stephanie: Yeah. That's really interesting about focusing on my account page and how much time they're spending there. I'm sure that things like product suggestions or also bots might be very important on that page to help showcase items that maybe they wouldn't otherwise buy when they're just quickly uploading something or just reordering. Are you guys experimenting with some of the suggestion features? Jeff: Most definitely. Yeah. That's part of the vision is to try to figure out and say, okay, we have these deep relationships with customers and they buy specific sets of products. How can we expand to purchasing a product set? How do we get them and introduce them to complimentary products and show them the right pricing and the right place so that they can say, "Hey, I should totally add that on." That's something that I should consider. It's an interesting challenge for us because we have different personas or groups of people that we're dealing with. Jeff: On one hand we're dealing with dealers and they're really reselling product. You're trying to show them maybe categories of product, where do they need to expand because they're buying for specific purposes. Then you have end users and those end users you might want to show them a different size or a different color. We're experimenting with what the best algorithm is that we can use to show them the right products and then also in the right places too. Stephanie: That's great. What tests are you most excited about that you're pitching to everyone right now and some people maybe aren't sure about? Jeff: I'm actually most excited right now about the lead gen side of our business. Stephanie: Tell me more about that. Jeff: When you start to think about what the power of Ecommerce is for a B2B organization. Ecommerce can really become the engine that powers the acquisition efforts of a company. Especially because we can get in front of hundreds of thousands of customers a month, whereas the traditional B2B sales force might only touch hundreds of customers per month. Maybe thousands, but definitely not hundreds of thousands. Jeff: The idea of... What does it take for us to build a really cool robust system to not only bring these leads in but then to try to figure out how do I score these leads and then not only take them and turn them into an immediate sale, but to determine which ones of these really can be turned into those more traditional B2B accounts that we have these deep relationships with that are going to buy from us for years to come, many tens of thousands of dollars, right? Jeff: The really exciting part to me is looking at it and saying, okay we are on the Ecommerce side, on the B2B2C Ecommerce piece of it. We almost have too many leads. We get so much traffic that comes in. So then how do you figure out, take all those leads and build a really robust system where you can make sure that they're getting exactly what they need, and you're closing as many sales as you can, but then how do you figure out a way to pass those accounts up, the right accounts to the right people so that you can build them into a much larger long term sustainable program. Jeff: For us, that means building a really cool inbound sales team that makes sure that we take care of those leads and that we foster them and do all the things that we need to do, but then building an outbound sales team as well that's going to go in and then say, "Hey, let's take these leads and take them to the next level." Then also figuring out a system for passing accounts up and down inside of the organization. You really want to be able to pass a lead up or a customer up that has substantial potential to be either a national account or what we'll call an enterprise level account. Jeff: But you also want the reciprocity of getting those accounts back or the smaller accounts back from the team. I will say that no one wants to give up that account. That's a big challenge inside of an organization when you're trying to say, "Hey, I'll give you some, you give me some." The way usually ends up being is someone... Everyone wants to receive, no one wants to give. But the system only really works if you can give the best to the... But then also that you can receive quality back. For instance, handing back to the E-com team, only the accounts that don't do any business, isn't really a win. Jeff: You really want your enterprise salespeople focused on enterprise level accounts. We're having to sort of wrestle through what does that look like in terms of structure. I don't know that we really have it all figured out yet, but it's a cool idea. Stephanie: I'm guessing there's a way to automate that and create rules. So it, like you said, can go up or down depending on certain criteria from when they're coming in. How are you all thinking about automating that process? So it's maybe less of a salespeople having to give and take and whatnot, and more like, Oh, this is automatically routed to you based on these metrics. Jeff: That's exactly what we're doing. We're exploring machine learning and big data to try to figure out a really good way of scoring customers because using that scoring, you can figure out how to pass customers up. Then a set of rules as well that says if these customers aren't of a certain size or if they have this kind of profile, they really belong in this group. But it's an interesting challenge from trying to figure out where do you get all this data from, and then how do you process it? We're exploring different options right now in terms of what that might look like and how we can best approach that without spending a ton of money before we bet that it actually works. Stephanie: Yeah. That's really cool. So outside of the prospect giving that information, what kind of things are you looking into right now to find the information to help with that scoring process? Jeff: It's actually challenging. You have certain pieces of information that are given to you which you have usually a name and an address. Their email address usually has a domain associated with it, especially in B2B. So you can pull a lot of information from that and you can start to sort your domain, your customers by domain. But really we're looking and saying, okay, well we do know the purchase history. The idea then is, okay, if you were to sort all your customers out, you can sort them on a scale of, let's say a one, two, three. You can say my best customers spend the most money with me. My worst customers spend the least amount of money with me, but that really misses part of the point. Jeff: You almost need to add a second access to this, which is really about customer potential. When it comes to customer potential, we're looking at the idea of what would it take for us to add some big data to this? To understand the size of their company and the profile of the company that they come from, or the industry that they come from as well, because the industry can be really important to us. But then the other side of it is also looking at what they purchased. Like for instance, people who purchase specific equipment or supplies, they're going to have a much higher lifetime value with us because those are proprietary or have maybe a really good pull through rate. Jeff: For instance, it may not be that it's a proprietary supply, but when you buy that machine, you have to go through a lot of supplies to make it worthwhile. You look at the data and you say, okay, that customer has a huge amount of potential. Not because of the amount that they bought from us, but because of what they bought or who they are, the company that they work for or their position. We're looking at the possibility of maybe even extending that into some of the databases out there that help you understand whether people are in market and what their roles are as well. Jeff: Because when you're dealing with B2B, you're not really selling all the time to the company, you're selling to a person inside of the company and that person has a role. You have to figure out, okay, well what role do they play in this picture? That helps us to sort them into personas. If you're dealing with a really small number of accounts, you can figure this out, but we have to automate it because it's not really feasible to do that in a one off basis. Stephanie: Yeah, definitely seems like you're going to need a whole entire data or business operations team who can build those rules out for you and have dashboards. That seems like a big project, but well worth it. Earlier, you mentioned that you guys have more traffic than you know what to do with and lots of leads coming in. Of course my first question is how are you getting this traffic? How are you acquiring potential customers? Jeff: Sure. I mean... We're in a niche industry, right? So that's part of it. We've been around for a really long time. Because of that, at least... Spiral has been around 80 years, My Binding for almost 20 on the web. As you start to look at that, we created a massive amount of content. Thousands of videos and pages. We really have in a lot of ways, the best websites in our sort of space and industry. Because of that, people are finding us to solve problems. What you find is that we built out these websites and either through SEO or through paid search we're driving a ton of traffic to the websites because they convert and that makes a ton of sense. Jeff: We're essentially... We have all of this content and it's really designed around this idea of how do we solve these problems for customers? We can drive more and more of that content. The website deals with a certain number of those sort of leads and converts on its own. The challenge for us tends to be, what do you do with the people that are maybe a little higher in the funnel? You're now talking about making sure they have a really awesome call center that is going to be able to answer those questions. Live chat is really big. We've extended our live chat hours all the way to midnight which is unheard of in the B2B space. Jeff: I want somebody there to talk to somebody if they have questions about products. Especially really big products. We're experimenting with the idea of doing triggers for live chat. We did that and that was really successful for us. We turned on the trigger and said, with the idea of if I walk into a store, somebody says, "Hey, how can I help you?" We did that on the Ecommerce site and we had massive numbers of people that were engaging with us. But the surprise to us was that many of those people were actually much higher in the funnel than we were used to dealing with. Jeff: In other words, they were now engaging with us and they weren't ready to buy. They were in the research space and they had lots of questions. Which is really cool but it just changes the model a little bit and you all of a sudden have to figure out how do I step up for that? How do I make sure that I have the right person to answer those questions? That's part of it. Driving the leads really comes to how do you acquire traffic on scale? Really good high quality traffic for the site. Then the question is, well, what can you do with it? Driving the traffic is really exciting from a standpoint of it doesn't have to be done in one way but you have to be maybe a little bit creative to do it because you really are trying to get in front of people that have problems rather than... Jeff: At least in our space, you don't come to a binding website unless you have a problem that the binding website can solve. It's not exactly an impulse purchase. You're going to show up and you're not going to just browse around. I wonder what kind of binding machines they carry. You probably are on a mission to solve some sort of problem. Right. Whether that's like your bosses told you that you need to buy a binding machine or you need to upgrade the way that your reports or presentations are going to look, or you have a deadline of Friday and you need to get these reports out for the annual meeting. Jeff: These are all sort of really common sort of scenarios and so then the question is, will this product work for my specific needs? That's a question that our customers are constantly asking. Building to that has been a really great sort of acquisition model for us to build around the idea that every customer that comes to us comes to us with a problem that we can solve for them, and then figuring out how do you work backwards to that? What problems could we solve? Then as you start to get creative with that and build massive amounts of content, that content lives out there forever. That's been really a big part of our success, is really the longevity but also the content generation sort of machine that we've built over the years. Stephanie: How has your content... What is the style now today? Is it only educational? Is it humorous and how has it evolved over time? Jeff: We've tried a lot of things over the years. We've tried to be funny. I think we think we're funny sometimes. We've tried a bunch of different things. We've tried to be really educational. It was really hard to figure out the ROI of that. What we've really... If you were to look at our content, we do a lot of content that is really close to the bottom of the funnel, but that would be really helpful. We go with that sort of helpful thing as well as deep. So the idea of building out a really robust and large set of content over the years about products. Jeff: We spend a lot of time making sure that we have all of the details about the product, even to the point where our competitors come to our sites to look up products because they don't have as good of information as we do. That's one piece of the content side of things for us. We have a lot of how to videos. We did a bunch of experimenting around the videos. We found that the videos that people really cared about would basically answer a couple of quick questions. But mostly it was, will this product work for me? How does this thing work? Jeff: We made a whole series of those videos, almost five thousand of them that are really around the idea of how does this product work and a quick demonstration essentially. Usually around a minute long that takes the product out of the box, show someone how to use it. Those really work well for us because they show a customer generally what are they looking for. A lot of customers they want to see what it looks like or they have a machine already and they want to say, "Is that's the thing that works with my machine.? They don't understand our language. Those videos have worked really well for us as well. Stephanie: That's great. Are there any surprising pieces of content that you didn't think would work that did, or surprising sources of customer acquisition that you wouldn't have looked into before? Jeff: We've had a few blog articles that have found traction in the world and the web that I wasn't really anticipating. We've written a lot of content over the years. Most of the blog articles get a little bit of traffic. They're like evergreen content, little bit of traffic over a long period of time. But occasionally we'll end up with one like... Something about how to laminate without a laminator. Stephanie: That's a good one. Jeff: Amazingly, there's a lot of people that look up that and I was shocked. It consistently drives more traffic than almost any other blog article for us. Which is odd. I'm not sure it drives a ton of business because they don't want to buy a laminator, but if you think about it, there's a whole segment of people that have maybe problems that we don't traditionally associate with our business. That would be one thing and then the other piece would be the language piece. Jeff: It's always surprising when I discover that the language that we use internally for our business doesn't match the language of the customer. An example would be we talk about binding covers all the time because we're in the world of binding. A lot of people they just talk about card stock. In the paper world, the card stock doesn't even exist. It's not a thing. People will talk about it. It's cover weight paper. Index weight paper. Card stock is like this sort of crafting term. Yet it's sort of taken on a vocabulary of its own in the world. Jeff: When people search for binding covers, often they'll use that word. That's always surprising to me as well. There's a whole list of those things where people basically they choose to use their own words to describe things. Now you're trying to figure out how do I technically be accurate about this product but really use their language? Because if you don't use their language, then you're not going to show up in search for this stuff and they're not going to feel comfortable with it. Stephanie: That's a really good reminder, especially with generational shifts that the new consumer might be using completely different language than what you're used to. How are you exploring what that language might be? I mean, especially a company that has been around since the thirties, how are they figuring out, oh, this is what they call it now, this is what the kids are saying these days? Jeff: Probably the easiest thing for us is to look through our search results and especially the no results found once because often it's those things. When people are typing in stuff in the search bar and nothing's popping up. You look at that and you're like oh... A smart merchandiser, someone who understands your products really well, they start to make those connections and they're like, oh, wait a second. That's what they mean. Obviously a lot of that like spelling mistakes and things like that. You can fix those in your search engine but when you start to look at it, you start to see sometimes patterns. That's one of the easiest ones. Jeff: The other two that are really helpful for us would be Google autosuggest. Just start typing things in Google and then figure out what Google thinks that you should add to the end of it. All of a sudden you realize, okay, maybe people are searching for maybe a slightly different side of things than we thought they were. Then the other one would be Amazon. Amazon, their product terms are awful. Yet they sell so much. Why? Because they tie into language. They have usually products that have all these different words in the titles that you would never imagine. Jeff: As you start to look at products that are really successful on the marketplaces, you can start to realize, okay, well maybe they're onto something there. They've managed to call out even the most important attributes of that product in a very search centric sort of model or they have really been able to hone in on maybe key words that we weren't thinking of when we've been building this out. Especially because often you start with whatever... A point of reference would be the manufacturer's title. It becomes quite difficult sometimes to sort of detach from that, but Amazon detaches automatically because they let people come up with their own titles for stuff. Jeff: Usually it's the sort of ecosystem that will change the title to try to optimize. Sometimes when you find really successful products that you're realizing, Oh, maybe people do care about that. Stephanie: I love that. That's really good tips to remember about, finding those keywords and how to discover them because yeah, I think even longterm key words would probably be really good for your industry. I'm thinking, how would I Google something like that? I would probably be like how to create a hard cover book for my presentation or something really long winded like that. It's a really good reminder about the keywords importance. Jeff: Then obviously you have your paid search stuff too. You can look and see in your paid search accounts, you can say, okay, what keywords are actually driving? If it was a broad or a modified broad match keyword, you're going to start to dig in and you can say, oh, it actually matched on this keyword and it drove a sale. Again, driving back and saying, okay, what am I driving sales on? It tends to be a really good place to start discovery as well. The only thing, the problem with that is that you might be so far off that you're missing the boat completely. That's where it takes a really good merchandisers to sort of nail that stuff down. Stephanie: I also think it was interesting earlier when you were talking about how to laminate without a laminator and thinking about selling something through saying, oh yeah, you don't need to buy through us. Here's how you do it because I'm sure a lot of people, like you said, are searching for stuff like that or how to fax without a fax machine. I know I've searched that quite a bit, but making fun of it and you might actually be able to convert someone who's like, Oh, I actually just do need a laminator to do this, but having a humorous video around that. Jeff: Yeah. As well as maybe they decide that they want to buy some cold laminating pouches. The idea is, if you can be really helpful in the long term, going back to that idea of video. We've done a lot of videos over the years. We understand that many, many, many times people use our videos post-purchase not pre-purchase. People are going to the video to figure out how does this thing that I already bought work. Well, that doesn't really help us but it does help us in the long term. Jeff: As you look at it and say, it's not going to win us the sale today, but it will win us brand awareness. It does potentially when you do supply sales. Because we're a very supply driven sort of space. If you think about it, if you buy a binding machine, you got to buy some supplies for it. Longterm, we want to have an awareness and be in front of customers so they understand who we are when it comes time to buy the supplies that they need. Stephanie: Just like you said, it's really important to continue to stay in front of that customer so they come to you to buy supplies and remember you guys. How do you go about doing that and keeping a customer retained? Because it seems like it would be easier with these legacy customers who are maybe in these year or three year long contracts. Now when you're moving towards Ecommerce and they can hop around really quickly, it seems like you wouldn't be able to retain customers as easily. So how do you go about staying in front of them? Jeff: I mean, there's a lot to that, the question. To give you maybe a general overview of our thoughts is a big part of our business and something that's really important to us. Especially on the E-com side of things, it really starts with delivering a really awesome experience upfront. So you need to be able to help them find what they need and then deliver it to them in a really reasonable timeframe or meet their deadline. All that kind of stuff. To have the product in stock and all of those kinds of pieces. That's actually harder said than done when you deal with a really large niche category. Jeff: That's the beginning piece of it. Once you've given them that positive experience, or if they've had a negative experience, you use your customer service to basically earn a customer for life. That's actually the motto of our customer service group. Earn a customer for life. As you look at this idea, you say, okay, well, we now have a shot at their business longterm. Now the challenge for us is, okay, what's the best way to reach them? The easiest way is email. We have a ton of automation in our emails. We send emails based upon what you've purchased with replenishment. We send life cycle campaigns based upon... Welcome to the store anniversaries campaigns, and then also best customer campaigns, win back campaigns and reactivation campaigns. Jeff: We have all these automations that go out. They're really helpful. We also have sales that go out on a weekly basis that keep people engaged and keep things front of mind for them. You combine all of that on the email side, but then you recognize that that maybe only gets you half the customers. The question becomes... Because there's a bunch that are opted out in the B2B space, it's really hard on deliverability to get into the inbox. More and more people are using advanced filtering programs to prevent spam from getting through to their employees. Jeff: As you look at that, you say, okay, well, email only takes you so far. So then what do you do? The real question is, back to that conversation we had earlier about lead scoring, how do you determine your best customers or your best potential customers and make sure that you get somebody to call them? To send them a personal email which are easier to get into their inbox or to find another way of touching them. For us right now, the two other ways of touching them that we're sort of exploring, one would be SMS and then another would be direct mail. We're kind of in the process of exploring a test on SMS. Jeff: I'm not too sure how we feel about it, honestly. We have to figure out how our customers feel about it, just from the standpoint of as you look at customers giving their personal cell phones for business purchases and getting text messages. But you think about it, that's a great way to get in front of people and stay in front of them as long as you're going to be super, highly relevant. Then the other piece of it that we do a little bit of would be on that retargeting side of things. If you don't know who that customer is exactly, or don't have their ability to email them, you can at least sort of [inaudible] do it, make sure you're sending or placing ads more frequently into their feeds on different platforms through retargeting. Stephanie: That makes sense. It seems from, especially in SMS perspective, it seems like the only angle you can go about is being helpful. Like oh, you probably are running out of supplies, order now. I don't know, you can get a discount or something. It seems like there's not too many ways for B2B companies to use texting without the customer being like, "Oh, I don't want to be thinking about work right now." Unless it's a trigger for them to be like, "Oh, I need to reorder this or else we're not going to have it on the day." Is that true or are you seeing other avenues? Jeff: Well, the first step would be to be helpful with order cycle. For instance, think about what Amazon has done with allowing you to get a text when the item is delivered. Which is a big problem for a bunch of our customers, especially in pandemic, but even outside of that. It might be delivered to a central desk or to the shipping and receiving area of their company like an alert. Alerts are a pretty good option for us to sort of get our toe in the water a little bit and to stay active. Then yes, something that's personalized. Jeff: Then also, what we're struggling with is what is the best time of day to do this? Probably don't want to send it to them in the middle of their evening. They're disconnected from work, but you also need to make sure that... It's got to be time adjusted for the time that they're in and they also really needs to be followed in their workday probably. Those are some of the things that we're sort of figuring out and testing right now and saying how is this going? Then what's also the most appropriate way to collect where people don't sort of get freaked out. Because it's one of those things, do you want to get text messages from your binding company? I don't know. You got to ask it in an appropriate way. Stephanie: Yeah. That's a really good reminder. All right. We have a couple minutes left and I want to jump into a quick lightning round brought to you by Salesforce Commerce Cloud. This is where I'm going to ask you a question and you have a minute or less to answer. Jeff, are you ready? Jeff: Okay. I'm ready. Stephanie: I'm going to start with the hard one first for you because I feel like you're in a game right now. I got to keep it going. What one thing will have the biggest impact on Ecommerce in the next year? Jeff: Well, I think obviously it's COVID. It's pushing people online in completely new ways. It's shifting customer expectations around a whole bunch of different things. It's ruined the Amazon two day expectation, which I don't mind, but it's also shifted the way that people shop, where they're shopping, how they're shopping, and even their mentality. I don't know that we even really totally understand how it's affected everybody yet because everybody's still sort of in this scrambling mode. But ultimately I think as this shakes out, it's going to change the landscape of how we market, but it's also going to change the landscape of how our customers interact with us. Stephanie: I like that. What one piece of advice would you give a new Ecommerce entrepreneur? Jeff: I would probably say stick with solving the customer's problems. I know that tends to be a B2B thing, but it's not really a B2B thing. If you think about it, I need the right sweater for me. Really be customer centric. That becomes really cliche and that's why I go to the idea of solving a problem. You got to think about what sort of value proposition are you offering to this customer that's unique, that is going to allow them to accomplish something that they wanted to accomplish when they came to your site. Jeff: I think by focusing and being really focused on the customer problem, I think you can build out really awesome experiences, and then that deep understanding of your customer will take you really far. Stephanie: That's a good one. What is your favorite day in the office? I'm trying to imagine what a binding company feels like. What's your favorite day in the office feel like? Jeff: I mean, most of my days are pretty full of meetings. A day without meetings would be an awesome day in the office. Stephanie: That's a lot of people. Jeff: I think so. In the world of the binding company, a day in the office doesn't look all that much different than a day in a normal office. It might be a little bit like an episode of the office. Stephanie: That's what I had in my mind honestly. Jeff: Yeah. It's like paper company. There is a little bit of aspects of that, but I mean, we're just like any other company. We're a retailer, we're a distributor. We deal with customers all day long. I would say the other thing, the best day in the office is the day that you have customers that love you and that are just heaping praises, especially on the customer service people and your salespeople. When you have customers who are just singing your praises, those are great days. Stephanie: Yep. That's awesome. I'm glad you mentioned the office and I didn't have to. If you were to have a podcast, what would it be about and who would your first guest be? Jeff: That's a tough one. If I were to have a podcast. I am super passionate about entrepreneurship. I'd probably do an entrepreneurship sort of a podcast about starting a business, growing a business, and the creativity that goes around that. If I could get anybody on the show, I would probably pick an entrepreneur. Maybe I pick the person from lemonade stand or one of those organizations that's really making a big impact on starting up entrepreneurs with kids. That's something that I really love. Stephanie: Yep. I like that. Brings back the memories of my parents make me [inaudible] my neighbor's yard for 25 cents which is well below market. Jeff: I think you could make at least 50 cents for that now. Stephanie: I think so too. All right Jeff, this was very interesting, such a good conversation. So many good tid bits that people can actually use from this interview. Where can people find out more about you and Spiral? Jeff: Sure. You can definitely visit one of our websites. We've got SpiralBinding.com. We have MyBinding.com and Binding101.com. You can find me on LinkedIn as well. Shoot me a message and ask me to connect and I'd love to meet you. Stephanie: Awesome. Thanks so much for joining Jeff. Jeff: You're welcome. Thank you.
Middle Market Mergers and Acquisitions by Colonnade Advisors
In this episode, Gina Cocking and Jeff Guylay continue their conversations around deal structure. Today we explore earn outs, a form of contingent consideration in which the buyer and seller share both the risk and upside/reward based on the future performance of the business. Other episodes in our series about deal structure include price and terms, roll over equity, R&W insurance, and roll ups. Earn outs have been used in about 20% to 25% of middle-market M&A deals in the last few years, and the use of this financial tool is expected to increase during and after the COVID-19 crisis. The episode features guest Mark Kopidlansky of Munsch Hardt. Mark shares an attorney's perspective on earn outs and what tactics work best for buyers and sellers. In this episode, Colonnade Advisors addresses the following questions as related to earn outs: What is an earn out? (00:49) Jeff: “Contingent consideration - that's the simplest way to think about it." Why are earn outs put in place? (01:37) Jeff: "It's a risk-sharing mechanism. They shift risk back to the seller. Earn outs can be an important part of getting transactions done." What metrics are used in earn outs? (02:28) Gina: "In my experience, the buyer always starts at the bottom of the income statement, EBITDA or net income. The seller prefers a metric at the top line level, like revenue or units sold. We end up with a disconnect, and that's where negotiations come in to determine the best metric to use." Are earn outs standard in middle market M&A transactions? (03:46) Jeff: "In a perfect world, we agree on a price, and the buyer pays in cash in full at closing. No hold back, no escrow, no earn out; but that's not the way that a lot of our deals happen in the middle-market. Earn outs are frequently used (and becoming increasingly so) in middle-market transactions.” Is it possible to structure the earn out with multiple metrics? (06:29) Jeff: "You could key the earn out to a top-line metric, and then gate the earn out provided that earnings don't fall a certain level.” Who should have control of the company during the earn out period? (06:51) Jeff: "In nearly all earn out situations, the seller is still in control of the business.” Are there instances where a seller would want a longer-term earn out period? (08:25) Jeff: "Some clients want a really long earn out because they think that there's a big pathway ahead. And they think there's a huge opportunity.” What percentage of deals have earn outs historically? (12:37) Gina: "15 to 25% of deals have earn outs as a component." How will the COVID-19 pandemic impact earn outs used in future transactions? (12:37) Gina: “My guess is that earn outs will be a tool that is deployed more consistently across deals because there is so much unknown (both downside and upside)." What happens when earn out discussions come up towards the end of a transaction? (13:33) Jeff: "When an earn out concept comes up late in the game, it's really a question of whether both parties want to get the deal done?" If the earn out equals one-times earnings in year one post-transaction, wouldn't the seller just keep holding the company and pay themselves that earn out? (15:38) Gina: "That gets back to the conversation around the seller's objectives. [Remember you may have already pocketed 7-8x earnings upfront.]” What percentage of the total transaction is typically structured through an earn out? (16:59) Jeff: "In general, an earn out is a small percentage of the total transaction. It's often 20 or maybe up to 30% of the purchase price. 25% on average." Can earn outs go towards other holdbacks? (17:26) Jeff: "Oftentimes the earn out will mitigate or minimize any escrow or hold back." What is the sell-side advisor's role in reviewing the buyers' bids? Jeff: "As advisors, we draw on our experience in looking at term sheets and work with our seller clients to think four steps ahead, like in a chess game. Thinking through what the likely outcomes will be based on experience with working with particular buyers or just on transactions in general.” Gina invites Mark Kopidlansky, from Munsch Hardt, to share an attorney's perspective on earn outs and what tactics work best for buyers and sellers. What suggestions do you have from a legal perspective around structuring earn outs? (22:13) As a seller: Negotiate some sort of release from restrictive covenants Pursue a consent to jurisdiction provision in your hometown Know that if you continue in a management role, and something goes wrong, a buyer is a lot more likely to negotiate with you to keep you happy Include in your employment agreement a clause that says you can quit for good reason if you are not paid under the purchase agreement/earn out Seek out a clause so that, if you quit for good reason, you are released from any non-compete agreement Featured guest bio and contact information: Mark Kopidlansky Email: mkopidlansky@munsch.com Bio: Mark Kopidlansky has extensive experience assisting principals and other participants in a variety of sophisticated corporate, securities and business transactions, including mergers, acquisitions and dispositions involving privately-held and publicly-traded companies, with a focus on high-end, middle market clients and transactions. His representation of middle market clients consists of counseling clients in general corporate and commercial matters including with respect to joint venture and partnership agreements, shareholder agreements, buy-sell agreements, executive and employee stock option plans and compensation packages, consulting agreements, severance agreements, distribution agreements, covenants not to compete and confidentiality agreements, and license agreements. Mark also has significant experience in capital market and capital raising transactions, including representing issuers in public and private equity and debt financing and refinancing transactions (including initial public offerings and other registered offerings, private placements and venture capital financings). His experience includes counseling clients with respect to corporate governance, disclosure and other securities law compliance matters (including compliance with SEC reporting and disclosure requirements). Some of his most notable experience includes serving as lead counsel on two award-winning transactions - the D CEO and Association for Corporate Growth 2016 "Midsize Deal of the Year" ($25 MM to $149 MM) and the M&A Advisor's 2015 "Energy Deal of the Year" (up to $100 MM). *** For more information on earn outs, read Colonnade's blog post, Earn Outs in M&A Transactions: https://coladv.com/earn-outs-in-ma-transactions/ To learn more about Colonnade Advisors, go to https://coladv.com/ Follow us on LinkedIn, https://www.linkedin.com/company/colonnade-advisors-llc_2
What is it that motivates us as believers to overcome our discouragement, and actually share the gospel with those we encounter on our way? In a continued discussion from our last episode with Pastor, teacher, and founder of “The Exchange Ministry” Jeff Musgrave says that he believes we should be motivated by heavenly rewards and having an approach that works. [Jeff] “As a pastor, if you wanted to have a great alter call, just preach on family devotions or evangelism, because everyone feels guilty. We try hard never to motivate people out of guilt. … we want to motivate them out of, “I think this is going to work”. [Caleb] “You talked about rewards … it’s almost like we don’t want to be motivated just by rewards, but … who invented the rewards?” [Jeff] “There are two things that we have to believe about Him to please Him. (Hebrews 11:6 ) Constant awareness that He’s with me. He’s a rewarder of those that diligently seek him.” The Exchange tools that Jeff sees as a gift from God, greatly simplify the process of sharing the gospel, giving confidence to us as believers that we can do this! But more than that, God Himself rewards us to do his will. Scripture teaches us that God rewards us for doing good works, denying ourselves, showing compassion to the needy, and treating our enemies kindly. As we’ll learn today these rewards from God include rewards for faithfully sharing the gospel with those we meet. Welcome to Echoes of Faith, a podcast about God working in our lives today and how His Word impacts our future. In this episode our host Caleb Phelps continues his discussion with Jeff Musgrave. He and his wife Anna founded “The Exchange” in 2010 and have presented their training in over 200 churches, to thousands of people. They recently delivered this training at Faith Baptist Palm Bay in September of 2019. Jeff and Caleb sat down to talk about the approach and how you the Podcast listener can be more motivated by God’s Word to put these principles into practice. And now, here’s pastor Caleb. https://exchangemessage.org/
What is it that motivates us as believers to overcome our discouragement, and actually share the gospel with those we encounter on our way? In a continued discussion from our last episode with Pastor, teacher, and founder of “The Exchange Ministry” Jeff Musgrave says that he believes we should be motivated by heavenly rewards and having an approach that works. [Jeff] “As a pastor, if you wanted to have a great alter call, just preach on family devotions or evangelism, because everyone feels guilty. We try hard never to motivate people out of guilt. … we want to motivate them out of, “I think this is going to work”. [Caleb] “You talked about rewards … it’s almost like we don’t want to be motivated just by rewards, but … who invented the rewards?” [Jeff] “There are two things that we have to believe about Him to please Him. (Hebrews 11:6 ) Constant awareness that He’s with me. He’s a rewarder of those that diligently seek him.” The Exchange tools that Jeff sees as a gift from God, greatly simplify the process of sharing the gospel, giving confidence to us as believers that we can do this! But more than that, God Himself rewards us to do his will. Scripture teaches us that God rewards us for doing good works, denying ourselves, showing compassion to the needy, and treating our enemies kindly. As we’ll learn today these rewards from God include rewards for faithfully sharing the gospel with those we meet. Welcome to Echoes of Faith, a podcast about God working in our lives today and how His Word impacts our future. In this episode our host Caleb Phelps continues his discussion with Jeff Musgrave. He and his wife Anna founded “The Exchange” in 2010 and have presented their training in over 200 churches, to thousands of people. They recently delivered this training at Faith Baptist Palm Bay in September of 2019. Jeff and Caleb sat down to talk about the approach and how you the Podcast listener can be more motivated by God’s Word to put these principles into practice. And now, here’s pastor Caleb. https://exchangemessage.org/
Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases. Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve. Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this. Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify! Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls. Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati. Nachi: And I think you have a bit of a disclosure for this month... Show More v Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years. Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too. Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal concerns. Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help. Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights. Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet. Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point drop in arterial oxygen partial pressure from 95 mm Hg to 60. Nachi: In another study of healthy volunteers on a long haul flight, this change caused 7% of passengers to report symptoms consistent with acute altitude illness. Jeff: Due to the principles of Boyle’s law, decreased cabin pressure also causes expansion of gases within anatomical spaces in the body such as the eye, GI tract, sinuses, middle ear, etc. This expansion can potentially threaten surrounding structures. Nachi: So there must be guidelines for those recent post-op for flying - right? Jeff: There certainly are, but I don’t think we need to get into the weeds on this one since nobody listening will likely be doing pre-flight screenings. I think one thing to remember here, is that though cabins are pressurized to several thousand feet, they CAN be pressurized even further if necessary. The airlines don’t do this because it takes a tremendous quantity of fuel to do so, but if pressurization will defer a diversion, this option may peak their interest. Though an anecdote, the only time I’ve ever suggested it is on a flight from someone recent post-op eye surgery who went blind midflight. We pressurized the cabin from 8000 to 4000 and then finally to sea level and his vision returned. Pretty cool stuff. But getting back to the text, next we have air quality. Only 50% of inflight air is recirculated, all of the flow is compartmentalized between sections of rows, and all the air is run through a HEPA filter. The authors note that the air is actually comparable to that of an operating room. Nachi: Then why are people always getting sick after flying…? Jeff: Well it’s hard to prove, but experts believe that most post flight respiratory illnesses are likely caused by exposure to fomites on high-risk surfaces of airplanes and in airports - like the trays on the seat back. Nachi: Interesting. Jeff: It’s also worth noting that the air is quite dry, though this is unlikely to produce any clinically significant events. Most of the dehydration that occurs is more likely due to inadequate water intake and excess caffeine and alcohol consumption depending on the time of day. Nachi: Don’t judge. Even though it may be 8 am, some of our night shift locums friends may prefer an airport cocktail after a long week away. Jeff: Oh I’m definitely not judging, facts only over here. Anyway, let’s move on to a little epidemiology. Nachi: Syncope and cardiac events account for a large proportion of in-flight emergencies, with cardiac events accounting for the largest percentage of diversions. Jeff: Gi, endocrine and respiratory emergencies follow syncope and cardiac events, with specific percentages varying based on which study you look at. Nachi: Thankfully obstetric emergencies are relatively rare, accounting for less than 0.1% of all emergencies. Jeff: Trauma and substance abuse related complaints have also been reported, but represent only a small percentage of inflight emergencies. Nachi: I think that covers the main pathologies you may encounter. Next we should touch upon the actual responders. Physicians reportedly respond 44% of the time, followed by nurses at 20% and EMS providers at about 4%. Interestingly, despite physicians being there only 44% of the time, they were involved in the care for over 70% of diversions. Jeff: It might seem crazy, but that’s definitely my experience. Many physicians, especially non-ED physicians are not familiar with caring for the acutely ill. Additionally, most physicians are very uncomfortable actually witnessing someone syncopize and then immediately checking vitals and finding the passenger to be bradycardic and hypotensive as is the case with many patients immediately after a vasovagal syncopal episode. I cannot tell you how many times we get called by pilots considering diversion based on a physician’s request only to have the symptoms completely resolve in just 10 minutes. Be patient, this is a common in flight pathology. Nachi: Your experience has not failed you - data from your own group showed that 31% of cases resolved before arrival. Even in cases where EMS was requested, patients were only transported 37% of the time and of those, only 8% were actually admitted for further work up. Death is also a very rare phenomenon, occurring in only 0.3% of cases. Jeff: Alright, so let’s move onto the actual logistics of responding. Each airline has its own protocols and policies with respect to medical responders - some will require credentials, others may not. In some instances, you may be the first responder, in others, the flight crew may have already been in contact with their ground based medical control. Nachi: In terms of supplies, the FAA requires an emergency medical kit and an AED on all commercial flights. These kits cannot be opened without direction from a medical professional on the ground or on board. Jeff: And while airlines may add additional drugs at their discretion, the FAA mandates certain supplies. You can remember these supplies by thinking of the 5 A’s - asthma, allergy, altered mental status, ACS, and ACLS. The 5 As should help you remember the bronchodilators, epinephrine, antihistamine, dextrose, nitroglycerine, aspirin, and lidocaine as the one antiarrhythmic available. Of course, there are also gloves, an IV start kit, and a few other basic supplies. Nachi: AEDs are also required and have been since 2001 and amazingly when a shock was delivered in flight, 40% survived to hospital discharge with a good outcome. Jeff: Just as on the ground, shockable rhythms do well with good BLS care. And lastly, airlines also have a portable oxygen tank in addition to the emergency oxygen that is stored in the event of cabin depressurization. The exact quantity varies, but portable cylinders are certainly available. Nachi: So next we have to talk about a topic that I’m sure many of you have wondered about - what are the medico-legal risks of intervening? Jeff: As with most incidents of concern over medico-legal risk, we really just shouldn’t be too concerned over the potential legal ramifications. Though we’ll get into specifics, the short answer is that you should definitely volunteer your services - there are lots of protections in place with a paucity of case reports of legal actions against medical volunteers who volunteers in flight. Nachi: Perhaps most importantly, remember that ultimately the captain is in charge and you are functioning in a strict advisory capacity. Remember that most airlines can handle most emergencies with their ground based medical control, their typical staff, and predefined protocols - you are an added bonus. Jeff: For many ED providers, functioning as a consultant will be unfamiliar. Nachi: If I’m a consultant, I’m going to demand a WBC before seeing the patient, as I’m fairly certain that’s rule number 1 in consultant school... Jeff: It’s actually rule #12, now get out of your seat and come see the patient…. But back to medicolegal issues. In the US, health care professions are protected by the good Samaritan law and the 1998 federal aviation medical assistance act. Nachi: The Good Samaritan law provides legal protection to medical providers who perform their services in response to medical emergencies outside of the hospital. The exact verbiage of the law differs from state to state, but all 50 states have some version of it in their legislation. Jeff: Similarly the aviation medical assistance act applies to “medically qualified individuals and offers broad medico-legal protection to the airlines in the event that a medical volunteer is accused of malpractice as well as to medical providers who respond to an in-flight emergency.” Nachi: More specifically, the act states that “...an individual shall not be liable for damages arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.” Jeff: That’s a bit of a mouth full to get out. But basically, you need to remember that the AMAA protects you from everything shy of gross negligence. Because of this, there have been no reports to date of a medical professional falling below that standard. Nachi: There is one caveat to all of this though: don’t forget about your own mental status - for example if you have taken any sleeping aids or had any alcoholic drinks. Though this may not preclude you completely from rendering care, do so only with extreme caution. Jeff: And I don’t think we were clear enough about this up front. Up until this point we have mostly talked about US based flights. Flights run by International airlines are a somewhat different ball game for a number of reasons. First, medication kits will vary widely. Many will carry medications similar to those mandated by the FDA, but there certainly is no international standard. Next, the availability of ground based medical consultation is similarly widely variable, with many in the middle east contracting for this service and almost no airlines in Africa offering such services. Nachi: And lastly, with respect to legal risk - the international laws also vary widely. According to French law, for example, a French physician who does not volunteer may be committing willful negligence. Similar laws exist in Germany, Australia, and Canada. However proving you were there and refused to provide care would be quite difficult. And lastly, it’s unclear how to determine which countries’ laws apply when - for example, is it the sending country’s laws, the receiving country’s laws, or the country whose airspace you are currently in? Jeff: All excellent points. Next, we are moving to my favorite topic of the article - diversion. This is a tremendously complicated topic and I think the authors handled it quite well. Remember, the decision to divert is multifactorial and you are only there to communicate your medical opinion about the passenger - leave the decision for diversion up to the flight crew. I cannot stress this enough. Getting on the radio with the pilot and ground based medical control and demanding a diversion is often very unhelpful and simply not the right approach and can really be quite costly. Nachi: All of this is so interesting. I can’t believe you do this and divert planes.... Can you go into a bit more detail about everything the pilot considers when they are deciding to divert? Jeff: So there’s quite a bit, but I can touch on some of the main considerations. First, you have to consider the medical needs of the passenger - can he or she be temporized to get to the destination? Is there a suitable airport for diversion with an accessible local hospital with the required resources? Logistically, you need to find an airport that can not only safely accommodate the plane you are on but also one in which the airline can refuel and guarantee that the passengers and crew are safe. Remember, if you are on an A380, there are only so many airports with runways long enough for a safe landing. Fun fact: planes also take off heavy - with tons of fuel that will be burned prior to landing. Say you were to take off from London, bound for the US. To turn around and land back at London Heathrow, you may have to literally dump thousands of gallons of fuel to get the plane to a safe weight for landing. Alternatively, you may have to fly in circles for some time to burn fuel off in planes that cannot dump. A heavy landing necessitates a thorough maintenance overhaul of the landing gear and can cost the airlines not only money but significant time, which is equally as valuable. Nachi: Speaking of cost - while exact costs are unknown, one airline estimates that the cost can be as high as $600,000 - we are not dealing with small numbers here... Jeff: No definitely not. That’s why it’s so frustrating when medical volunteers demand the plane divert without talking through the medical scenario with the crew and ground based control - often temporizing measures are adequate. Nachi: And we alluded to this earlier - Physicians advise diversion more frequently at 9% of the time followed by EMS providers and nurses. When the airlines are left to their own means, they divert at rates roughly half that - just 5% of the time. At half a million dollars for some diversions, and an overall very low level of morbidity and mortality, a 50% reduction amounts to massive savings for possibly no clinical difference. Jeff: I can’t stress this enough - you are a consultant, helping the captain and the ground based medical control to come to most appropriate plan of action. When your advice causes the airlines to deviate from their standard protocols, that’s where they potentially run into trouble. Nachi: There are just two controversies to discuss this month and I actually think they are extremely pertinent. The first one relates to using personal medication or medications from other passengers. Given the relative paucity of medications in most airline medical kits, it may occur to you that someone else may have a helpful medication on board. While there is no strict rule against this, it could result in an increased level of scrutiny if there is an adverse event. So consider this a last resort. Jeff: The next controversy to discuss is the issue of gifts. There is a widespread belief that accepting gifts from the airlines would void legal protections. To date, there is ample airline-based data to suggest that medical providers’ legal protections are not negated in the event that the airlines wanted to reward a medical volunteer. Additionally, there are no reported cases of providers losing legal protection for receiving compensation for their services in flight. Nachi: Interestingly, some international carriers even offer points or other bonuses for registering as a medical volunteer. While I’m hesitant to call this controversy a myth, it seems like there isn’t much evidence to support it. Jeff: Agreed, don’t expect a gift, but if you do receive one, you can keep it and enjoy it without concern for your legal protections. Nachi: Alright so that wraps up the new material for this special edition of EMplify - let’s close out with some key points and clinical pearls. Jeff: Aircraft cabins are typically pressurized to about 8000 ft, resulting in a 4-10 point drop in oxygen saturation in healthy adults as well myalgias, fatigue, and generalized discomfort on long haul flights. Nachi: Only 50% of the cabin air is recirculated. When recirculated, it is subjected to HEPA filtration, which is adequate to prevent infection by airborne pathogens but not the infectious respiratory viruses, which are spread by droplets. Jeff: Dehydration on long flights is likely due to inadequate water intake and the increased use of diuretics such as caffeine and alcohol. Nachi: There is about 1 in-flight emergency per 11,000 passengers or 1 in 604 flights. Syncope and cardiac events are most common followed by GI, respiratory, and neurologic events. Jeff: Most in-flight emergencies are minor. When EMS is requested upon arrival, roughly 1/3rd are transported and less than 10% are admitted, with mortality estimated at 0.3% of cases. Nachi: AEDs are required on all US-based flights. Jeff: Airlines have a limited supply of supplemental oxygen for use in medical emergencies in addition to that provided to the entire plane in the event the cabin becomes depressurized Nachi: All US airlines have some form of ground-based medical assistance. Ultimately any decisions are the responsibility of the pilot in command – medical volunteers function in a strictly advisory capacity. Jeff: Medical volunteers are protected by both the Good Samaritan law and the 1998 Aviation Medical Assistance Act. Nachi: The Aviation Medical Assistance Act protects medically qualified individuals, unless they are guilty of gross negligence or willful misconduct. Jeff: International laws and protections vary widely. In some European countries, for a physician to not offer their services during an in-flight emergency may constitute willful negligence. Nachi: The decision to divert is multifactorial and can cost as much as $600,000 in some circumstances. Jeff: When physicians and EMS providers respond to in-flight emergencies, diversion rates are nearly double that of when the airlines work solely with their ground based support, increasing diversion events from 5% to 9%. Nachi: It is largely a myth that accepting any gift or payment after responding to an in-flight emergency would void your legal protections; the AMAA has no language regarding compensation and to date there are no such reported cases of lost legal protection. Jeff: And that’s the end of this months episode of EMplify: Assisting With Air Travel Medical Emergencies. This also marks the end of our run as your hosts. Over the past 3 years, we’ve thoroughly enjoyed hosting EMplify and having the unique opportunity to share high quality evidence based medicine with you all. As health care continues to move towards a quality over quantity paradigm, understanding evidence based practice will be increasingly more important. Nachi: We thank you all for giving us your ears and your time to help hone your clinical practice. Naturally, a big thanks also goes out to all of the contrubutors to Emergency Medicine Practice -- authors, peer reviewers, and of course the kind and thoughtful staff at EB Medicine. Jeff: We have no doubt that Dr. Ashoo, who will be taking over, will keep you on the edge of your seat as he brings new material to you. Couldn’t be more excited to have him as our successor. Nachi: As always, 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 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 any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: The [DING SOUND] 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.
Achieve Wealth Through Value Add Real Estate Investing Podcast
James: So few things; we want to go through some of the markets and some of the value-add stuff and I think you do a lot of student housing things. Also, we can go through that as well. Yeah, that should be what it is. And okay, let me just get started. So 1 2 3... Hey audience, welcome to Achieve Wealth Podcast where we focus a lot on value-add real estate investing. Today, we have Jeff Greenberg who has more than 40 years experience in management, staff supervision, development, and training. Jeff has been investing since 2007 and has more than 40 million multi-property projects consisting of around 2,000 units. So deals that he controls consist of student housing and some of the multifamily units across, Georgia, Arizona, Texas, and Ohio. And Jeff focuses a lot on value-add student housing, which is very interesting. Until now, we have a lot of podcast interview on conventional multifamily in workforce housing, but now, we're going to talk a lot more about student housing. Jeff has also done market rate and also senior living multifamily properties. Hey, Jeff, welcome to the show. Jeff: Well, how you doing today? James: I'm good. So thanks for coming in. I want to go with more details on how did you get started because you rent a thousand units across different states. So can you describe to our listeners and audience on how did you get started? Jeff: Well, probably similar to a lot of other people, I started out with single-family, but actually never did any single family deals. That was in 2007 when the prices were going down so fast that it was hard to do much in the single-family area as far as REO properties, the bank's weren't releasing them. So I did bump into a guru and so I did go to seminars and did get some mentoring around in 2007-2008. And then started with my first property that I ever bought, other than my own personal residence, was a 20-unit property and it was a syndicated deal. So we brought in investors into that first deal and that was essentially my entry into it. skipped right past all the single-family stuff. James: And what year was it, Jeff? Jeff: That was the first property we bought, actually it was in 2010. James: Okay. So 2010 you started with 20 units and the guru and the cost that you had taken was that more multifamily or was it more a single-family size? Jeff: It was all multi-family stuff. James: Okay, got it. So you got into that and then you started buying 20 units and which market was that? Jeff: Well, that Market was in Harlingen, which is in South Texas. Okay. It's near Brownsville and McAllen, for those people that know that area. James: Okay. Okay. So 2010 was supposedly supposed to be a perfect time to start investing in real estate after the 2008 crash. So can you describe what happened in your first deal? I mean at high level and what happened and how did you come up, in terms of the results for the first day of... Jeff: Yeah. The first deal, that property was only three years old. It was built in 2007. It was a hundred percent occupied and it was in a very slow growth market. So we had big plans for raising rents and they were already paying electric so we were planning on billing back water. And the problem was it was very difficult to raise the rents. We were getting a lot of resistance and doing the bill back of the water, we met with a lot of resistance. So we had nowhere else to go. It was already a hundred percent occupied because it was a new property. And so that was a plan which didn't work very well because we couldn't get those rents up. It took them a long time to get the rents up. So the lesson learned from there was that you needed to do more research on to the potential for the value-adds. And in that property, we held it for six years; we were supposed to sell in five. We held it to 6 because we drew a line in the sand as far as what price we would take and it took us an extra year before we are able to get that price in order to get the investors a fair return. But it took us an extra year. Otherwise, there wouldn't have been much much of a profit on that property. So it was a seminar. James: I mean, that's awesome that you're sharing your first lessons learned, right? Because sometimes you know, we forget that there are things that we missed out or there are things that you know, we don't really see it when you go and buy a multi-family. Sometimes you buy in a hot market and it went up 200-300%. People think that they did the work but that's not going to be the case all the time. Jeff: Well, that's basically what happened on the next property though. So the next property was a property we bought in Houston where it was a foreclosed property that we were buying it. The owner we were buying it from actually bought it as a foreclosure so he had had it for about two years. It is 62 units so he bought it for 600,000 and we bought it for 1.3 after he had it for two years and so we got it for about under 21,000 a unit. And at the time, in Houston, the values were going from 25,000 to maybe 35,000 a unit so we still bought it under market value and then in three years, we sold it for 2.7 million. And the reason we got that value part of it, it was 85 percent occupied when we got it. We got it up to 95 percent occupied. The revenue was about 36,000, we got it up to about 42,000. But also at that time, the cap rates compressed so we bought it at a 9 cap and sold it at a 7 cap. So we got the advantage of the market, the market appreciation as well as what we did for it so that was a perfect storm for us. So it completely made up for our first one, in that the investors got a 120% return on a three-year whole. So a 40% annualized return, which nobody complained about. James: Yeah, absolutely. Jeff: But that's unusual and that was totally different from the other property where the investors got a lot better than they would have in the bank, but they didn't get a fantastic return. So different properties, different deals. James: So I mean that too is conventional multifamily, right? Jeff: Yeah. James: And how many conventional multifamilies did you do before you start hitting into student housing? Jeff: Well, the next one after that actually was a student house. I mean, I was invested in another person's deal that was about 700 units 20 million dollar deal that we were in. But the next deal I did after that, actually, we broke up our partnership. My partner back decided not to do real estate anymore and I continued on my own and that's when I got a small property in Ohio. I had a 19-year-old student that went and found this property for me in Oxford, Ohio, and that's when I got into student housing. So we were talking, we mentioned earlier as far as how it getting into student housing, I really didn't plan on it. It was my intern that found the property and said, "Hey, let's get this," and the numbers look good and we got into it. So that was our first student housing deal in Oxford. James: Yeah. I mean, I'm going to go a bit deeper into that. But I mean you are now in California, you are based California, but you have been buying in McAllen, Texas and Houston and Ohio. So how did you decide on where to go or is it just whatever opportunity that comes to you? Jeff: Well, I've been pretty opportunistic, basically, when an opportunity comes in. Right now, we're kind of reversing out a little bit and trying to do more focus on markets. But at that point in time, we were just looking at opportunities and when an opportunity came we did our research on the market and did it afterward, rather than doing it up ahead of time. We decided do we really want to be in this market and if we did then we went up to the property. But it was more properties came to us from different directions. The one in Georgia, I had a lady working with me that I had trained and she developed a relationship with a broker in Georgia and that was pretty much where we got the Georgia property from, which was our next student housing property. James: So one thing I want to clarify. You said you had an intern and you have this lady that you have been training. So do you have interns working for you or do you have students that are looking for deals? Jeff: Yeah. The first one was an intern that I had trained and then after that, there was a group of people that came to me and asked me to train them and so I started training them and teaching them how to find properties. And in the last three years, we've done a couple of deals together, but they basically found the properties. Yeah, and you know that I've been training them as we've been going, showing them a lot of the different aspects of it; doing due diligence with them and taking them on the tours with a lot of those students. Since then things have changed a little bit but at that time, those were people that I have trained. James: So is it like part of your mentoring program or you just train for fun kind of thing? Jeff: It wasn't a formal mentoring program, but it was kind of a mentoring program. James: Okay got it. Jeff: But it was just more informal that I had helped people and in turn, they would bring properties in and if I like them, would go after them. Say it saves me underwriting a hundred deals to find one, they would underwrite a hundred deals, bring me one and I'd only have to look at a few of them. So much of our deals that I had to look at, you know, when they would bring them supposedly all ready to go and I would decide yay or nay on them if I liked them. James: Okay, got it. So coming back to the student housing and you said one of your interns found it. And, I mean, can you describe how did he find that deal? Jeff: Well, he was embarrassed to tell me, actually. He was embarrassed to tell me until after we had closed that he actually found in on LoopNet. And you know there are deals on LoopNet but usually, they're overpriced or maybe there's some other problem with them and it so happened that the seller was beaten up by two other buyers prior to my purchase. We got it for a much lower rate. So at the price that we got it at, it was a great deal but at the original price, it wouldn't have been. James: Got it. Got it. So let's describe the process. So this intern brought you the deal. So what are the few things that you look at the deal that you think you're going to take a second look at it? Jeff: Well, I mean several things. The one thing I had my interns do is I want to do as little work as possible myself. So I told them I want bullet points on why I want to be on that market, you know, what's the advantages of this market? With student housing, the emphasis is more on the school, but all the different reasons that this is a great market to be in and also as well as the numbers for the property itself. And basically, they have to come in and give me a sales pitch and convince me with a presentation that this is a deal I want to do. And on the regular market rate ones, you know the typical stuff with the employment and the population growth and the age of the population and all of that typical stuff that we look at. Over the student housing, it's the size of the college, the percentage of rooms available on campus versus off campus, basically, the health of the university. The location of the property, how close it is to the university, those kinds of things that we look for more so on the student housing. James: So, can you go a bit more, dig deeper into how far from the campus which you consider in campus versus other campuses? Jeff: Well, as far as what we look for, typically, we want something within a mile of the campus. My Georgia one is a block away, my Ohio one is within what they call a Mile Square. My Arizona property is a little bit farther out. It's two miles off campus and that one, it's a little bit more of a struggle but you're not going to get the prime rates and we understood that because when you're two miles out. So you want it close by the campus, you want it on the right side of the campus, rather than way away from the classrooms where people still have to walk a mile across the fields to get to campus. So you want to be on the the the closer side where the classes are but it will help you out also if you're near. the bar district or where all the hangouts are that sometimes will make up for being a little bit far from the campus. If you're where all the hangout places, the cool places are that helps you out. The other thing in student housing is the bedroom bathroom parody. If you could get a one-on-one with a one-bedroom and one bathroom that's going to be a lot better than your four twos or your 3 ones or whatever. The more bathrooms you have, they like that. Also, it seems that student nowadays, they want to share with fewer people. So a 4-2 wouldn't be as popular as a 2-1, you know where you still got two people sharing a bathroom, but you only have two people that have to get along with each other. And if you could get a 1-1, you're even better off; that they're a lot happier with. In fact, I was talking to someone the other day that I had some 4-2 that I actually split them in half and made two ones out of them. Just had to put a kitchenette in order that they have fewer people to share. James: Okay, interesting. So have you started focusing fully on student housing now or you're still doing conventional multifamily? Jeff: We're doing both because I do like the fact that people mess up student housing and it gives us an opportunity, you know, everybody we know from the groups we're in, everybody's looking for value-add multifamily, but there are fewer people looking for value-add student housing. And so that just gives me a little bit of an advantage on that. But other than that, I mean that's the main reason I'm looking at student housing is that there are fewer people looking at it and if you know what to do with the student housing, there are certainly some great opportunities. I don't think I would recommend it as somebody's first opportunity, the first investment because there is a little more risk into it, but it's a good asset class. James: So let's discuss some of the risks that's involved with student housing. So can you outline a few risks that a newbie should watch out for student housing? Jeff: Yeah. Well, part of the risk is missing the lease up window, wherein multifamily if you don't get it leased it up this month, maybe I'll lease it up next month. But on student housing, if you get it leased up by a certain time and each campus is usually different, if you don't get it leased up in time, during that time, you may be stuck with empty units for the whole year. So you've got to get it leased up during that time. The other thing is, you're going to have higher turnover and it depends on the property as well. My Georgia property, we're hardly getting any turnover because there are not a lot of other options in the market. My Ohio property there's plenty of other options so they may go from one property to another each year. Same with my Arizona property, they may switch around. So it's going to depend on what's available at their price range if there's going to be turnover. My first year on the Ohio property, I think was like 85 percent turnover, which most people will freak out thinking, you know, okay, 85% and it's all at once. It's everybody's gone at the same time. And so, you've got to turn all these units and have them ready for the new tenants coming in. So we always budget for a higher expense as far as because of the turnovers because turnovers, as we know, is one of our bigger expenses so we'll budget for that. A lot of people think that student housing, you have a lot more in the way of damage and we really haven't seen that, we haven't seen a lot of damage. And the thing is we charge back everything that's caused by the students that not that normal wear and tear. I mean, we get things; wine stains in the carpeting or iron marks where they put an iron down on the carpeting and melted the carpet, shot glasses or beer caps in the garbage disposal. We do get lockouts, you know, where were you're having to fix the door because somebody kicked it in, in order to get in or you get domestic disputes where some boyfriend goes and punches a wall because he's pissed off or something. I mean, we do get some of those but the deposits cover most of that stuff. James: Got it. I'm sure the parents will pay too, I guess. Jeff: Yeah. Yeah, if it gets beyond the deposit we have then the parents will usually jump in. James: And how much is the turnover cost that you usually budget for student housing like in conventional usually like for me I usually budget like $100 per unit, per year? Jeff: As far as for turnover? James: Yeah. Not repair and maintenance, just turn over. Jeff: Well, if we look at the overall repair and maintenance budget usually we're about five or six hundred, overall. And my student housing ones, my Ohio, I believe we're at 1,800 per units. James: Repair and maintenance? Jeff: Yeah. James: Well, that's a lot. Jeff: I have to lower that down. I don't even think we're using that but that's what I originally put it about. James: Okay. Got it. Yeah. Because usually total repair and maintenance plus turnover is like 500 to maximum $600 on conventional. Jeff: Yeah, I mean, mainly because of your turnover costs. On that property, we've been painting every wall every time we turn over. I'm not sure if we need that but we've been doing that. It's been a little bit higher. I mean, it's been higher on that one. The other one in Georgia, our turnover costs aren't nearly as much. James: And what do you expect other than, do you do anything special to reduce your turnover cost? Jeff: Well, we try to encourage re-leasing and we do give lower rates for those people that are releasing as well as if they release early, we do give them discounts on that. And in the thing is, on my Georgia property, if they release, we may keep their rents at the same rate or maybe just raise it slightly in order to keep them in because that saves us a lot of money. That saves us a lot of money on the turnovers. James: Okay, correct. What about the interior? Like carpets vs. vinyl vs metal. Jeff: Typically, I mean, we don't have to make it too fancy. But we do put, I believe in the Ohio one, we've got the role on vinyl flooring. In the bedrooms, we do have carpeting. It's just Formica countertops. We don't need to do anything fancy and that's going to depend as well on the demographics of your clients. My Ohio property is upper middle class. It's Miami University and it's probably an upper-middle-class clientele. My Georgia property is a very low economic clientele, they would be thrilled with anything we put in there. So we just kind of resurface the Formica countertops. We did some chemical wash on the showers and the tubs and repainted everything. We do have nice laminate floors in there, except for the bedrooms. The bedrooms are the only rooms with carpeting. We just painted the cabinets. From the state that they were in, what we did just totally brightened up the property. I mean, just totally changed it. They were a mess and this isn't an old property. That's a 1999 property but there was some old indoor-outdoor carpeting in the hallways that just look just totally disgusting. That we put all vinyl laminate in the hallway and it looks great now. James: Awesome. And what about during the summer? I mean a lot of them don't stay in the unit, right? So they still pay for the summer or does it get re-rent or is it vacant or what's happening? Jeff: Again, that depends on each of our markets. And the Georgia one, I believe we are 70% for this summer, which is high. I think last year we were about 60 percent during the summer. So those that are going to summer school can stay there. But in August, we'll be back up at 98 to 100% on that property. That was a property we bought at 30% occupied and now we're over 100, we're at 100 like it's not over. We're at 100% occupancy on that one. James: And what about students which is more like, you know, four-year degree versus postgraduate degree, have you tried experimenting with that? Jeff: You know, my Ohio property, we have some studio apartments and a lot of those are rented to graduates as well as young Professor. So yeah, those are great tenants if you can get them. The graduates, they're a little more mature and you never hear anything from them so those are great on some of the properties. We do have graduates in some properties, but most of them are second-year students. Typically the schools require that the students stay on campus the first year so as freshmen, so we usually get them as sophomores. James: Got it. So coming back to the demand side of it for student housing. I'm just trying to understand but I lost my train of thought here. I mean, for example, let's say the price, in terms of rent, I mean the rent is much higher compared to the normal workforce housing. Do you think that's a benefit as well? Jeff: Yes. Yes. Absolutely. And the rent is higher than we get more benefit from the additional rent than it costs us on any additional maintenance expenses. So there is a higher cost benefit that we do get from the student housing. So that's one of the things we like. The other thing that we do like also about the student housing is it is fairly recession-resilient and you know, we all know that we're at a high point in our market right now, we don't quite know what's going on, as far as where we're going to be in the economy. And student housing, historically, has done very well during down markets and that's something also that I look at when I look at properties. How well did it do during the last recession and to see how far down it dipped. And typically you find that student housing and as well as self-storage typically do well in those markets. And so that's another reason why we like looking at those deals. James: Well, yeah, I mean the rationale is people go to school when the economy is downturn right? Jeff: That's part of it. And the other thing is parents are going to try to get their kids into college as soon as they get out of high school because if they lose them to the workforce for a year or two, it's going to be really tough getting them back in. So if a parent is going to be paying for their kid, they are going to find a way to do it. Otherwise, they may not get them in the college later on. James: Got it. So, in terms of value-add and I'm sure you are trying to make your community, in terms of student housing much better than other communities. So is there one of the value-adds that you do in your community that you think, you know, you will be able to command much higher rent and much higher occupancy? Jeff: Well, the one we haven't really done is the bed to bath parity. And as I mentioned the person that broke a 4 2 into a 2 1 that was a value-add because as I said, the students prefer not to share. If you could add another bathroom, so you've got 2-2 even if it's a small little bathroom, you know, or just a makeup area with a sink that's of great value because the students now don't like to share the bathrooms. In Ohio, I've got some 4-4s, as well as some 4-2s but they love having their own private bathroom. In Arizona is all 5-2s - five bedrooms, two baths. That's not as desirable. If I could put in some other baths, I would probably you know, make people happy but that's well expensive. That's not a real cost-effective way of doing it. But also in the Georgia property, we put Wi-Fi throughout the property. So essentially, anywhere they get on the campus or on the property they've got the Wi-Fi. So that was definitely a value-add that we put into it. James: What about other things like study rooms or the Library, the community? Jeff: We just redid our office and we did put in a workspace. James: A workspace, a business center. Jeff: Yeah a business center. Exactly. We did put in a business center where they could come in and print if they need to print documents because a lot of people, a lot of the kids have their tablets or their laptops or their phones or whatever, but they may not even have printers these days. And I guess a lot of the stuff they submit right online in a PDF to their teacher whatever but we did create the business center so they could come in and print stuff out if they need to. And also have a scanner where they can scan their documents. The other thing that we were looking at but we may leave for the next owner because we are selling this property, is a picnic area. We haven't built that yet; put a picnic area with some barbecues and that kind of stuff but that's the last phase of what we've been trying to do on this property. The main thing on this property is, the students have loved it, just fixing it up so it's much more livable. It was pretty disgusting when we got there. I mean it was a nasty place and that's why it was 30% occupied. And now, we've got the premium property in the market. James: Yeah. I mean, there you go. I mean, value-add in terms of managing it. So people love that. Jeff: And then the other thing that we did on this particular property is we got a relationship with the school. We went on campus and talk to all the coaches and told them we wanted them to send their athletes over to the property. And at first, well, the track coach went and looked at us like we were from Mars and said, "Why would I want to send my kids over there?" And then we invited him to come over and look at the property to see what we have done. And now we've got a bunch of athletes over there now after they've seen the improvements we've done. We also have participated as a sponsor with the athletic department where we give them a donation every year and we've been able to get an advertisement spot on their Jumbotron during all home basketball and football games and so we've been putting our advertisement there. That's why we're essentially 100% with waiting lists on the property. You know, we got a relationship with them, we went and communicated with the police chief and the mayor. The mayor actually came out to our open house wearing one of our t-shirts, the mayor of the city. So we got really involved with the community and it's a small market but we did get involved with that and all of that essentially added value. As I said, we've got a waiting list now, we can raise rents. The main thing that we were emphasizing throughout this two-year hold, we've only had it for a little over two years, was getting the occupancy up. That was the big thing. I wanted the occupancy up, I didn't care about raising rents. Now, we've got the occupancy now, we're going to start raising rents. Or what we're doing is we're actually selling it. So we're leaving it for the next person. The next guy could come in raise rents without having to do anything. They can come in and raise rents without having to do anything just because we've redone this entire property. James: Awesome, awesome. Very, very, very, very interesting tips on how to get engage in student housing marketing. So what about financing, who gives the financing? Is it still agency loans or is it small Banks or how's that? Jeff: Well, we'll start off with the Georgia, probably. The Georgia property we paid all cash. At 30% occupied we weren't going to be looking for a lender. Yeah, my Ohio property that was a challenge and it ended up that I went with a privately owned bank. It's not a small bank, it has 36 branches so I wouldn't call it really small but it's privately held and they loan in Kentucky and Ohio, I think. So if anybody's looking for either student housing or lending, they do those two states. They're actually a Kentucky-based lender. The Arizona one was just a regular bridge lender that funded that one and eventually, we'll go out of the bridge into an agency loan. James: So you think you can get an agency loan on student housing? Jeff: Yeah. We can get an agency loan. James: Because I know usually when I go to an agency, they usually ask, you know, how many percents are students, how many percents are corporate housing and all that so I'm not sure. Jeff: Yeah, I don't remember if it's Fannie or Freddie that will do student housing. But they do require a certain population. I think it's 15,000 student population, something like that. James: Got it. Oh, really? Okay, that's interesting. Jeff: Yeah, but I don't remember which one it was but one of them will do agency. James: Yeah, that's awesome. So, let's go back to slightly more personal questions. So do you have any proud moment in your real estate career that you're going to remember for a long time, that you think 'I really, really did something that I'm really, really proud of', do you want to share that? Jeff: Oh, I could go back to the Georgia property where I had a period that I actually was brought to tears. When we were doing that video that I was talking about that we gave to the school to put on there, our advertisement, I actually went down and did the interviewing of the students myself for that property because I have a background in video. And the stuff that our property management was taking was just horrendous. I went down there and interviewed the students and I didn't tell them who I was, they didn't know I was one of the owners or the owner. And the last question I asked them was if you had an opportunity to talk to the owner or to let the ownership know, what would you tell them? And some of the answers that I got were just tearjerkers. I mean, I had one girl that said that she was so happy with her new room that she now can actually bring her mom and show her where she lived that she was actually proud of where she was living now. And some of the other students were just saying, how much safer they felt, you know, much nicer environment. We had gotten rid of all the riffraff. We had gotten rid of a lot of people that were not students, but they were just living there and just smoking dope and we had increased the security and we had the police coming by, you know, just to keep things safe. And so just talking to these kids, they're not kids, they are 19- 20-year-old, you know, young adults, but that was one of the most rewarding moments I had. Because here they were, this is a low economic area where most of these students have very disadvantaged upbringing and we were giving them a nice clean safe place to live that they can be proud of. And they appreciate it much more so than some of the other properties where we may have upper-middle-class people in there that probably don't appreciate what you're doing as much as these guys do. So that was just an absolute, you know, great opportunity to be there with these guys. James: Yeah. It's very interesting on how we as entrepreneurs and operators change people's lives and it's just so fulfilling when you do that. And for me, It means a lot. Making the money, I mean, this story, you will always remember it. Sometimes you forget about how much money you made in that deal but you will remember how you impacted people's life, which is amazing. Jeff: Yeah, I mean, that's what I think about. I mean certainly we're all going to make money on this deal, you know, a good amount once we sell this but that feeling, you know, I'll have all the time. I mean that was great, you know hearing these guys. James: So any advice that you want to give for newbies who want to walk your path in multifamily and student housing in general; if they want to be as successful as you? Jeff: The thing is, find somebody that has walked the walk. You know, it could be a mentor, it could be a formal mentor, it could be somebody that's doing it. If you find somebody in your area or someone you meet up that is successful in whatever it is they're doing, be it multifamily, student housing, you know, senior living whatever; you find somebody else that's successful and find a way of being some kind of service to them. How you can help them out and go to them with that, hey, I would like to help you out. Do something and learn from them. That's the best way to learn anything is to be working with somebody else that's doing it. You know that would be what I would do. I did some formal mentoring in the beginning and that helped me get started. I would have loved to have been working side by side with someone with more experience. As it was, my partner and I were both about at the same level when we started but being around someone that's been there and done that is a great way to start out in this business. James: Awesome. Awesome. Hey Jeff, we almost there to the end. You want to let our audience know how to reach you? Jeff: Well, you can email me jeff@synergeticig.com or you could go to my website, which is also www.synergeticig.com You could also get a hold of me at Bigger Pockets and I'm around on the forms a little bit. James: Yeah, I remember when I was starting in real estate, I used to see you a lot on Bigger Pockets. So it's good. Jeff: I haven't been on as much lately. I need to start renewing some of that but I was on a lot in the beginning. That got me a lot. I mean it got me on my first podcast so... James: Awesome. Awesome. Well, Jeff, thanks for adding value to our listeners and audience here. I'm sure we learned a lot. I learned a lot as well, in terms of student housing and the nuances of how to add value in student housing and how to operate and at least look at the deal. And so it was very good to have you here, and that's it. Thank you very much and talk to you soon. Jeff: Thank you.
Jeff & Will talk about their past week of business decisions and the coming week they’ll spend at the Podcast Movement conference. They also remind the authors in the audience to check out the new Big Gay Author Podcast. The guys talk about the production of The Wiz they just saw as well as the current season of Pose. Together they review Lucy Lennox’s Wilde Love and Jeff reviews Dreadnought by April Daniels. Amber Smith joins Jeff to talk about her young adult novel Something Like Gravity. Amber reveals how the characters of Chris and Maia had been the main characters in different books before she decided they’d be great together in a single book. Amber also discusses how she got started writing, the trademarks of her books and the research she does to create her characters. Complete shownotes for episode 201 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript – Amber Smith This transcript was made possible by our community on Patreon. You can get information on how to join them at patreon.com/biggayfictionpodcast. Jeff: Welcome Amber to the podcast. It is great to have you here. Amber: Thank you so much for having me. I’ve been really looking forward to this. Jeff: So I reviewed ‘Something Like Gravity’ back in episode 195 and it was the summer book that I didn’t know I was looking for. I’d like you to start us off by telling everybody, in your own words, what this book is about. Amber Well, this book is about a lot of things, but really, at its center, it’s a story about falling in love for the first time and finding yourself in the process. It’s told between our two main characters, Chris and Maia, and both of them are going through a really difficult time in each of their lives. Chris has recently come out as transgender and he’s really trying to figure out how to navigate his life now that everything’s suddenly changing, and he’s also trying to process this really terrifying assault that he survived the year earlier. Maia is dealing with the recent death of her older sister. And so both of their lives look very different, but the one thing that they have in common that brings them together is that they’re both trying to figure out who they are going to become in the face of these life changing events that they’ve been through. Jeff: What was your inspiration behind the book? Amber: There are various threads of inspiration, but it’s funny, I actually started writing this book as two separate books. Chris was the protagonist of one and Maia was the protagonist of the other. And I do generally work on two things at the same time because, if I get stuck on one I can sort of hop over to the other thing I’m working on. I always thought of these as separate books in the beginning and Chris’s story was primarily about coming out, and being queer, and being trans, and trying to figure all of that out. And Maia’s was a story about grief. At a certain point, I think it became too hard for me to continue working on these stories because both of them were super personal. I was drawing from a lot of my own experiences with coming out as a lesbian and also, you know, dealing with the loss of loved ones myself. At a certain point, I thought, you know what can I do to kind of make this easier on myself? And I thought about giving Chris a love interest. And when I started to think about what would be the kind of person that would be really good for Chris, and would kind of balance him out, and all of those wonderful things that happen in a relationship. I immediately thought of Maia – this other character that I was writing, and that’s when I realized, oh my gosh, I think these stories were always meant to be one story. And it just took me a while to realize it. Jeff That’s amazing to me on a couple of levels. I can’t do two projects at once because it makes my head want to explode. But also there’s – just coming back to the title, ‘Something Like Gravity’ is like gravity just pulled between these two stories and brought these two together from the disparate places that you had them. Did the characters fundamentally change when you brought them together or did everything just click into place once that happened? Amber: Well, not necessarily so. I think the biggest part was that I had been working on these stories for so long. I don’t think much of my original writing made it into the final book. I think doing that writing on both of the stories prior to lining them as one, really helped me to get to know each character in that sense because, I knew each of them so well, I knew their voices, I knew their histories. It was sort of easy to bring them together, but I had to rewrite everything better. I think it was almost like telling the stories of two people I knew really well already. Jeff: Any chance that those original stories get to become prequels or something? Amber: Oh my gosh I love that idea. Something to think about. Jeff: As you noted, I see both Chris and Maia have these weighty things that they’re dealing with on both sides. What was your process to present that authentically to the readers? Amber: I always, whenever I’m starting a story, I begin with my own experience and I always sort of view writing as therapy in a way. So like Chris and Maia’s experiences start out as something very real that’s happened in my life. But then as I write them they become something else. So, I don’t know. I think I just always have in the back of my mind the roots – like emotion, or the emotional world that I lived in as kind of the parameters for this story. And so hopefully that helps to keep things feeling real and authentic. Jeff: And then you put the love story in with this. The way that you counterbalance what they’re going through with this super sweet love story. It was unique to me how that worked because for some of the story at least, they’re almost not dealing with their issues because they’re finding this in each other. How did that kind of all mix together for you? Amber: I think one of the things I’ve realized as I was writing the book, separately in the beginning, was that I was focused so much on the pain that each of these characters felt. I’ve written about trauma, and assault, and grief, in the past and it felt like I was sort of rehashing – or reopening old wounds of my own. I just thought I really need to do something different here. And it took me a while to figure out that I wanted this to be a love story because, as you know, it took me a while to kind of wrap my head around why was I writing it that way in the first place? I had this switch flipped in my mind when I started to think about the love story aspect of, you know, what I’d love to do with this book is make love be more powerful than the pain that each of them were experiencing. And so that kind of helped me to steer this story in a different direction. And then when I really started thinking about it, that love, and connection, and relationships, those are the things that really helped me heal during the hardest times in my life. And so I think it can be so easy to focus on the darkness sometimes but, when I really thought about even my own life, I realized the things that really got me out of those dark places were my connections with other people, and learning how to love myself, and falling in love for the first time. And so that became something I want to do – explore more than that other side of things. Jeff: And it’s interesting too that essentially the secondary story for both characters is their relationship with their parents. For Chris it’s his parents coming to understand that Chris has come out as trans, and for Maia they’re going through the same grief that she is, having lost their daughter. How did you approach layering that in? Because, again, you’ve balanced this out so beautifully, how it just all kind of ebbs and flows together – but there’s a lot in play here. Amber: Oh thank you. You know, I think the family dynamics with each of the characters – I will say that’s the one thing that kind of carried over when I was working on these as separate books. In my original ideas for both Chris and Maia, one of the big things that they were dealing with were these really complicated family issues that were going on. Yeah. So I think I just I always knew from the beginning I wanted part of their journeys to be trying to work out all of this messy, complicated, emotional stuff with their families and with themselves. I don’t really know how I layered it in because I think it was just always in the back of my mind that that stuff needed to be there. And I had thought of Chris and Maia’s relationship, the way that they grow and discover more about themselves, as kind of the framework of getting to the place where they were able to deal with their family stuff because they evolved too. Jeff: Did you have to do a lot of research? In your acknowledgments in the book you list out a whole bunch of people and things that you looked at to help craft all this, and so it seems like there was quite a bit that went on to create the characters, and create the situations, and then, as we kind of talked about it a little bit, getting it authentically on the page. Amber: For this book in particular I really reached out to a lot of different readers and friends, people who have gone through similar things to Chris and Maia. So I had friends, who identify as trans or non binary, read different sections of the book looking at Chris’s perspective. I even had a professor at one of the universities here in North Carolina really go through the entire manuscript with a fine tooth comb because, while in particularly looking at Chris’s side of the story because even though I kind of started with a kernel of my own experience, for Chris as a queer person. I’m not transgender, so I wanted to be very careful that I wasn’t doing anything in my narrative, and my representation, that would be in any way harmful or misrepresenting Chris as a transman. And so that was super super helpful. I found that the areas that I was really worried about in Chris’s story, were not the areas that were pinpointed by my readers as being problematic. I think that goes to show, it really was important for me to seek out those other perspectives, because the things that I thought might be issues were not what they thought were issues. So yeah, that was a really big process… getting that feedback from those other readers. Jeff: One of the things I’d mentioned in my review, what struck me about the book, is a sweet love story, two characters with trauma, and yet the book itself kind of felt like this lazy summer vacation. I think some of it is because of where it set. So it’s a small town, and you’ve got Chris and Maia essentially living on farms and separated by this field, and I could just envision hanging out on the porch, and just kind of letting the summer go by. Bike rides, and these adventures they went on – where they went to the to the adjacent town to check things out. And it really kind of held the story together – and kind of kept it in this very innocent place. Was that deliberate, or did it just happen that way, because of how it all pieced together as you were going? Amber: You know, that part of this story really was deliberate. Once I started trying to figure out how to weave Chris and Maia’s stories together, I really sat down and I did a lot of pragmatic planning and plotting, which is not something I usually do at all. I think I knew trying to combine two stories, I really had to know where I was going because it could get really confused. So one of the first things I decided was the setting and the timeframe. I decided I wanted it to take place in a rural North Carolina town, which Carson is fictional, but it’s based on a lot of the small towns on the outskirts of Charlotte where I live. I knew I wanted it to take place across the course of one summer and I did that partially because of that feel that you’re talking about. I really wanted to give Chris and Maia a space where it felt like their lives and their realities are somewhat suspended for a little bit of time, so that they could have the freedom to figure out what they’re going to do, figure out how to process what’s happened in their lives. And I always felt, growing up, summer is sort of this weird Time Warp kind of area, where things just don’t happen in the same way as the rest of the year. And so I definitely wanted to bring in that kind of like lazy feel because it feels like we have all the time in the world, but of course, we know summer only last so long. That’s also a little bit of a ticking clock I could put in there. Jeff: What do you hope readers take away from the book? Amber: I really wanted readers to be able to look at Chris and Maia’s story and find pieces of themselves in each of these characters. Even if a reader isn’t trans, or queer, or grieving, I hope that they might be able to find some commonality with Chris and Maia. And maybe that’s just the simple fact of being able to relate to falling in love for the first time, but that for people who do identify with the things that Chris and Maia are going through, maybe if the reader is trans, or non-binary, or going through a major loss, or some kind of upheaval in their lives, I would hope that they could look at Chris and Maia as a way of knowing that there are people in the world who understand what they’re going through and they’re not alone. Jeff: Let’s talk a little bit about Amber Smith’s origin story. What got you into writing and coming specifically into writing these powerful young adult books? Because this is not your first one that deals with weighty material. Amber: I sort of came to writing in a very roundabout way – as a lot of people do. So, when I was growing up, I always wrote. I always kept journals. And when I was a little bit older, like a teenager, I wrote poetry, but all of my writing was very personal and not something I would ever show anyone. It was more like therapy. Like, even when I was a little kid, I remember the little diaries. And it was like I would just write about what happened that day, just sort of like dumping everything out of my head. So I was actually much more involved in the visual arts all throughout my life. That’s what I really focused on when I was in high school. I ended up going to college for painting. I had my BFA in painting and then I went on to get my master’s in art history because I had worked in some art gallery settings as an undergrad and I was like, “You know, I think I want to be a part of this whole art world in this way, maybe not as an artist, but as someone who kind of brings art to people.” And so I did that for a long time. I was working in my role as a curator, and during that time I was doing a lot of writing for my work, but it was more writing about art history and biography-type writing. Even though I loved what I was doing in the art museum world, I really missed working on my own creative stuff and so it was then that I really looked at writing as, not just a therapeutic outlet, but it became more of my creative outlet, and that’s when I started working on my first book. That first book actually started out as very much therapeutic writing and then the longer I spent with this story, it kind of morphed into something more fictional, and I’ve I guess I was sort of hooked at that point. I realized, “Wow, you know, I can really do a lot with fiction.” And it was really healing, just like when you read a fictional book, it can be a lot easier to sometimes relate to a fictional character and have empathy for their situation, and kind of see the big picture more so than we can sometimes do for ourselves. And that’s sort of what writing became for me very early on. That’s how I got here. Jeff: That’s a good story. I like how you went from essentially one creative expression to another – from creating works of art to now creating a different work of art, if you will. Amber: ‘Something Like Gravity’ is the first book where I’ve been able to kind of bring in some of my art background. So that was really fun. Jeff: Yeah, with Maia’s photography, I could see how that could bridge that gap a little bit. Amber: Yeah. Jeff: What would you say is the trademark of an Amber Smith book? Amber: I would say the trademark is the story is going to be emotional. It’s going to deliver some difficult stuff and it’s going to be very real. So I definitely don’t like to kind of sugar coat things all that much, so it can be a little gritty. Jeff: Gritty is a good word for it actually, having now read this one. Who are some of your author influences? Amber: Oh, you know, some of the authors who really influenced me the most are the authors that I read when I was in high school. I remember YA wasn’t necessarily a thing yet when I was a younger teenager, but in my senior year of high school I remember there were several books that came out right at that time and I was a big nerd, so I volunteered at my school library, and my librarian was like my best friend, so she would give me all of the books that were coming in – for me to take home and read her first, before anybody else. I remember reading ‘Speak’ by Laurie Halse Anderson. And that book really stands out for me. It just changed my life because I think it was one of the first times I remember feeling like a book truly brought me this deep sense of comfort. I was seen and understood. I was not alone. And that really stayed with me. And then there were other books that came out right around that time, ‘The Perks of Being a Wallflower’. That was a huge book for me that I read when I was in high school. Let’s see. Sonya Sones, her debut, ‘Stop Pretending’ came out and it was written in verse. And that was also the first time I had read something like that and it really made an impact. I think back to those books I read when I was a teenager, and the ones that really affected me were those ones that were about really serious issues, and they are the ones that made me feel like I was not alone. There was hope things could get better. I guess that’s sort of where I’m coming from now as a writer. What were the stories I needed when I was a teenager? Jeff: And what’s coming up next for you? Amber: Well, I’m not entirely sure. I have a couple of things in the works. I’m pretty sure what is going to be next is going to be a middle grade book. So, going a little bit younger. So that’s really exciting. I’ve been wanting to kind of explore different genres. I think back, middle school was actually a lot more traumatic for me than high school. So it’s funny I haven’t gone there yet. Jeff: I look forward to seeing what that could be because, over time, I’ve read some really compelling middle grade books. Amber: Yeah. Things that have been coming out recently too are just amazing. Jeff: What’s the best way for everyone to keep up with you online so they can follow along with what you’re doing and when new stuff comes out? Amber: I always keep updates going on my website ambersmithauthor.com, but I’m most active on Instagram. On Instagram I’m @ambersmithauthor. I’m also on Twitter as asmithauthor and Facebook as well. So definitely keep up with me there. I love hearing from readers, and I just I get so excited when I see messages come in from you guys. Jeff: Fantastic. We’ll link up to all those places, the books we talked about, and of course, ‘Something Like Gravity’. Wish you the best of luck with that as this summer continues this year. Amber: Thank you so much.
Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours. Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin. Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage! Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!! Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first... Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function. Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year. Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone. Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure. Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin. Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications. Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin. Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin. Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently. Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin. Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine. Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism. Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding. Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies. Jeff: First up is CT. There are no clear cut guidelines here, so Drs. Maher and Taub had to rely on observational studies and expert opinion. Remember, most standard guidelines and tools, like the canadian and nexus criteria, are less accurate in anticoagulated patients, so they shouldn’t be applied. Instead, most studies recommend a low threshold for head imaging, even with minor trauma, in the setting of DOAC use. Nachi: That is so important that it’s worth repeating. Definitely have a low threshold to CT the head for even minor head trauma patients on DOACs. Basically, if you’re on anticoagulation, and you made it to the ED for anything remotely related to your head, you probably win a spin. Jeff: I suspect you are not alone with that stance... There is, however, much more debate about the utility of follow up imaging and admission after a NEGATIVE scan. Nachi: Wait, is that a thing I should routinely be doing? Jeff: Well there’s not great data here, but in one observational study of 1180 patients on either antiplatelet or anticoagulant therapy, a half a percent of them had positive findings 12 hours later, and importantly none required surgical intervention. Nachi: Certainly reassuring. And for those with positive initial imaging, the authors recommend repeat imaging within 4-6 hours in consultation with neurosurgical services or even earlier in cases of unexpected clinical decline. Jeff: Interestingly, though only a small retrospective study of 156 patients, one study found markedly reduced mortality, 4.9% vs 20.8% in those on DOACs vs warfarin with traumatic intracranial hemorrhage. Nachi: Hmm that actually surprises me a bit with the ease of reversibility of warfarin. Jeff: And we’ll get to that in a few minutes. But next we should talk about ultrasound. As always with trauma, guidelines recommend a FAST exam in the setting of blunt abdominal trauma. The only thing to be aware of here is that you should have an increased index of suspicion for bleeding, especially in hidden sites like the retroperitoneum. Nachi: And just as with traumatic head bleeds, a small observational study of those with blunt abdominal trauma found 8% vs 30% mortality for those on DOACs vs warfarin, respectively. Jeff: That is simply shocking! Let’s also talk lab studies. Hemoglobin and platelet counts should be obtained as part of the standard trauma work up. Assessing renal function via creatinine is also important, especially for those on agents which are renally excreted. Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. DOAC levels may be indicated in certain specific situations, such as while treating life-threatening bleeding, development of venous thromboembolism despite compliance with DOAC therapy, and treating patients at risk for bleeding because of an overdose. Jeff: In terms of those who require surgery while on a DOAC - if urgent or emergent, the DOAC will need to be empirically reversed. For all others, the recommendation is to wait a half life or even multiple half-lives, if possible, in lieu of level testing. Nachi: Coagulation tests are up next. Routine PT and PTT levels do not help assess DOACs, as abnormalities on either test can suggest the presence of a DOAC, but the values should not be interpreted as reliable measures of either therapeutic or supratherapeutic clinical anticoagulant effect. Jeff: Dabigatran may cause prolongation of both the PT and the PTT, but the overall correlation is poor. In addition, FXa inhibitors may elevate PT in a weakly concentration dependent manner, but this may only be helpful if anti-fXa levels are unavailable. Nachi: Which is a perfect segway into our next test - anti-factor Xa level activity. Direct measurements of the anti-Fxa effect demonstrates a strong linear correlation with plasma concentrations of these agents, but the anticoagulant effect does not necessarily follow the same linear fashion. Jeff: Some labs may even have an anti-FXa effect measurement calibrated specifically to the factor 10a inhibitors. Nachi: While measuring thrombin time is not routinely recommended, the result of thrombin time or dilute thrombin time does correlate well with dabigatran concentrations across normal ranges. Jeff: And lastly, we have the Ecarin clotting time. Ecarin is an enzyme that cleaves prothrombin to an active intermediate that can be inhibited by dabigatran in the same way as thrombin. The ECT is useful for measuring dabigatran concentration - it’s not useful for testing for FXa inhibitors. A normal ECT value could be used to exclude the presence of dabigatran. Nachi: So I think that rounds out testing. Let’s move into the treatment section. Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Tourniquet application, direct pressure, endoscopy for GI bleeds, etc... should all be used as needed. And most importantly, for airway bleeding, pericardial bleeding, CNS bleeding, and those with hemodynamic instability or overt bleeding, those with a 2 point drop in their hemoglobin, and those requiring 2 or more units of pRBC - they all should be considered to have serious, life threatening bleeds. This patient population definitely requires reversal agents, which we’re getting to in a minute. Nachi: A type and screen should also be sent with the plan to follow standard transfusion guidelines, with the goal of a hemoglobin level of 7, understanding that in the setting of an active bleed, the hemoglobin level will not truly be representative. Jeff: Interestingly, in the overdose literature that’s out there, bleeding episodes appear to be rare - occurring in just 5% of DOAC overdose cases. Nachi: Finally, onto the section we’ve all been waiting for. Let’s talk specific reversal agents. Praxbind is up first. Jeff: Idarucizumab or Praxbind, is the reversal agent of choice for dabigatran (which is also called pradaxa). According to data from the RE-LY trial, it reverses dabigatran up to the 99th percentile of levels measured in the trial. Nachi: And praxbind should be given in two 2.5 g IV boluses 15 minutes apart to completely reverse the effects of dabigatran. Jeff: As you would expect given this data, guidelines for DOAC reversal recommend it in major life-threatening bleeding events for patients on dabigatran. Nachi: Next up is recombinant coagulation factor Xa (brand name Andexxa), which was approved in 2018 for the FXa inhibitors. This recombinant factor has a decoy receptor for the FXa agents, thus eliminating their anticoagulant effects. Jeff: Recombinant factor Xa is given in either high or low dose infusions. High dose infusions for those on rivaroxaban doses of >10 mg or apixaban doses >5 mg within the last 8 hours and for unknown doses and unknown time of administration. Low dose infusions should be used for those with smaller doses within the last 8 hours or for last doses taken beyond 8 hours. Nachi: In one trial of 352 patients, recombinant factor Xa given as an IV bolus and 2 hour infusion was highly effective at normalizing anti-FXa levels. 82% of the assessed patients at 12 hours achieved hemostasis, but there were also thrombotic events in 10% of the patients at 30 days. Jeff: And reported thrombotic events aren’t the only downside. Though the literature isn’t clear, there may be limited use of recombinant factor Xa outside of the time of the continuous infusion, and even worse, there may be rebound of anti-Fxa levels and anticoagulant effect. And lastly, the cost is SUBSTANTIAL. Nachi: Is there really a cost threshold for stopping life threatening bleeding…? Jeff: Touche, but that means we need to save it for specific times and consider other options out there. Since this has only been around for a year or so, let’s let the literature play out on this too... Nachi: And that perfectly takes us into our next topic, which is nonspecific reversal agents, starting with prothrombin complex concentrate, also called PCC. Jeff: PCC is FDA approved for rapid reversal of vitamin K antagonist-related hemorrhagic events and is now being used off label for DOAC reversal. Nachi: PCC comes in 3 and 4 factor varieties. 3-factor PCC contains factors 2, 9, 10 and trace amounts of factor 7. 4 factor PCC contains factors 2, 9 10, as well as purified factor 7 and proteins C and S. Jeff: Both also contain trace amounts of heparin so can’t be given to someone with a history of HIT. Nachi: PCC works by overwhelming the inhibitor agent by increasing the concentration of upstream clotting factors. It has been shown, in healthy volunteers, to normalize PT abnormalities and bleeding times, and to achieve effective bleeding control in patients on rivaroxaban, apixaban, and edoxaban with major bleeding events. Jeff: In small studies looking at various end points, 4 factor PCC has been shown to be superior to 3 factor PCC. Nachi: Currently it’s given via weight-based dosing, but there is interest in studying a fixed-dose to decrease both time to medication administration and cost of reversal. Jeff: Guidelines currently recommend 4F PCC over 3F PCC, if available, for the management of factor Xa inhibitor induced bleeding, with studies showing an effectiveness of nearly 70%. As a result, 4F PCC has become an agent of choice for rapid reversal of FXa inhibitors during major bleeding events. Nachi: Next we have activated PCC (trade name FEIBA). This is essentially 4Factor PCC with a modified factor 7. Though traditionally saved for bleeding reversal in hemophiliacs, aPCC is now being studied in DOAC induced bleeding. Though early studies are promising, aPCC should not be used over 4factor PCC routinely as of now but may be used if 4Factor PCC is not available. Jeff: Next we have recombinant factor 7a (trade name novoseven). This works by activating factors 9 and 10 resulting in rapid increase in thrombin. Studies have shown that it may reverse the effect of dabigatran, at the expense of increased risk of thrombosis. As such, it should not be used as long as other agents are available. Nachi: Fresh Frozen Plasma is the last agent to discuss in this section. Not a lot to say here - FFP is not recommended for reversal of any of the DOACs. It may be given as a part of of a balanced massive transfusion resuscitation, but otherwise, at this time, there doesn’t seem to be a clear role. Jeff: Let’s move on to adjunct therapies, of which we have 3 to discuss. Nachi: First is activated charcoal. Only weak evidence exists here - but, according to expert recommendations, there may be a role for DOAC ingestions within 2 hours of presentations. Jeff: Perhaps more useful than charcoal is our next adjunct - tranexamic acid or TXA. TXA is a synthetic lysine analogue with antifibrinolytic activity through reversible binding of plasmin. CRASH-2 is the main trial to know here. CRASH-2 demonstrated reduced mortality if given within 3 hours in trauma patients. There is very limited data with respect to TXA and DOACs specifically, so continue to administer TXA as part of your standard trauma protocol without modification if the patient is on a DOAC, as it’s likely helpful based on what data we have. Nachi: Next is vitamin K - there is no data to support routine use of vitamin K in those taking DOACs - save that for those on vitamin K antagonists. Jeff: Also, worth mentioning here is the importance of hematology input in developing hospital-wide protocols for reversal agents, especially if availability of certain agents is limited. Nachi: Let’s talk about some special circumstances and populations as they relate to DOACs. Patients with mechanical heart valves were excluded from the major DOAC trials. And of note, a trial of dabigatran in mechanical valve patients was stopped early because of bleeding and thromboembolic events. As such, the American College of Cardiology state that DOACs are reasonable for afib with native valve disease. Jeff: DOACs should be used with caution for pregnant, breastfeeding, and pediatric patients. A case series of 233 pregnancies that occurred among patients on a DOAC reported high rates of miscarriage. Nachi: Patients with renal impairment are particularly concerning as all DOACs are dependent to some degree on renal elimination. Current guidelines from the Anticoagulation Forum recommend avoiding dabigatran and rivaroxaban for patients with CrCL < 30 and avoiding edoxaban and betrixaban for patients with CrCl < 15. Jeff: A 2017 Cochrane review noted similar efficacy without increased risk of major bleeding when using DOACs in those with egfr > 30 (that’s ckd3b or better) when compared to patients with normal renal function and limited evidence for safety below this estimated GFR. Nachi: Of course, dosing with renal impairment will be different. We won’t go into the details of that here as you will probably discuss this directly with your pharmacist. Jeff: We should mention, however, that reversal of the anticoagulant in the setting of renal impairment for your major bleeding patient is exactly the same as we already outlined. Nachi: Let’s move on to some controversies and cutting-edge topics. The first one is a pretty big topic and that is treatment for ischemic stroke patients taking DOACs. Jeff: Safety and efficacy of tPA or endovascular therapy for patients on DOACs continues to be debated. Current guidelines do not recommend tPA if the last DOAC dose was within the past 48 hours, unless lab testing specific to these agents shows normal results. Nachi: Specifically, the American Heart Association suggests that INR and PTT be normal in all cases. ECT and TT should be tested for dabigatran. And calibrated anti-FXa level testing be normal for FXa inhibitors. Jeff: The AHA registry actually included 251 patients who received tpa while on DOACs, which along with cohort analysis of 26 ROCKET-AF trial patients, suggest the risk of intracranial hemorrhage is similar to patients on warfarin with INR < 1.7 and to patients not on any anticoagulation who received tpa. However, given the retrospective nature of this data, we cannot exclude the possibility of increased risk of adverse events with tpa given to patients on DOACs. Nachi: Endovascular thrombectomy also has not been studied in large numbers for patients on DOACs. Current recommendations are to discuss with your stroke team. IV lysis or endovascular thrombectomy may be considered for select patients on DOACs. Always include the patient and family in shared decision making here. Jeff: There are also some scoring systems for bleeding risk to discuss briefly. The HAS-BLED has been used to determine bleeding risk in afib patients taking warfarin. The ORBIT score was validated in a cohort that included patients on DOACs and is similarly easy to use, and notably does not require INR values. Nachi: There is also the ABC score which has demonstrated slightly better prediction characteristics for bleeding risk, but it requires high-sensitivity troponin, limiting its practical use. Jeff: We won’t say more about the scoring tools here, but would recommend that you head over to MD Calc, where you can find them and use them in your practice. Nachi: Let’s also comment on the practicality of hemodialysis for removal of the DOACs. Multiple small case series have shown successful removal of dabigatran, given its small size and low protein binding. On the other hand, the FXa inhibitors are less amenable to removal in this way because of their higher protein binding. Jeff: Worth mentioning here also - dialysis catheters if placed should be in compressible areas in case bleeding occurs. The role of hemodialysis for overdose may be limited now that the specific reversal agent, praxbind, exists. Nachi: In terms of cutting-edge tests, we have viscoelastic testing like thromboelastography and rotational thromboelastometry. Several studies have examined the utility of viscoelastic testing to detect presence of DOACs with varying results. Prolongation of clotting times here does appear to correlate with concentration, but these tests haven’t emerged as a gold standard yet. Jeff: Also, for cutting edge, we should mention ciraparantag. And if you’ve been listening patiently and just thinking to yourself why can’t there be one reversal agent to reverse everything, this may be the solution. Ciraparantag (or aripazine) is a universal anticoagulant reversal agent that may have a role in all DOACs and heparins. It binds and inactivates all of these agents and it doesn’t appear to have a procoagulant effect. Nachi: Clinical trials for ciraparantag have shown rapid and durable reversal of edoxaban, but further trials and FDA approval are still needed. Jeff: We’ve covered a ton of material so far. As we near the end of this episode, let’s talk disposition. Nachi: First, we have those already on DOACs - I think it goes without saying that any patient who receives pharmacological reversal of coagulopathy for major bleeding needs to be admitted, likely to the ICU. Jeff: Next we have those that we are considering starting a DOAC, for example in someone with newly diagnosed VTE, or patients with an appropriate CHADS-VASC with newly diagnosed non-valvular afib. Nachi: With respect to venous thromboembolism, both dabigatran and edoxaban require a 5 day bridge with heparin, whereas apixaban and rivaroxaban do not. The latter is not only easier on the patient but also offers potential cost savings with low risk of hemorrhagic complications. Jeff: For patients with newly diagnosed DVT / PE, both the American and British Thoracic Society, as well as ACEP, recommend using either the pulmonary embolism severity index, aka PESI, or the simplified PESI or the Hestia criteria to risk stratify patients with PE. The low risk group is potentially appropriate for discharge home on anticoagulation. This strategy reduces hospital days and costs with otherwise similar outcomes - total win all around. Nachi: Definitely a great opportunity for some shared decision making since data here is fairly sparse. This is also a great place to have institutional policies, which could support this practice and also ensure rapid outpatient follow up. Jeff: If you are going to consider ED discharge after starting a DOAC - there isn’t great data supporting one over another. You’ll have to consider patient insurance, cost, dosing schedules, and patient / caregiver preferences. Vitamin K antagonists should also be discussed as there is lots of data to support their safety outcomes, not to mention that they are often far cheaper…. As an interesting aside - I recently diagnosed a DVT/PE in an Amish gentleman who came to the ED by horse - that was some complicated decision making with respect to balancing the potentially prohibitive cost of DOACs with the massive inconvenience of frequently checking INRs after a 5 mile horseback ride into town... Nachi: Nice opportunity for shared decision making… Jeff: Lastly, we have those patients who are higher risk for bleeding. Though I’d personally be quite uneasy in this population, if you are to start a DOAC, consider apixaban or edoxaban, which likely have lower risk of major bleeding. Nachi: So that’s it for the new material for this month’s issue. Certainly, an important topic as the frequency of DOAC use continues to rise given their clear advantages for both patients and providers. However, despite their outpatient ease of use, it definitely complicates our lives in the ED with no easy way to evaluate their anticoagulant effect and costly reversal options. Hopefully all our hospitals have developed or will soon develop guidelines for both managing ongoing bleeding with reversal agents and for collaborative discharges with appropriate follow up resources for those we send home on a DOAC. Jeff: Absolutely. Let’s wrap up with some the highest yield points and clinical pearls Nachi: Dabigatran works by direct thrombin inhibition, whereas rivaroxaban, apixaban, edoxaban, and betrixaban all work by Factor Xa inhibition. Jeff: The DOACs have a much shorter half-life than warfarin. Nachi: Prehospital care providers should ask all patients about their use of anticoagulants. Jeff: Have a low threshold to order a head CT in patients with mild head trauma if they are on DOACs. Nachi: For positive head CT findings or high suspicion of significant injury, order a repeat head CT in 4 to 6 hours and discuss with neurosurgery. Jeff: Have a lower threshold to conduct a FAST exam for blunt abdominal trauma patients on DOACs. Nachi: Assessment of renal function is important with regards to all DOACs. Jeff: While actual plasma concentrations of DOACs can be measured, these do not correspond to bleeding outcomes and should not be ordered routinely. Nachi: The DOACs may cause mild prolongation of PT and PTT. Jeff: Idarucizumab (Praxbind®) is an antibody to dabigatran. For dabigatran reversal, administer two 2.5g IV boluses 15 minutes apart. Reversal is rapid and does not cause prothrombotic effects. Nachi: Recombinant FXa can be used to reverse the FXa inhibitors. This works as a decoy receptor for the FXa agents. Jeff: Vitamin K and FFP are not recommended for reversal of DOACs. Nachi: Consider activated charcoal to remove DOACs ingested within the last two hours in the setting of life-threatening hemorrhages in patient’s on DOACs. Jeff: Hemodialysis can effectively remove dabigatran, but this is not true for the FXa inhibitors. Nachi: 4F-PCC has been shown to be effective in reversing the effects of the FXa inhibitors. This is thought to be due to overwhelming the inhibitor agent by increased concentrations of upstream clotting factors. Jeff: tPA is contraindicated in acute ischemic stroke if a DOAC dose was administered within the last 48 hours, unless certain laboratory testing criteria are met. Nachi: Emergency clinicians should consider initiating DOACs in the ED for patients with new onset nonvalvular atrial fibrillation, DVT, or PE that is in a low-risk group. Jeff: So that wraps up Episode 31! Nachi: As always, 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 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 any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: And the address for this month’s cme credit is www.ebmedicine.net/E0819, so head over there to get your CME credit. As always, the [DING SOUND] 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!
In today's podcast Mason chats to Jeff Chilton. Jeff has been working in the medicinal mushroom industry since 1973 and is an absolute specialist in his field. Jeff is the founder of Nammex, the leading supplier of organic mushroom extracts in the world today. With over 40 years of mushroom growing experience, Jeff was one of the first people to bring mushroom extracts to the North American market. All you medicinal mushroom nerds out there make sure you catch this episode, Jeff is a deep reservoir of knowledge and insight! The gents wax lyrical over: The ins and outs of mushroom harvesting. The difference between products made from mushroom mycelium as opposed to their fruiting body. Cordyceps Cs-4. The inferior nature of grain grown medicinal mushroom products. The nature of the medicinal mushroom industry at large, and what to look out for in regards to quality and authenticity. Following your passion in business. Retaining your integrity in the mushroom industry. Polysaccharides and betaglucans. China as a superior source Who is Jeff Chilton ? Resources Q: How Can I Support The SuperFeast Podcast? A: Tell all your friends and family and share online! We’d also love it if you could subscribe and review this podcast on iTunes. Or check us out on Stitcher :)! Plus we're on Spotify and Soundcloud! Check Out The Transcript Here: Time to talk tonic herbalism people. Maybe some medicinal mushrooms and philosophy for longevity, so pour yourself a tonic and get ready to get super human, baby. Let's start the show! Mason: Hello everybody. Welcome back to the podcast. Got one that, I've been really looking forward to doing this interview. Jeff Chilton, I'll go into a little breakdown now, rather than just jumping ahead to why I'm really into his work. He's been in the mushroom industry since 1973. When it comes to mushroom cultivation, back then, he was really pioneering. Especially, a lot of the mushrooms that we have available today via cultivation in the west. Mason: He had a lot to do with the developing the manufacturing of those. Then in 1989, switched over to the manufacturing of medicinal mushroom extract, so he's OG in this medicinal mushroom world. There was no real trending back then. And I, like him, we met two years ago at a herbal symposium in Oregon. That's when I really ... super aware of him and just how he was just via just his own integrity and just educating the market. Mason: He became this internal watchdog of the industry. Just in the sense of just calling out real bad practices that are going on in the medicinal mushroom industry, and still today, and educating people, so you can spot a product on the market which is telling fibs, and really doesn't have the good stuff that we have all come to know and love about medicinal mushrooms. Mason: So NAMMEX is his company, also Real Mushrooms, and I love the fact that we can sit down as colleagues, offering medicinal mushrooms, having more at it from the Taoist perspective and Jeff just rocking gin that specialization of mushrooms and especially being such an originator of the entire industry. I really love to be able to sit down, talk with him and ask him about the history, especially he's really been shining in educating people about the difference between growing medicinal mushrooms on wood and on mycelium. And we dive into nuances of that. Mason: Basically we talk about the industry and we talk about setting up relationships in China and just how amazing it is to be able to source really incredible, the most high quality mushrooms that you're gonna be able to get in the world outside of a wild cultivated situation. Where we are talking about medicinal qualities. Getting those from China and being able to educate people about the beauty of getting them from China. We talk a little bit about that. Mason: Also what it's taken for us to develop the relationships with growers and farmers and so I think you'll find it really interesting hearing me from 2011, Jeff from 1989 really navigating the difference in our stories. As well we go into organic because Jeff has pioneered in getting the first certified organic mushroom supplement in the US which is really amazing. We go a little bit into that, I share my two cents on where I see organic is at. More so the reason why I like Jeff is because he's not like most companies that just think the be all and end all is paying for this little sticker, jumping through a couple of hurdles and getting the sticker on your product. Mason: But what we call going beyond organic. And Jeff does that with the organic certification and I share my two cents on where I'm at with that whole thing. But mostly just how much I love that he's non-stop out there educating people. Not just trying to flog a product, not just trying to grow this crazy big business. But I think that's kind of inevitably happening, it's just a nice slow growth of a business. Because it has a lot of trust and it has a lot of consistency in its messaging. And we talk a lot about that and have a lot of laughs and get a couple of stories about the history of the mushroom kingdom and those mushroom people back in the day. We talk about mushroom conferences and a bunch of other things. I think you'll really enjoy it, I hope as much as I did, here's Jeff Chilton from NAMMAX. Mason: Jeff, thanks for joining me, man. Jeff: Hey Mason, thanks a lot for having me. Mason: Absolute pleasure, so remind me where are you again in the world? Jeff: I am in British Columbia, Canada. I like on Vancouver Island out on the West Coast. You and I are actually connected by the Pacific Ocean. Mason: Vancouver Island especially, for some reason that just keeps on calling in. I keep on having friends, awesome friends and now you. You're waiting there. And I'm like "What is the pull?" Jeff: Yeah. You have gotta come. Definitely come in our summer time because otherwise you'll just be hit by all of those things you don't like, which is rain and all the rest. Mason: Well, it brings mushrooms, yeah? Jeff: It's true. Mason: When is it really on for you there? What months is it on for mushroom harvesting? Jeff: Mushroom season is really going strong in October. First couple weeks in November still happening but then things cool off too much then it slows down and there's nothing happening. We get rains in August, which really primes things then in the last couple weeks in September we could see things starting to pop up. Mason: All right, I love it. October, that sounds good to me. Let's dive in a little bit because we met maybe we were chatting it must've been two years ago. Jeff: At the American Herbalist Guild Conference in Oregon, which was just awesome. Mason: That was amazing, I mean, we were in Silverton? Is that right? Jeff: Silverton, exactly, yeah, that's where we were. Mason: But apparently not the witch one. No, I think that's on the other side. Tony was looking at Silverton but that's where all the witches were. Jeff: Oh, ah Mason: That's a different Silverton. I can't remember the name of the hotel but their grounds rolling in and the ginkgo trees, big ginkgo trees as well lining it. And then all the herbalists who came and did their herb walks were just frothing at how much they were able to go and show everyone how to forage, how to identify. Because the array of herbs there was incredible. That place is designed. Jeff: It was absolutely designed. It was a huge property and they put in all sorts of different plants, herbs and different kinds of trees. It was a beautiful venue there are a great place to have that. Even on the Saturday night when they had a band playing and everybody was dancing. I had a great time. Mason: That's so good, yeah. I imagine that place gets a lot of herbal symposiums going through it. And man, the best thing, the fig tree was kicking. Did you get up there and face on the fig then, during that symposium? That was the best part of it. Right next to the pine. Jeff: Oh my goodness, no. I hardly had a chance to get outside which is back to my place where I was staying on the grounds and then down to the venue. But I was locked into my booth most of the time and talking to people. And then in the evenings it was nice. It was a fun thing. And I know you said you had a chance to get to hear Christopher Hobbs while you were there. That had to have been really great because I always enjoy seeing Chris. I know he was really busy in fact, funny thing was Chris told me, he said "God, I'm sorry I didn't spend more time with you. I ran into an old girlfriend." Mason: Oh, right, I'm happy for him. Jeff: Me too. Mason: You're like, 100%, I can't contend with that. So '86 Hobbs wrote the book. Were you aware when his book 'Medicinal Mushrooms' came out, because when was NAMMAX first created? Jeff: I started the business in 1989. I'm trying to remember whether I knew Chris at that point in time or not, but he was part of the whole herbal industry, so to speak, and Herbalist Guild and all of that back then. I wasn't nearly as much in touch with herbalists until I started my company. Before that it was just pretty much just mushroom people and all the people that were in the mushroom world over here. There are a lot of them. Mushrooms really happening. Long before the herbal industry figured it out and got wind of it.Chris was one of the first because he was an herbalist but also was interested in fungi. So that was really cool. Mason: Yeah, I think he studied and formally became a mycologist as well. Jeff: Well, no, he was a botanist, definitely a trained botanist and a history orf botany in his family. Herbalists and things like that. And now he went on and he got a PhD in molecular genetics. Mason: Okay, he's going down that route. I like that book because he was really able to balance the mystical aspects of the mushroom herbal kingdom especially and then dive deep down into the science. It's something that only him and Steven Hardliner. Steven is the master at going down deep, molecular how a particular compound is interacting with a particular viral passade. And then blowing into full throttle Earth poetry in the next paragraph. It's a real gift. Going back to the 80s, you were running with the mushroom clique in America. Yeah, tell us the story. Jeff: The thing was in the 70s... Well, first of all in the late 60s magic mushrooms were really great interest. That was one of the things that I was really studying at university. I had this interested in mushrooms in the 60s and I reading all about a man named Gordon Wasson. Are you familiar with Gordon Wasson? Mason: Just the name and loosely, but not really. Jeff: Yeah, so Gord Wasson was a New York banker with a Russian wife. He learned about mushrooms being used deep in the mountains of Mexico by Curanderez and went down there in the 50s and spent the next five summers down there. He classified a whole bunch of different psilocybes during that period because he took a French mycologist with him. And so, five summers. But he basically opened up this whole world of Look! Still today after thousands of years there are people in the world that are still using these psychoactive mushrooms in their healing practices. Man, that was a mindblower. Jeff: So I was reading Watson and other people that were involved in that and they had published these books that were incredible books. I mean Watson went on to publish a book called 'Soma: Divine Mushroom of Immortality.' He published that in 1968. Jeff: Then somebody came along a man named John Allegro came and published a book called 'Sacred Mushroom and the Cross,' which talked about mushrooms in early Christianity. So, Mason, listen, think about it for a second. In 1968 two books are published. One says that a mushroom is at the root of Christianity. The other one says a mushroom is at the root of the Hindu religion. Jeff: And then all of a sudden from there it just... You get going forward and you find that mushrooms, you see symbols of them and you start to hear stories about them used through all sorts of different groups throughout history. Pre-history actually, because as that came out people started looking and discovering this. That was really part of my study in university because I was studying anthropology. And mycology on the side. Jeff: Going into the 70s in Olympia, Washington where I lived and worked on this big mushroom farm there was a whole core of people that were interested in mushrooms. It was an amazing group of people. Paul Stamos is one of those people. Ultimately he and I wrote the book called 'The Mushroom Cultivator' in 1983. We even had a group. We had four people, Paul and I and two other people, where we had four different mushroom conferences. These conferences were so ... You would have enjoyed it so much. We had people there that were speaking about how to identify mushrooms. I was speaking on cultivation of mushrooms, speaking on the anthropological aspect of mushrooms. We had great people there speaking. There was Andre Wyle was at our conferences. And it was just a great time had by everybody, right? You can imagine. All these mushroom people coming together. 200 people coming together for a weekend. Amazing. Mason: So good. I mean, it's different, you got this original crew, there's always something special when you've got the original crew. Jeff: Yeah. Mason: There's a medicinal mushroom symposium every year that moves around the world. It was in Colombia a couple of years ago and then in Italy. Do you know that one? Jeff: You're actually talking about the International Medicinal Mushroom -- Mason: Conference? Jeff: Society IMMS and you know what? And that was more of a scientific group that was formed much later. I know the principles of the group. It started somewhere around 1999. They're having a conference in China on the 18th of September this year. You should come. I'm gonna be over there at this conference. I know lots of other people are gonna be there as well. It's gonna be an interesting time. I'm gonna be giving a paper there, which will be fun. There will be lots of other people too. I don't know what time of year you go to China. Mason: Yeah, I go in September. I think this year we've got our staff retreat in September. I'm gonna check the dates, but otherwise I've been wanting to get along anyway. I've been trying to revolve it around going to Wudang mountain and doing some Taoist training as well. This is where I've been tossing up this year, what time to get over there. But that sounds a bit serendipitous. Jeff: Yeah, well, the conference is I believe the 18th to the 22nd of September. That's normally kind of early for us. We like to go over more in November. We go every year. November's really harvest time for a lot of mushrooms like Shiitake, Maitaki, Wood ear. A little bit later is Hericium, Lion's mane. In September it's the Reishi harvest. Mason: Yeah, Reishi harvest is normally for us in September. Where's your Lion's mane growing? Which region? Jeff: It's growing in Fujian province. Mason: Okay. Ours is a little bit earlier, in September as well. In Heilongjiang. In the northeast. Jeff: Okay, yeah, because in Fujian province it is late, late November when it's quite cold. It's back to the mountains, quite cold. Maybe up in Heilongjiang it's colder in there right? Mason: It's chilly. Jeff: (laughs) Mason: That's spoken like a true Australian. Jeff: Let's fly in and start up north there and step off. I just can't wait to get to Yunan province. Mason: (laughs) Jeff: I can't wait to get down into that tropical vibe. Although, nothing beats that crisp air. Jeff: Well that's good. I'm at that point where -- I don't know when your periods of this business growth have been -- but I've been real head down, bum up in the business. Not really been in that space of upgrading my information. Of course, I'm always reading and everything, doing all these things. I feel like that's like, you're at a point in your business where you are traveling around and you're educated. You're back at that point where you're free to go and educate and then go and educate yourself non-stop, constantly, which is really nice. I'm nearly back there. Jeff: Yeah, you know what it's like. We are so swamped right now. We've got so much demand for the product right now. We're growing and over the past two years we've hired four people, two people for lab and another person for regulatory and, can you imagine, we've got one person that's strictly regulatory affairs and deals with all the paperwork that we have to deal with. The paperwork is really monumental. We get forms from companies that are 220 questions! Mason: Companies that you're doing business with and they wanna know, looking at purity or is it you getting stocked with them that they want all those questions answered? Jeff: No, they qualify their suppliers. And so this is all about GMPs for the most part and how your product is manufactured. They want to know that everything is according to the GMP, quality, and the standard operating procedures and all the rest. Mason: I think that's where Real Mushrooms. Was it your son that created Real Mushrooms? Jeff: Real Mushrooms, yeah. Sky created Real Mushrooms in 2015 as part of NAMMAX so it's just one division of the company. He runs Real Mushrooms as well as other things because he's in training to allow me to go fishing and he can stay and do all the work. Mason: Great. NAMMAX is providing more providing bulk for people that are putting it into products and stuff? Jeff: We're a business to business. We sell the raw materials and then Real Mushrooms is retail products and mostly sold online. Maybe getting it into the stores at some point, but right now an online business. But we're business to business where we sell to companies that then put the raw materials out under their own brand. Mason: Does NAMMAX do... I'm increasingly aware because I think NAMMAX... we get a lot of people asking at SuperFeast but we don't really specialize in that B2B space. But one thing I want to talk a little bit about later is a lot of people who, like NAMMAX has bridged it and made it really accessible. Especially with you and the middlemen not having to deal straight with trying to... I'm still appreciating, it took me quite a few years but you'd know the in's and out's beyond what it's like developing relationships, critiquing, getting the authenticity on the testing. Also developing a relationship based on integrity and qualifying on that level takes so long. I feel like NAMMAX has really made it possible. Mason: I know a lot of people in Australia who are like "Ah, great, I can just go and NAMMAX can just do it all for me." Which is really great, because there's a lot of people. I like it because there's a lot of people jumping onto the bandwagon, and Australia has got this nice buffer. We don't have too much shit here, which is really good. And that's something that's nice for me to be able to say about my competitors as well. Australian community doesn't need to be as wary, I think, as the U.S. world because the U.S. is a bit...I didn't realize it's a shit fight. I know talking to you a lot back in the day, I don't think I presented that I was from SuperFeast. We were just talking about mushrooms and I was just learning a bunch off you and learning about your history. Mason: As a company when I started out it was an absolute no-brainer that we weren't gonna use fillers, that I wasn't going to be using mycelium product myself. We'll talk about that, it has its place. Of course, growing on good-quality wood. In Australia we're just small companies. I started in Mum's spare room getting products for me and Mum. Then talking to you I was like... and then reading your blogs and really falling off the back of it just like that. Wow, because you actually really inspired me after that talk going, "Well of course, I do talk about the fact that we don't use fillers and we don't grow on grains." And all these kinds of things, but it was getting to that point I didn't realize people really needed to know the in's and out's of your product and be able to ... Mason: After seeing what happened in America with how much trickery there is and the percentages of polysaccharides there is, lets' go into it a little bit now. You've been watching it and been the internal watchdog of the industry, which I really like. When did that first start cropping up? When did people start jumping on the mushroom bandwagon and fibbing about the levels of polysaccharides and active ingredients? Jeff: The interesting thing was that having been in the supplement industry since 1989, the key thing for me was that I was a mushroom grower by trade. So i spent ten years as a commercial mushroom grower on a very big, big farm. Not a hobbyist growing in my basement or a closet or something like this. A commercial mushroom grower, large farm. Millions of pounds of mushrooms every year. So I knew how it all worked, I knew the economics of it all. I realized back in the late 90s, for example. Or even the early 90s that you couldn't actually produce mushrooms in North America and turn them into a supplement, because it's a dry powder it's not a fresh product. Once you dry that thing out it's 90% water you gonna get ten times as much money for that pound of mushrooms. It doesn't work in the supplement world. Jeff: That's where going to China and I went to farms, I went to factories, I went to research institutes, I went to conferences. The 90s was just amazing to see what was going on. I went north to south, east to west. Yunan province all the way up to Jilin province. It was all over China seeing this industry and seeing the research. One of the things, you talked a bit earlier about quality how do you know. Here I am visiting these companies going to all of these conferences. I'm having people coming up to me all the time saying, "Will you buy my product? Here it is." And they just show me a brown powder and I'm just like, it's a brown powder, I don't know what it is! How can I really know what that is. And then getting to know companies and people that were genuine and you could go to their factories and see what they were doing. Especially if they were only producing mushroom products and then building the relationships to that. Jeff: Then I turned around and back in the United States here are these companies that come along and they start to produce mycelium on sterile grain. The worst part about it is they sell it as a mushroom. Mason: Some people might not know what, so, we're talking about the fact, which you alluded to, which I completely agree with, that the only way to make a viable super high-quality product that's a powder is doing it in China. Based on the fact that, say you have 10 or 20 kilos worth of raw product that's gonna then give you a kilo of the powdered product in the end, it's not viable in the U.S. so to make it viable in the U.S., the way it generally works is that it's grown on a grain substrate, like rice, brown rice, oats, this kind of thing. Jeff: Yeah, and the thing is, what people need to understand is that a mushroom is just one part of this fungal organism. So the other parts would be a spore, the spore germinates in to a fine filament, those filaments come together, they create mycelium, which is the actual body of the fungus. Which normally if you're out there hunting mushrooms you never see that because it's in the ground or it's in the wood. So most people are unaware of that. But that mycelial network amasses nutrients. When the conditions are right it produces the mushroom. That's what we see because up it comes and it's like "Wow, look at that thing there!" And then that matures, it produces spores, and then we have a complete life cycle. Jeff: The interesting part, Mason, is that growing mycelium, which is the vegetative part of this organism, on sterile grain as a mushroom grower, what that is and what that was developed as mushroom spawn. Which is like the seed that is used to grow mushrooms. Because mushrooms don't have seeds they have spores. You don't plant spores when you grow mushrooms, you plant live mycelium. The mushroom growing world, what they developed is "Okay, we'll take that live mycelium and we'll put it onto some kind of a carrier. Then that carrier we can spread into our compost or whatever it was that they're growing their mushrooms in. If you take a gallon of grain, you've got maybe thousands of grains in there you coat that with mycelium, and then you take those thousands of grains and you can mix them into a big pile of straw or compost or something. Each one of those mycelium grows off of and it grows into this thing. So that myceliated grain actually was developed in the 1930s as mushroom spawn or essentially seed to grow mushroom. Jeff: It's an easy process, it's done in a lab and people in the United States, we can't grow mushrooms. Why don't we just take that process, we'll grow out the mycelium. Mycelium in and of itself it's got beneficial properties because it is a fungal hyphae that has beta glucans in its cell walls. If you grow it in a certain way like in liquid or something it can produce certain medicinal compounds. But when you grow it on grain and then you don't separate it out from the grain at the end of the process you end up with mostly grain powder. That's what companies started to do. They started to grow the mycelium on grain. At the end of the process they would dry it -- just like you're drying a mushroom, but -- they'd dry it, they would grind it to a powder. No mushroom there at all. No mushroom, it's just myceliated grain, and it's mostly the grain powder. Finally, the worst part about it is then they call it mushroom when they sell it. Mason: I definitely know I've been surprised, because my first trip to the States I went and bought all the different brands. I was floored by some of the grainy non-mushroom powder that I was buying. That was like white powder, it's in your face. Jeff: Yeah, white powder and you taste it and you're like, "How's it supposed to taste like mushroom? It tastes kind of like flour." Mason: Yeah, it's like flour, sawdust. So are there companies doing a mycelial growth that are more on the ethical spectrum, that they're not doing a full grain wash and that they're growing on a particular grain that they're able to separate out a lot of the mycelium? I know that a lot of the mycelium is embodied grain. That's just a reality that you're not gonna be able to get rid of. But I'm trying to play that... is that possible in your experience? Jeff: In China they grow mycelium in large tanks of liquid. Mason: Like Cs-4 Cordycep, yeah. Jeff: Yeah, Cs-4 Cordyceps. They've been doing that for 50 years. But the thing is that it takes a lot of money to put in a big facility that can grow and these tanks are huge and you have to have a steam generator. It's a big investment but to actually grow out the mycelium on sterilized grain does not take a lot of money, it doesn't take a lot of expertise. It's a very simple process. Anybody can do it. In my book that I published in 1983, it tells you how to manufacture mycelium on grain at home in your kitchen. It's not difficult so it's very easy and ultimately, the stuff is so cheap to produce. And these people are selling it as mushroom and making a fortune doing it. It's really immoral in my opinion, and unethical. And especially if you're calling it mushroom. Mason: I think because we sometimes maybe look at the market and what we subconsciously are looking for when we want a mushroom and most of the studies have been on if you're like... Most of the time we're looking for a fruiting body. That's the mushroom. It's the unspoken that we know that we're talking about is the fruiting body there? And I guess there are some companies that have been quite averse or trying to sign typically validate the mycelium. When I was first kicking around all this there were people going "Look, just have it all. Have the fruiting body, have the mycelium, have all these..." and I very quickly, before I had a company was like "Mmm, no." I'm not in this to justify a particular aspect of the market or go for ease. I'm in it personally, and especially in the beginning, being a dreadful romantic, trying to connect to a herbal system, particularly Taoist tonic herbalism for me. Jeff: Exactly. The people who grow those products and they say "Oh, we want to have all parts of this. We want to have the spore, we want to have the mushroom, we want to have the mycelium." It's like they say "It's full spectrum." Well, the problem is that they leave out the fact that (A) there is no mushroom in it, and (B) the grain! How can it be a full spectrum product if they've got all of this grain in the product? That's what they don't like to talk about. They don't like to talk about the fact that it's mostly grain and all of this other stuff about "Oh, you know, the fruit body's in there and the spore's in there." Absolutely not. It's really a lot of smoke and mirrors. Jeff: That's what's so hard to take is that when there are people out there actually espousing that and claiming that they've got a full spectrum product when in fact it doesn't take much in the way of analysis to prove what they do and they don't have. We've run analysis and what's really interesting is if you analyze it, for example, with a proximate analysis, which is proteins, carbohydrates, fats, ash, minerals. Those products line up perfectly with the grain they're grown on. Mason: Are there exceptions to that? Jeff: No. All of these products and there, it's the myceliated grain products. If it's grown on brown rice it lines up with brown rice. If it's grown on oats it lines up with oats. Literally the two lines run together. The way I like to think about it too is I talk to people and I tell them what they're growing is tempeh. And they say what tempeh is, it is cooked soybeans with fungal mycelium grown on it. If you look at that tempeh and it's all white that's the mycelium but if you look at tempeh and you cut it open you can see it's mostly the soybeans. And if you were to dry it out, look, Mason, mycelium is 90% water. Just like a mushroom. The soybeans are 50% water. When you dry that tempeh out the mycelium just goes "Fffft!" Just tell me, where's the mycelium? And you've got all of these dried soybeans and you're like, well, it's mostly dried soybeans, that product. Mason: I'm sure you get it a lot as well. Yours, there's obviously a few brands in the U.S. becoming more aware of the others. I didn't go looking for them but as you move into a market. SuperFeast, I spoke to you about it the other day. We've got so many people ... like [inaudible 00:29:50] story. I've realized in business a lot of the time it's like, same with you, I like the people. I like the unique stories. People are like "Bring SuperFeast over, there's no one doing that like what you're doing over there!" I like, yeah. Jeff: (laughs) Mason: And it's the same. When you're upfront about the nuances although there's a lot of companies doing medicinal mushrooms like yourself and Taoist herbs like us, medicinal mushrooms. There's nuances there and the sourcing and there's nuances in the story. What I like is, which is going to get to the polysaccharide claim, and the full spectrum claim for the people growing the mycelium. Because people are in an egoic, competitive make money mentality a lot of the time. They think they have to be everything to everyone. Versus just being very upfront. I'm always quite upfront, I don't really look at that. I don't try and standardize color or anything in any way. I don't try and standardize the constituents. I don't even sell on the percentages of constituents. I don't focus on it. I'll move more in that direction because more and more people want to be satiated. I can say yes, we test for percentages of the active ingredients to ensure that they're in alignment with the Chinese cornucopia and ensure that they're actually active. And all that kind of stuff. Mason: But going over into the States now and hearing about all these other brands and I'm with you whenever it's growing on grain I can't get behind it. Not to be disrespectful, and I'm always trying to be really amicable in my talks. There's a place for it, but less and less can I find that place. Jeff: And I understand what you're saying too because if a person is genuine. For example the herbalists, who are at an American Herbal AHG conference. These are people that want to provide good products, they want to provide a body of knowledge to help people. That's who you wanna be, that's who I wanna be. I'm not in this to make a lot of money. I'm not in this to build some big company and go Oh, gee, isn't this great? Because I'm selling $20 million a year of this or that. That does not excite me at all. That has no meaning for me. What has meaning for me is that I'm producing a quality product that I've been working on for years and I can tell you the product is what I say it is and I want it to help you. I want you to be able to take this product and feel confidence that you're getting what the Chinese have used in traditional Chinese medicine for thousands of years. That's what I want. Jeff: I don't want to sell you something that is not what it really is and is a placebo and expect you to buy the product from me and I walk away going "I'm managing this great at my company. I'm making so much money and it's wonderful." No, I'm sorry, that's not me. I'm not interested. Those people turn me off. It's like the difference between being in a group of people that really understand mushrooms or herbs and being in a group of people that are just talking business and numbers and all that kind of stuff. And I don't give a shit about that. Mason: Yeah. I think it's interesting. Watching your business I can see in the beginning it probably would've started out that everyone knew Jeff and knew your level of integrity and how you just wanted a good product. In that little circle it was like 'Great, we'll just go and get Jeff's product.' Then as you grow I think what you've done really well ... just to put it as an example of why I'm bringing this up, we're getting to this point where we're growing as a company where it's beyond Mason at the markets and everyone knows that Mason has the badass tonic herbs. Or people are coming along to the talks and all the health clique. We've started emerging. Mason: I think you would've gone through this years ago when you emerged beyond the health clique. And it's very dramatically people aren't associating directly with you or the founder, it's the company. They don't even know or care who the founder is and therefore you need to have these things in place. We're getting to the point where everyone who's a SuperFeast customer is just like, "Yeah, we don't even care about organic, we know what you guys are doing," and we're going on that old philosophy and we're documenting that and there's all those other checks in place like independent testing for pesticides and metals and all that in place and available. Mason: But it's getting to that point now where the people on the very outside... I still don't know if we're really gonna shift because I still personally don't care and I don't change my company for perception's sake. But you can see Wow, that organic would be really, really useful for those people on the outside. Or the testing to know what percentage of what's going on inside and being able to present that. I think we'll move in that direction. I think you've done that really well and really maintained the trust in the brand of course, and in yourself. But maintaining you there as the one that's rolling this along and not then just relying, you know, the organic certification or the percentages. Mason: I think that's what I find really commendable, because most people then they rest on their laurels. Once they change over into, not standardizing but testing for minimum constituents like beta-glucans or organic. they then rest on that. Whereas that means nothing to me at all. Being able to talk to you I'm like, Yeah, because organic, I don't know what your take on that. I know there's some terrible organic products out there. Just the fact that we know we can go organic there's five different companies we can go to, so you just go and find the company that suits you. We can go with the company that's the hardest to jump through. Mason: I won't go into the details of what's going on, why we're probably not going to go in that direction. For us there's so many little micro-farms that we're being nimble with whom we're working with. When we're beyond mushrooms we've got a lot of other herbs going on. We need to cut that farm out if they need to move on and do something else and we'll go and we've got that team to go around and constantly go and find these people. So every time we want to nimbly adapt and go down a different direction when someone's doing a little more traditionally than the other person, all right, get the organic certify up. Or lie, which is what I think a lot of people are doing. They get the organic certification, then when they change up those little farmers, because we're dealing with independent farmers as well, not a company that can provide the organic certification. I don't know why I went on that rant. So that's why we're not going on down that route. Mason: It's something I see. I know there's a bunch of companies who are coming to NAMMAX, which I think is just been so good for the Australian industry. For people to know that they're very quickly going to be introducing a really good quality. You can tick off the organic but I hate it when it's just organic that they are going for and not just an incredible product with a story behind it as well. So I really commend you for offering that out. Jeff: I've always really believed in chemical-free food. Organic is more than just chemical-free it's how it's grown. When you're growing out of soil it's building the soil and not just depleting it. For me organics is a holistic way of looking at things. I've always considered that to be very important and I support that type of agriculture no matter what it is. A lot of these companies that are producing myceliated grain, they're organically certified! Jeff: It doesn't necessarily mean that it's going to be a great product. These companies have what I call all sorts of merit badges. 'We're big and we're organic, we're kosher, we're this, we're that,' which ultimately means nothing at all. There's a lot more to it than just that. The one thing I really like about what you're doing too is that you're introducing the philosophy of it and that's something that you really believe in. That to me is important and that's what people look at. They look at who's behind the company and what that person has to say, is that person ethical, righteous, person or not. You're not up there as a smooth talking business salesman or anything like that, right? Mason: You should see me try and sell something I don't like. I'm a bumbling mess. I think I told you that back in the markets people used to say god-made...you could sell ice to the Eskimos. But I'm terrible if I'm not talking about herbs or philosophy behind it. Jeff: That's because you're doing something you believe in. That's where everybody should be. Not everybody has that opportunity, but if you can have that opportunity. I was lucky enough that I followed my passion and I didn't do that because I wanted to be rich. I did it because I loved it. I always say to people, if you really like to do something, whatever it is, just do it. Follow your passion. Maybe you're going to be poor for a long time. Make something that you feel good about. Mason: Honestly, and I really mean it not just because you're on the podcast talking it up or trying to flatter you. But when I met you, you had a happy disposition to be in business that long. In the beginning I was trying to escape the business side of things. Quite scared about having a business and not coming out the other end alive. You have a sunny disposition and you still have control of your company and the standards and you're still educating about the same thing that you're educating, of course it's evolved, but you were educating about beforehand. And there's something that I've learned a bit about in that. There's something humbling and nice about not being in that pursuit for aggressive growth while still growing at a nice, sustainable rate. But staying true to what you were doing in the first place. I educate about basics of herbalism and medicinal mushrooms in the beginning and then I'll move on and doing other things. The more I go along the more I want to settle back into doing what I did all along. Mason: I've got a weird thing about going back to the organic, I'll almost shy away from something if it's organic because I see it as a marketing ploy a lot of the time. And I think it is a lot of the time. With little things. When growing Lion's mane there's a lot of people who will use organic fungicide because they don't pick when they're watering out to the Lion's mane. I like to use this example because we don't have a plastic covering, it's just a straw and a hut to keep it nice and dark and it gets watered. That's the only part that gets watered. And one of the things I talked about in the beginning with Lion's mane, I just heard about it through the grapevine, that fungicide is needed if you're watering straw a lot of the time in order to, all right, we know why fungus grows. But found someone who wasn't doing that and found people who were doing organic Lion's mane who were using organic fungicide on the huts. Little things like that they get me so dejected about the marketing ploy behind it. But I think you're the one organic product that I would be over the moon to use. Mason: And the other example is Ron Teeguarden. I think we talked about him. He was such a rogue in the industry herbally. You were telling me about the acupuncture when he was offering acupuncture because he's a barefoot herbalist and all the acupuncture's guilds are like "Screw you, you need to be regulated." And he's like "Hey." Jeff: I know, it might've been somebody when you were in LA but it wasn't me. I don't know Ron that well. He's been around a long time. He's done his own thing, he's not out at the shows or anything like that. He's very well-known and in a sense he's been the herbalist to the stars. He's in Los Angeles, right? A lot of people in Los Angeles that are into herbal medicine and living properly in term of what they eat and things like that. They would go to Ron and Ron has one of the very first herb bars where you can walk in and have this type of a drink or that type of a drink. He was really in it very early and doing stuff that nobody else was. He was an outlier in that sense. I don't think he really needed to go into the industry proper. He's done a little more now that before. He didn't have to. Mason: He, on the level of sourcing philosophy. I bumped into him years ago. I was at that place where I was starting to grow, people are asking why I'm getting my herbs from China and people asking me if I'm organic and all these kinds of things. I want to keep on doubling down on my philosophy, what I'm doing here. One thing that I drew from yourself as well and then be proactive and educating the market. Not in pushing your own product, just generally being happy about the market being educated as well. And Ron was like...In fact I talked with him for about five minutes. More or less he was like "Listen, if you have that spark," I remember, "do not deviate from that sourcing philosophy." And it really stuck with me and from that day I did. I doubled down and I was not going to try and... I'm going to continue to not worry about what's going on and just do me. It's a lot of fun. I was at Dragon Herbs Tonic Bar about three weeks ago. I frequent the Hollywood one when I'm in L.A. Mason: Before we go too far off the mycelium grown, one of the things you've really educated, not only the market, but businesses in the market around medicinal mushrooms in the market, is how to identify a true polysaccharide read on medicinal mushrooms. Rather than people including 60% polysaccharides or even 30%, yet when you go down into the class of beta-glucan it's actually been tested you've been hoodwinked and they've gone dry from age or whatever. Can you talk a little bit about that? Jeff: This is something in the herbal industry too that you learn right away, and I learned it back in the 90s, was that so many herbal extracts, when you make the extract they oftentimes need some kind of a stabilizer. Otherwise they can get gummy, they can jut come together if it's a powder. Putting a carrier with a lot of extracts was pretty common. What happened was sometimes companies would cheat a little bit. The next thing you know instead of 10% carrier it was 50% carrier or 80% carrier. And they're not revealing that to anybody. You think you're getting an herbal extract, not just mushroom extract, an herbal extract and it ends up being mostly maltodextrin or dextrose or something like that, and they're not telling you, then it is really deceptive. So there's a lot of companies that were doing that in the industry. Jeff: As I went along, the whole time that I'm working with people in China I'm like, "Look, I want extracts where we aren't using any carriers. It has to be made in a certain way," because I'm looking for the pure essence. In traditional Chinese medicine they take the herbs and they throw it in a pot and they boil it up and pour it out and "Here, drink this!" There's no carriers in there. Mason: That's right, not sliding agents. Jeff: That's right. If you have to put something in a capsule you've got 150 milligrams of different types of fillers and binders and flow agents. Putting it into a pouch is so nice because then you don't have to put those things in with it. It's just the pure herb. Early on in the 90s everybody's testing for polysaccharides and nobody's testing for beta-glucans. And beta-glucan is a polysaccharide. Unfortunately all these carriers are polysaccharides too. A lot of people can hide that from you that you've got carriers on their product. No, no, we don't use carriers, it's 100% mushrooms, stuff like that. That's where with any kind of supplier you have to build up a level of trust. Like I say, they show you a brown powder and say. "Here's our product, it's shiitake mushroom extract. Isn't it great?" You can test it. Jeff: This is the thing, Mason, it's not like you can take a mushroom product other than a reishi extract, consume it, and then a few hours later or a day later go, "Wow, yeah! Did I ever get a kick out of that!" No, it doesn't work that way. You can organoleptically, I can taste the shiitake extract and I can tell you yeah, that's definitely essence of shiitake. Or with reishi it's so bitter I can taste all those bitter notes in that reishi extract, that is an awesome extract. Jeff: I used to give a reishi extract to a friend of mine who was a deep herbalist making his own liquid extracts and a big business ultimately. He'd taste some of my extracts in the beginning and he'd go, "Not bad, but it tastes a little bit burnt." And I'm like, "Oh shit." When it was dried it was maybe in the oven a little longer, and he could pick up on it. I thought that tastes pretty good. That was in the early days when I didn't know any better. I thought it's great and high triterpenes and all this. He'd go "Yeah, it tastes a little bit burnt." Those kind of things teach you a little bit about, okay, how's it made. Let me tell you, in the 90s the facilities that were making herbal extracts were nasty. They were old facilities Mason: Not too much GMP regulation back in those days. Jeff: It wasn't like stainless steel everywhere, no. Everywhere was dark from all the herbs they'd been cooking for who knows how many years. Now all that's been torn down and you see nothing but brand new factories in China. Everything is stainless steel and it's beautiful and there's none of that anymore. But back then, actually, it wasn't until we got the megazyme test and I started using that. And that was in 2012 or 2013. Up until that point I thought, well, the polysaccharide number was high, that's great. Then we starting testing the products and that's where we really pulled back the curtain. My main supplier, awesome! The test results we got from that. Beta-glucan and alpha-glucan and the alpha-glucan, that was where any of the carriers were revealed. Jeff: And then another company that was supplying me with some products, only a few, not many, fortunately. And was swearing up and down they never used any carrier. Jesus, their alpha-glucan level was way up there. I was shocked and really upset because I thought their product was good because occasionally I'd test it for polysaccharides it was 50-60% and I was thinking, great product. I could taste it, it tasted okay. Nothing but mushrooms they were producing. But here they were. They were putting them on a carrier and telling me they weren't. That's the kind of thing that you face when you're over there. Jeff: How do you qualify these products? You can go to the factory. They can show you around, you can look at all the mushrooms in their warehouse, you can look at them cooking these things up, the final products. They don't show you the bags and bags of maltodextrin that are hidden back in the warehouse somewhere that they're using as a carrier for the liquid extract. That literally pulled back the curtain and I went and confronted that with them. They claim no. Finally they actually admitted it and I'm like, okay, see you later. I'm not buying another product from you because you lied to me. Fortunately it was a secondary supplier. They weren't my main supplier at all, but I needed a secondary supplier. I visited them and it was all mushrooms that they were doing and they were in the heart of mushroom country and it was nothing but mushroom. Yet they had all these carriers in there. I was really upset not only with them but with myself because I got taken in by it too. And that's what you have to do. Jeff: Look, Mason, have you ever been at Ali Baba and looked at all the mushroom products being sold? Mason: It's always funny, and as you know, everyone's jumping onto the bandwagon right now. You can see people trawling through Ali Baba going "Oh, just tell me which one is awesome." I haven't been in there in a long time. I got curious, to be honest. I think we were in the office having afternoon drinks and seeing what was on Ali Baba. It is insane. Jeff: It's totally insane. So many companies selling mushroom extracts. Sometimes they're selling at prices where you're like, "No, wait a minute, you can't sell me that extract for $20 for a 10:1 extract. That's impossible. You load it up with starch, that's quite possible, right? That's where analysis, for me, has been very helpful. Especially the beta-glucan analysis because that gives me that alpha-glucan which is the whole carrier. That's what unmasked all of those myceliated grain products. There's definitely a place for analysis. There's also a place for getting to know the grower. I don't believe in organic pesticides. I don't give a shit. Don't use whatever it is, you have to grow this. I know it's more difficult but you have to grow this without sprays and all that. Jeff: The thing about China is that when you're traveling through China and I've been back in the mountains in all these different places and you go back and you look down and this little valley and here's this beautiful rice fields down there and you're going "Oh, isn't it great, back here. Everything's idyllic." And then you see somebody walking through the rice field and they've got a backpack sprayer. And they're going along spraying chemicals on this rice crop. I'm like, "Ugh, shit. Really? Do you have to do that?" And I think to myself, even the smallest growers out there are using some chemicals. That's where I'm like... And I want to be sure. And that's where we test and test to make sure that everything is staying on track because these things can slip in. Somebody can cheat. You have to ride herd on the whole thing. Otherwise it can slip right through your fingers. Jeff: That's been good for me in the sense of having an organic product that has meant that we put these constraints on the people that we work with. We say look if your product shows one of these things in there I'm sorry we're not selling it. If you and if you shipped it over to us and we find it in there after you've done the testing that's all good and we find it in there it goes the landfill I'm sorry, we can't sell it. That has been a really good quality, that's how we keep that quality up. In that sense I kind of believe in it all and think it's important. It helps us keep the product a little bit more real. Mason: As you say said there's all these things that can go by... even though it is organic, you can get organic pesticides and all this kind of stuff. I have taken your product and of course I really love it. You know that you're going to go that extra mile with it. It's a trip around it, there's a stigma around China is isn't that whole thing polluted? Jeff: Well, that's the other side of it right now, Mason. People are so afraid of anything coming out of China that this gives them a little bit more confidence in it. They can say what they want about organic and all but we've got pesticide tests that can demonstrate what it is and of course the always have to do heavy metals and micros and all of that. Mason: Alpha-toxins Jeff: For us, especially as a raw material supplier to companies large and small we have to be able to give them confidence because you know they're selling a Chinese product that they buy from us and lot of people are just like you know when it comes to China it's like no no no no it's like not going to do it so I have to talk to a lot of people. And I say, well, hey look. There's products in the United States that are absolutely full of chemicals. So it doesn't matter where it's grown. It matters where it's grown but it's not this country or that country. You can grow good, clean products anywhere in the world if you're doing it properly. Mason: It's so good. Of course people are realizing that the ultimate Chinese herbs and medicinal mushrooms are going to be coming out of China. I really like how it's still dominating and making it really easy for people to get One thing that's organic and Two very quickly have all those things to provide so enough people are going to be able to go, Oh, okay, so it's from China and we can trust it. That's something that makes it really easy, because people are going to jump on the mushroom bandwagon. We found it as well, a similar thing. People want to come, they're like okay, tell us about Chins. Okay, tested three times for pesticides before it comes to market, each batch. Plus here in Australia the TGA facility and heavy metals and alpha-toxins and microbes. At some point people go "Hmm, shit, okay." And testing of the water. And when we can going and doing radiation testing in the areas. And then going live and seeing pictures of you at your reishi farm is magic. Mason: When I was going live around China going, you know we're still going up while we're outside the mountains going to the fields where the eucommia bark trees were grown or up in Yunnan. Just drove five hours in the middle of nowhere to get to the poria farm, where there's wild pine and people are going "Holy shit! Look at that land! The land of the dragon. It's calling me. It's real." All of a sudden popping that thing that first of all, yes, you just need to be vigilant, that's absolutely number one. I've only changed suppliers once. In the beginning I found someone I had really enjoyed their product. And then what I've decided was one of my areas in going forth is I need someone that could absolutely school me. If I'm requesting things and they weren't able to "bang" school me on that immediately, then I'm not going to be able to do business. Mason: And it got to this point where I was confirming no municipal water. Only springs, only well water. Only creek water in the area. Nothing from the tap every touching the crops. At one point "Okay, sometimes that's a bit hard." I was like "All right, I'm gonna change now." That's when I started going down that route and ended up... developing relationships, developing a friendship first, understanding the intent behind the philosophy behind the business, understanding who owns the business that you're going to be dealing with and what their motives are and what their history is. These are the things where people don't realize what goes into it. People go "Can you tell me your supplier?" And you're like Jeff: (laughs) Mason: At this point it's not about me being scared about you having access to that supplier but so much has gone into this relationship. It's not just about finding someone and sourcing off them. Although, it's nice and easy to do that. If I was beginning right now I'd love to be buying just from suppliers on NAMMAX because it's cool. All the certificates, all the independents, and then all the years of vetting and tweaking that leads to this point where trust is inevitable and you become even more switched on to what to look for if anything ever comes up. If anything slips or changes you know the questions to ask and where the slip in quality could possibly be. And large ways you know how to put things in place that would stop that from ever happening to begin with. It's an interesting industry. Jeff: We go there every year and we'll do an audit. We'll visit farms, the factory we'll be sure we confer with our partners to make sure everything is good. This year we're at the point where we're hiring someone to be on the ground in China that will do a lot of checking and stuff for us on a regular basis. More regular than us going over there once a year. It's gotten to a point where we really need that coverage of somebody right there that we can say "Can you go out to this farm or this factory?" Also, communications because sometimes communications... although some of our partners speak English but some of them not so well and then they have to use a go-between and that's not always the best. So we're gonna have somebody now that's right there in China and can do that for us. Can you imagine going to China and traveling around without having somebody with you to help you through the liaise and talk? Mason: I have the best intentions of getting my Mandarin up to scratch and as soon as I'm out of it, it all slips out of my head. I haven't fully entered into that poetic language realm. The language is sticking. Can you speak Chinese? Jeff: No, I speak Spanish, but Sky's learning Chinese. He has three classes a week, an hour each class with a Chinese speaker he does it over Zoom or something like that. He's very diligent about it. We get over there. He's speaking with them in Chinese and they love it. He's learning more, but unless you actually go and live somewhere for a while it's always tough. I've been thinking about it. You go over and spend two weeks, three weeks, whatever, then you leave. That's nothing in terms of really getting in and learning a language. That's swimming on the surface. Mason: I gotta get onto it because I'm gonna do some Taoist training there. Jeff: Yeah, that'd be really cool. You're young enough that you still can do that. I'm way beyond doing anything like that. Mason: Come on, they'd love you up in the temple. Jeff: Not only that, where I love to be is in Patagonia Mason: Dude, that's the other place my heart lies, down in Patagonia. I want to become an old Argentinian man. I want to become a cowboy. Jeff: Exactly, I know where we can get some horses, Mason, so let me know. Mason: All right, that's it. That's on. China this year, maybe Patagonia next year. Jeff: Yeah, two years ago Andrea and I went out and spent the day with, we had a gaucho that took us out. We went all over this one area. It was a hot day too. We were on horseback the whole time, cruising through, very slow. Slow living at its best, right? Mason: Yeah, that's it. Drinking, eating a lot of meat, drinking a lot of yerba mate. Jeff: Yeah, when you're on a horse you're not going to go very fast. You're going to cruise along. It's life in the slow lane. Mason: I love it. So before we finish up is there anything that is coming up now that's exciting you about educating people about this market and about this industry with medicinal mushrooms? Jeff: People really still need a lot of education with mushroom. Part of what I do too which I really like is I talk about the nutritional value of mushrooms. My thing too is eat mushrooms. I think mushrooms may be the missing link in terms of food. A lot of people are like, fungus, never eat it, right? And I'm like, "Dude, you've gotta get on and eat mushrooms, it's a fabulous food. They've got great benefits, you get medicinal benefits as well as nutritional benefits." That's the key for me, I'm pushing that really hard when I talk to people, saying "No, it's a fabulous food." And in China they have this whole thing of food is medicine. Jeff: That's in Ancient Greece too. Food as your medicine. Everything that you take into your body should be something that is beneficial. And medicine as a very loose way in terms of it's feeding you and keeping you healthy. And that's what we should all be thinking about. What we consume is keeping us healthy and we should look at our food as that. That's providing me with all of these benefits. I say if you want a supplement, you feel you need more, that's great. You can supplement. But definitely use mushrooms for food. That's a big category for me. Jeff: As a mushroom grower, can you imagine? I'm working on an agaricus farm. For ten years every day I'm going in I'm going through the rooms and each room ultimately is producing 20,000 pounds of mushrooms. There's mushrooms everywhere around me growing and I'm stoked. I love this. I've got mushrooms that I'm eating all the time. I've even got small beds of mushrooms that I bring stuff home and I'm growing them in my house because it's so interesting to me. The farm I was on it wasn't just an agaricus, we had a scientist that was growing shiitake and maikitake and oyster mushrooms. Back in the 70s when those weren't even on the markets anywhere. And I had access to these mushrooms. Besides the wild mushrooms that we were navigating. I'm like, make them part of your diet because it's a wonderful food. Jeff: That's my message to people is this is a forgotten food, bring it home. Mason: I love it so much. Thanks for reaching out, I really appreciate you reaching out and having you on here. It's not only do I admire you as a person, admire what you've done and your business. I spoke to you a little bit about it. I like talking to the other people who are perceived competitors. There's so much room in this market and everyone's doing their own thing and has their own story. This whole red ocean we have to fight over a scrap of people who are going to be buying mushrooms and not focusing on educating together is absolutely ridiculous. It's always awesome to meet people who trail-blazed that attitude in the industry. Calling out people that are bullshitting and then coming together and educating together and getting the world healthy together in our little way. There's something really nice about that that makes it possible to be in business for so much time, for so long, see so much shit yet still have such a positive attitude about it. Jeff: That's absolutely right. I really love what you're doing too and I love the whole Taoist part of what you're taking to people and bringing to people. That philosophy is really awesome. That's what brings something really unique. When I hear you talking about mushrooms up around, what's the lake up there in the mountains? Mason: Mumbai Jeff: Yeah, that was so cool and you're hanging out there, talking about the mushrooms really excited about it all. That is really special. I love your energy, Mason, I'm really happy that we've been able to get together and have these meet-ups, speak and let's carry it on, let's keep doing it and stay in touch for sure. Mason: Absolutely. We'll get some videos in another podcast together, 100%. I'll go check out these dates, see if I can swing a Jeff: I'll send you the info on it so that you can check it out. If you can come you'll have a ball because there's gonna be lots of mushroom peop
Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing. Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article. Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30. Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go… Show More v Nachi: Nah! Just some definitions, nothing personal! Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits! Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery. Jeff: Well that’s kind worrisome. Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!! Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled! Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia. Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark. Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017. Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs. Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group. Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures. Which again reiterates why this is such an important topic for us as EM clinicians to be well-versed in. Nachi: As far as types of procedures go – while there are many, there are 3 major ones being done in the US and these are the lap sleeve gastrectomy, Roux-en-Y gastric bypass, and lap adjustable gastric banding. In 2017, these were performed 60%, 18%, and 3% of the time. Jeff: And sadly, no two procedures were created alike and you must familiarize yourself with not only the procedure but also its associated complications. Nachi: So we have a lot to cover! overall, these surgeries are relatively safe with one 2014 review publishing a 10-17% overall complication rate and a perioperative 30 day mortality of less than 1%. Jeff: Before we get into the ED specific treatment guidelines, I think it’s worth discussing the procedures in more detail first. Understanding the surgeries will make understanding the workup, treatment, and disposition in the ED much easier. Nachi: Bariatric procedures can be classified as either restrictive or malabsorptive, with restrictive procedures essentially limiting intake and malabsorptive procedures limiting nutrient absorption. Not surprisingly, combined restrictive and malabsorptive procedures like the Roux-en-y gastric bypass tend to be the most effective. Jeff: Do note, however that 2013 guidelines do not recommend one procedure over another and leave that decision up to local surgical expertise, patient specific risk factors, and treatment goals. Nachi: That’s certainly an important point for the candidate patient. Let’s start by discussing the lap gastric sleeve. In this restrictive procedure, 80% of the greater curvature of the stomach is excised producing early satiety and weight loss from decreased caloric intake. This has been shown to have both low mortality and a low overall rate of complications. Jeff: Next we have the lap adjustable gastric band. This is also a restrictive procedure in which a plastic band is placed laparoscopically around the fundus leaving behind a small pouch that can change in size as the reservoir is inflated and deflated percutaneously. Nachi: Unfortunately this procedure is associated with a relatively high re-operation rate – one study found 20% of patients required removal or revision. Jeff: Even more shockingly, some series showed a 52% repeat operation rate. Nachi: 20-50% chance of removal, revision, or other cause for return to ER - those are some high numbers. Finally, there is the roux-en-y gastric bypass. As we mentioned previously this is both a restrictive and a malabsorptive procedure. In this procedure, the duodenum is separated from the proximal jejunum, and the jejunum is connected to a small gastric pouch. Food therefore transits from a small stomach to the small bowel. This leads to decreased caloric intake and decreased digestion and absorption. Jeff: Those are the main 3 procedures to know about. For the sake of completeness, just be aware that there is also the biliopancreatic diversion with or without a duodenal switch, as well as a vertical banded gastroplasty. The biliopancreatic diversion is used infrequently but is one of the most effective procedure in treating diabetes, though it does have an increased risk of complications. Expect to see this mostly in those with BMIs over 50. Nachi: Now that you have a sense of the procedures, let’s talk complications, both general and specific. Jeff: Of course, it should go without saying that this population is susceptive to all the typical post-operative complications such as venous thromboembolic disease, atelectasis, pneumonia, UTIs, and wound complications. Nachi: Because of their typical comorbidities, CAD and PE are still the leading causes of mortality, especially within the perioperative period. Jeff: Also, be on the lookout for self-harm emergencies as patients with known psychiatric disorders are at increased risk following bariatric surgery. Nachi: Surgical complications are wide ranging and can be grouped into early and late complications. More on this later… Jeff: Nutritional deficiencies are common enough to warrant pre and postoperative screening. Thiamine deficiency is one of the most common deficiencies. This can manifest within 1-3 months of surgery as beriberi or later as Wernicke encephalopathy. Symptoms of beriberi include peripheral neuropathy, ataxia, muscle weakness, high-output heart failure, LE edema, and respiratory distress. Nachi: All of that being said, each specific procedure has it’s own unique set of complications that we should discuss. Let’s start with the sleeve gastrectomy. Jeff: Early complications of sleeve gastrectomy include staple-line leaks, strictures, and hemorrhage. Leakage from the staple line typically presents within the first week, but can present up to 35 days, usually with fevers, tachycardia, abdominal pain, nausea, vomiting sepsis, or peritonitis. This is one of the most serious and dreaded early complications and represents an important cause of morbidity with an incidence of 3-7%. Nachi: Strictures commonly occur at the incisura angularis of the remnant stomach and are usually due to ischemia, leaks, or twisting of the gastric pouch. Patients with strictures usually have n/v, reflux, and intolerance to oral intake. Jeff: Hemorrhage occurs due to erosions at the staple line, resulting in peritonitis, hematemesis, or melena. Nachi: Late complications of sleeve gastrectomies include reflux, which occurs in up to 25% of patients, and strictures, which lead to epigastric discomfort, nausea, and dysphagia. Jeff: I’m getting reflux and massive heartburn just thinking about all of these complications, or the tacos i just ate…. Next we have the Roux-en-Y bypass. Nachi: Early complications of the Roux-en-Y Gastric Bypass include anastomotic or staple line leaks, hemorrhage, early postoperative obstruction, and dumping syndrome. Jeff: Leak incidence ranges from 1-6%, usually occurring at the gastro-jejunostomy site. Patients typically present within the first 10 days with abdominal pain, nausea, vomiting, and the feeling of impending doom. Some may present with isolated tachycardia while others may present with profound sepsis – tachycardia, hypotension, and fever. Nachi: Similar to the sleeve, hemorrhage can occur both intraperitoneally or intraluminally. This may lead to hematemesis or melena depending on the location of bleeding. Jeff: Early obstructions usually occur at either the gastro-jejunal or jejuno-jejunal junction. Depending on the location, patients typically present either within 2 days or in the first few weeks in the case of the gastro-jejunal site. Nachi: If the obstruction occurs in the jejuno-jejunostomy site, this can cause subsequent dilatation of the excluded stomach and lead to perforation, which portends a very poor prognosis. Jeff: Next, we have dumping syndrome. This has been seen in up to 50% of Roux-en-Y patients. Nachi: Early dumping occurs within 10-30 minutes after ingestion. As food rapidly empties from the stomach, this leads to distention and increased contractility, leading to nausea, abdominal pain, bloating, and diarrhea. This usually resolves within 7-12 weeks. Jeff: Moving on to late complications of the roux-en y - first we have marginal ulcers. Peptic ulcer disease and diabetes are risk factors and tobacco use and NSAIDs appear to increase your risk. In the worse case, they present with hematemesis or melena. Nachi: Internal hernias, intussusception, and SBOs are also seen after Roux-en-y gastric bypass. Patients with internal hernias usually present late in the postoperative period following significant weight loss. Jeff: Most studies cite a rate of 1-3% for internal hernias, with mortality up to 50% if there is strangulation. Nachi: And unfortunately for us on the front lines, diagnosis can be challenging. Presenting symptoms may be vague and CT imaging may be negative when patients are pain free, thus laparoscopy may be needed to definitively exclude an internal hernia. Jeff: Strictures may occur both during the early and late period. Most are minor, but significant strictures may result in obstruction. Nachi: Trocar site hernias and ventral hernias are also late complications, usually found after significant weight loss. Jeff: Cholelithiasis is another very common complication of bypass surgery, occurring in up to one third of patients, usually occurring during a peak incidence period between 6-18 months. Nachi: For this reason, the current recommendation is that patients undergoing bypass be placed on ursodeoxycholic acid for 6 months preventatively. Jeff: Some even go as far as to recommend prophylactic cholecystectomy to prevent complications, but as of 2013, the recommendation was only ‘to consider’ it. Nachi: Nutritional deficiencies are also common complications. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications. Patients typically take vitamins postoperatively to prevent such complications. Jeff: And next we have late dumping syndrome, which is far more rare than the last two complications. In late dumping syndrome, 1-3 hours after a meal, patients suffer hypoglycemia from excessive insulin release following the food bolus entering the GI tract. Symptoms are those typical of hypoglycemia. Nachi: Lastly, let’s talk about complications of lap adjustable gastric band surgery. In the early post op period, you can have esophageal and gastric perforations, which typically occur during balloon placement. Patients present with abd pain, n/v, and peritonitis. These patients often require emergent operative intervention. Jeff: The band can also be overtightened resulting in distention of the proximal gastric pouch. Presenting symptoms include abd pain with food and liquid intolerance and vomiting. Symptoms resolves once the balloon is deflated. The band can also slip, allowing the stomach to move upward and within the band. This occurs in up to 22% of patients and can cause strangulation. Presentation is similar to bowel ischemia. Nachi: Later complications include port site infections due to repeated port access. The infection can spread into connector tubing and the peritoneal cavity causing systemic symptoms. Definitely start antibiotics and touch base with the bariatric surgeon. Jeff: The connector can also dislodge or rupture with time. This can present as an arrest in weight loss. It’s diagnosed by contrast injection into the port. Of note, this complication is less common due to changes in the technique used. Nachi: Much like early band slippage and prolapse, patients can also experience late band slippage and prolapse after weeks or months. In extreme cases, the patients can again have strangulation and symptoms of bowel ischemia. More mild cases will present with arrest in weight loss, reflux, and n/v. Jeff: The band can also erode and migrate into the stomach cavity. If this occurs, it usually happens within 2 years of the initial procedure with an incidence of 4-11%. Presenting symptoms here include epigastric pain, bleeding, and infections. You’ll want to obtain emergent imaging if you are concerned. Nachi: And lastly there are two rare complications worth mentioning from any gastric bypass surgery. These are nephrolithiasis, possibly due to increased urinary oxalate excretion or hypocitraturia, and rhabdomyloysis. Jeff: That was a ton of information but certainly valuable as most EM clinicians, even ones in practice for decades, are unlikely to have that depth of knowledge on bariatric surgery. Nachi: And truthfully these patients are complicated. Aside from the pathologies we just discussed, you also have to still bear in mind other abdominal conditions unrelated to their surgery like appendicitis, diverticulitis, pyelo, colitis, hepatitis, pancreatitis, mesenteric ischemia, and GI bleeds. Jeff: Moving on to my favorite - prehospital care - as always, ABCs first. Consider IV access and early IV fluids in those at risk for dehydration and intra-abdominal infections. In terms of destination, if it’s feasible and the patient is stable consider transport directly to the nearest bariatric center - early efforts up front will really expedite patient care. Nachi: Once in the ED, you will want to continue initial stabilization. Special considerations for the airway include a concern for a difficult airway due to body habitus. Make sure to position appropriately and preoxygenate the patients if time allows. Keep the patient upright for as long as possible as they may desaturate quickly when flat. Jeff: We both routinely raise the head of the bed for all of our intubations. This is ever more important for your obese patients to help maximize your chance of first pass success without significant desaturation. Nachi: And though I’m sure we all remember this from residency, it’s worth repeating: tidal volume settings on the ventilator should be based on ideal body weight, not actual body weight. At 6 to 8 mL/kg. Jeff: Tachycardic patients should make you concerned for hypovolemia 2/2 dehydration, sepsis, leaks, and blood loss. Consider performing a RUSH exam (that is rapid ultrasound for shock and hypotension) to identify the cause. A HR > 120 with abdominal pain should make you concerned enough to discuss urgent ex-lap with the surgeon to evaluate for the post op complications we discussed earlier. Nachi: If possible, obtain a view of the IVC also while doing your ultrasound to assess for volume status. But bear in mind that ultrasound will undoubtedly be more difficult if the patient has a large body habitus, so don’t be disappointed if you’re not getting the best views. Jeff: Resuscitation should be aimed at early fluid replacement with IV crystalloids for hypovolemic patients and packed RBC transfusions for patients presumed to be unstable from hemorrhage. No real surprises there for our listeners. Nachi: Once stabilized, gather a thorough history. In addition to the usual questions, ask about po intolerance, early satiety, hematemesis, and hematochezia. Definitely also gather a thorough surgical history including name of procedure, date, known complications post op, and name of the surgeon. Jeff: You might also run into “medical tourism” or global bariatric care. Patients are traveling overseas to get their bariatric care more and more frequently. Accreditation and oversight is variable in different countries and there isn’t a worldwide standard of care. Just an important phenomenon to be aware of in this population. Nachi: On physical exam, be sure to look directly at the belly, making note of any infections especially near a port-site. Given the reorganized anatomy and extent of soft tissue in obese patients, don’t be reassured by a benign exam. Something awful may be happening deeper. Jeff: This naturally brings us into diagnostic testing. Not surprisingly, labs will be helpful in these patients. Make sure to check abdominal labs and a lipase. Abnormal LFTs or lipase may indicate obstruction of the biliopancreatic limb in bypass patients. Nachi: A lactic acid level will help in suspected cases of hypoperfusion from sepsis or bowel ischemia. Jeff: And as we mentioned earlier, these patients are often at risk for ACS given their comorbidities. Be sure to check a troponin if you suspect cardiac ischemia. Nachi: If concerned for sepsis, draw blood cultures, and if concerned for hemorrhage, be sure to send a type and screen. Urinalysis and urine culture should be considered especially for early post op patients, symptomatic patients, or those with GU complaints. Jeff: And don’t forget the urine pregnancy test for women of childbearing age, especially prior to imaging. Nachi: Check an EKG immediately after arrival for any patient that may be concerning for ACS. A normal ekg of course does not rule out a cardiac cause of their presentation. Jeff: As for imaging, plain radiographs certainly play a role here. For patients with respiratory complaints, check a CXR. In the early postoperative period, there is increased risk for pneumonia. Nachi: Unstable patients with abdominal pain will benefit from an emergent abdominal series, which may show free air under the diaphragm, pneumatosis, air-fluid levels, or even dilated loops of bowel. Jeff: Of course don’t forget that intra abd air may be seen after laparoscopic procedures depending on how recently the operation was performed. Nachi: Plain x-ray can also help diagnose malpositioned or slipped gastric bands. But a negative study doesn’t rule out any of these pathologies definitively, given the generally limited sensitivity and specificity of x-ray. Jeff: You might also consider an upper GI series. Emergent uses include diagnosis of slipped or prolapsed gastric bands as well as gastric or esophageal perforations. Urgent indications include diagnosis of strictures. These can also diagnose gastric band erosions and help identify staple-line or anastomotic leaks in stable patients. Nachi: However, upper GI series might not be easy to obtain in the ED, so it’s often not the first test performed. Jeff: This brings us to the workhorse for diagnostic evaluation. The CT. Depending on suspected pathology, oral and/or IV contrast will be helpful. Oral contrast can help identify gastric band erosions, staple-line leaks, and anastomotic leaks. Leaks can be identified in up 86% of cases with oral contrast. Nachi: CT will also help diagnose internal hernias. You might see the swirl sign on CT, which represents swirling of the mesenteric vessels. This is highly predictive of an internal hernia, with a sensitivity of 78-100% and specificity of 80-90% according to at least two studies. Jeff: While CT is extremely helpful in making this diagnosis, note that it may be falsely negative for internal hernias. A retrospective review showed a sensitivity of 76% and a specificity of 60%. It also showed that 22% of patients with an internal hernia on surgical exploration had a negative CT in the ED. Another study found a false negative rate of 32%. What does all this mean? It likely means that a negative study may still necessitate diagnostic laparoscopy to rule out an internal hernia. Nachi: While talking about CT, we should definitely mention CTA for concern of pulmonary embolism. In order to limit contrast exposure, you might consider doing a CTA chest and CT of the abdomen simultaneously. Jeff: Next up is ultrasound. Ultrasound is still the first-line imaging modality for assessing the gallbladder and for biliary tract disease. And as we mentioned previously, ultrasound should be considered for your RUSH exam and for assessing the IVC. Nachi: We also should discuss endoscopy, which is the test of choice for diagnosing gastric band erosions. Endoscopy is also useful for evaluating marginal ulcers, strictures, leaks, and GI bleeds. Endoscopy additionally can be therapeutic for patients. Jeff: When treating these patients, attempt to contact the bariatric surgeon for guidance as needed. This shouldn’t delay imaging however. Nachi: For septic patients, make sure your choice of antibiotics covers intra-abdominal gram-negative and anaerobic organisms. Port-site infections require gram-positive coverage to cover skin flora. Additionally, give IV fluids, blood products, and antiemetics as appropriate. Jeff: Alright, so this month, we also have 2 special populations to discuss. First up, the kids. Nachi: Recent estimates from 2015-2016 put the prevalence of obesity of those 2 years old to 19 years old at about 19%. As obese children are at higher risk for comorbidities later in life and bariatric surgery remains one of the best modalities for sustained weight loss, these surgical procedures are also being done in children. Jeff: Criteria for bariatric surgery in the adolescent population is similar to that of adults and includes a BMI of 35 and major comorbidities (like diabetes or moderate to severe sleep apnea) or patients with a BMI 40 with other comorbidities associated with long term risks like hypertension, dyslipidemia, insulin resistance and impaired quality of life. Nachi: Despite many adolescents meeting criteria, they should be referred with caution as the long term effects are unclear and the adolescent experience is still in its infancy with few pediatric specific programs. Jeff: Still, the complication rate is low - about 2.3% with generally good clinical outcomes including improved quality of life and reducing or staving off comorbidities. Nachi: Women of childbearing age are the next special population. They are at particular risk because of the unique caloric and nutrient needs of a pregnant mother. Jeff: Pregnant women who have had bariatric surgery have an increased risk of perinatal complications including prematurity, small for gestational age status, NICU admission and low Apgar scores. However, these risks come with benefits as other studies have shown reduced incidence of pre-eclampsia, large for gestational age neonates, and gestational diabetes. Nachi: 2013 guidelines from various organizations recommend avoiding becoming pregnant for at least 12-18 months postoperatively, with ACOG recommending a minimum of 2 years. Bariatric surgery patients who do become pregnant require serial monitoring for fetal growth and higher doses of supplemental folate. Jeff: We also have 2 pretty cool cutting edge techniques to mention this month before getting to disposition. Nachi: Though these are certainly not going to be done in the ED, you should be aware of two new techniques. Recently, the FDA approved 3 new endoscopic gastric balloon procedures in which a balloon is inflated in the stomach as a means of simulating a restrictive procedure. Complications include perforation, ulceration, GI bleeding, and migration with obstruction. As of now, they are only approved as a temporary modality for up to 6 months. Jeff: And we also have the AspireAssist siphon, which was approved in 2016. With the siphon, a g tube is placed in the stomach, and then ⅓ of the stomach contents is drained 20 minutes after meals, thus limiting overall digested intake. Nachi: Pretty cool stuff... Jeff: Yup - In terms of disposition, decisions should often be made in conjunction with the bariatric surgical team. Urgent and occasionally emergent surgery is required for those with hemodynamic instability, anastomotic or staple line leaks, SBO, acute band slippage with dilatation of the gastric pouch, tight gastric bands, and infected port sites with concurrent intra abdominal infections. Nachi: And while general surgeons should be well-versed in these complications should the patient require an emergent surgery, it is often best to stabilize and consider transfer to your local bariatric specialty facility. Jeff: In addition to the need for admission for surgical procedures, admission should also be considered in those with dehydration and electrolyte disturbances, those with persistent vomiting, those with GI bleeding requiring transfusions, those with acute cholecystitis or choledococholithiasis, and those with malnutrition. Nachi: Finally, patients with chronic strictures, marginal ulcers, asymptomatic trocar or ventral hernias, and stable gastric band erosions can usually be safely discharged after an appropriate conversation with the patient’s bariatric surgeon. Jeff: Definitely a great time to do some joint decision making with the patient and their surgeon. Nachi: Exactly. Let’s close out with some Key points and clinical pearls. Jeff: Bariatric surgeries are being performed more frequently due to both their success in sustained weight loss and improvements in associated comorbidities. Nachi: There is an increased risk of postoperative myocardial infarction and pulmonary embolism after bariatric surgery. There is also an increased risk of self-harm emergencies after bariatric surgery, mostly in patients with known psychiatric co-morbidities. Jeff: Nutritional deficiencies can occur following bariatric surgery, with thiamine deficiency being one of the most common. Look for signs of beriberi or even Wernicke encephalopathy. Nachi: Staple-line leaks are an important cause of postoperative morbidity. Patients often present with abdominal pain, vomiting, sepsis, and peritonitis. Jeff: Strictures can also present postoperatively and cause reflux, epigastric discomfort, and vomiting. Nachi: Intraperitoneal or intraluminal hemorrhage is a known complication of bariatric surgery and may present as peritonitis or with hematemesis and melena. Jeff: After significant weight loss, internal hernias with our without features of strangulation are a late complication. Nachi: Late dumping syndrome is a rare complication following Roux-en-Y bypass occurring months to years postoperatively. It presents with hypoglycemia due to excessive insulin release. Jeff: Esophageal or gastric perforation are early complications of adjustable gastric band surgery. These patients require emergent surgical intervention. Nachi: Overtightening of the gastric band results in food and liquid intolerance. This resolves once the balloon is deflated. Jeff: Late complications of gastric band surgery include port-site infections, connector tubing dislodgement or rupture, band slippage or prolapse, and band erosion with intragastric migration. Nachi: Given the myriad of possible bariatric surgeries, emergency clinicians should be cognizant of procedure-specific complications. Jeff: Consider obtaining a lactic acid level for cases of suspected bowel ischemia or sepsis. Nachi: Endoscopy is the best method for diagnosing and treating gastric band erosions. Jeff: Septic patients should be treated with antibiotics that cover gram-negative and anaerobic organisms. Suspected port site or wound infections require gram positive coverage. Nachi: Pregnant patients who previously had bariatric surgery are at risk for complications from their prior surgery as well as pregnancy-related pathology. Jeff: A plain radiograph may be useful in unstable patients to evaluate for free air under the diaphragm, pneumatosis, air-fluid levels, or dilated loops of bowel. Nachi: CT of the abdomen and pelvis is the mainstay for evaluation. Oral and/or IV contrast should be considered depending on the suspected pathology. Jeff: Have a low threshold for emergent surgical consultation for ill-appearing, unstable, or peritonitic patients. Nachi: So that wraps up Episode 30! Jeff: As always, 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 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 any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And the address for this month’s cme credit is ebmedicine.net/E0719, so head over there to get your CME credit. As always, the [DING SOUND] 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! Most Important References Altieri MS, Wright B, Peredo A, et al. Common weight loss procedures and their complications. Am J Emerg Med. 2018;36(3):475-479. (Review article) Colquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014(8):CD003641. (Cochrane review; 22 trials) Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring). 2013;21 Suppl 1:S1-S27. (Society practice guidelines) Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism. 2018;79:97-107. (Review article) Contival N, Menahem B, Gautier T, et al. Guiding the nonbariatric surgeon through complications of bariatric surgery. J Visc Surg. 2018;155(1):27-40. (Review article) Parrott J, Frank L, Rabena R, et al. American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient, 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741. (Society practice guidelines) Chousleb E, Chousleb A. Management of post-bariatric surgery emergencies. J Gastrointest Surg. 2017;21(11):1946-1953. (Review article) Goudsmedt F, Deylgat B, Coenegrachts K, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass: a correlation between radiological and operative findings. Obes Surg. 2015;25(4):622-627. (Retrospective review; 7328 patients) Michalsky M, Reichard K, Inge T, et al. ASMBS pediatric committee best practice guidelines. Surg Obes Relat Dis. 2012;8(1):1-7. (Society practice guidelines)
The guys talk about the television they’ve been watching so far this summer, including American Ninja Warrior on NBC, FX’s Pose, American Masters: Terrence McNally: Every Act of Life on PBS, Grand Hotel on ABC, Good Trouble on Freeform and What/If on Netflix. Jeff reviews In Case You Forgot by Frederick Smith & Chaz Lamar. Jeff interviews Roan Parrish about Raze, the latest book in the Riven series. They talk about the research she did for the series, including going on tour with a band, as well as the eclectic music she enjoys. The origin of Roan’s collaboration with Avon Gale is also discussed along with what got Roan started with writing gay romance. Complete shownotes for episode 196 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript - Roan Parrish This transcript was made possible by our community on Patreon. You can get information on how to join them at patreon.com/biggayfictionpodcast. Jeff: Welcome, Roan, to the podcast. It is so great to finally have you here. Roan: Thank you. I'm so happy to be here. Jeff: And it's a perfect opportunity because just last week, you released raise "Raze," just the third book in the "Riven" series. And for those who don't know, tell us about the series and, of course, this latest installment. Roan: Sure. So "Riven" starts out with the book, "Riven," also the series title. And it's kind of an anti-rock star romance. It's about Theo, who's the lead singer of the band, Riven. And they've suddenly hit it big and are super famous. And everyone in the band loves being famous and their success. And Theo hates it. He hates being famous. He hates being the center of attention. He hates, like, people knowing things about him or looking at him when he leaves the house. So he loves the music, but he finds fame, like, the worst thing ever. And so he's about to go off on a new leg of the tour and is sort of, like, wandering the streets of New York, feeling a little bit sorry for himself. When he hears this song coming from a bar, like, someone just strumming guitar, and it's one of the most beautiful things he's ever heard. So he goes in the bar to see who's playing this or what the song is. And he meets Caleb, who is the one playing the music. And Caleb, we learn later, has been a musician for a long time, a working musician, but has sort of gone away from the scene and hidden himself away in his uncle's house out of town because he's had some addiction issues, and he's trying to stay clean by staying away from everything that reminded him of the scene, including music. So they start to talk to each other and they bond over music. And then little by little, they fall in love. The problem being, of course, that for Theo being in the scene and being public is kind of part of his thing. And for Caleb, everything about that just brings back a lot of bad memories. So they have to sort of work together to figure out how that's gonna impact their relationship and if they can get through it. And then it kind of takes a hard left, I feel like this is the thing that I should say for people who haven't read the series, is that the series really does hang together. It has the same secondary characters. It deals with a lot of the same themes, like, the themes of ending up someplace that you never thought you would be. But then in book two, we met Reese, or we've met Reese in book one, but we have a book about Reese who was Caleb's best friend and Reese's husband, Matt. And Matt has nothing to do with the music scene. And the book is told from his perspective. So for people who go in expecting that the whole series is about music, it is in some ways, like, music as a through line. And certainly, this idea of fame and this idea of struggling with fame is a through line. But book one is sort of anti-rock star. And then book two is like working musician and person who's not involved with music at all. So I feel like that's the thing I should say. Jeff: Well, they it does hang together because you've got the working musician. Roan: Yeah, totally. And Reese, who is the working musician is someone who toured with Caleb when Caleb was still playing music. So the characters all hang together and the series hangs together, but it's not a kind of musician book, if that make sense. Jeff: Yeah, that makes sense. Roan: And then "Raze," which is book three, it also hangs together. "Raze," it's similarly about characters ending up someplace that they never thought they would be. And in this book we meet Huey, who was in the first two books, and has been a sort of a little bit of a shadowy figure who we never knew his backstory, we didn't know who he is, he just pops in and dispenses wisdom, and pops out again, he doesn't say much else. And so he was Caleb's sponsor in Narcotics Anonymous. And he's still been working as a sponsor. And he is so used to taking care of everyone else being a sponsor, helping people work through their own addiction issues, dealing with his own, that he doesn't really ever focus on his own life. He's built up this kind of wall of focusing on everyone else, so he never has to think about himself. And we meet Felix, who is doing the same thing, taking care of everyone else but him himself, but through his family instead of through NA. So he grew up and help take care of his younger brothers and sisters, and always helped his sister get whatever she wanted, and has now found himself as his sister goes off to do her music thing, found himself kind of like, "What the hell am I doing with my life? Who am I? I kind of forgot to ever notice what I wanted." And so the two of them come together. And two people who are so used to looking out for everyone except themselves, as you can imagine, when it comes down to trying to make a relationship, they kind of don't know how to do it. They don't know how to ask for what they want. They don't even know what they want from each other. And so feelings kinda bubble up and nobody knows what to do with them. And then it ends really happily. Jeff: As all romance must. Roan: That's a must. And there's even a kitten. So, yeah. Jeff: What attracted you to writing this series? Roan: I think that there's themes that go together. I love music. And I've always been a huge music fan. And one of the things that I've always thought was interesting is that music is so personal, to me, anyway. And I know for many other people, like, each of us, listens to music and feels something - has associations that are deeply personal. And something about the weirdness of something so personal, experienced on a large scale of fame has always struck me as really odd. So you can be at a concert with the band and have thousands and thousands of people there. And each person has been hit with his music in a really personal way. And yet, we're all there together in a super public space, having kind of a personal experience, like, smooshed up together with each other. And I've just always found that really strange. And I know for people who make music, the process of making music is really personal. And it's really different than the process of performing music. And so I think I was interested in what would it feel like to do something really personal in front of a lot of people and then watch as this thing that you've made gets loose on the world, and you no longer have any control over it or what people think of it. And to me being famous seems like absolutely the worst thing I can imagine outside of, like, actual torture. And I know that for some people, that's not the case. But, yeah. So I was interested in writing, like, the genre of rock star romance is a thing. And I was interested in looking at it from the perspective of what would a rock star romance look like, if instead of rock star being a desirable thing, it was a terrible thing or a thing that caused a lot of problems for the rock star. Jeff: What was the process around some of the research, because, like, you talk about this very personal thing. How do you research that? And then how do you try to read and put it in a book so everybody else gets it? Roan: You know, I mean, I don't know. I can't really claim that I did it correctly. I've never been a musician. I like singing karaoke to Paula Abdul once with five other people very drunk in college. And that's about my performance level. But my sister-in-law, my sister's wife is a musician. And she's very personal and writes very personal music and then performs it. And, you know, I've been to many of her shows, obviously. And I went on tour with her in Europe once, like, carrying her stuff and hanging on for the ride. And one thing that struck me was, like, people would come up to her after the show and tell her like, "Your music has meant so much to me. I was going through such a hard time and your music spoke to me in these really hard moments." And so I would see that and I know that people are having these personal responses and have personal relationships with the music. And I know that my sister-in-law does as well. And then, like, the moment that the two of them would be having together would be personal. But there was still this whole performance element that I kinda…yeah, just seems like a very strange crucible of the personal and the public smooshed together, and maybe the performativity of that, in some way, like, hides the personalness…or not hides necessarily, but, like, you need a little bit of distance, like, the lights and the smoke machine, and the darkness, and the space between the stage and the crowd to insulate you a little bit in order to take something that's so personal and project it out in public. Jeff: I love how you kinda had the personal research going on there that you actually went on this tour and got to see all of it kinda go down about as close to it as you could without being the actual performer. Roan: Yeah, yeah, which is awesome. And I mean, like, I've had many friends who do music. So I knew that if I had, like, specific questions, you know, I had some questions about, like, the studio stuff and how you laid out tracks that I was able to ask friends about. But I really do think it's, like, the feeling of performing that I was trying to capture and the sense of what it felt like to have something that was yours, like, the music, and then watch other people make it theirs. And although I've never been a performer in any way, I mean, that's a little bit, like, what happens with books is that I sit at home in my pajamas, like, with cat hair all over me, and I write these books. And then when they're published, it's not mine anymore, it belongs to the people who read it. And I don't really have any control over it. So that part was easy to kind of understand. Jeff: Of course, you mentioned your love of music. And your bio actually mentioned that you listen to torch songs and melodic death metal. Now, I get eccentricity because my playlists are, like, wildly, you know, strangely hooked together in some way. But these two seem very different. What attracts you to these two individual styles? Roan: I think I was trying to write my bio in a way that was, you know, like on dating sites, you wanna say the two things that seem most opposed. So you can be like, "Listen, this is what you're getting as a human being who is essentially at odds with himself," maybe that's just me. Anyway, yeah, I love both of those genres. I think they're both simultaneously really raw and really beautiful. Like, torch songs, I love because they are heartbroken, and tender, and they tell a story, and they're so vulnerable, and beautiful. And melodic death metal is like, doing the same thing, only it can't be vulnerable, or, like, it needs a really harsh bass riff, and loud guitar, and loud drums in order to do something that's that tender and that personal. And I find not like screamy death metal, but yeah, melodic death metal. I find it like one of those puppies that growls at you until you get a little bit closer, and then little by little it sorta lets you pet it. And then by the time you're petting it, it's like, "Oh, no, I really do love this. Please don't ever stop petting me," but then, like, someone else walks in the room and they're all growly again. Jeff: I love that analogy. So awesome. Jeff: Now, speaking of music, with the "Riven" series seems such an obvious thing to perhaps you write to music if you're a writer who does that. Was there a particular playlist that sort of pushed you along in the writing of the series? Roan: You know, I actually didn't listen to music at all writing the series, which is sort of strange when you say it like that. I go through phases of whether I like to write with music on or not. And there have been books that I've written where I listened to the same music over and over. Like, when I wrote...what book was it? Oh, "Out of Nowhere," which is the second book "In the Middle of Somewhere" series, I listened like obsessively to "The Civil Wars" just over, and over, and over. And for some reason, the mood of those albums was, like, exactly the mood that I needed to be in to write that book. But with the "Riven" series, I didn't listen to music at all. Jeff: Interesting. Okay. Roan: Yeah. And none of the music in the books is real. Like, I made up all the band names and all of the music. And I wonder if maybe part of it was like, I didn't want real music in my head because I was making it up. Jeff: That would make sense. Yeah. If you're having to write any kind of song lyrics or anything inside the book, I could see where you would wanna, like, accidentally just pick up something. Roan: Right. Well, it was super adorable actually because one of my best friends who reads all my stuff first is, like, she likes music a lot, but she's like a top 40 radio kind of tastes music person. And so she thought that all of the musical references in my books in the "Riven" series were real, because she knows that I like lots of different kinds of music, and she just didn't know that they were fake at all, which is totally adorable. Jeff: Oh, that's awesome. So you could have an extra career then as a songwriter if you're writing lyrics. Roan: Maybe a band-namer. I like the band names more. Jeff: So I have to ask for the audio book then that you've got song lyrics - does that mean your narrator is actually singing the lyrics? Did you make Iggy sing and Chris sing? Roan: No. And, you know, I don't think that I have a chunk of lyrics long enough to be sung. They're like a couple snippets. But I didn't even think about the fact that I could have written a song of it for the audio book. That would have been awesome. Too late. Jeff: Something to think about maybe for a future book or another installment in the series. Roan: Yeah, yeah. I could do it as like an extra or something, I guess. Jeff: And speaking of the series, is there more to come in this series? Roan: There's not. Like, The Good Place that we were talking about earlier, I have decided that book three is the end. Jeff: Okay. Time to wrap up that universe. Roan: Yeah. And, you know, I say that and obviously maybe I would go back in the future and write another one. But I think the fact that the last book is about a character whose story we've kinda been wondering about for the whole series, it felt like a good place to stop because it's sort of the wrap up of, like, solving the last interpersonal mystery. So that felt like the right place to stop. And there are definitely tendrils. Like, people who've read a bunch of my books will notice that Riven, the band, is mentioned in another book, and that some characters from the "Middle of Somewhere" series are briefly alluded to in "Riven." So there's, like, little Easter eggs for people who have read all the books because I sort of think of everything as being connected in that way. So it'll pop back up, I'm sure. Jeff: I love that. I love the broad interconnected universe thing. Roan: Yeah, yeah. Secretly in my head, all of the books are connected in lots of ways that I don't necessarily put on the page. But, like, I like to get a couple in there. Jeff: Nice. Now, you also co-write with Avon Gale. What got that collaboration going? Roan: You know, that collaboration happened completely by accident, or on a whim, I should say. And I'm so glad it did. So I was living in New Orleans a couple years ago. And Avon and I were friends on the internet. And she offered when I was moving back from New Orleans to Philadelphia, she was like, "I love a road trip. What if I fly to New Orleans and drive with you," because it's a many day drive and you have a cat. I had like my truck and then I had my car hitched to the back of the truck, and it was a whole big thing. So I was like, "Oh, great. This will be fun." So we started driving from Louisiana to Pennsylvania. And it was, like, a torrential downpour. And we couldn't hear the radio. We couldn't do anything. And so Avon was like, "Okay. Well, I'll just tell you about this book that I've been working on. And I am really stuck on it. I can't get the plot right." So I was like, "Okay." And I'm pretty introverted and Avon is very extroverted. And we going in... Jeff: And it's very true, she is. Roan: Yes. And, you know, I really just love a clear communicator, so I loved it. She was like, "Basically, I talk constantly. And if you want me to stop, you have to tell me to stop." And I was like, "Oh, that's amazing. I run out of steam socially in approximately two-and-a-half hours, and I'm still listening to you, but I won't respond." And she was like, "Okay, great." And thus, it was. And so she basically narrated to me the entire plot of this book that she was trying to write, and she was having trouble with it. And I kept doing this probably obnoxious thing where I was like, "Oh, what if you did this?" Or, "What if you did that?" Or, "Oh, my gosh, it's so funny, because if that were me, I would totally do this." And she, instead of being annoyed, was like, "Well, you should obviously write this book with me." And that book was what it turned into "Heart of the Steal," which is the first book we wrote together. And it was so fun because then as we were driving, we just plotted the whole book. And she had her little, like, computer that she was typing on while we drove. And I drove the truck the whole way. And so I would like yammer at her and she would take notes, and then in the hotel rooms at night, we would kinda hash it out. And so it happened on a total whim, and then turned out to be really fun. And so we planned it on that trip. And then I went and visited her months later, I guess. Yeah, some months later, and we actually wrote "Thrall," which was the second book that we co-wrote together, like, in the same place. So we wrote it, like, together, even though we don't live in the same place. So it was two very different writing experiences, but both equally awesome. Jeff: That's fantastic. And I have to imagine it's a nice way to kill the time in a road trip to just write a book. Roan: Oh, yeah, totally. And it's really fun because I don't know about you or about other writers in general, but, like, I find that traveling is one of the best, like, brain, what do you call it? Like, catalyzers, brain catalyzers, something about moving through space constantly, whether it's, like, on a train or just walking or whatever. It's, like, the rhythm of moving through space makes my brain also work in a forward rhythm. And I find myself, excuse me, getting so many ideas when I'm just, like, walking a long distance, or on a train, or on a bus, or something. And so something about driving and plotting the thing together was, like, super, some word… Jeff: Awesome. Roan: Yeah, awesome. Jeff: Probably better than awesome, but awesome was the first thing that popped into my head. Roan: Yeah, yeah. Jeff: And then I totally get what you're talking about there, too, because I've done a lot of plotting and some writing on planes. Because it's like, yeah, there's something about just that that just you've got the time, and, like, the brain is working, so use it. Roan: Yeah. And it's, like, looking out the window of something moving through that kinda space with everything passing so quickly, it almost feels like it changes the rhythm of thoughts or something. Jeff: Yeah. And kudos to Avon for being able to type in a moving vehicle because I don't know that I could do that. Roan: Oh, my God, she has, like, motion sickness proof. I swear to God. Jeff: That's just crazy. Roan: Oh, I know. Jeff: But we definitely got to talk a little bit about "Thrall." I reviewed it back in Episode 157. I was just blown away by it. For folks who don't know, tell us about what that book is and what in fact does make it so special? Roan: So "Thrall" is our modern "Dracula" retelling, basically. And for anyone who's read "Dracula," you'll remember that "Dracula," it's an epistolary novel, so it's told through letters, and diary entries, and, like, newspaper clippings, telegram, stuff like that. And so we did "Thrall" in the same way, we made it an epistolary novel. But since ours was modern, and that one was 19th century, instead of letters and journal entries, and stuff like that, we have emails, and g-chats, and tweets, and podcast descriptions, and stuff like that. So the whole thing is written in that way, this combination of different print media. So we have the main characters that people will recognize from "Dracula." And Mina, and Lucy, who are the two characters that people will know from "Dracula," in our version, have a podcast, a true crime podcast in New Orleans. And they get caught up in basically trying to solve the mystery of Lucy's brother who seems to have disappeared. And so in getting caught up in that mystery, they stumble upon this a role-playing game kind of thing, where they use an app, and they go to different places, and they try to solve clues, hoping that it will take them to Lucy's brother. And so in addition to it being an epistolary form in general for the whole book, then kind of within that epistolary form, there's this mystery that they're trying to solve on a computer, I mean, on a phone app. So it's like a game inside an epistolary novel that's an adaptation of another epistolary novel. Jeff: And epistolary just not something you see very much. At least I don't, especially in the romance genre that I tend to read in general. What was it like as a writer, and just plotting to take on such a different narrative format? Roan: Yeah, it was awesome. It was really, really cool. I love form, like, I'm super interested in what different things you can do with form. And one of the things that, like, when I'm reading other things I'm always interested in is what form did this author choose, whether it's something simple, like, short chapters, or long chapters, or, like, flashbacks versus telling everything in order, all of that stuff, I think, has such an impact on the way the story gets delivered. And so I was really excited to play with the form. And I think that with the genre of romance, one of the reasons why we don't see epistolary stuff so often is that it's, like, an additional level of remove between the two characters. And romance seems, to me, to be all about intimacy and connection. And sure, it can be really romantic or sexy to write a love letter or love email, I guess, in 2019. But there's still something where you're not in the moment. There's no, like, tracking a touch as it happens, or a kiss, or whatever it is. And so I think that going into "Thrall," we were like, "How the hell do we make a romance happen when the characters essentially are never in the same scene?" Like, in order to be texting each other, they probably aren't together. In order to be chatting each other, they're probably not together. And so any evidence of an encounter, which is all we could show, also demonstrated their distance. So that was a challenge. And we got around it in a couple of different ways, including characters literally writing out sex scenes that they wished would happen like fantasies, having chats that were more intimate. But yeah, the romance part, I think, was actually the hardest to portray via the epistolary form because it introduces that necessary distance, which is sort of the anti-romance. It was much easier, for example, for the mystery, or the suspense parts because those things can be portrayed that way no problem. But, yeah, the romance part was tricky. Jeff: Well, as I said the review, I think you guys pulled it off so amazingly. If people have not read "Thrall," they should really pick it up and give it a try. Roan: Oh, thanks. Jeff: Because maybe a little much to call it a breath of fresh air, but it's certainly gonna be something very different than what I think most people tend to read. Roan: Yeah, it definitely is different. And it's one of those books that Avon and I knew going in, but it's not everyone's cup of tea. It's an adaptation. It's an adaptation of "Dracula." It's an adaptation of "Dracula" without vampires. It's a romance where you don't ever see the characters touch necessarily. But like, I feel, like, for people who are interested in form for people who are interested in Dracula or interested in suspense, and all that stuff, we were really excited to just do something totally new for us. Jeff: Yeah. It was super cool. Please do more of that sometime. Roan: I would love too. Jeff: So laying a little bit of your origin story, how did you get involved in writing M/M romance? Roan: You know, at the risk of making, it sound completely accidental, it was kind of accidental. My good friend from graduate school, got a job in Phoenix, and didn't know very many people. She didn't have many friends. And she and I both started reading both young adult and M/M mysteries in grad school. And so I went to go visit her and she was having a hard time. Like, I said she didn't know very many people, didn't have any friends, and she just wanted like, escape reading. And we were, like, in the kitchen cooking dinner or something, and she was saying that she just wished that there was, like, a romance novel that she could read about someone who was in her situation. So someone who was a new professor in a new place, didn't know very many people and was kind of struggling to fit in. And because she's my friend and I wanted to make it all better, I was like, "Oh, no worries, I'll write you a story. Everything is gonna be okay." So on the plane home from Arizona, I wrote the first chapter of what would eventually be "In the Middle of Somewhere," my first book, thinking that, like, I would send it to my friend, and she would read it and be like, "You are such a nerd. I can't believe you actually wrote me this story. I was just complaining. You're weird." But instead, she read it and wrote back and was like, "Oh, a story. Oh, my gosh. What happens next?" And, of course, I didn't know what happened next because there was no next. I thought that it was going to be a little one-off thing. But then I wrote the next chapter and I emailed it to her, and she wrote back and was like, "What happens next?" And I actually wrote the whole first half of the book that way just chunking out a chapter, emailing it to my friend, and I was really writing it for her. I never thought I would show it to anyone. I never intended to send it to a publisher. I didn't even have a plot, I just was writing these little sections. And around halfway through the book, I suddenly realized that, like, it was getting kinda long, and I should probably figure out how it was gonna end. Otherwise, I would just end up writing this, like, email missive to my friend forever, which was really fun. But also, I thought she would get sick of it eventually. And then when I finished the book, I thought that was gonna be the end of it. And it was my friend who was like, "No, you should totally try to publish it." And I owe it all to her, I never occurred to me to send it to anyone. And I would never have done it if she hadn't made me. Jeff: Well, kudos to her for making that happen. And that's the best accident story ever. I mean, just amazing. Were you writing before that at all? Or was this just really like, "Hey, I could write. I'll write you something. No worries." Roan: Well, you know, I've always written different things. I was a poetry major in college of all the super useful things to pursue. And so I wrote poetry or some short fiction. And then I did my PhD in literature. So, you know, I wrote a dissertation, I wrote nonfiction for years, and years, and years. But I've always loved to write. And I love reading novels. And so sitting down to write a novel, I think it actually helps that I wasn't thinking of it as writing a novel. I just thought of it as writing the story for my friend. So I didn't have any of the self-consciousness or like that internal editorial voice that I'm sure if I had planned to send it out, would have like, killed me as I was trying to start. And in terms of, like, as we get back to your original question, which I don't know that I actually answered in terms of, like, why M/M romance specifically. I hate misogyny, and sexism, and can't deal with stories where I read female characters and feel intensely alienated from them. And I find often in romance, not all by any means, there are some amazing, amazing, like, revolutionary really amazing people writing romance with women, but I've often found that reading romance novels that are, like, heterosexual romance stories make me feel alienated, and angry, and the opposite of anything that I associate with romantic. And so, yeah. Jeff: Who are sort of your author influences? Roan: Oh, man. Well, you know, growing up, I read everything. I'm a real, like, moody reader. So I go through phases. And when I'm in that phase, that's all I read. So, like, when I was in elementary school, I was obsessed with S. E. Hinton Hinton, "The Outsiders" and "Rumble Fish," those books. And she writes with this very kind of, like, spare style, but lots of sensory detail. And I think that that's definitely something that I've always really admired was the ability to evoke feeling even while being very spare. And then when I was in middle school, I was obsessed with Anne Rice, obviously, because middle school. And I read her books over, and over, and over. And I think that she is like the master of the kind of Baroque sentence structure that when you're deep in, reading one of her books, you don't notice that she's, like, in a strange Yoda way, like, flipping a subject and predicate to make things sound, more flourishy and purple prosy. You don't notice it because you're so deep in it that, like, of course, that character would talk that way. But if you go and you read another author or another book, you realize suddenly what she was doing. And so I think from her, I got just, like, I really respected this immersive detail-rich all the senses engaged kind of writing. Also, I really love long books, and the ability to sustain a story over 800 pages, and keep going with this level of detail. I mean, I know it's not everyone's bag, like, some people really like a short one and done, but I mean, I will read a series that goes on forever if I'm still engaged. And I just think that she does that incredibly well. Then, oh, gosh, I'm taking you on a tour. I don't know if this is actually answering your question, but I do think... Jeff: It is actually. Yeah. Roan: Oh, okay, good. The real answer is, like, I learned things from every single author I read. And sometimes, it's things that I don't ever wanna do. And sometimes, it's things that my mind is blown because I'm like, "Holy crap, I didn't even know you could do that." Sometimes it's like I feel like I'm weak in one area at a moment. And so I wanna go read someone who I think does something really well and try to learn it. Oh, Francesca Lia Block was a huge influence when I was a teenager. She writes this kind of magical realism that is, like, very urban set - in LA, deals with real world problems, but has this, like, pink fog over the entire thing. And I was really, really taken by that. That way of combining urbanity with fantasy, and so that's definitely something that I took from her. I went through a really deep, like, epic historical fiction kick, which maybe is that same kind of, like, very immersive detail, huge cast of characters, all that stuff. And, oh, gosh, I'm totally blanking on her. Oh, Sharon Kay Penman is her name. Okay. Sorry, this is maybe a tangent. But this story blows my mind and is, like, one of the more impressive things I've ever heard in my life, if you'll indulge me for a moment. Jeff: Of course. Roan: So Sharon Kay Penman writes these, like, hugely epic, 1,000-page long, British Isles historical fiction. And she wrote this book called "The Sunne in Splendour," in, like, I wanna say the early 80s, maybe mid-80s. And the book is epically long, and just detail, and hundreds and hundreds of characters, and like tons of things translated into Welsh. It's about Welsh civil wars, or wars with England. Anyway, she wrote the book and, like, on a typewriter, and had it in one of those, you know, the boxes that reams of paper come in…you would put your manuscript in this box. So she was going to drive her book to her publisher. And she stopped at the bank to, like, deposit a check or something. And when she came back out, her car had been stolen with the copy of the book inside, the only copy of the book, which I don't even know how that happens. So the car stolen, she's just sure she's never gonna get it back. And whereas, like, I don't know, I would probably immediately go home and, like, order seven pizzas, and you wouldn't see me for a month. She drove home and started writing the book again. Jeff: Wow. I would have done the seven-pizza thing and then walked away for, like, at least a week. Roan: Yeah. Like, I would have told every single person who would listen that my life's work had been ripped from me. And it was the worst thing that ever happened to me and which, you know, I think that's actually speaking pretty well of my life that that would be the worst thing. But, yeah, I just, like, that level of tenacity and dedication to a project, it just blows my mind. Anyway, she's amazing. Jeff: Yeah, that's awesome. And just, like, I can't even imagine, it speaks so well to these days where we're like, "Did you back that up on Dropbox?" Roan: Yeah, at least someone's like, "Oh, man, I just spent, like, 20 minutes writing that email and it got wiped." And I'm like, "Sharon Kay Penman." Jeff: So what's coming up next for you? What's yet to come this year? Roan: Well, do wanna be the first person to know because I actually just found out yesterday? Jeff: Oh, breaking news. Roan: Breaking News. Yeah, I just sold a new book, which I'm pretty excited about. Okay. The concept is, there is a guy who has a bunch of animals. He's like, kind of antisocial, kind of pissed off at the world for reasons that I will not divulge yet. And he likes animals better than people. So he has all these rescue dogs and a bunch of cats that hang around. And basically, all he wants to do is take his dogs on these long rambling walks and think about how fucked up his life has gotten. It's the only thing keeping him sane, it's just, like, rambling walks with these dogs. And one night he is walking with the dogs and one of them starts chasing something. And he starts chasing the dog and falls down a hill and breaks his ankle. So all of a sudden, he can't do the one thing that he's liked, which is walk his dogs. So he goes online, and he finds this app that, like, match makes pet owners with people who wanna hang out with animals, but can't have pets of their own, because he's looking for someone who could help him walk his dogs, since he can't do it anymore. Then you have this other character, who's super shy lives with his grandma is, like, husband saving up to try to, like, get a new apartment so that he could have a dog. And then his grandfather dies, he has to move in with his grandmother, and he can't have an animal because she's desperately allergic. So he goes on the matchmaker app, and gets matched with this dude who needs someone to walk his dogs. And so the Meet Cute is a dog walking app, and a grouchy meets a shy guy, and lots of animals, and love. Jeff: Well, this sounds awesome. When do we get to see this? I'm guessing 2020 sometime? Roan: I think so. I don't have a date on it. I'll start working on it soon. But, yeah, I think it's gonna be, like, cute-ish in tone. And I don't know, I keep, like, accidentally writing animals into every single one of my books. And I don't even mean too. And this time. I was like, "Well, I mean, I keep doing it by accident. Maybe this time, I'll just, like, actually do it on purpose." Jeff: And what's the best way people can keep up with you online and find out when this next thing comes out? Roan: Well, they can check out my website, roanparrish.com, where I post all things that exist. And then in terms of social media, I've been very active on Instagram stories lately. I just bought a house, my first house, like the first non-one-bedroom apartment that I've been living in. And I've been doing all these, like, garden planting, and baking, and projects, and stuff. So I've been really liking Instagram stories. So people should follow me there and tell me all the things that I'm doing wrong in my garden. Jeff: They may not think you're doing wrong. Roan: I mean, it's my first time and I feel, like, I'm doing everything wrong. But we'll see, it might grow. Jeff: I bet it does. And congratulations on the first house. That's such a huge thing. Roan: Oh, thank you. I really went, like, in the space of one month from a person who thought that they would always live in one-bedroom apartments to a person who bought a house. And so it was very shocking for me. I keep wandering to the extra room and being, like, "What's gonna go in here? I don't know." Jeff: It's part of the fun of home-ownership. Roan: Yeah. Mostly, it's like my cat goes in there. And that's what happened. So I mean, I'm on all the social media things. I'm everywhere as Roan Parrish and people can find me. But Instagram stories is totally the most fun. And for people who, like, wanna know about when books are coming out, but don't dig the social media vibe, BookBub is a great place to find me because they'll just get emails when I have books coming out or on sale. Jeff: Fantastic. Well, we will link up to everything we talked about in the show notes. We wish you the best of luck with the release of "Raze." And thanks so much for hanging out with us. Roan: Oh, thanks so much. It was a blast. Book Reviews Here's the text of this week's book reviews: In Case You Forgot by Frederick Smith and Chaz Lamar. Reviewed by Jeff Frederick Smith and Chaz Lamar are new to me authors and I loved reading their first collaboration, In Case You Forgot. Frederic and Chaz are two black gay men writing about two black gay men living in West Hollywood. This year in the life story left me wanting sequels because I want to read even more about these two interesting characters. Zaire James and Kenny Kane are in similar positions. Coming up on his 30th birthday, Zaire decided it was time to separate from his husband, even though a lot of his family and his friends thought Mario was perfect for him. Kenny, approaching 40, was dumped by Brandon-Malik via text as he was en route to his mother’s funeral. Both of these guys need a reboot. For Zaire that means moving into WeHo--it happens that he moves in across the street from Kenny. He’s got a new job at a social media firm and he’s looking for what comes next. He’s got a family that wants him to find it too--the James Gang siblings--brother Harlem and sisters Langston and Savannah--are always on him to get his life together and find his happy. Kenny, on the other hand, is working on getting his consulting business off the ground since he’s recently finished his doctorate. He’s trying to mostly focus on the business, but he also wants to find Mr. Right. Kenny also carries the weight of having watched his first boyfriend, Jeremy, die after a stabbing. He’s working on his life with some therapy. So what happens in this book? Life. Kenny and Zaire, at times together and at others separate, look for a good date that may lead to more, celebrate birthdays, experience success and failures. The last line of the book’s description captures this perfectly: “...they hope new opportunities, energy, mindsets, and connection will reinvigorate what is missing in their lives--drama and all.” That’s exactly what I liked about In Cast Your Forgot, the slice of life feel. It’s happy, sad, angry, messy and full of great triumph and really bad mistakes. It takes a lot to make this kind of loose plot work, especially since the two lead characters aren’t always together as the year progresses. Frederick and Chaz made it work though. One of the reasons it works is the cast of supporting characters from family, friends, roommates and co-workers. Among my favorite parts of the book was the use of social media to plan their lives and sometimes even to stalk their exes, at times to the chagrin of the friends trying to help them move on. There’s also a Labor Day trip to Palm Springs that was one of my favorite parts of the book because of the realness of how it unfolded and how it tweaked Kenny and Zaire’s relationships. The characters reminded me of Noah’s Arc, a show I loved that ran on Logo in 2005 and then was a movie in 2008. The show focused on queer men of color in various states of life and relationships. Kenny and Zaire would fit right in there. I do want to set some expectations around this book. As you may have figured out, it’s not a romance. It’s categorized that way on the Bold Strokes Books site as well as at retailers. I think that’s wrong. It doesn’t have any of the typical romantic story beats and, most importantly while Kenny and Zaire date for a bit in the middle of the book they don’t get an HEA or HFN as a couple….although the book does end with both characters in good places. If you want a great look at a year-in-the-life of some terrific characters who are trying to get their lives together, I highly recommend In Case You Forgot. And I’d love to see sequels to this book. Frederick, Chaz, please write romances for these guys...
Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, 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 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 any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] 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! Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)
April was our most downloaded month ever. Thank you to our listeners! Jeff and Will discuss their upcoming travel schedule. They will be at the Romance Writers of America national conference, Podcast Movement, Dreamspinner’s Author Conference and GayRomLit. Jeff reviews Top Secret by Sarina Bowen & Elle Kennedy and Red, White & Royal Blue by Casey McQuiston. Jeff interviews Casey about her debut novel. They talk about the inspiration for Red, White & Royal Blue and the impact the 2016 election had on the story. In addition, they discuss the recently announced movie adaptation, what got Casey into writing romance and what she’s working on next. Complete shownotes for episode 187 along with a transcript of the interview are at BigGayFictionPodcast.com. Here’s the text of this week’s book reviews: Top Secret by Sarina Bowen and Elle Kennedy. Reviewed by Jeff. I’ve been a huge fan of Sarina Bowen’s for some years now. Her Understatement of the Year is among my favorite books of all time and I also love Him and Us which were co-written with Elle Kennedy. Sarina and Elle are back with their first m/m romance in three years with Top Secret. They’ve written an extremely satisfying enemies to lovers romance that sizzles but also has some extremely sweet parts as well. Keaton’s a college junior from a privileged family whose been with his girlfriend since high school. For her birthday, she announces that she wants a threesome. After brief thought Keaton agrees. He lives in a frat house where one of his frat brothers is Luke. Luke basically keeps to himself barely gets along with anyone in the house. Luke’s a townie, going to school on an academic scholarship and as a despicable mom and older brother who only want to take advantage of him. He lives in the frat because it’s cheaper than a dorm and he’s running for president because that means free room. Keaton looks to an app to help find the right guy for this birthday present. He signs in as LobsterShorts and soon ends up talking to SinnerThree. Once SinnerThree finds out it’s Keaton’s first three way, he wants to make sure Keaton would be cool with him in the mix and to start considering what the rules would be. SinnerThree even gives sexy homework. This gets Keaton thinking because he’s buried his feelings about guys for a long time. Of course, SinnerThree is Luke, who lives right across the hall. What makes this book work so extraordinarily well is the two sides of Luke and Keaton we see between their public personas and their chats on the app. Luke wants to escape the town and the life he’s known growing up. He strives to excel in school so he can get the high-paying job and never be reliant on anybody again. Meanwhile, Keaton knows he’s got all the privilege but he also chafes at the expectations that his family and friends put on him and he keeps all that to himself because it’s what he’s supposed to do. When they’re chatting as SinnerThree and LobsterShorts the conversation occasionally drifts from figuring out what Keaton’s boundaries actually are to discussing their realities and what they want out of life. Their emotional shields fall away. The way Sarina and Elle transition from sexy to sweet and back again is perfect. Of course, the night finally comes and Keaton and Luke find out they’ve been talking for weeks. The night doesn’t go as planned, but they don’t stop exploring their sexual feelings or sharing closely guarded secrets. Both guys have great growth as Keaton comes into his own, embracing his true sexuality and the career he wants after college. I’m particularly happy this wasn’t a gay-for-you story but rather about a young man figuring out who he is. The battle for Luke is about his sexuality at all–he’s proudly bisexual. He can’t fathom that anyone could love him because of his terrible family. He’s been so battered by them, that he’s hesitant to accept help from anyone because it would surely come with strings. Thankfully, even though Keaton bungles quite a few things with Luke, he also works to make it right. It’s a credit to Sarina and Elle that they have created such fully fleshed out characters who evolve so much through the story. I was invested in so much more than the romance because I wanted these guys to find their way too. The motley crew of frat brothers also brought some great depth to the story as they were a mix of those who were genuinely kind and others were douchey. The parents were also an interesting contrast between Luke’s trailer trash and Keaton’s very well-to-do. Keaton’s father and mother are far more than meets the eye too. I don’t want to get into spoiler territory, but I have to call out them out too. It’s an example of Sarina and Elle creating multi-dimensional characters. Another extraordinary part of the story for me was how the black moment played out. A lot of stuff goes down and there were plenty of opportunities to cheapen the story. The way the last twenty percent of the book played was perfect even while it provided me with quite a few moments of stress. We’re headed into summer and this book is perfect for vacation reading. I highly recommend Top Secret by Sarina Bowen and Elle Kennedy. Red, White & Royal Blue by Casey McQuiston. Reviewed by Jeff I knew this book would be exactly right for me. I have a thing for the royal trope and the idea of an American first son and a British prince getting together made this a must read. What I didn’t expect was how Casey McQuiston elevated the material putting this enemies to lovers romance on the list of my all time favorites. Alex Claremont-Diaz is the first son. Henry is the prince. They have secretly crushed on each other for years. They developed an enemies vibe at the Rio Olympics when they had a less than good encounter, especially from Alex’s point of view. Move forward to today and a near international incident set off by the two at a royal wedding. As part of PR disaster control, a story is created that Henry and Alex are actually the best of friends. After some forced outings to appease the press they start talking to each other more and get past their public personas. One of the things that makes this story works so well is Casey has created an alternate history that many of us would like to see. Claremont took office from Obama so the Trump nightmare never happened. And it’s wonderful that her son is Mexican-American given the current hate filled climate around immigrants. There’s even a couple of lines in the book about how it’s not lost on Alex that there are some people who hate that a Mexican-American took the job of first son. Alex and Henry talk a lot about the lives they want. They’re both expected to meet family obligations and be leaders for their countries–it’s not really what they want though. The texts, emails and phone calls as Alex and Henry reveal more and more of themselves are absolutely priceless. At times funny and others heartbreakingly honest, they talk about how they feel trapped. As the first sparks of romance blossom between them their enemy side is quite fiery as they have rage filled kisses before succumbing to the fact that this is something that they both desperately want. The back-and-forth between sweet romance and the slightly angry romance enhanced the story as they fight against their feelings. The reality stays firmly rooted throughout the story and I loved that. Sometimes the royal trope, as much as I enjoy it, is far more fantasy than reality. It’s part of what makes the trope so good–that chancea prince might be your neighbor. This world could exist–a prince and a member of the first family. Casey gives them all the trappings, including secret rendezvous’s that are partially orchestrated by their security teams. Of course, as must happen the romance is horribly revealed and damages them both. The guys had to really work for the happy in this book, which makes the ending so sweetly satisfying. There were a lot of ways the end could’ve played out, but I can’t imagine one that would’ve been more perfect than what Casey gives us. I haven’t felt as overall thrilled by a book as I have by Red White & Royal Blue in quite some time. It reminded me of reading Becky Albertalli’s Simon vs. the Homo Sapiens Agenda and the wonder of such rich, vivid characters in a charming story that deserves to be real. Casey captured not only an America that I desperately want to live in but a romance that was everything that I ever wanted. I could gush on and on about this book, and will more in the upcoming interview. For now I’ll leave this by saying that I beyond highly recommend Casey McQuiston’s Red White & Royal Blue. This interview transcript is sponsored by Dreamspinner PressDreamspinner Press is proud to publish Hank Edwards and Deanna Wadsworth’s new book Murder Most Lovely. Check it out, and all the new mystery and suspense titles from your favorite authors like Amy Lane, KC Wells, Tara Lain, and Rhys Ford, just to name a few, and find a new favorite author while you’re at it. Go to dreamspinnerpress.com for everything you want in gay romance. Jeff: Casey, welcome to the podcast. Thanks so much for joining us. Casey: Thank you so much for having me. I’m very excited. Jeff: So, before we got to this segment, I spent a ton of time just going over “Red, White & Royal Blue” as being one of the best things I’ve read this year and one of my top books maybe in the “ever” category because it’s everything I needed in a romance with the prince trope and essentially royalty in the U.S. with the first son. And, I mean, Alex and Henry are so awesome. Tell us what your inspiration was behind this book? Casey: Yeah. So I first started…actually, it’s weird. A couple of days ago, I was going through my Timehop which shows you, you know, what you tweeted two, three, four years ago, and I realized that, a few days ago, which is April 13th, was the day that I tweeted, “Hey, I just had this idea for a book.” And it took me back to that moment of the exact lightning strike moment when I knew what I wanted to write. And this is a question we’ll get into later, but it was one of many attempts at a book I had started and none of them had really taken hold of me like this one did. So it was early 2016, I was obsessively following the presidential election, which, you know, we all were at the time with a lot of optimism. And, at the same time, I was reading two books. I was reading “The Royal We,” which is by Heather Morgan and Jessica Cocks, and it’s basically almost a novelization of Will and Kate with a bunch of different things changed about it. So I was reading that. And I was also reading a super dry Carl Bernstein Hillary Clinton biography, which was a fun little juxtaposition. And I had this idea in my head of I want to do… I’ve seen so many sub-versions of prince charming trope, but I feel, as a queer person, I’ve never seen one that seems the most obvious to me, which is, you know, what if, he wasn’t the perfect, going to produce a million heirs, prince, you know. And then on the other side, I was I loved “Chasing Liberty” when I was growing up and “My Date with the President’s Daughter” and I was really into the idea of a rom-com starring this rebellious first kid, and I couldn’t decide which one I wanted to do first, and I was like, “Wait a minute. If I put them both in the same story, I don’t have to pick.” So, honestly, it was me being indecisive that led to that decision. And on a wider scale, a bigger scope, I just really was looking for the perfect, fun escapist tropey rom-com that was so undeniably fun that the fact that it was also queer wouldn’t keep it out of the mainstream, you know, because a big thing that I want to do as an author and as a queer person is push those stories into the mainstream and be like, hey, you know, it’s kind of what they say in “Love, Simon,” everybody deserves to have a great love story, you know. And so everybody deserves to have a big shiny tropey, fun rom-com, you know. So, yeah, that was kind of where it came from for me. Jeff: And there is so much rom-com-y goodness floating in this book. I think you pulled a little bit from everything. Without giving spoilers, because there could be some depending on what you pick for this, what are the rom-com moments that just sticks out for you as one of your favorites among all of them? Casey: Wow, that’s a good question. I have pulled so many tropes from so many of my different favorite rom-coms. But there is this one thing that I love in every rom-com which is the gratuitous karaoke moment, which is actually if you ever watch “Crazy Ex-Girlfriend,” it’s a song on “Crazy Ex-Girlfriend” like “Shake Me Up.” Okay, yeah, that. So it’s like “27 Dresses” does it, and “10 Things I Hate About You” does it where it’s like somebody gets up and sings a song in front of a bunch people for no reason. And it’s like, “No, this doesn’t happen in real life, but it’s super fun.” And so writing the whole karaoke scene, which I don’t think is a spoiler, that was so much fun for me because I was, you know, as musical theater kid in high school, we all were, and so I got to be so indulgent with that, and it was such a blast. I loved it. Jeff: I think you picked a great one right there because you’re right, there is that moment. There’s even that movie, which of course I’m blanking out on right now, that was like…it was a Rebel Wilson movie earlier, I think this year, that she’s, like, there’s always the karaoke moment that she ends up trapped in the karaoke moment in her own little thing. Casey: I love the karaoke moment. Jeff: That says a lot about people, the songs they pick. Casey: It does. It’s character shorthand for sure. Yeah. Like when Bea gets up and sings “Call Me” by Blondie in the book I’m like, “This is what she’s about, you know.” Jeff: Yeah. There have been so many accolades on this book before it even got published. I mean, we were reading about it, I think in “Blush” almost two months ago now. What’s resonating so much with all these pre-readers? Casey: God, you know, I mean, just to start off, I’ve been, completely blown away by the response to it. When I wrote this book I was like, “This is so niche.” It’s a queer political rom-com with royal elements. And also we talk about gerrymandering in it, and I was like, “This is so niche,” no one’s gonna care, no one’s going to publish it. I was like, “I’m going to try and query this for a month, and then I’m just going to self-pub,” you know. And the fact that people have engaged with it so much and that it has gotten, I think three-star reviews now which is just blowing my mind completely, so beyond grateful for those. It’s just been so staggering and incredible. But, I don’t know, I think that right now the world is really depressing. We live in a world right now that is at times literally on fire, you know. And it is so important to have these little oases or moments of respite and little escapist things because when I first started writing this book, I’m so neck deep in the news cycle and I really couldn’t finish it until I pulled out of it because I realized that wasn’t what it needed to be. It didn’t need to be mired in all of the negativity and all of the darkness that was going on in the world. It needed to be this spark of hope, you know, that would kind of feel… I think about when Obama won re-election in 2012, and I was with my friends. I was in college at the time and we went out on the balcony, and popped a bottle of $60 French champagne, and I think about how I felt in that moment and I was like, “I want this book to feel like that moment,” you know. And I think that a lot of people have been missing that feeling. I think that we have so few things, especially when we look at the political sphere right now, to be excited about and to be hopeful about. And I think that we’re all just nostalgic almost for when we had hope. And I think that what this book does is it lives in the space of being here and now and still having hope, you know, and I think that’s really resonating with people. And then I also think that people are just excited to see…we’re seeing it with Helen Hoang and Jasmine Guillory who are writing romances that are integrating, you know, neurodiverse characters and just racially diverse characters. I think a lot of people are tired of seeing, you know, the same two straight white cisgender, neurotypical people falling in love, you know. And so I think that people are hungry for something that’s different in rom-com that can show that different types of people can have that same big, huge, escapist magical love story. So that’s kind of where I think it comes from. Jeff: You noted that you started writing this in 2016, essentially before the election happened. Do you think you would have written the same book had Hillary won? Casey: That’s a great question. And the book I had planned to write before the election went the way that it did was a different book. There were so many threads that I ended up dropping. I, at one point, had…and this was before anything about Russia had come up. I, at one, point had… a Russian double agent involved in the campaign and I was like, “This is too unrealistic. No one’s going to buy this. I’m cutting this,” you know. And now I’m like, “God…” But, yeah. I mean, it definitely…I think it would have been more lampooning the Democratic Party…not that I have anything against the Democratic Party as someone who is registered as Democrat, but it would have been more of “Veep” style, you know, that we’re all on the same side here, so we’re going to send each other up kind of thing. And instead it’s still very tongue in cheek, and it still has that “Veep” side to it, but it needed to have more of…. it needed to be less cynical, basically, you know, because I don’t think that we can really afford a lot of cynicism right now beyond what, you know, roasting the President on Twitter is cynical, I guess. But, yeah, I think that there are certain things that happen in the plot that never probably would have been explored if the results of the election had gone differently because I don’t think I would have felt as much of an urgency to put those into the story. So, yeah, it definitely would have been different. It definitely would have been a lot different. But the President was always the same. President Claremont was the same character from the moment I came up with the idea for the book. She’s like Tami Taylor, from “Friday Night Lights” meets Wendy Davis, the politician from Texas, meets a tiny bit of Selina Meyer from “Veep” and probably every strong female in my life, you know. So, yeah, long story short, yes, it would have been different. Jeff: One of the things I like about it so much, and you touched on this a little bit, is that it’s not two white guys getting together because Alex is Mexican-American. And certainly given how things have played out under the current administration, having that element in the White House as first son, it says a lot. And Alex comments on this, you know, periodically as he’s kind of going through things and how that aspect of his heritage plays into things. Did you have that set early on or did that kind of manifest as we saw how immigrants were being treated post-election and even during the election cycle for that matter? Casey: Sure. Well, the minute…it kind of was, like, the plot itself that informed what Alex would be because, like I said, the first character I came up with was the president and everything kind of formed around her. And I’m from Louisiana, and I have this huge chip on my shoulder about democrats, and liberal people, and progressive people in red states because I was one for so long. I live in a purple-y state now. But, you know, I feel they’re so often written off and discredited, and I can probably count on one hand the number of actual presidential candidates who came and campaigned in my hometown, which is the capital of Louisiana. And people just don’t see anything worth investing in. So I wanted to do a southern Democrat. I didn’t think that a Louisiana Democrat was that realistic, so I did a Texas Democrat. And from the minute I knew she was from Texas, I was like, “Well, it would make sense for her to have married a Mexican man, or a, you know, a first or second generation Mexican man.” And it just kind of went from there where I was, like, “You know, I really do like that idea of that.” I spent so much time in Texas, I know so many people from Texas, I know so many Tejanos and people… it just made sense to me. And then, you know, the more that the rhetoric kind of got really vitriolic about Mexican immigrants around the election, I was like, “Yeah, fuck you. Actually, I am gonna put some Mexican people in the White House.” Yeah, that’s what’s gonna happen. I did as much as I could with it. Obviously, I’m white, and I did a ton of research, I talked to a ton of Mexican friends of mine, and especially Tejano first or second generation people. And then what I’m really excited about with the movie is that we have the opportunity to bring in more people on the creative side who are Latino who can offer more of that voice, that can go farther than I could go with it and that can explore more things with it. So, yeah. It just felt really natural to me, he’s from Texas, of course, he could be half Mexican. That’s just so typical there. So, yeah, it was a very natural progression of the character for me. Jeff: And in a weird twist, I’m actually interviewing you from Dallas. Casey: Yes, I know. I was just thinking about it. That’s so funny. Yeah. I feel like that’s appropriate. I feel the stars aligned to have you interview me from Texas. Jeff: And finish the book while I’m in Texas. It was kind of crazy. Casey: Yeah. That’d be so appropriate. I’m really excited because my second tour stop is in Austin, and I’m so excited. I haven’t been to Austin, like, a year or two, and it’s just feels so right to go back with this book. So I’m so excited. Jeff: There is a ton of history in this book. Henry goes into a lot of history of the monarchy. And one of the things I loved is in the emails that Alex and Henry are trading, they end up and quote a lot of literature or other letters of historical people. How much of that was in your head, and how much was “I need to go off and do a ton of research?” Casey: So, for me, a lot of…when I was talking about… there’s parts where after Alex starts figuring stuff out, he starts, like, develops independent research of, like, let me remediate myself on queer American history, and reconnect with it, which I think is something that a lot of queer people in their 20s do. Especially for me when I was 20, 25, and then I started to figure myself out, I was like, “Wow, I need to know the first thing about my own community.” And so I went back and really read a lot and educated myself. And so a lot of the American history, American queer history was stuff I was already familiar with because that’s something that I felt was my responsibility to learn in the past. But, yeah, I definitely didn’t know a lot about queer British history at all. And so that was a lot of reading for me, a lot of, you know, finding history threads on Twitter, and then okay, I’m gonna go look up all these stories individually, and find out what’s the real truth, because things get twisted online. But, yeah. The letters kind of started with…and this is gonna date when I started writing this, but I was really coming off the “Hamilton” high, you know, which I think we all were in early 2016. It was like, “Oh, man, I’ve been mainlining Alexander Hamilton history for six months, you know.” And, you know, I was really interested… I love all of Hamilton’s love letters with Eliza, but there was also his letters with Florence that were really fascinating to me, and I had started looking into that and that was how I found this book called “My Dear Boy” by Rictor Norton. And I found that because I was researching the Hamilton Lawrence letters, and that was where I found a lot of the letters that are featured in the emails. And then I also was looking into Virginia Woolf, and Eleanor Roosevelt, and all those figures from history who also have a lot of archive letters that are very interesting. And, yeah, honestly, it was almost…I had a blast with it because it was just a queer history, like Easter egg hunt. And, you know, I intentionally did that in the book because I pictured this book…I pictured it being something that a lot of people at different points in their journey with queerness would read, and I would want…let’s say some 19-year old who’s just figuring things out, and they don’t really know anything about queer history, I’m like, “Well, here’s the name of something that you should go look up.” “Here is ‘Paris Is Burning,’ go watch it,” you know, kind of thing. And so it was, it’s really, a bunch of sneaky history lessons. I’m a nerd, and I was like, “You should know this, too.” But, yeah, I had a blast doing that. And then just research, in general, was just so much fun. I spent so much time poring through the royal collection archives online, just for throwaway jokes and stuff. I was a journalist for six years before I quit to do this full time. And so, yeah, I’m a huge nerd and I love historical context for everything because that’s just what I’ve been wired to do for so long. So, yeah, that’s kind of where it all comes from for me. Jeff: And my musical theater geek self loves that “Hamilton” had a play in that because I kind of felt that I was reading some of it’s like, “This seems very ‘Hamilton’ in some ways that they’re using this.” Casey: I battled with myself over whether “Hamilton” was a thing that existed in this universe, and if I should mention it in the book, and I was like, “I’m not gonna,” because it’s still so fresh and I feel it’s gonna date the book a lot. But it’s definitely, like, there’s this undercurrent of we’re doing colonial rap battles under the text, you know. Jeff: That’s one of the things I like about this so much is that it is current revisionist history, you know, because, I mean, most of it, and this doesn’t get to a spoiler, most of it is leading into the 2020 election, with Claremont being President in the here and now and having succeeded from Obama. Yeah, its current revisionist history. It’s very interesting how that plays itself out. Now, I think we mentioned that this is your first book that’s out there in the world. What got you into writing romance and specifically m/m romance? Casey: I mean, I have always consumed all types of media and this is my one sacrilegious answer that I give in interviews which is I’m really more into movies and TV than I am into books, and that is the most media that I consume. It’s not what I write, I’m not a screenwriter, I’m not good at that type of writing, but it is where I pull most of my influences from, and what I consumed the most as a kid, I mean, unless you count “Harry Potter,” which everybody read… Jeff: Which does very much exist in the “Red, White & Royal Blue” universe, which I also love. Casey: Oh, yeah, very much so. But what I engaged with about all of those things was the relationships in them. I’ve watched “Lost” and I was like, “I don’t care about Dharma, or the clues or what this island actually means to the polar bear,” I was like, “I care about that everybody’s gonna end up together that I want to end up together in the end, you know,” and it was always like that with everything I watched. I’ve watched “Buffy,” and it was always about that for me. It was like, “This is cool, mythology is cool, whatever, but, like, Spike,” you know. And it really that was just what grabbed me, and so I knew that was what I was always gonna wanna write. And I tried to write other genres. Every other book I tried to start writing was young adult, magical realism, or young adult fantasy, which is clearly not my genre. And I tried a bunch of different false starts in those genres, and it didn’t pan out for me. And this was, like I said, the first time, I had an idea that completely grabbed me. And I think, like I said earlier, I gravitate to writing queer fiction for the same reason that straight people gravitate to writing straight fiction which is that I’m a queer person, and it’s my experience, it’s what I know. I didn’t really come into this book with an idea of what the gender should be more than what the story would be and it formed around that because I didn’t think that the story would take on all of the same qualities. If it was two women, you know, I thought that it would be a little different tone. I felt if it was two women there’d be a porn parody within 15 minutes of it coming out, you know. And so it’s just, there’s just different ways that lesbian couples and gay men couples are perceived by the world I felt, and for this story it made more sense with two men, and I also wanted to do that prince charming trope sub-version. And so it just kind of told me what it wanted to be. But my next book is…it’s about two women, and it’s a completely different story. And so, yeah, I really…honestly, it’s just me trying to make queer rom-coms a mainstream thing more than anything else. Jeff: More power to you. And, so far, it looks like you’re doing a great job with that. Casey: Thank you. Thank you so much. Jeff: This question may not have a good answer based on what you just told us about your kind of TV and movie thing, but are there authors who influence you? Casey: Well, yeah, I mean there are definitely authors that influence me. I loved Oscar Wilde growing up which is, you know, I was 15, my sisters, I remember being at my sister’s college graduation with highlighter and sticky tabs going through “The Importance of Being Earnest.” So, yeah, I did my term paper in high school on “The Picture of Dorian Gray,” and I was like, “This is straight behavior.” But, yeah, Oscar Wilde was a huge influence on me. The “Harry Potter” books, yes, of course, they influenced me. I read a lot of non-fiction and a lot of memoirs actually because I love the voice of them, and I think that’s what helps me to have a good narrative voice. So I love Carrie Fisher’s writings, I love…Nora Ephron’s memoirs are all incredible, Mary Karr. Let’s see, what else. I’m looking at my bookshelf right now. What else do I read? Jane Austen, obviously, the classics of romance, you know. And then more recently, my favorite author right now is Taylor Jenkins Reid. “The Seven Husbands of Evelyn Hugo” is my favorite book I’ve read in the past couple years and definitely has earned a spot on my all-time faves shelf. And so that’s definitely… And I loved how she does a lot of…she does a lot of what we call in journalism alternate story formats, so epistolary style things that are threaded into the book, which is something that obviously I really love too. And then yeah, that’s…I mean, I read a lot…at least I read a lot of non-fictions like Rebecca Traister and Roxane Gay, those are those are all my faves. But then I pull from a lot of a lot of TV and movies. The biggest influences on this were “Veep,” “Parks and Rec.” There is this web series called “The Gay and Wondrous Life of Caleb Gallo” that I love, and it’s so millennial absurdity that it really kind of like… there’s a shout out to it in the book because they play the song, “Loco In Acapulco” by The Four Tops in that show, and I put that in the book. Yeah. So I’m kind of all over the place. I have a lot of influences and a lot of things that kind of all feed into what comes out of my brain. Jeff: So let’s talk movie. You hinted that a little bit ago. Amazon and Greg Berlanti picked this up before, you know, again before it’s even published out to the world. What was your reaction when you first heard that that was a done deal? Casey: Well, I mean, it was so many stages of reaction because what people don’t see behind the scenes is that the process is crazy. It starts with I have a Hollywood agent, and she sends it out to people and then one producer expresses interest and then more producers can if they want to, and then it turns into you’re on the phone with, you know, such and such from whatever huge production company, and it’s like, “I’m not qualified to do this.” And you talk to those and you pick your producer, and that’s how I picked Berlanti. And I was just really excited to even have a chance to work with them because I’ve loved so much of their work, not even just looking at “Love, Simon,” and going back to “Political Animals” which was a six episode series that’s on Netflix. It’s got…honestly, I have to say one of my touchstones too because it’s got Sigourney Weaver is the president in that which is just amazing, and they’ve got Sebastian Stan as one of the president’s kids, and he’s very tortured, and recovering from addiction, and he’s gay, and he’s Sebastian Stan so he’s crying, you know, and very beautiful. But, yeah. So I just knew that he had the range for it and I also knew that based on “Love, Simon” that production company had the chops to get an unapologetically queer rom-com into the mainstream. But also it was on a personal level, I just remember going to see “Love, Simon” in the theater and that was probably a week after I signed my book deal. And I showed up with an entire eight-inch Jimmy John’s sub in my purse because I knew I was going to cry and I like to eat my feelings. So it was literally me alone. I had to drive 15 minutes out of my city because I was living in Louisiana at the time to find a theater that was playing it, and it just me alone in the theater with my sandwich and was just weeping to Jennifer Garner, you know. And I just remember getting in my car and thinking if my book could make people feel half as seen as I just felt by watching that movie, then I will be so, so happy. And so I’d have the chance to do, to kind of pay forward what that feeling was for me to the next round of people, especially queer people, meant so much to me. And then yeah, Amazon, they just care so much about the project. They’re so passionate about it. They want it to, you know, really…they’re actually really invested in diversifying what is in the market, and taking some risks, and doing projects like this. And it’s just so incredibly mind-blowing, and it really doesn’t feel real yet to have people want to invest those kinds of resources in a story that I wrote. More than anything, I’m just so excited about what it could represent and what it could mean to people. I think about like…and not to at all compare the histories of these communities, but I think about “Black Panther” and “Crazy Rich Asians” and what those movies meant to have as big cinematic events geared around a demographic that wasn’t usually catered to by the mainstream, you know, and what it meant for those people and what it represented for the future of storytelling for different groups. And I like the idea of being able to make any kind of similar impact with movie is incredible. And I really hope that we can do that, and I really hope that it can be the beginning of a lot more queer rom-coms, you know. So, yeah, it’s amazing. I’m so, so humbled, and amazed, and really excited to see what comes next with it. Jeff: As you were writing, I think all authors tend to cast their books to some degree. Do you have in mind, and knowing this is totally separate from anything that Amazon and Berlanti might do… Casey: Sure. Sure. Jeff: …do you have in mind who Alex and Henry are, at least in your head, as you were writing if you had to assign them an actor? Casey: Well, it’s so hard because…and this is kind of an indictment of the state of Hollywood and that is slowly beginning to change, but there really aren’t a lot of young Latino actors out there choose from, you know. And so it was… there really wasn’t a definitive Alex in my head because I have looked and looked and it was so hard to find someone that fit. And that’s what’s exciting to me about the movie is I think that we will get a chance to kind of give a star making role to some young unknown Latino actor, which would be amazing, and I would love to do that. And Henry is just very elusive. There’s five million charming white British men, but in my head, he’s just so specific-looking, and I have not yet found anyone that matched him. But the parts that were, I think, easiest for me to assign an actor to were like… I always pictured Daniel Day-Lewis as Richards with like the silver foxy and then, Ellen Claremont in my head from day one has been Connie Briton. And then, I mean, Rafael Luna in my head is Oscar Isaac for sure, you know. Jeff: Oh, yeah. I like that. Casey: There’s some characters that I came up with the character first and then tried to figure out what they looked like, and there are other characters where… with Rafael Luna I was like, “I want a character who looks like Oscar Isaac. What’s he going to be?” you know, and that was kind of how that came to be. But, yeah, I’m really excited casting is going to be so much fun, and I’m very excited about it. And I’m really, really excited about just getting to see, you know, what we can do for some…I think there’s gonna be a lot of unknowns in the lead roles, and that’s going to be amazing because they’re going to be able to really step into and embody those characters without it being distracting, like, “Oh, that’s like so and so. I look at them and all I see is the character they played in ‘Game of Thrones’ or whatever.” Yeah. so I think that’ll be, you know, a fun thing. But, yeah, that’s kind of it for that. Jeff: Do we get to see more of Alex and Henry in the future do you think? Casey: I think that I would not rule that out, and that’s all I can really say about that. Jeff: Sure. Casey: Yeah. I think that that would be amazing. I would love to do that. Jeff: And you mentioned your next book is going to be a female pairing. Casey: Yeah. Yeah. So it’s completely different from this. It’s a much smaller scope of a world. It’s just a girl who moves to New York, and she’s from the south. I don’t think I will…I don’t know if I will ever write a protagonist that’s not from the south because that’s just so deeply ingrained in me and in my voice. But she’s from south, she moves to New York, and she kind of stumbles into this roommate situation where it’s just sort of ragtag band of misfits kind of thing. And she develops this huge crush on this hot chick who’s on her subway commute every day. And it’s kind of based on the idea of that way that you fall in love with something on public transit for like 20 minutes, and then you step off, and it’s like they never existed anywhere other than the train. They’re just there for 20 minutes, and you never see them again. But the thing is that she sees this girl every single time she’s on the train. And there’s kind of a twist as to… I will say there’s some light rom-com-y style time travel shenanigans that happened, and the girl on the train is not exactly everything that she seems. And so the whole book is about their relationship and at the same time trying to figure out what’s going on with this girl. But it is rom-com, and it’s super fun, and, of course, it has a gratuitous karaoke moment. Jeff: Excellent. Casey: Well, it’s more of like there’s a gratuitous karaoke moment, and there’s a gratuitous drag show moment. Yeah, so, range. But I’m really excited it. I’m hoping…I mean, obviously, we haven’t set a date for it yet, but it is super, super personal, book of my heart for me, and I’m really excited for people to read it. Jeff: Fantastic, definitely looking forward to that. Casey: Yeah. Yeah. It’ll be awesome. I’m excited. Jeff: What’s the best way for folks to keep up with you online so they could track your progress with what’s up with Alex and Henry and also the new book and everything else? Casey: Yeah, Twitter for sure. I’m kind of been taking a step back lately because since we announced the movie my notifications have been busted, you know. But, yeah, I’ll definitely be back on more especially during tour. I tweet out playlists and a lot of little trivial information like their birth charts and things like that on there, and then also Instagram. That one is more for like I’m here for this tour date kind of thing. So yeah, those are my big two ones. It’s casey_mcquiston on Twitter, and then casey.mcquiston on Instagram. Jeff: Very cool. Well, we will put the links to all of that in the show notes. Casey: Thank you so much. I appreciate it. Jeff: “Red, White & Royal Blue” comes out on May 14th, and we wish you just continued success because it’s been so much already and look forward to seeing the movie and everything else that comes from it. Casey: Yeah, thank you so much. I’m so, so grateful, and it’s been so much fun. So thank you so much for having me on.
Achieve Wealth Through Value Add Real Estate Investing Podcast
Jeff Adler, Vice President of Yardi Matrix share his view of the latest state of Multifamily commercial asset class. Show: Achieve Wealth Podcast Guest: Jeff Adler Title: Multifamily State of Union with Jeff Adler Host: Hi Audience, welcome to Achieve Wealth Podcast, a podcast where we are tuning in to learn as much as possible. Today, we are bringing in an awesome guest, who is the keynote speaker at many conferences, many high-level conferences, so was able to get his time to spend with us today to go to as what I call the state of the Union of multifamily real estate. So today we have Jeff Adler who is the vice president of Yardi Metrics. Yardi Metrics is a US multifamily office, industrial and south storage as an information toolset in coordinating underwriting and asset managing commercial real estate investment. So if you have subscribed to Yardi metrics report, which is awesome, very, very data rich and I think it should be part of your decision making in selecting markets and looking at trends in terms of a commercial real estate, especially on multifamily. Your mail would have come from Jeff Adler. So I'm very pleased to bring Jeff on board. Jeff, why don't you tell my audience something about yourself and your company that I would have missed out? Jeff: I'm based here in Denver. You already made fixes. Basically the data division of Yardi systems, which is well known in the property management sphere, across all different asset classes, we cover the multifamily office, industrial self-storage in all those different other asset classes. But my background was primarily in multifamily. I was the chief operating officer of a [01:49unintelligible] in Denver, for about 10 years from 2002 to 2009 and I joined matrix about five years ago. So that's kind of what we do. And some of the work that I do is the basic products, the tool kit that helps you identify opportunities under find deals, underwrite deals, understand markets, understand entities and players in those markets. And then on top of that work, I have a team along with Jack Kern that talks about investment strategy, investment themes and the overall economy. And so we try to put everything into context from kind of what's going on in the global economy, straight down to which deals should you buy that fits your investment strategy. And that's kind of what we do. So happy to be on the podcast and give you any information about what it is we're thinking. Host: Yeah, I'm really excited because I read the reports that are created by Yardi Metrics on whenever you guys send by-market, by-economic at high levels so it's very, very informative and I love it. Jeff: As a part of what we do to get our name out, you can go to yardimatrix.com/publications and for free, sign up for our [03:16unintelligible] reports where we do those 10 multifamily markets a month, six office markets a month. We also do a monthly report that's free on the multifamily market nationally, the office market nationally and self-storage market national. So there's a lot that you can plug into that kind of can set a context so we provide free. And then if you want to learn deeper then you can talk with us and go deeper into the data service. So that was the resources that are available to all of your sort of listeners. Host: Yeah, yeah. I would encourage all your listeners if you want to do commercial real estate, especially multifamily or an office or self-storage, go and subscribe right now. It's an awesome, awesome tool and information is free and it's really good. Jeff: What else can I do for you? Let's get in there and let's start talking. Host: Yeah, yeah. Correct. I mean I know we talk a lot about multifamily because I'm a multifamily operator. We own 1400 units in San Antonio, Austin, Texas. But I want to always understand about other asset class. I mean, recently I launch a book, it's called Passive investing, Commercial Real Estate, which I also talk about other asset classes. So I'm very happy to ask you questions about other than multifamily, you know, as a start. So compared to multifamily office and self-storage, what are the good and bad about each one of this asset class from your perspective since you look at all of this? Jeff: Yeah, personally, I think multifamily is in an incredible sweet spot. So let me take a multifamily and we can compare it to other asset classes. The reason is is that there is an overall shortage of housing in the United States, which to a greater or lesser degree in different markets. And then it's really kind of an overhang from the kind of the crash. So we had a surplus of housing in going into the crash. But really now we have deficits, on a cumulative basis since '06, we've got a 200,000 unit multifamily and single family deficits. If you go from the bottom of the crash, it's about 2 million units. So how is this being expressed? And we also have, we have a number of demographic trends; people getting married later, having kids later, having fewer children, having student debt. So if you look at all the divorce rate, look at all of these demographics, we seem to have like a secular shift in the number of renters and the renter households population in the United States overall. And you see that expressed in very high occupancy rates since the crash that are still hanging in the 95, 96 level at the national level, which is very, very high and rent growth that historically if you look at, and I've done this back in 1970, CPI and the rent growth are very, very tightly coordinated. Since the crash, the rent growth has been about cumulatively five to 600 basis points higher than CPI, it is an anomaly so it's not like the normal cycles you can go back to, this is fundamentally different. You can look at the extent that there is new supply coming on, about 300,000 units a year. It's Class A, kind of an urban core or in places that are sort of urbanizing notes. There's the big opportunity for, I'll call it non-institutional investors, it's been in class B and Class C I would probably say 50 unit to 100 units where there's not a lot of institutional competition. There is a deep need for housing and the price umbrella of the new supply is so big; I mean the new stuff that's coming in is five to $600 a month different that is coming from the masses, sort of majority of the workers and renters can afford and are paying so you're really insulated from new supply pressure. And so again, if you look at the demographics in terms of the demand and job formation is really pretty good and then you look at the fundamentals of supply, it’s very expensive to bring new supply to market. There is a labor shortage, material costs are going up, impact zoning fees are high so you have the kind of the recipe for a great demand-supply balance and multifamily and this severe problem is happening on the coast. So just talking to your maybe constituency in Texas, right? You can look at the severe problems that are occurring in California with job growth and affordability, there is a significant out-migration from New York, New Jersey, Illinois, and California. They're moving into all of the markets in North Carolina, in Texas, in Arizona, in Nevada and so you have in addition to the tailwind of organic economic growth happening throughout Texas you have relocation; and in a relative business-friendly environment with a very high level of supply response relative to other parts of the country. So you have a lot of very positive things. So I'm very, very positive on multifamily as a sector, particularly class B and C assets; C is a little tougher because only just until recently you began seeing finally a wage growth at the bottom end of the skill sector, people would traditionally go into a C class asset. B class asset, in my mind, is a little bit better because there's more income growth there and there's more sort of to work with. C class assets, generally speaking, you make your money on having very low expenses, very low turnover by picking your customers very, very carefully so that you get a community that's going to stay there and can tolerate maybe 2% rent increases, but you really can't push rent five, six, 7% in that group, they just don't have the income. Whereas in class B, you can push rents higher, expect a higher level of turnover because there's a deeper pool of people who can kind of pay the rent. Those strategies, particularly for the non-institutional investor are very attractive. And I really find there's a deep market in terms of demand and I view the economy as in pretty good shape. There are some pressures; we're late into the cycle here so the biggest issue I see short term is that potential end version of the yield curve. Long-term rates are two- sevenish, they were at three- two and now they are two-seven again, short term rates are at two and a quarter. There's not a lot of room between the 10-year and the overnight rate. The importance of that is, is that if the short term rates go higher, bank lending will pull back, the data has been historical and you're 12 to 18 months from a recession; we're not there yet, but it's a tight rope. My best guesstimate right now is we probably have another, I think in 2021ish is when it's likely to have a recession. I don't think it's going to be a big one, I think it's going to be kind of a mild one and the reason I think that is we did a big blowout in '09. And if you go back historically, and I'm bouncing around on you a little bit, but if you go back historically, the best analogy is what happened in the 1930s versus post role, World War Two recessions, they're different animals. So I think we're coming off of a big blowout, really a depression we got through very quickly because of great action on the part of the Federal Reserve. So I do see a recession coming up, but I do think it's going to be a mild one. So really multifamily is best positioned, in my view, to serve right through this recession. And so I think, again, multifamily is a great asset class; its guard a tremendous amount of institutional and investment capital and will continue to. There are other asset classes out there. So office has traditionally been, I would say a big kind of institutional asset class requires tremendous amounts of capital and it's really viewed as a bond alternative. If you think of that as a bond alternative, it's bought largely for cash; if it yields 4- 5%, that's great. Again, we're viewing it relative to bonds and it requires a tremendous amount of capital to keep those assets fresh. If you're an opportunistic office investor, you really have to take something like a suburban office, which is really beat up to hell and change its fundamental character connected to transit, make it into a canvas, and create a place. Now that has tended to require a tremendous amount of capital in order to play there. So I kind of view office is just really more of an institutional capital play because of all the capital requirements that are required for it. And it's hard for a non-institutional player, in my view, to have success in office unless you are riding off the coattails of a smaller building attached to these other investments; it's just a very hard thing to make work. Now, the big playing industrial, you know, and I'll slip over to storage in just a second is really kind of what's going on with e-commerce. I mean that's what's driving industrial is the commerce need and really the pullback and retail. So retail is littered with strip malls that we just don't need or it can be repurposed to other uses. So what I do see often is people who are opportunist to be looking for sort of beat up retail assets that are distressed and changing the nature of that asset or for industrial what's driving the market is not knowing so much manufacturing, which really isn't driving space requirements, but it's really ecommerce and those tend to be very large facilities. I mean like 500, 300,000 square feet, a million square feet that are in near population centers to handle the demand. So there's active development pipelines and industrial. Again, it's very hard I think for a non-institutional player to sort of access the action because of the capital requirements that are needed in the industrial. Self-storage is very much a different place; it is historically owned mostly by small owners and non-institutional players. The capital requirements to get into the sector are, generally speaking, much lower than multifamily or any of the asset classes. Right now, the issue at the moment is that there's been a significant level of development. Self-storage to the sector did incredibly well during the downturn. And the reason it did was that most of the people who have stuff and only about 10, 11% of the population use storage but most of the people who did use it, needed it to store their extra stuff; in a downturn, they didn't stop using it. In fact, in some cases, people use more of it because if they were going through struggles in their homes, downsize in their homes or apartments, they moved their stuff into a self-storage facility. So the sector did incredibly well in the recession, has attracted a fair amount of capital and now more and more institutional capital is trying to get in. There's been a lot of development that's been going on and so the big issue in self-storage is finding an asset that's not under supply pressure or finding pockets. And then self-storage is a very local kind of asset class but the bottom line is the world is within three to five miles, that's it. Somebody could use somebody across town and it just doesn't matter. It's really that three-mile pocket or like a 10 to 15 minute drive time because people are using storage only to the extent that is near them. So a lot of storage developers basically track new development in multifamily and will plot the deal down close by or they'll look for new home construction and plops something near there. They will look for pockets where there is less than about seven square feet per person and that's the tools we provide, where you can actually find the pockets of population that are not currently served. It is a good asset class for a non-institutional investor to get in and it does complement very nicely with multifamily because they're a complimentary kind of asset classes. I would say though, that we don't necessarily cover single-family rentals per se, but I would say, again, single family rentals along with, kind of 50 to 150 unit multifamily in self-storage, they're all complements of each other. They were around people who need space to live but don't have the capital to actually get into buying a home. And so I find we kind of track, we cover self-storage, we cover multi-family and we track single-family rentals because I view it as a complementary asset class. I know a lot of people in that sector; I actually was in that sector myself for a year and I just knew that entire space is very good for, kind of the smaller institutional player and the non-institutional investor. Kind of a long expedition but [18:27unintelligible] Host: Yeah, I didn't know that you guys have some tools to look at the self-storage demand analysis, which is very interesting so that's a really good explanation. So coming back to multifamily, so what you're saying from what I heard from you is the 2008 crash, the whole crash is equal into 1930s crash and that's a huge crash and we don't expect to see that in the next coming crash, right? Because a lot of people have that short-term memory about 2008 and everybody's like, okay, I'm not buying it. It's going to go down like what 2008 happened, is that correct? Jeff: I mean, 2008 was an 80-year event. We're not going to see something of that magnitude in our lifetimes. What we're likely to see on a go forward basis, is something akin to the recessions that occurred prior to 2008, 2001 recession, the '91 recession even further back. So these were typical kind of recessions that we're not driven by debt blowouts, but what connotes a depression is that they are fuelled by overleverage in assets classes. A typical recession is where there's inflationary pressures and goods and services, which then lead [20:00unintelligible] kind of cooled by rising interest rates and it's kind of a minor. deleveraging. So if you want to kind of get deep into this, for anyone who's on this, Ray Dalio, who's the CEO of Bridgewater Associates, has a great video on YouTube, a 30-minute video on how the economic system works. And he pretty much lays out basically the notion of a minor debt cycles, which occur every seven to 10 years and a major debt cycle which occur every 75 to 100 years. We just went through a major kind of blowout so we're unlikely to see a major blowout again in our lifetimes. We'll now do normal minor recessions and so you've got to be forward-looking as opposed to sort of backward-looking. So with that in mind, right, the debt position of households and businesses are actually in pretty good shape. The issue we have is that the debt position of the federal government is the thing that's a concern. Now, fortunately, and again, I'm taking a bit of a tangent, our debt is denominated in our currency. So the debt really isn't going to be a problem because it can get inflated away. Other countries don't have that luxury and if you're worried about potential inflation, well you want to be in real estate because it basically marks to market on inflation and our debt is denominated in $6. So paradoxically in a weird kind of way, real estate is very attractive because it's yield relative to current interest rates is high. But even if, God forbid, we had inflation, a recycle that came back, if your debt is denominated in $6, you make money because your debt depreciates and your income goes up nominally because your rents are sitting in nominal dollars. So I would say, real estate is kind of like, it's a win-win. Like if there's no inflation, it's good; if there's lots of inflation it's still good but I wouldn't do it, make sure your debt is in fixed. It's fixed versus I wouldn't go with a floater right now in terms of floating rate, interest rates, that wouldn't be a good idea. Host: What about floating rates with hedge? I mean some people they say there's a cap on the floating rate. A lot of people do bridge loans or short term loans or they do a hedge. Jeff: Again, I'd say, a bridge loan is designed because you have a value-enhancing program that you're going to execute. It's usually a one to two-year bridge loan and for that purpose, it's just fine, right? Because you're going to do something different; you're going to create value, you're going to add cap or you're going to reposition the property so that makes perfect sense. And then you want something that gives you your payments as low as possible while you're executing your value-add. When you're done with that value-add repositioning, if you choose to hold the asset, that's when you have to think about permanent financing and you don't want to be kind of on a floating rate, IO forever, in that case, because you're not getting the advantage of what might happen in the broader economy. You're basically, maximizing current return but you have an exposure. So I kind of view bridge loans as appropriate in the context of a value-creating program. But outside of it, it's very dangerous, you've got a lot of risks you're taking on. Host: I'm out of all my short term loan so now I'm on long-term fixed rate loan, all agency loan, which is good but I know a lot of my listeners, have this notion of, hey, let's go do a bridge loan, I mean, it's easy to make deals work under a bridge because you get higher leverage. But there's also a notion of, oh, now we're going to hedge the bets on the interest rate hike by having an edge and there's a cap that they can do. Jeff: But I would say here, but if the cap came into play, it's a cap per year. Suppose there is a lifetime cap is at a very high level if you have to get out of a bridge loan, what do you have to get into is going to be very unpalatable at the time. So I do think, again if I was giving advice to an investor is to say a bridge loan is great for a specific objective you're trying to accomplish, but it is not a long-term old strategy or if you're doing it, just understand you're going to maximize current income but you are taking on an asset risk that's rather significant. You know, everyone will make their own decisions and if they choose to do that, then they choose to do that but you should be aware of the risks that you're taking and not kid yourself about it. Host: Yeah. Especially on syndication where we are raising money from private investors and we just have to make sure we communicate that to the investors and that he's okay with that, right? Jeff: Yeah. Host: Interesting. So you're talking about yield curve inversion, right? Where the daily yield curve might be higher than the 10 year Treasury, at high level so what is causing that? Jeff: Well, what you have is an interesting kind of situation here and this is more geopolitical if anything, but it has deep implications for us in real estate if you're trying to understand the demands side. So this is the issue of, again, demand looks great, the economy is expanding, jobs are being formed, unemployment's low, wages are rising, all sounds great. So what happens in these periods of time? Well, normally, you would begin to see inflation; it would kind of rear its head and the Federal Reserve executing its mandate to try to kind of make sure the place doesn't get out of line, would tend to be pushing up rates on a short term basis to quote-unquote cool the economy. But what we're seeing very interestingly is, we're having economic growth, but where's the inflation? You're not seeing inflation really be systemic above a 2% rate. Which is what their stated goal for price stability is and why is that? Because growth isn't that great in Europe, growth isn't that great in Japan and the trade pressures that the administration is putting on China is basically hurting the Chinese economy, which is why they're at the table in the first place and so there really isn't the system long-term inflationary pressures. So as a result, long term rates, it's your step in the market, the Federal Reserve has no influence really on long-term rates. They set short term rates but long term rates, they can't set directly. They can try to influence it and they did try to influence it in the past by buying up mortgages and other long-term securities but there's a lot of where generationally, and some folks get it simple and don't quite realize it, we're in a demographic period of time where there's a lot of global savings. And you can look at those global savings, they are going into bonds. And if you look at Europe or Japan, because their economies are actual have declining populations, they're in a saving mode significant significantly. They're not in a consumption mode, they're in a saving mode, and they’ve got a lot of capital to deploy. The interest rates in Germany, for 10-year German government bond, are negative so our 10-year notes, a 2.7, the equivalent of what Italy is paying. So if you're a European investor, do you want to put your money into Italy or the United States? Because that's really the choice so if I had a choice between Italy and the United States, I'm putting money in the United States and so we are attracting a lot of capital on a long-term basis, which is keeping our 10-year rate pretty low. And there's no real evidence of inflation to justify an investor saying, oh my goodness, I need to be compensated for inflation and so I should get out of bonds and other assets that would cause the long-term like [29:24unintelligible] So if long term rates aren't rising that much and there's not a lot of inflation, the Fed pushed up short term rates to the point where the fourth quarter, when the stock market meltdown was really a function of the market saying, well if the Fed keeps raising short term rates, they will create a yield turn version. And what happens is that short term rates are higher than long term rates. Well, if you're a bank, banks are in the business of lending money, borrowing money on a short term basis and lending money on a long-term basis. Well, if there are not enough margins in there for them to do that, they have costs, they stop lending because they would lose money if they borrowed short and lend long, it's not profitable so they choose not to lend money. Well, what you're talking about there is a contraction of credit in the economy. Well, when credit contracts, guess what? You know though it takes a little bit of time, you get a recession, you'll get a recession tomorrow or within 12 to 18 months you get a recession because there's a contraction of credit and that's worked its way through the system. So if you think about us as in real estate, we deal in metrics that are rents, occupancies and things like that, our cash flows, those are lagging indicators. So what's happening in the real economy, what's happening in the economy is wage growth, employment. Those are the things that happen in the real economy. I look at the capital markets as a precursor to what's going to happen and then we have an economy which is then a precursor to what's going to happen with real estate operating metrics. So by paying attention to the capital markets, I tried to keep our clients and our organization two years ahead of what will eventually show up in rents and occupancies and cash flows in real estate properties. So that's why I kind of dwell on the yield curve because if I looked at it, there are five models that we look at in terms of capacity, utilization, wage pressure, and of the five, the one that is, I'll call it the current binding constraint is the yield curve. So it's not the only thing I look at, but it is right now the key thing that I look at. Host: Yeah. So that's the best explanation on yield curve and how it's going to impact because I wrote so many reports and listened to so many webinars by brokers and all that, but that's the best explanation, I get it completely. So what you're saying is if there's a yield curve, banks stopped lending bridge loan is more dangerous because if you are predicting that's going to happen by 2020 or 2021 and if you are initiating a bridge loan right now which has three year span, you are going to be landing in a spot where you may not have any funding at that time if the banks stopped lending, Jeff: Right. And also you don't the maturities come up in a crash, right? Because what's going to happen, what happens in a downturn, even if it's a minor recession, is people withdraw from the market in terms of transacting, they don't transact. So what transactions do occur tend to be at a depressed level, not depressed level then it's considered quote-unquote, it's a current market value. If you have a bank loan or a line of credit is coming due, they are going to revalue your loan devalue based upon an artificially depressed evaluation. And then they're going to say, oops, your loan devalue is a mess so basically they're going to squeeze you out. They're going to force you to add in more equity or to basically liquidate the line. So you do not want to be in a situation where your debt, if you have a five year term, you're going to see through this problem or seven-year term, but your two to three-year term right now, you bear a risk that you're going to have to come for refinancing when there is an artificial kind of re-evaluation of your assets. And what's great about real estate is it really is a long-term value. That if you can last through a problem and not get squeezed out, generally speaking, you're going to be fine. Particularly in multifamily where the cash flows are much more durable, you may see a dip in occupancy of a few points. Your new leases might transact with lower rent, but you've got a lot of existing cash flow; you can always squeeze back on some of your expenses for six months, you can ride through a problem as long as your debt isn't coming due. That's the main thing, don't be squeezed out in the downturn. So you're dead strategy and multifamily is critical to your survival and value creation. Host: Absolutely. That's good advice. Coming back to what you call the level of players in the market, right? So if you look at it in the past before coming back, what do you think about the high loan? Because I think in 2015, the lenders have loosened up, giving up more IOs to a lot more people. It is become default to have like three year IO, four year IO. When I started at that time, I know it was hard to get even one year IO and one year IO was sort of attractive because valuable then, but then 2000 was when lenders started opening up the flood gate and now it's like five, six years, seven-year IO kind of thing. What do you think about that? How would that impact [35:19unintelligible] Jeff: Yeah, from a cash flow perspective, if you have an IO to an interest-only payment and you can get that for five or six years but it's still fixed; so on the conversion, it's a fixed rate kind of conversion, then great, you just got a great deal. You want your IO to be at a fixed rate and you don't want it to be floating. So if you can get a fixed rate IO for a certain number of years and you're guaranteed to convert to an amortizing loan at the NBIO period at a fixed interest rate, well, you kind of got your cake and eat it too, right? Because you got the benefit of not paying down the principal during the IO period, but you didn't expose yourself to the risk of having to go through a negotiation. So great; if you can get it, go for it, right? I mean, that's fantastic. You guys can put that in your pocket or put that into the property so that you're going to be able to expand your cash flow. It really depends upon who your investors are and what their goals are, whether it's cash now or value appreciation later. Host: Yeah. Where I was going with that question was a lot of people have justified the deal, doing deals because the numbers with IO, it looks much better now and it looks really good, right? So a lot of investors are coming in, especially at the level where we are right now, where there's a lot of syndicated commercial real estate deals are happening. There are very less sophisticated people who just look at as [37:18unintelligible] cash and cash, you get 8% cash, they just jump on investing in but that 8% could be IO and in the next three years, let's say rent doesn't go up or you have a deep in occupants, it's what you're talking about that 8% and once the IO kicks in, that 8% becomes 3% right? [37:36unintelligible] become negative so your basic concern is the loan. So I think, I don't know, in my perspective, there's a lot of deals happening right now in the past since 2015 with IO, especially at the less sophisticated level right now. Jeff: I would say, IO, it should be gravy, it should never be the main dish. Host: Okay. [38:01crosstalk] Jeff: If you're expecting the IO to make the deal work, your betting that by the time the amortization kicks in, the rents will have grown high enough to cover the amortization. I haven't run the numbers on that, but that would be the thinking, you have to get comfortable around is okay, what has to happen when amortization starts since that it actually was a good deal. And then say, well, the rents have to grow at 1% a year or 2% a year, 3% or 4% a year so you really need to stress test that assumption. But you know, this is where people take risk and so if you're taking this kind of risk, understand that in a downturn, that's going to be the first people who will basically get shut out. They can't make their principal, they paid too much and when I had to start amortizing, they couldn't make a go of it. So I view that just as similar as the equivalent of a debt maturity; it's like, okay, if you've got an IO period of two years that you bought the deal on the assumption that in order to get your hurdle, the IO period is what made the hurdle work for you, you're basically are sitting at a two year refi’ and you better understand that what your debt service requirements are when you walk in into that. I know we're spending a lot of time on debt strategy here and I think that's kind of okay because the fundamentals are good, generally speaking. There's not a lot of too much supply so the demand is decent, the supply is decent and your death strategy. So there's one part of this, which is your value added, your value creation strategy; what are you doing to create value for your residents, to make your property more attractive to them and a better living experience so that you'll be at high rents and high occupancy? And that's entirely valid and I think, my view would be in terms of enhancing the resident experience, I think there's a bunch of IOT upgrade packages to existing properties that I think add a lot of security issues that people will pay for, not so much to manage your thermostat, but if you kind of know that your kid can come in and you can see on your phone when your kid came in from school and that they're safe, there's value creation there. So I think we as owners have to look critically at how are we adding value to the living experience? Not just the four walls, but stickiness, right? Creating stickiness that keeps people kind of in place and so I think there's a whole set of strategies there. The debt strategy used to make sure it's honestly to make sure that you don't get kind of shaken out. That's really my goal as data strategy is not to get shaken out in a downturn. And if you could protect yourself from being shaken out in the downturn, then the fundamentals will basically bail you out. And so as we're talking about IO, which is people reaching to make the deal work when in some cases, I'd rather you focus on what can you do to add value, you can increase the revenues so you didn't have to go that crazy out financially. Host: Correct. Jeff: So focus on the value creation part that they had provided the increased rents where you don't have to go five years IO and kind of crazy kind of amortization and you're sort of sitting on a time bomb. So that would be kind of my take is; we're talking about debt, but it's more in the nature of put yourself in a situation where you can ride out a storm. Host: Yeah, that's awesome, absolutely the right thing. Just make sure you're on a fixed rate loan, and the other thing that is very subtle is even though you're on a fixed rate loan, make sure if you have IO and make sure you have enough buffer when the principle kicks in. Because from my calculation at 80% leverage, you need at least 5% cash on cash buffer and on the 75, it's like 4%, in terms of return; you need to make sure you're still able to service that debt. Let's move on to a bit more different topic. So selecting a marker; so let's say, someone who wants to start in multifamily, multifamily real estate is very local, at the same time, multifamily is an asset class where it's very, very intensive in terms of property management so how would you recommend, how do they select the market? Jeff: I look at a number, I'll call it very basic kind of fundamentals and it's on our website and in our materials, we only have a four-box model and that attractiveness of the city. And first of all, we come from the perspective of, how is wealth created in this economy? And I would tell you that I believe wealth is created in this economy based upon the force of ideas and the creation of new products and services, which tend to have an intellectual capital component. So where and in which cities are new ideas being formulated into new products and services? We call that intellectual capitals notice strategy. So we want to be in cities and within that, in or adjacent to the parts of major metropolitan areas where there's a concentration of people who are doing work with their heads, primarily. And then within that context, we use a four-box model. Well, one is first of all, how business friendly is the state within the United States, in the state, at the state level, and at the city level, how friendly is the environment to the formation and creation and continuance of business. Next, we look at how many people are being educated in this area. So it's universities, community colleges, maybe even trade schools, but we're looking for, where is intellectual capital being created? So basically higher education and also, I focused on the quality of the K through 12 school system as well as alternatives for quality education for the port, like charter schools. A third component is amenities; what kind of amenities and culture is being fostered that will attract and retain folks who are highly creative intellectually? So you're looking for arts and recreation and culture and music and trails and things that sort of like people who are active, healthy and thinking with their mind; where is that in your community or any community? The fourth box is really the quality of the public-private partnerships. They're going on attempting to foster this environment that makes it conducive for the creation of intellectual work and the attraction and retention of talent, which then powers the growth in a market. Well, we have found, we've done this for the top 40 cities metropolitan areas in the United States is that these cases happen inside metropolitan areas and they don't happen everywhere. it's not uniform, there are clusters of them in any particular metropolitan area and we'd gone actually through the work of mapping those. Now all of that is you kind of sort your way through that; we do this all across the United States. I track also very clearly domestic migration; you've seen a tremendous amount of domestic migration out of high-cost cities and into cities and states that our score well on these kinds of, all these four attributes. So for Texas; Austin, Dallas, Houston, and to a lesser extent, San Antonio all score well in these areas. And that is where, if you look at where people are moving from and where they're moving to and where businesses, moving from and moving to, that's why, getting a view of the entire country, that's why Orlando, Tampa, Las Vegas, Phoenix, Atlanta, Raleigh, Salt Lake City, are all doing incredibly well because they have a combination of good governance, good weather, which helps. Plus these other condition where businesses are moving and where talent is moving. Now it's not to say that if you're in a core, we call it global gateway city, these cities aren't going away anytime soon, they are major centers of intellectual capital, but they are in places and in circumstances where you're kind of swimming upstream as a real estate investor and there is an increasing level of political risks associated with that as well. So among the core cities, the top six, and usually you can think of these cities as generally speaking--I'm I on the right track, Jim, with what you wanted to hear? Host: Yes. Absolutely, go ahead. Jeff: I could keep going on this [48:41 crosstalk] the core cities are viewed as Boston, New York, Washington, Chicago, LA, San Francisco, and sometimes I'll cross Miami because it operates as a core city. And if you look among those core cities, Boston and Miami are kind of like the best positioned and the other ones less so because of a very high cost and the tax bill and the tax law isn't helping. So those areas were bleeding people anyway and now they're bleeding more. So Boston is pretty well positioned, Miami is pretty well positioned. But even with Miami, there's significant out-migration from Miami to Orlando and Tampa. So I like Orlando and Tampa in that regard and I know there are certain markets that I think are great markets but there's a lot of supply currently. Dallas is an example in Texas. Houston is how you diversify the economy but there's also a large supply response. So in Houston, I would say you have to be very localized; you want to be in places where there's some traffic congestion and you're very close to places where either the Anderson Medical Center or the energy corridor where people want to be and there's a certain level of stable demand so that's, that's kind of the story of Houston. But there are also other cities, Seattle, Denver, Charlotte, these are great cities; they do have a lot of [50:18unintelligible] if I was talking to someone in the Midwest, I would say Minneapolis is a really good city because the weather goes against it, but it's a kind of a core, a great market, particularly in the suburbs. Indianapolis and Columbus; their downtowns are sort of emerging and in creating something because of their good intellectual capital and very low-cost position. So they are kind of like the king of that hill as it were and they're getting benefits of outflow from Chicago. Most of the Chicago outflow is going to Florida or the Carolina's not so much inside the Midwest. So this is the way I think about cities; you want to be in places and so if you're a smaller investor that says, look, I'm only going to invest wherever I am, I'm going to only invest to the extent that I can drive to it and I'm two hours away. Okay, fine, that's great. Go and look for the locations within your two hour driving radius. Go look for those locations that have these conditions, where is intellectual work happening and some of the best strategies are to be in an area and find that area and then find an area that's low cost to rent adjacent to it. So even though you have a cost advantage that's within 10 minutes of drive time of intellectual capital note and intellectual capital notes or sound honestly in most of the top 40 US cities, you can find them, they're there. We do this for our clients, but anyone can do it if they do have the time to spend, and again, if you're investing within a two hour radius of where you are physically located, then your job is to get to know your economy, your regional economy and understand where interesting work is getting done. That's where you would tend to spend your time, that's how I think about it. So when I come back with certain cities that are attractive or certain studies that aren't attractive, it's first looking at the basis and its intellectual capital work and then layering supply conditions on top of that. Host: So are you saying that an investor in Texas should not go to some of the other cities and look for deals? Jeff: I mean understand that when you sort of non-institutional investor go out of your immediate ability to touch the real estate, if you have to get on a plane and you're a non-institutional investor, you are eroding your returns. So what is your competitive advantage as a non-institutional investor? So you have to be very sort of upfront with yourself and I would say your competitive edge as a non-institutional investor is not going to be necessarily a cost of capital because they're going to low cost of capital. It's going to be that you can have more intimate knowledge and you can get to the real estate more closely and you can provide more attention to it than anyone else can, that's your advantage or investing in assets that a large institution would not attempt to invest it, maybe a 50 unit property because they won't want to touch that. It’s a little subscale scale and you can't have a major property management company manage it; it just doesn't work in their strike zone. So you've got to look for assets that you're not going to have competition from institutional investors and where you can bring a competitive advantage. And if you have to get on a plane to see it and you have to have a third party property manager who you eventually can get to it, where's your competitive advantage? Host: Yeah, you're absolutely right. A lot of people think that where they are they kind of start finding deals and they start going somewhere else and they become out of state investor, right? Jeff: [54:35unintelligible] out of state investor, I would say if you're at the point of having a big office and a large staff and a big discretionary fund, then you have the infrastructure to go across geographies, across the United States. If you are someone who doesn't have those advantages, well, play to your strengths; which is, go to places that those investors can't go or won't go and focus on your intense knowledge. The local economies that you can get to within two hour drive time and depending upon the cities in the region you live in, two hours is not slim tickets; focus on where you can add value. I think all of us have to focus on where we are going to add unique value and that's what we should spend our time on. That is definitely how we, as an organization, decide how we're going to spend our time. And if I can't find a way to add competitive value to create value, I'm just not going to go do that activity because someone else can do it better. I need to focus on what I can do uniquely better that no one else can do or very few people can do. And that is getting, if you're a multifamily investor is being in asset classes that are smaller, that institutional investors and knowing where the nodes are and being in an adjacent place to those nodes with a class B or C asset and focusing on value creation to the resident that makes your property more desirable, more valuable because you don't want to be just a box. But then you're in a commodity market, you want to create differentiation; either in the living experience, the things that you offered and ideally like IOT upgrades or other sort of a upgrades where people will pay you for these additional services because they add so much value to their lives and that's what you want to focus on. Host: Awesome advice. Let me ask you one more question before I let you go. So between the primary, secondary and tertiary marker so I think we have to define primary very specifically; primary means, the entire coastal city that gateway cities, right? Jeff: So the way I define primary, primary i snot a good term. We kind of US international gateway cities so there's seven US international gateway cities. There are primary markets, which are really the top 30 metropolitan areas. And primary in my mind would include places like Dallas and Houston and Austin, they're big markets. Then we have, I would call secondary markets where the economies are not nearly as diversified and then you're getting into smaller and smaller metropolitan areas. That makes sense? Host: Okay. Yeah, it makes sense. So people go nowadays to look for Yale on the tertiary market, secondary and tertiary markets so do you think that's a good strategy? Jeff: I've seen people go to Huntsville, Alabama and they've gone to very, very small markets in a search for yield because their investors are looking for current returns. First, is the metropolitan area you're investing in going through a process where it's changing its fundamental character. So if you were able to identify that Denver 15 years ago was going to go from a tertiary market to a solid kind of viewed as a major metropolitan investment-grade market, you made a lot of money because in that transition of the city, it was able to attract in a new group of investors who had a higher willingness to pay. So one strategy if you're going to a smaller city, is the city in a process of changing its fundamental nature? That's a key issue because if it is, then you're going to basically riding on a trail. And I would say there are some cities like believe it or not, Orlando and Tampa and Phoenix that is changing the fundamental nature of their city to be less volatile and have a broader and more stable kind of basis to their employment. If you're going to a really tiny market, and I again, I've seen an investor go to Huntsville, Alabama and buy an asset next to a NASA facility, well that would mean a lot of sense, right? You have found a very interesting special situation in a very small market with good intellectual capital characteristics. But the city, let's say Huntsville, I may be doing dishonor to Huntsville, I'm not familiar with what's going on in Huntsville but if the city is not fundamentally changing, it's character, then your issue is that there's not a lot of other people for you to sell to when it comes time to sell. It's the asset is what it is and you are basing your return on what overall capital market conditions are when you decide to sell. And if you never decide to sell, it may be a great cash flow play; I'm not saying it wouldn't be. You need to be kind of honest with yourself; if you're going to a smaller market than you've been in the past, are you going there because you think that the city is changing its fundamental character and will change to have the characteristic of a bigger city and will grow to that bigger city? In which case, I would say it's a very viable strategy, very worthwhile strategy. If you're going only because you're getting a higher cap rate and that's it and you are taking on a lot of risk and you want to be honest with yourself and not kid yourself. Host: Also I've seen in the past when the recession hits, the tertiary market is the first one to get hit as well, is that right? Jeff: Because, the exception of this asset that's near NASA, those economies are not broadly diversified. They are generally the basis that local economy, it's usually one or two industries and there's a greater likelihood that one or two industries will get hit and you will have exposure that you can't get around and there's nobody else for you to rent too. So yeah, it is very clear so you do want to understand what's the basis of the local economy and do you understand what that basis is and are you willing to accept the exposure that comes with your renter pool being dependent on one or two industries? Yeah, you might pick right and say these one or two industries will not be affected by changes in the broader economy. Okay, but I will say generally speaking, that these other industries in a smaller city will tend to be more focused on manufacturing and extraction, mining, and then some kind of extractive industries, which are generally because the real estate cost is lower. So there's less intellectual capital work being done, it's more extraction or manual or transformation of things and those do tend to get hit pretty hard in a downturn. So I just think you're taking on more risk. Host: Got It. I don't want to take up too much of your time, I got so many other questions but I have to respect your time. Jeff: We'll have to set up another time and you may do round two. It's been a pleasure being on your podcast. Host: Yeah. Do you want to let people know how to reach you or how to subscribe to Yardi? Jeff: Sure, the easiest way to do is go to www.Yardimetrics.com. That's one word and on that website, you'll see the publications department, you can sign up for stuff, you'll see my contact information if you want to reach out to me personally or any of my team and that's really the best way to kind of get in touch with what we do. And hopefully, this has made some sense to you and I wish you all much success in your investing. Host: Thank you, Jeff, for being with us. Thank you. Jeff: All right. Take care now. Bye. Bye.
Show Notes 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 moving into uncharted territories for the podcast… we’re talking psychiatry Nachi: Specifically, we’ll be discussing Depressed and Suicidal Patients in the emergency department. Jeff: As a quick survey of our audience before we begin, how many of you routinely encounter co-morbid psychiatric conditions in your ED patients, especially depression? Nachi: That would certainly be all of our listeners! Jeff: And how many of you struggle to admit or transfer patients for a formal psychiatric eval? Show More v Nachi: Again, just about all of our listeners I’m sure! Jeff: And finally, how many of you wish there was a clearly outlined evidence-based approach to managing such patients to improve care and outcomes? Nachi: That would certainly be helpful. So now that we are all in agreement with just how necessary this episode is, let’s dive in. Jeff: This month’s issue was authored by Dr. Bernard Chang, Katherine Tezanos, Ilana Gratch and Dr. Christine Cha, who are all at Columbia University. Nachi: In addition, it was peer reviewed by Dr. Nicholas Schwartz of Mount Sinai School of Medicine in New York and Dr. Scott Zeller of the university of California-Riverside. Jeff: Quite the team, from a variety of backgrounds. Nachi: And just to put this topic into perspective - annually, there are more than 12 million ED visits for substance abuse and mental health crises. This represents nearly 12.5% of all ED visits. Of note, among these visits, nearly 650,000 individuals are evaluated for suicide attempt. Jeff: Looking more in depth, of the mental health complaints we see daily, mood disorders are the most common, representing 43%, followed by anxiety disorders, 26%, and then alcohol related conditions at 23% Nachi: And as is often the case, these numbers are likely underestimates, as many psychiatric complaints, especially depression, often go unnoticed by the patients and providers alike. In one study of patients who presented with unexplained chest and somatic complaints, 23% met the criteria for a major depressive episode. Jeff: Sad, but terrifying, though I suppose it all makes this issue so much more valuable. Nachi: Before we get to the evidence and an evidence-based approach, let’s start with some definitions. Jeff: Certainly a good place to start, but let me preface this with an important point - arriving at a specific psychiatric diagnosis in the ED is likely neither feasible nor realistic due to the obvious limitations, most namely, time - instead, you should focus on assessing and collecting information on the presenting symptoms and taking a comprehensive psychiatric and medical history. Nachi: According to DSM-5, to diagnose a major depressive disorder you must have 5 or more of the following: depressed mood, decreased interest or pleasure in most activities, body weight change, insomnia or hypersomnia, restlessness or slowing, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate or indecisiveness, or finally recurrent thoughts of death and or suicide. In addition, at least 1 of the symptoms must be either a depressed mood or loss of interest. Jeff: These symptoms must last most of the day, nearly every day, for 2 weeks. Nachi: And these symptoms must cause clinically significant distress or impairment across multiple areas of functioning. Jeff: So those were criterion A and B. Criterion C, D, and E state that a MDD does not include factors from substance use or medical conditions, psychotic disorders, or manic episodes. Nachi: Once you’ve had the symptoms for 2 years with little interruption, you likely qualify for a persistent depressive disorder rather than a MDD. Jeff: And if your symptoms repeatedly co-occur around menses, this is more likely premenstrual dysphoric disorder. Nachi: Moving on to suicide and suicide related concepts. Suicidal ideation is the consideration or desire to kill oneself. Jeff: These can be active or passive thoughts, for example, “I don’t want to be alive” vs “I want to kill myself.” Nachi: Other important terms include, the suicide plan, suicide attempt, suicide gesture and nonsuicidal self-injury. The plan typically includes the how, where, and when a person will carry out their attempt. Jeff: A suicide gesture is an action or statement that makes others believe that a person wants to kill him or herself, regardless of the actual plan. Nachi: I think that’s good for definitions, let’s discuss some more epidemiology. Based on 2005 data, the prevalence of 1 month MDD was 5% with a lifetime prevalence of major depression of 13%. Jeff: If those figures seem a bit high, another CDC study found that in a general population survey of a quarter million people between 2006-2008, 9% met the criteria for major depression. Pretty big numbers... Nachi: Sadly, though outpatient visits for depression and suicide related complaints have decreased over the years, while ED visits remain stable, implying that the ED is a critical entry point for depressed and suicidal patients. Jeff: It’s important to also recognize at risk populations. In several studies, the prevalence of MDD is reported as being nearly twice as high in women as it is in men. Nachi: MDD is also much more common in younger adults, with a prevalence of about 20% in those under 65 and a prevalence of just 10% in those 65 and older. Jeff: Additionally, being never-married / widowed / or divorced, being black or hispanic, having poor social support, major life events, and have a history of substance abuse are all serious risk factors for depression. Nachi: In terms of suicidality, nearly half of depressed adults in one study felt that they wanted to die, with ⅓ having thought about suicide. Taking it one step further, somewhere between 14-31% of depressed adults have attempted suicide, and roughly 1 in 10 depressed adults ultimately die by suicide. Jeff: And while it seems crass to even mention the financial impact, the number is shocking - suicide has an estimated economic burden of $5.4 billion per year in the US. Nachi: That’s an incredible amount and much more than I would have guessed. Jeff: In terms specific risk factors for suicide and suicide related complaints - white men over 80 have the highest rate of suicide death in the US, with 51.6 deaths per year per 100,000 individuals. Nachi: You snuck in an important word there - suicide DEATH. While old people die the most from suicide, younger adults attempt suicide more often. Jeff: Along similar lines, while women attempt suicide nearly 4 times more frequently than men, men are 3 times more likely to die by suicide, likely related to their respective choice of suicide methods. Nachi: Lesbian, gay, and bisexual men or women are another at risk population, with rates of suicidal ideations being nearly twice that of their heterosexual counterparts Jeff: Despite the litany of risk factors we just ran through, the strongest single predictor for suicide related outcomes is a prior history of suicidal ideation or attempt, with individuals who have made a previous attempt being nearly 6 times more likely to make another. Nachi: And lastly, those who have had symptoms severe enough to warrant psychiatric admission have an increased lifetime risk of suicide also at 8.6% vs 0.5% for the general population, in one study. Jeff: Alright, so that wraps up the background, let’s move on to the actual evaluation. Nachi: When forming your differential, a crucial aspect is identifying potential secondary causes of depressive symptoms, as many depressive symptoms are driven by etiologies that require different management strategies and treatment. Be on the lookout for toxic-metabolic, infectious, neurologic disturbances, medication side effects, and recent medical events as the etiology for depressive episodes and suicidality. Jeff: Excellent point, which we’ll reiterate a few times throughout the episode - always be on the lookout for medical causes of new psychiatric symptoms. Next, we have my favorite, prehospital care - when doing your scene assessment, look out for possible signs of overdose such as empty pill bottles lying around. It’s also important to assess for the presence of firearms. Of course, this should not be done at the expense of acute medical stabilization. Nachi: And don’t forget to consider transport directly to institutions with full psychiatric services, especially for those with active suicidal ideations. Jeff: Once in the ED - start by maximizing the patient's privacy. Always use a nonjudgmental approach and use open-ended questions. Nachi: If feasible, map the chronology of depressive symptoms and their impact on the patient’s functional status. It’s also important to elicit any psychiatric history, including prior hospitalizations. Jeff: Screening for suicidality is critical in all patients with depressive symptoms given the elevated risk in this population. Though not broadly adopted in many EDs, there are a number of screening tools to assist you in this process, including the PHQ-9, ED SAFE PSS-3, and C-SSRS, which all asses for severity of suicide risk. These have been developed primarily for the outpatient and primary care settings. Nachi: And not surprisingly, MDCalc has online tools to help you use these risk assessments, so you can easily pull up a scoring tool on your phone should the appropriate clinical scenario arise. Jeff: The PHQ-9 was validated in various outpatient settings, including the ED. This is a self-administered depression questionnaire that has been found to be reliable across genders and different cultures. Interestingly, the PHQ-9 questionnaire contains one question about suicidality - how often is the patient bothered by thoughts that you would be better off dead or hurting yourself. Responding “nearly every day” increases your odds from 1 in 250 to 1 in 25 of attempting suicide. Nachi: The next tool to discuss is the ED-Safe PSS-3. The PSS-3 assesses for depression/hopelessness and suicidal ideations in the past 2 weeks as well as lifetime history of suicide attempt. Jeff: In one study, using this tool doubled the number of suicide-risk cases detected. Nachi: Once someone has screened positive for recent suicidal ideations, further screening must be done via a secondary screener. Jeff: In one study, following this approach decreased the total number of suicide attempts by 30% following an ED visit. Nachi: And what would you advise to clinicians that are concerned that questioning a patient about suicidal ideation may actually encourage or introduce the idea of suicide in those who hadn’t already considered it? Jeff: Great question - It has been found that there has been no associated introduction of negative effect when a patient is asked about suicidal ideations. Concerns about iatrogenic effects should not prevent such evaluations. Nachi: Definitely reassuring that this has been looked into. Let’s move on to the physical. Jeff: The physical exam should include a cognitive assessment that focuses on identifying medical conditions, as well as a behavioral mental health status exam that focuses on identifying the presence and degree of depression. Nachi: And as you said, we would mention it a few times -- In the ED, you always want to make sure you aren’t missing an underlying medical condition that manifests as depression. Jeff: So important. Alright, let’s move on to diagnostic studies. And thanks to a systematic review of 60 studies on this topic, there is actually reasonably good data here. Nachi: According to this review, in patients with a known psychiatric disease presenting with exacerbating psychiatric complaints, routine serum and urine tox screening is not recommended. Additional screening tests should be considered in those with new psychiatric symptoms who are 65 years or older, those who are immunosuppressed, and those with concomitant medical disease. Jeff: a 2017 ACEP clinical policy also recommends against routine lab testing in those with acute psychiatric complaints. They too call for a focused history and physical to guide testing. Nachi: It’s also worth highlighting one other incredibly important point from that ACEP policy - urine tox screens for drugs of abuse should not delay patient evaluation for transfer to a psychiatric facility. Jeff: Definitely a great policy to check out if you find yourself in all too frequent disagreements with your local psychiatric receiving facility. Nachi: You should also consider serum testing in those taking psychotropic medications with known toxic effects, such as lithium, as toxicity would change management. Jeff: Ok, last point about the work up, imaging studies of the brain should not be routinely ordered unless you have a high degree of suspicion. Nachi: That wraps up testing. Let’s move on to treatment. Jeff: First and foremost, you must maintain a safe environment. Effective precautions include alerts to staff about the potential safety risk in addition to searches of the patient and his / her belongings if applicable. Nachi: With the staff notified and the patient searched, the patient should be placed in a room without potentially dangerous items, like tubing or needles. Those who are at a very high risk may warrant continuous observation. Jeff: Speaking of safety, you will definitely want to engage in safety planning with the patient. Safety planning can be completed by any emergency clinician and should take about 20-45 minutes. Nachi: And while this is typically done by a psychologist or psychiatrist, this is something any emergency clinician can also easily do. Jeff: Safety planning beings with a brief interview. Next you establish a list of personalized and prioritized steps to help the patient through his or her next crisis. In a full plan, you should identify: warning signs, internal coping strategies, people and social settings that provide distraction, people whom the patient can ask for help, professionals or agencies whom the patient can contact during a crisis, and lastly how to make the environment safe (for example, lethal means counseling). Nachi: Of course, while the plan is meant to be a step by step approach for the patient, you should encourage the patient to seek professional help at any time if it is necessary. Jeff: Great point. And while safety planning typically is most effective when combined with other interventions, research suggests that it does enhance outpatient treatment engagement after an ED visit and in one study, reduce subsequent suicide attempts by 30% vs usual care. That’s a huge win for something that’s not that hard to do. Nachi: Similar to safety planning, let’s discuss no-suicide contracts. No-suicide contracts or no-harm contracts are verbal or written agreements between the patient and the clinician to articulate that he or she will not attempt to hurt him or herself. Though there isn’t a ton of evidence, at least one RCT showed that safety planning was superior to contracts. Jeff: Lethal-means counseling on the other hand is a potentially helpful prevention strategy. In lethal means counseling, you merely have to address the patient’s access to lethal means. By slowing their access to their lethal means, it is thought that the relatively short-lived suicidal crises may pass before they could access said means. Nachi: For example, you could provide options for restricting access to lethal means, such as disposal, locking up and giving the key to someone else, or temporarily giving the means to a friend. Jeff: And this may be a good time to involve friends and or family, especially when dealing with suicidal youths. Nachi: This is such an important and simple intervention that has actually been shown to reduce suicide attempts and deaths. Unfortunately, few ED clinicians address lethal means. Jeff: Pro tip: since most ED clinicians chart with templates, add something to your standard suicidality / psychiatric template about lethal means. This will serve as an important reminder to address it in real time. Nachi: That is a really great idea to ensure you don’t skip over this underutilized counseling. Jeff: The next aspect of treatment to discuss is follow up. Follow up is critical for both depressed and suicidal patients. Follow up can come in many forms and at a minimum should include the national suicide prevention lifeline. Nachi: The authors even simplify this for us a bit, providing 5 easy steps to help make sure patients follow through with ED discharge recommendations. Jeff: First, provide a standard handout that includes a list of outpatient providers. Next provide the patient the 24 hours crisis line number. After that, ask the patient to identify the most viable resources and address any barriers the patient may have in getting there. Next, schedule a follow up appointment, ideally within a week of discharge, and lastly, document the patient’s preferred follow up resources and steps taken to get them there. Nachi: And if this seems too burdensome for a single provider, think about identifying a staff member who may help the patient with follow up - perhaps a social worker or case manager. Follow up is so important, it’s critical that the ball not be dropped after you’ve put in so much hard work to make the plan. Jeff: As always, the team approach is preferred. Alright so the last treatment to discuss is actual pharmacotherapy. Since commonly prescribed antidepressants take up to 6-8 weeks to have a clinical effect, the administration of psychotropic medications is not routinely initiated in the ED. Interestingly, there may be a role for ketamine, yes, ketamine, in conjunction with oral meds. More on that in a few minutes though... Nachi: Let’s talk first about special populations - the only one we will discuss this month is military veterans. Jeff: Recent evidence has demonstrated an association between exposure to blast and concussive injuries and subsequent depressive and anxiety symptoms. Nachi: In part, because of this, among veterans presenting for emergency psychiatric services, approximately 52% reported suicidal ideations in the prior week and 70% reported current depressive symptoms. Clearly this is a major problem in this population. Jeff: But to bring it back to ED care, in one study, among depressed veterans with death by suicide, 10% had visited a VA ED in the 30 days prior to their death. Nachi: And this is in no way meant to be a knock-on VA ED docs - they are dealing with a very at risk population. But it is worth highlighting the importance of the ED visit as an excellent opportunity to begin to engage the patient in long term care. Jeff: Exactly, every ED visit is an opportunity that shouldn’t be missed. Nachi: Let’s talk controversies and cutting-edge topics from this issue. Jeff: First, let’s start by returning to ketamine and the treatment-resistant depression and suicidality. Nachi: Recent trials, including RCTs have found that low doses of ketamine administered via a variety of routes, may have a significant therapeutic effect towards reducing suicidality in patients in the acute setting. Jeff: To this end, Esketamine, an intranasal version of ketamine has already been FDA approved for treatment resistant depression. Nachi: This has huge implications for some of the psychiatrically sickest patients, so be on the lookout for more in the future. Jeff: Next we have the zero-suicide model. This is a program of the national action alliance for suicide prevention that involves a multi pronged approach to reducing suicide based on the premise that suicide is preventable. This model involves educating clinicians on best practices, identifying screening and assessment tools for engagement, treatment, and disposition. Nachi: Though not yet implemented in the ED setting, this may offer a novel approach to ED patients with psychiatric emergencies in the ED. Jeff: The next controversy is a big one - alcohol intoxication and suicide risk. There is a bidirectional relationship between depression and alcohol abuse and dependency. Not only is alcohol abuse a lifetime risk factor for completed suicide, those who make suicide attempts or present with suicidal ideations are more likely to be intoxicated. Nachi: In addition, formerly intoxicated patients may deny their previous thoughts and intentions when sober. Interestingly, though such patients have an increased lifetime risk of death by suicide. Jeff: Given this paradox and the evidence that exists, the authors recommend observing the patient until they have reached a reasonable level of sobriety. This effective level of sobriety should be based on clinical assessment and not blood alcohol levels. If the patient unfortunately has reached a place where they are at risk of withdrawal, this should be treated while in the ED. Nachi: It’s worth noting that ACEP guidelines and guidelines from the american association for emergency psychiatry have both supported a personalized approach that emphasize evaluating the patient’s cognitive abilities rather than a specific blood alcohol level to determine when to pursue a formal psychiatric assessment. Jeff: Very important point - in this high-risk population, you are targeting a clinical endpoint, not a laboratory end point and this is backed by several national guidelines. Nachi: Moving on to the next topic - let’s discuss post discharge patient contact. Jeff: Though not something many ED clinicians routinely do, this may be something to consider implementing in your department. And this doesn’t even have to be something as time consuming as a phone call. In one study, sending a brief postcard 9 times a year with a quick “hope things are well” type message to patients discharged after deliberate self-harm reduced self-poisonings by 50%. Nachi: Though other studies including other methods of follow up have not shown as drastic results, generally the results have shown a positive impact. Jeff: Next we have to discuss the various screening tools. Though we previously mentioned screening tools in a positive light, using such decision-making tools is still of limited utility due to the fact that they rely on self-reporting and suicidal thoughts and behaviors are complex and may require the consideration of hundreds of risk factors. Nachi: And while implicit association tests are being developed to predict suicidal thoughts and behaviors, and computer models and machine learning are being used to enhance our screening tools, there is still a long way to go before such tools perform more independently with acceptable performance. Jeff: The last cutting-edge topic to discuss is telepsychiatry. Nachi: Just as telestroke has changed stroke care forever, as technology advances, telepsychiatry may provide a solution to easily expand access to outpatient services and consultation in a cost effective manner - offering quick psychiatric care to those that never had access. Jeff: Let’s move on to the final section of the article. Disposition, which can be a bit complicated. Nachi: The decision for discharge, observation, or admission depends on clinical judgment and local protocols. Appropriate disposition is often fraught with legal, ethical, and psychological considerations. Jeff: It’s also worth noting that patients with suicidal ideations tend to have overall longer lengths of stay when compared to other patients on involuntary mental health hold. Nachi: There are however some suicide risk assessment tools that can help in the disposition decision planning such as C-SSRS, SAFE-T, and ICARE2. C-SSRS is a series of questions that assess the quality of suicidal ideation. SAFE-T is 5 step evaluation and triage tool that assesses various qualities and makes treatment recommendations. ICARE2 is provided by the American College of Emergency Physicians as a result of an iterative literature review and expert consensus panel. It also integrates many risk factors and treatment approaches. Jeff: It goes without saying that none of these tools are perfect. They should be used to assist in your clinical decision making. Nachi: For depressed but not actively suicidal patients, ensure close follow up with a mental health clinician. These patients typically do not require inpatient hospitalization. Jeff: Let’s also touch upon involuntary confinement here. Patients who are at imminent risk of self harm who refuse to stay for evaluation may need to be held involuntarily until a complete psychiatric and safety evaluation is performed. Nachi: Before holding a patient involuntarily, it is important to fully familiarize yourself with the state and county laws as there is wide variation. The period of involuntary confinement should be as short as possible. Jeff: With that, let’s close out this month’s episode with some high yield points and clinical pearls. Risk factors for major depression include female gender, young or old age, being divorced or widowed, black or Hispanic ethnicity, poor social support, and substance abuse. The strongest predictor for suicide-related outcomes is history of prior suicidal ideation or suicide attempt. When evaluating a patient with depressive symptoms, try to identify potential secondary causes, as this may influence your management strategy. When assessing for depression, perform a complete history and consider underlying medical causes that may be contributing to their presentation. Consider serum testing for the patient’s psychiatric medications if the medications have known toxic effects. 1. Routine serum testing and urine toxicology testing are not recommended for psychiatric patients presenting to the emergency department. Imaging of the brain should not be ordered routinely in depressed or suicidal patients. Depression places patients at a significantly increased risk for alcohol abuse and dependence. In addition to providing appropriate follow up resources to your depressed patients, emergency clinicians should consider making a brief follow up telephone call to the patient. Telepsychiatry may improve access to mental health providers and allow remote assessment and care from the ED. Suicide risk assessment tools such as C-SSRS, SAFE-T, and ICARE2 can help when deciding on disposition from the ER. It may be necessary to hold a patient against their will if they are at immediate risk of self-harm. Though not routinely administered in the ED for this purpose, psychotropic medications, such as ketamine, have proven helpful in acute depressive episodes. Patients who are actively suicidal should be admitted to a psychiatric observation unit or inpatient psychiatric unit. Nachi: So that wraps up Episode 28! Jeff: As always, 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 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 any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And don’t forget to check out the lineup for the upcoming Clinical Decision Making in Emergency Medicine conference hosted by EB Medicine, which will take place June 27th-30th. Great speakers, great location, what more could you ask. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0519, so head over there to get your CME credit. As always, the [DING SOUND] 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! Most Important References 1. Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007: statistical brief #92. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006. (US government report) 12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington DC: American Psychiatric Association; 2013. (Reference book) 15. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807-816. (Survey data; 49,093 patients) 16. Centers for Disease Control and Prevention. Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010;59(38):1229-1235. (Government survey data analysis; 235,067 subjects) 97. Murrough J, Soleimani L, DeWilde K, et al. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med. 2015;45(16):3571-3580. (Randomized controlled trial; 24 participants) 100. Griffiths JJ, Zarate CA, Rasimas J. Existing and novel biological therapeutics in suicide prevention. Am J Prev Med. 2014;47(3):S195-S203. (Review article)
The guys talk about having more books than shelf space and also their upcoming 24th anniversary. Will reviews An Easter Promise by A E Ryecart. Jeff reviews Play It Again by Aidan Wayne. Jeff interviews Hank Edwards and Deanna Wadsworth about their collaboration, Murder Most Lovely, the first in the Lacetown Murder Mysteries series. They talk about how they came up with the book, their process for co-writing and what’s still to come in the series. We also find out what’s coming up for each of them in 2019. Complete shownotes for episode 186 along with a transcript of the interview are at BigGayFictionPodcast.com. Here’s the text of this week’s book reviews: An Easter Promise by AE Ryecart. Reviewed by Will. This is the continuing story of Rory and Jack, who we first met in the holiday story, A Kiss Before Christmas. In that story, Jack finds the homeless Rory huddled on his doorstep and offers him a place to stay. As they learn more about one another, Jack asks Rory to pose as his fake boyfriend when he goes home for the holidays. An unexpectedly severe winter storm prevents them from that trip, but in the few days they’ve been together they’ve fallen in love. I read A Kiss Before Christmas last year, and I still highly recommend it. In An Easter Promise, it’s now Spring and our two heroes are finally making the trip to visit Jack’s family in his ancestral manor house in the countryside. This is a particularly nerve-wracking experience for Rory, whose childhood couldn’t have been more different than Jack’s well-heeled upbringing. Things go relatively well as Jack shows Rory around the expansive estate, but they then get frosty when Jack’s mom makes it clear that she believes that Rory is after her son’s money. Gold-digging accusations aside, as a favor to her, Rory steps in as a last-minute contestant in the Best Bake competition at the village festival. Though his brownies were obviously the best, he doesn’t win. Afterward, Jack announces that he and his culinarily gifted boyfriend are going into business together and are opening a bakery. This once again raises the suspicion that Rory is only after Jack for his money, causing a major rift in family relations. Jack tells his mom where she can stick her suspicions, and is ready to return to London, but when Rory takes the family dog for a walk, he gets lost on the moors in a sudden storm. If reading fiction set in the U.K. has taught me anything, it’s that going for a walk on the moors is always a bad idea. The family organizes a search party and journeys into the dark night to find Rory. He is eventually found, and Jack makes amends with his parents. Flash forward a few months to the opening of the bakery and the beginning of a new chapter for our romantic heroes. I really like both of the stories featuring Rory and Jack and sincerely hope that this isn’t the last that we’ll see of them. The opening of the bakery certainly presents several new story possibilities. A.E. Ryecart, if you’re reading this, I’m a fan and a series set in this world would be greatly appreciated. Play It Again by Aidan Wayne. Reviewed by Jeff. I was completely delighted by new-to-me author Aidan Wayne’s Play It Again. Part of what drew me in initially is that part of it relates to what we do here on the podcast. Dovid is a YouTuber alongside his sister Rachel. They run a channel called Don’t Look Now. Among the things they do is review eateries in Seattle for how accessible they are because Dovid is blind. They also interact with their fans, go on trips, open mystery boxes–it’s the full YouTube gambit. Over in Ireland, Sam runs a Let’s Play channel where he plays a popular videogame. Rachel and Dovid become obsessed with Sam’s channel because of his easy-going, fun delivery. Dovid calls out Sam’s channel in an episode and sends Sam’s subscriber count through the roof and when Sam contacts Dovid to thank him they end up talking frequently. Dovid and Sam are single–but as I mentioned live on opposite sides of the globe. Neither of them, quite cutely, realizes how flirty they’re being as they message each other. Initially Dovid offers Sam advice on how to manage his new subscribers and ways to grow his channel but as they move beyond that and get to know each other the realization comes that perhaps there’s more there. This isn’t the first book I’ve read that relies heavily on text messages, instant messenger, email and so on. I loved how these wove into the story. There’s a good deal of, what I’ll call, regular storytelling too, coming from both points of view. Dovid and Sam have quite a lot internal dialogue about their growing predicament. Just getting time to talk on the phone is a challenge with the nine hour difference between them. It doesn’t stop them though from being ridiculously cute and challenging themselves to let this relationship go through its formative stages without being in the same physical location. Of course, the guys have to get together and that happens when Dovid and Rachel had the chance to do a European tour, which includes Ireland. As much as Dovid and Sam questioned themselves as they did the long distance thing, the jitters ratchet up as they meet. Aidan does a great job of showing the hesitancy–from Dovid wanting everything to be perfect to Sam wondering if he’s worthy of Dovid. Sam comes from a family where he was put down a lot and Dovid goes into protector mode when Sam talks about this, which is incredibly touching and sexy. For all the exploration they did via email, the time they spend together in Ireland really made me appreciate the romance that Aidan spun even more. They’d bonded so much before, they almost fall into old married couple mode with how they try to take care of each other. Dovid is particularly mindful of Sam’s asexuality and makes sure Sam isn’t doing anything he doesn’t want to do. It’s wonderful to see two such diverse characters finding their happy. Speaking if the HEA, I’d wondered how it would manifest in a book where the two characters spend probably eighty percent of the book on separate continents. I adored how Aidan brought Sam and Dovid together. I would love to see more in this universe to know how Dovid and Sam are getting on. Besides the wonderful romance, I loved the attention to detail that Aidan put into showing the work Dovid and Rachel do on their channel. From the talk of creating Patreon campaigns to managing social media and how to interact with the audience, I enjoyed it and I don’t think it’s too much for people who don’t do this kind of thing. Another excellent detail, Dovid and Rachel receive a package from a fan in Michigan–it contained Faygo Red Pop and Mackinac Island fudge, two childhood favorites that made me smile and gave me cravings! So, in case you haven’t figured it out, I totally recommend Play it Again by Aidan Wayne. I’m also looking forward to their upcoming book, Hitting the Mark, which comes out at the end of May. This interview transcript is sponsored by Dreamspinner PressDreamspinner Press is proud to publish this week’s guests Hank Edwards and Deanna Wadsworth and their new book Murder Most Lovely. Check it out, and all the new mystery and suspense titles from your favorite authors like Amy Lane, KC Wells, Tara Lain, and Rhys Ford, just to name a few, and find a new favorite author while you’re at it. Go to dreamspinnerpress.com for everything you want in gay romance. Jeff: Welcome to the podcast, Hank Edwards and Deanna Wadsworth. Deanna: Hello. Jeff: Thanks for being here. Hank: Thanks for hosting us. Jeff: You guys have written a book together… Deanna: We did. Jeff: …which is super cool. April 30, which is the day after this comes out, you’re releasing the first book in the “Lacetown Murder Mysteries” called “Murder Most Lovely.” Tell us about this new series. What is the scoop? Deanna: Who wants to go first? Hank: Deanna? You go first. Deanna: Okay, I’ll go first. So like a year ago I went out to dinner with my husband, had some cocktails and at like 11:00 at night after having like wonderful conversations in my brain with myself because I think I’m clever, I messaged Hank, and I said, “Dude, we need to write a book together.” And he’s like, “We should.” And then we did. Hank: I might have had some cocktails that night too. I can’t remember. Deanna: You may have. Hank: Might have. Deanna: And it was, “Yeah, we should,” kind of moment. And we didn’t really know where it was going. Hank: We had no idea. Deanna: What’s that? Hank: We had no idea, like nothing. That was just the random start of things. “We should do a book.” We didn’t have an idea or anything. Deanna: It was a completely inane, “Dude, we should write a book together,” kind of moment. And then seriously, the next day, we had some conversations like, “What should it be? Superhero?” And then we just kind of like spitted ideas back and forth. And Hank was like, “We would write the fuck out of a rom-com.” Am I allowed to say fuck? Jeff: Yes, you are. We’ll put a little explicit logo on the episode and you can cuss as much as you want. Deanna: So he was like, “We would write the fuck out of a rom-com.” And I’m like, “We would.” And then we’re like, “What should it be?” And we just spitballed ideas back and forth. Like, I mean, literally, like there was probably like 30 or 40, like, things we shot back and forth at each other. And then Hank picked on two of them. And he’s like, “I love the idea of a mortician and a hairdresser.” Then we ran with it. Hank: Yeah, and we just ran with it. And it just started writing. I mean, we didn’t plan, like, “You take one chapter.” What we did was each of us wrote up a character bio and sent it to each other. And so I wrote up… Deanna: It was so great. Hank: You what? Deanna: It was so great, like blind dates for our character. Hank: It was. It was really fun. So you had Michael, right, and I had Jazz. Deanna: Yeah, you made Jazz. So tell us about Jazz. Hank: So Jazz is very sassy and very snarky. And he’s a talented hairstylist and he’s uprooted his life after separating from his husband, who is a best-selling novelist and mystery novelist. And so he’s moved to this small town on the coast of Lake Michigan in Michigan. And some Michigan love there, Jeff. Yes. Jeff: I love that. Hank: Yes, always. And so he’s starting over and he’s just trying to kind of like rebuild and he works at a fun little salon but he’s kind of, he’s 49 but he tells people he’s 41 and… Deanna: He tell’s people he’s 35, remember? Hank: And he tries that too. Deanna: He totally lies about his age. He says he’s 35. Hank: We had, our editor actually called us up and she was like, “Is this right?” Because he shouldn’t have been around back then. Jazz lies about his age. Deanna: He’s almost 50 but he says he’s 35. Hank: Right. So that’s how that started. And then she brought up Michael. Deanna: Yeah. Hank created Jazz, the hairdresser, which is funny because I actually legitimately am a hairdresser in real life. But when we were talking, Hank had said, “I’ve always wanted to write a hairdresser.” I’m like, “You take the hairdresser. Run with it.” And then I took the mortician, which sounded really great and exciting. And after dozens of Google search, Google decided that I obviously want to be a coroner and mortician and they send me casket ads, but yeah, whatever. So I created a…it was fun because Hank created Jazz, this sassy, almost-50 hairdresser who’s super sarcastic, he’s got long honey blonde hair and super stylish and wears eyeliner and he’s really sassy and he has a big potty mouth. Hank: Oh, yeah. Deanna: Oh, he does. And then I didn’t know who Hank was creating when we came upon this conversation. It was very much, “Hey, you pick your guy. I’ll pick my guy. We’ll see what happens. And I made Michael Fleishman who is a 42-year-old, very uptight, very socially awkward Jewish guy who runs the local funeral home and he’s also the county coroner to our fake county…is it Carver County? Hank: Carver County, yeah. Deanna: Carver County on Lake Michigan, which is sort of like in somewhere between, I don’t know… Hank: Like Saugatuck and… Deanna: Saugatuck and… Hank: Yeah, Muskegon. Deanna: Muskegon, somewhere, a fake county in between there and he’s the county coroner. He’s very uptight and super horny and has this like hilarious like sexual imagination but he’s really reserved and he is obsessed with mystery novels. And he goes to a bookstore in Lacetown, which is our fictional town on Lake Michigan, during a literary festival to meet his favorite also author, Russell Withingham, which happens to be Jazz’s husband. They’re separated but they’re not divorced yet. Hank: And that’s the meet-cute. Jeff: Wow. Hank: I know, right? Deanna: Total rom-com, meet and greet during the rain under an umbrella, cute scene. Until Jazz gets his little…I mean, he really worries Michael thinks he’s a bitchy queen and he kind of is. He’s totally the queen. Hank: He’s really fun to write. Deanna: It’s so fun. Jeff: So when you got these characters who are obviously really opposite to each other, you could just hear it in the bios, what was it like to mash them together? Hank: Oh, man. Jeff: Sparks had to have flown off the pages. Hank: Oh, yes, right away. It was really fun. The first chapter is their meet-cute. And we had…I mean, we do a lot of like editing, right? So we’ll write the first pass and we’ll talk about it. We message a lot during the day and stuff like that, talk about where we want to go with things. And then we use Google Docs to write together. Yeah, so that was a lot of fun to just see the whole creation of it and like set up that setting and understand how they were going to meet and how that was going to go and how Michael would be so taken with Jazz at first sight. It was really fun. Deanna: Totally. Like, “Oh, you’re so handsome. Why is he talking to me?” Hank: That’s really fun. Jeff: And of course you’ve got the mystery element in this too. So rom-com mystery, which trying to think, I haven’t necessarily seen that kind of combo a lot because there’s straight up romantic suspense, of course. And then there’s like cozy mystery and maybe this ekes a little towards that with the rom-com–iness. But did you know that this was going to be like something to go for? Or did you just like mash these two elements together and say, “This thing…” Deanna: We thought about doing like a film noir concept, like a 1940s film. But see, that’s the thing. Like when Hank and I started writing, we didn’t have a direction. We were very much open to anything. And it was sort of like he created Jazz, I created Michael. We knew we wanted a murder. We knew we wanted it to be like… Hank: We wanted a murder. The murder got pretty gruesome too. I was really shocked. Deanna: Yeah, we wanted some things but then as we began to write it, it began to have elements of a real murder. So like our sheriff is blustering and funny. And Michael has his kitty cat, the little Mr. Pickles. Hank: Mr. Pickles. Deanna: Mr. Pickles, the fat, black-and-white kitty, which my dog is growling at right now. Jeff: Which we should note, for the people who may not be watching the video, Deanna just held up this stuffed kitty. And you’re going to be giving these away at GRL in a few months. Deanna: Yes, we have a few couple. So like when we created the story, I guess maybe other people with their writing collaborations might be different than we were. But Hank and I were not in a competition with each other. We were not like…we just knew we were going to have fun because we like each other and we know each other personally. And we were just like, “Let’s have fun with this.” And there was no like obsessive competition with like, “I don’t like the storyline.” Or, “I like this.” It was just sort of like, “What do you want to do? Okay, that sounds fun.” And we both ran with it. And we ended up developing this city on Lake Michigan and this little town and these little side characters. Jeff: Let’s talk about the mystery side of it. Who is dead? Deanna: Oh, yes, the mystery side of it. That’s right. So I’ll talk and then I’ll let Hank talk because I’ve been blabbering too long. So we decided we wanted it to be, like, film noir idea. And then it became like a legitimate murder mystery where there is a dead body and it’s gruesome and it’s creepy and it’s sad. And there’s like some crazy shit happening. And there’s like cops that need to come in. And there’s like a real mystery. And there’s actually a couple side mysteries that are happening over the book arc of the next two novels, novel two of which we will be submitting in the morning. We would have submitted it today but I’m being a typo psycho. I am. I’m a typo psycho. Hank: She’s finding a lot of good stuff, though. I like the changes. So, yeah. So the murder actually got more gruesome than I was anticipating. We were like, “Let’s go.” “Wait, do we want to go?” “Yeah, let’s do it. Let’s do it.” So it’s…do we want to say who it is? I mean, it happens early on. So I don’t think it’s a spoiler, right? Deanna: Oh, I don’t know. Why don’t we just talk about how creepy the murder is. Hank: Okay, we’ll just leave it just like that. Deanna: Not who is murdered. Hank: Someone’s murdered and maybe their hands are missing. Deanna: Or chopped off. Jeff: Oh, wow. Hank: So, yeah, that’s kind of… Jeff: That’s more gruesome than I expect in a rom-com. Hank: I know. Jeff: I’ll say that. Deanna: Oh, wait ’till you hear about the serial killer. Wait, that was a spoiler. I didn’t say it. Hank: But in the first book… Jeff: Is that a spoiler that we’re leaving in or a spoiler that we’re taking out? Deanna: We’re leaving it in but we’re not gonna respond about it. Jeff: Fair enough. Hank: That’s right. Jeff: A little breaking news there for the podcast that we will not do follow-up questions on. You were saying, Hank, on this murder. Hank: So yeah, so it was gruesome. And then there’s the discovery. But Michael is kind of, you know, he can’t help but be a little excited about it because it’s his first murder because he’s a small town, county coroner. And the only… Deanna: He’s not only a mortician. He’s the county coroner too. Hank: Right. So it’s up to him now to, like, investigate it. He’s never had a murder like this. He’s had a murder but they knew the victim and the attacker. So this is completely new for him. And he reads murder like mystery novels, so he’s really excited about it. So he’s, like, starting to play, like, detective. And then the sheriff is kind of, you know, like all blustering and yelling at him like, “Fleishman. Dilworth.” You know, that’s Jazz’s last name, Jazz Dilworth and he like calls everybody their last name and yells at them. And they’re always a suspect, so, “Don’t leave town.” Deanna: Everyone is a suspect until Musgrave says they’re not a suspect. Hank: “Don’t leave town.” Yeah. Sheriff Musgrave. Jeff: So if I understood correctly, you kind of just created this on the fly. Hank: Yep. Deanna: Totally. Jeff: For both the romance and the mystery? Deanna: Totally. Jeff: How did that play out in like the day-to-day writing? Because I can’t even like imagine having co-written something that there wasn’t more of a plan to it. Hank [softly]: I know! Deanna: How did it go? Hank: Actually it went smoother than I expected. Deanna: It was so much fun. Hank: Yeah. And it was a lot of fun because we chatted a lot on Facebook Messenger. And we’d text and we call each other now and then. We’d have conversations, phone conversations, and we’d plan out where we wanted things to go. And then one of us would say, “Okay, I’ll do this and then you can write that.” And then we just kind of took it. And then it was really fun because like you’d go through and you’d read…you know, how you like read through what you’ve written and it’s somebody else has written something new and you’re like, “Wow, this is like a whole new story.” Like you don’t know what you’re reading, you don’t know anything of what to expect. So it was really fun. Deanna: So awesome because, like, first, I gotta say, writing with Hank Edwards has been a pleasure. Because not only is he a great writer and like stupid funny, like so funny, I can’t even tell you how many times he writes something and I’m just like…laughing. But he and I are not…we’re not competitive individuals. We’re not like jumping into this, like, “Well, this is what I want. This is what I want.” It was so easy, where it was just like we just…Hank created Jazz and then Jazz has this profile that we went with. I created Michael and we had this profile we went with. He and I created an exterior mystery that happened to them. But because he created such a good profile and I just created such a strong profile, both of us knew who Michael and who Jazz were. And then it was like, “Well, Michael wouldn’t do that,” or, “Jazz wouldn’t say that.” And we didn’t like try to, like, undermine the other person. I don’t know. I just feel really blessed. I love you. I just feel blessed to be able to write a story with someone who is so easy and so fun and our sense of humor is both very similar and darkly twisted and inappropriate, like we both knew when our editor was gonna go, “Mm-mm. No.” Hank: I told her several times, I’m like, “This is gonna get cut out and you put it in and it’s gonna get cut out. I’m telling you right now.” And she’s like, “I want to leave it in.” I’m like, “Okay, but it’s gonna get cut.” And it did. Deanna: And I’m like, “They’re not gonna let us use the C-word.” And he’s like, “Maybe they will.” No, they didn’t. But it was so much…I don’t know. It was just one of those things that were really easy because Hank is so fun to work with. It was just easy. I mean, not that writing and editing is easy. But even as we went through the process, there would be scenes…we each knew where the scene was going to go. We knew what scene was going to happen next. And if it was…because our work…he’s very typical 9:00 to 5:00 work schedule, Monday through Friday, and I am Wednesday through Saturday, noon to 8:00, those four days. So like he would do all the stuff Wednesday through Saturday and then I’d open it up on Sunday, and then I’d do all the stuff Sunday to Tuesday. And then it wasn’t like we were fixing or changing each other’s work. It was like, “Oh, that’s a great scene.” And then I would add to it. And then he would take my scene and add to it. And it was just like layering and layering cool stuff with what was already funny. So it was like I knew what I was writing on Tuesday. I wrote this whole scene. And then Hank would write the next scene. And when I would get a chance to read on Thursday, he was like, “Oh, what am I going to read? I know what’s gonna happen but how is it gonna happen?” And he is so funny. So funny. And, I mean, it was just so great writing together. Jeff: So, Hank, for you, what’s kind of your side of that story as you’re like going through and doing your part on the book on your days? Hank: So it was a lot of fun. Like Deanna said, because I’ve been writing during my lunch hours at work, so like Monday through Friday I’d have like an hour and I usually go and I hide somewhere at the building and I’ll, like, be able to focus and write. And it was really fun to go through Google Docs and be able to accept all those changes because we always do the suggestions, right, so like the track changes so we can see what each other has done. And it’s always so much fun to see. It looks like, you know, like Deanna said, it’s like, “Oh,” it’s like a little present. You know, like, “There’s something new.” And I go through. But then seeing how she did the layering, I was talking to my husband, Fred, and I was like, you know, it’s like I’m picking up such good ideas about how to layer emotion in. Deanna is awesome at doing that and like pulling out the emotions in a scene and like digging in deeper where it needs to be. You know, that’s something that I’ve always kind of like, you know, I’m always like, “Write the action. Write the action. Write the action.” Deanna: But that’s what I love about his writing because he will write action that conveys emotion, whereas I would have written a long, drawn-out emotional monologue. And somehow the two just worked so great. I think. Hank: We are a good blend together like that. So, yeah, it’s really funny and she’s funny and really darkly funny. So it’s been a lot of fun because there’s some stuff where I like write something dark and funny and then, you know, you get the comment. It’s always fun to get that comment like, “LOL. Oh, my God.” And so then like all of a sudden like further down the page, she’s added somebody I’m like, “Oh, my God, you did not just write that.” So it’s really funny. Deanna: We’re so wrong. We’re so wrong, we’re so right, Hank. Hank: Yes. Jeff: Well, I really like the organic method it sounds like you guys had. Because like my brain can’t even begin to process trying to co-write without a plan. But I’ve heard other people do that and it works out great. What, as you got the draft done, what was the revision and also, I guess, making the book seem like it had one voice? What was that like? So was it like two different people at work? Deanna: Can I respond to this? Hank: Of course. Deanna: Okay, so, Hank would send me…well, it was in Google Docs. So we would get scenes together. So I feel like the way it went before anyone else read anything or we got any feedback from editors, from beta readers, or whatever, it was like we had our strong characters decided who they were and what they were and what the mystery was. And he would write a scene and then I would get it and I’m like, “Oh, it’s a good scene. I love where it’s going. Maybe…” Okay, so like I’m not going to give a spoiler, but there’s a scene at the end of Book 1 where the murderer is caught and our two heroes are like in this epic battle fighting them, like the murderer, right? Okay. So Hank writes that scene and I’m like, “Ah,” and then I go in and I add some fighting, some struggling, and maybe a little dialogue. Hank comes back in, he adds a little more dialogue. He remembers that the gun is on the other side of the room. Whatever the detail is, we both keep adding layers. And I think it comes back to the point that we’re both so invested in our characters and we weren’t, like, competing to try to be the better person. And I think that’s a lot of it. I mean, I think you can’t co-write a book together if you’re competitive or need center of attention. Hank and I just had so much fun. It would be like, “Oh, yeah. Add that, add that.” And he’s just like “Oh, my God. We’re great. That’s great. You shot him. Oh, I didn’t expect to shoot him. Let’s do that.” Whatever it was and we kept adding these layers and it became so much fun. But in the end, when we would get a scene and it was completed, we would…each of us would go back and read through the whole manuscript and be like, “Oh, we missed that detail.” And Hank would send that to me. And I’d be like, “Oh, yeah, that’s right. I forgot about that.” And he would add it. Or I would like, even today, we’re actually like one day off submitting Book 2. We were going to submit it today but I am like typo crazy. So I sent the manuscript to my Kindle so I could find any misspellings and typos. And I was like, “Oh, my God. We have a scene where Michael and Jazz are sitting in Michael’s living room with the TV. And in Book 1, he only has a TV in his bedroom. What are we going to do?” And Hank is like, “That’s cool. Good for catching that.” And I feel like that’s kind of how we’ve been like we’ll catch something and go. “Oh, I’m glad you caught that.” Hank: Yeah. But to your point, Jeff, you said like about planning and writing off the cuff, so the first book, I think, Deanna, you can tell me if I’m wrong. But the first book was really, I mean, it wasn’t easy because writing is hard but it was easier. Book 2, it was more of a struggle I think with writing it. Deanna: Book 2 was more of a struggle. Hank: And we had a lot going on. So we have like an overarching mystery, we have another, like, contained mystery. Deanna: Yes. Hank: So we’ve talked about it and we’re like Book 3, we really need to plan it out more. We’re gonna… Like once we let this book to get out a little bit, we’re going to like start planning Book 3 and then really like… Deanna: We need a serious luncheon with some planning. Hank: Yeah, so, absolutely. Deanna: Book 1 was very organic and natural. And Book 2, I mean, you’ll probably agree, Hank, I think we fell in love with our side characters so much we got distracted with all these sides stories. Even our editor was like, “Why are you talking about that and that?” We’re like… Hank: “Because we like them.” Deanna: So we had to cut a lot of scenes and really focus back on the romance, on book 2. Jeff: DVD extras, deleted scenes. Hank: DVD extras, exactly. Jeff: But let’s talk about those side characters a little bit because there’s a whole paragraph of the blurb for Book 1 that details the side characters. Michael’s sassy assistant, Kitty, the grumpy Sheriff Musgrave, Russell’s creepy PR rep, Norbert, Michael’s grandfather who likes his Manhattans strong and his women saucy. And of course, who we’ve already met, Mr. Pickles Furryton the Third. Hank: Yes. Mm-hmm. Jeff: So did you guys split those up in the same way that you took Jazz, Hank, and Deanna took Michael? Or did these get created on the fly as you needed them? Deanna: They were on the fly. Hank: Yeah. Deanna: We just like… Hank: We just do, kind of. Yeah. Deanna: I think I came up with Mr. Pickles Furryton the Third and Hank created Sheriff Musgrave. Because I think when we were talking, Sheriff Musgrave was actually like an old man and Hank made him this whole, like, Ron Perlman kind of character. Hank: Yes. Very Ron Perlman. Deanna: He has a lot of attitude. And Kitty, I don’t know where she came from. Hank: You created Kitty. Deanna: Did I? Okay, because I imagine her. Do you watch “Blue Blood” with Tom Selleck? Jeff: I have not. Deanna: Oh, anyways. His secretary is this voluptuous like blonde chick and I pictured her. And I don’t know who created Grandpa. Hank: I think we both did. Deanna: You had Steve. Hank: Oh, yeah, the handyman. Deanna: We both made Ezra. Hank: The apprentice. Deanna: I don’t know anything about them. That’s not a spoiler at all. Jeff: That’s very impressive to just kind of create on the fly like that. Two people pantsing would make my head explode, but. Hank: It was insane. I don’t know how we managed to do it but… Jeff: I think you had fun with it all the more. Hank: …we had really good feedback from the editor. Deanna: We did have so much fun, Jeff. Hank: Yeah. Deanna: I don’t know how lucky I am. Like a year ago, I sent him a drunk text message that we should write a book together. And we have had the best year. Jeff: Had it even crossed your minds before the drunk text to do this in some, like, other random moment? Deanna: No. Hank: Never ever really even talked about it? I mean, we see each other GRL. She comes up for Ferndale Pride because she lives about an hour and a half away from me. Deanna: I’m northwest Ohio, he’s southwest Michigan, so we’ve done some pride festivals together. But in all freaking honesty, the whiskey made me do it, Jeff. I literally texted him, “Hey, full disclosure, I’ve been drinking. We should write a book together.” I do believe, Hank, that was the quote. Hank: Pretty much. Yeah. Deanna: And he was like, “We would write the fuck out of a rom-com.” And I was like, “We would.” And then we ran with it. And then that’s that. It was just, like, all fun. Jeff: And it’s interesting that you’re evolving in Book 2 and probably in Book 3 too. You had the fun moment. Now you kind of have to make everything keep tying together in the next two books. Hank: Yes. It’s all got to come together now for the third book. Yeah. Jeff: Because that’s like, yeah, when you have all that tied together stuff, because I’ve been reading a lot of romantic suspense lately where it’s like something that arcs across a trilogy or whatever, and it’s like…it’s exciting. Hank: Right. Deanna: Yeah. Book 2 is tentatively called “Murder Most Deserving,” and it was a lot harder to write than the first book. Hank: Yeah. Jeff: As fun though, I hope? Hank: Oh, yeah. Deanna: Oh yeah, just as fun, but there were moments I feel like we both checked out. And we’ve had this conversation. We know that we checked out because we had decided on a storyline for Michael and Jazz. And then we were like, “This doesn’t feel right.” Because it’s not your book, it also belongs to someone else, you don’t just say, “Oh, that storyline can’t happen,” because two of you decided together so you keep going with it. And then there’s moments where we had to talk and we’re like…where I was like, “I don’t like this.” And he’s like, “Yeah, I don’t like it either.” And I thought I said I didn’t like it. I’m like, “Maybe you said you didn’t like it. But I didn’t really expect you didn’t like it and I don’t know why we didn’t like it. And I don’t even know why we’re doing it.” And it was like we had…I mean, there was like, there was a couple of moments like that on the story. And there was also like we said in the beginning, we love our side characters too much. And we gave them a lot of screen time they did not deserve, even though we love them. So we had to distract and take a lot of stuff out. Not that we wanted to take it out but it was like why is this thing here? No one cares… Hank: Right. Deanna: …except us. So it was a little different. Like we created this wonderful world and in Book 2 we kind of just went crazy. We, like, went crazy with the Cheez Whiz. It’s like, “I love Sheriff Musgrave. I love Missy.” And we just wrote all these scenes and we’re like… And part of that I will say is my fault because I sent a lot of scenes to Hank before we even plotted the book. I was like, “I wrote this funny scene I’m going to send you.” And he’s like, “I love it.” And we wrote it. Hank: And I was like opening emails from Oprah. “And you get a storyline, and you get a storyline.” Deanna: Totally. Jeff: Maybe these could become short stories for these characters if you can’t get them into the book. Hank: That’s great. Jeff: So take a moment to brag on each other. And outside of working on this book, what do you like about each other’s work? Hank: I’ll go. Jeff: Hank first. Hank: All right. I love Deanna’s depth of characters. So her books, I think the first one I read of yours was “The Legend of Sleepy Hollow.” And I was like, “Oh, Ichabod. Oh, you naughty boy.” But then I can’t remember in what order then I read them but like “Easy Ryder,” I love that book. That is an awesome book. And I love the time period and I love the characters and I just love all of it and the discovery. That’s a road trip, another…you love the road trip books. Deanna: Apparently. Hank: Apparently. And then “Wrecked” is awesome. It’s really good. But she has a way of just like, you know, pulling up those emotions and really getting into the romance of it and doing an awesome job with it and having the characters. And then the conflict is organic, it’s not, like, fabricated. And it all blends together. She’s got a really good sense of story. Jeff: Nice. Deanna: That’s so sweet. I feel like, Hank, your dialogue sells your story. You could write a whole book on just dialogue with nothing else and people would buy it and laugh. You’re hilarious and your dialogue is great. And I feel like our styles mesh well because I do write more… I like to write a lot of the internal monologue and the emotion. But I’ll tell you an example, and this is a semi-spoiler in Book 2. But this is what I love about Hank’s writing. Okay. I’m not gonna tell too much of the story but there is a scene where something really shocking happens for our character, Jazz, the hairdresser. And the scene is in Jazz’s point of view. You’ll know what I’m talking about in a second. So the scene is in Jazz’s point of view and then Michael, our mortician, bursts through the door. And everyone is like, “How did you get here?” And he’s like, “I ran here.” And that sounds like simplistic but the emotional intensity of why Michael would run five blocks to the salon where Jazz works on a mere phone call just conveys so much intensity with three words, “I ran here.” And that’s what I love about Hank’s writing. I mean, I write the long emotional, internal monologue. And Hank writes that same intense emotional monologue in three words, “I ran here.” And I think, I mean, I’ve always…that’s what I love about his books. But I feel like those two things complement each other in our writing. Like I like to write the long drawn out emotional and he writes that same scene in three words, “I ran here.” And that’s why I love writing with him. Jeff: Cool. They’re hearting each other for those people not watching the video right now. Jeff: So you mentioned three towns…three towns, no, three books in the “Lacetown” series are planned. Do you foresee life in the universe beyond those three since you’re having such a good time? Deanna: Yeah. Hank: We talked about it. We’ve discussed it, yeah. We’ve got the trilogy planned and then we’ll see what happens with it. Deanna: We have at least two in our head. Jeff: That’s cool. Deanna: Beyond the three. Jeff: Now what about separately? What’s coming up next outside of the “Lacetown” series for you both? Hank: You have something coming up soon, Deanna. Deanna: Well, I have one thing coming up for sure and hopefully two. I also write young adult fiction just like Hank does under his…is it RG or RD? Hank: R.G. Deanna: R.G. Thomas. Hank has a young adult series under RG Thomas. And I have a young adult series, K.D. Worth, which is very different from my Deanna Wadsworth writing. It’s young adults/new adults because my characters are 19 and there are some, I don’t know, level-three sexy moments. So you can’t really…like you know people get funny about young adult that has sexy stuff in it. There’s a strong spiritual element with the main character who was trying to kill himself because of his family sending him to like one of those creepy pray-the-gay away camps. And the moment he kills himself he’s saved by a young teenage Grim Reaper, who decides that he wants to give him a second chance in life. And there’s a sassy foul-mouthed, because no one understands why Deanna would write a character like that, a sassy foul-mouthed angel who helps these boys on their journey. And that story is called “The Grim Life.” And Book 3, the final series, the final saga in that trilogy “The Lost Souls” is coming out this fall. And I’m really, really excited about that. I mean, a lot of M/M or gay romance, whatever you want to call it, authors know that young adult isn’t where the sales and money are at, sadly, but this is like a really intense…I don’t want to say pet project because that trivializes it, but it’s really a series that means more to me than almost anything I’ve ever written. Hank: Yeah. You’ve been working on these for what? Like two years now? Deanna: Yeah, four. It took me two years to write Book 3 because I just emotionally invested in it. There’s a lot of death and questioning of what goes on on the other side and where God sees your soul and all these like intensely hard questions. And to make things harder on myself, I put a school shooting in Book 3 because why not? Hank: No, why? Deanna: It’s so emotionally intense that you can’t write it. So that comes out this fall. But I’m hoping my second book in my Pride of the Caribbean Cruise series comes out which is a merman. Hank: Nice. Deanna: A merman… Hank: On a cruise. Deanna: …on a Caribbean cruise. It’s like I like to be intense or I like to be funny. I can’t be… Hank: There’s no in between, right. Jeff: Either end of the spectrum. Hank: That’s right. Deanna: That’s what I do. So that’s what’s coming out for me. Jeff: Cool. Hank: I will be working on the final book of the “Critter Catcher” series, final book for now. It’s tentatively titled “Dread of Night.” So and I’ve got about six chapters written. I’m working on a big pivotal scene also, so I need to just like…now that Book 2 has been sent off for consideration I can like, you know, kind of focus on that because I’m really bad at like jumping between projects too. Like my mind gets stuck in the other characters because while I’m working on this other I’m like, “But wait, what about…?” So, yeah. Jeff: Cool. All right. What is the… Hank: There’s other stuff to work on too but that’s the big thing coming up. Deanna: I love the “Critter Catcher” books. They’re so good. I manipulated Hank into giving me the last book when I was sick last summer. I was like, “Shouldn’t you send it to me? I know that you’re going to submit it for publishing in a month, but I’m really sick.” Hank: “I need to beta it. I’m sick.” Yeah. Deanna: Yes. I did do that. Jeff: And it worked too, right? Deanna: It worked. Hank: I did. I sent it. I was good. Deanna: And it was worth it. Jeff: So what’s the best way for readers to keep up with you guys online? Let’s start with Hank. Hank: I have a website. It’s hankedwardsbooks.com. You can also find my young adult fiction at townofsuperstition.com. And I do have those books listed on my Hank Edwards’ website just to make it easier. And then I’m on Facebook. I have a Facebook page. It’s facebook.com/hankedwardsbooks. And I really don’t use…Twitter confuses me. I get really…it’s just this noise. It’s like people yelling at each other. And so I have a Twitter account but I’m not out there much. But I am on Instagram. I usually post pictures of my cats. You know, and that’s @hankedwardsbooks as well. Jeff: Cool. And Deanna? Deanna: I’m on Facebook, deannawadsworthauthor. And Instagram, I go by @deannawads. I don’t know why I didn’t finish my last name but I don’t know. Everybody called my grandpa Wadsy. So I should have done Deanna Wadsy but I screwed that up. But I’m on those two. A little on Twitter and a little on Pinterest, all under Deanna Wadsworth. Mostly my most activity is on Instagram or my website, deannawadsworth.com. And that’s it. And you should totally read Hank’s R.G. Thomas books. It’s like Harry Potter but gay with, like, dragons. And little garden gnomes. I fricking love those books. You better write another one after we write our book. After we write our book. You’ve got to. Hank: Got it. Jeff: You’ve got your marching orders now, Hank. Hank: I do. I get them a lot. Deanna: He doesn’t have a wife, but… Hank: It’s all right. Deanna: …I’ll jump in that role. Hank: She’s my work wife. Jeff: All right. Well, this has been a blast. We will definitely link up to everything in the show notes that we’ve talked about here. And we wish you the best of success on the “Lacetown Murder Mysteries.” Hank: Thanks very much, Jeff. It’s been fun. Deanna: Thank you, Jeff.
Show Notes 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 moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections. Try to create a rapport that is comfortable and open for your patient to provide as much detail as they can. Nachi: And as with any infectious work up, tachycardia, hypotension, and fever should all raise the concern for possible sepsis. In your sepsis source differential, definitely consider PID in addition to the usual sources. As a mini plug for a prior issue, PID was actually covered in the December 2016 issue of Emergency Medicine Practice, in detail. Jeff: Getting back to the physical exam: though some question the utility of the pelvic exam as our diagnostics get better, the literature suggests the pelvic definitely still has a big role both in diagnosing and differentiating STDs and other pathology. Don’t skip this step when indicated. Nachi: Now that we have a broad overview, let’s talk about specific STDs, covering diagnosis, testing, and treatment. Jeff: If following along in the article, appendices 1, 2 and 3, list detailed physical exam findings for the STDs were going to discuss, while table 3 lists treatment options. A great resource to use while following along or as a reference during a clinical shift! Nachi: First up, let’s talk chlamydia, the most common bacterial cause of STDs, with 1.7 million reported infections in 2017. Most are asymptomatic, which increases spread, especially in young women. Jeff: Chlamydia trachomatis has a 2-3 day life cycle in which elementary bodies enter endocervical and urethral cells and replicate, eventually causing host cell wall rupture and further spread. Nachi: Though patients with chlamydia are often asymptomatic, cervicitis in women and urethritis in men are the most common presenting symptoms. Vaginal discharge is the most common exam finding followed by cervical ectropion, endocervical mucus, and easily induced bleeding. Other presenting symptoms include urinary frequency, dysuria, PID, or even Fitz-Hugh-Curtis syndrome, which is a PID induced perihepatitis. In men, epididymitis, prostatitis, and proctitis are all possible presenting symptoms also. Jeff: And of note, chlamydia can also cause both conjunctivitis and pharyngitis. Nachi: This article has a ton of helpful images. Check out figures 1 and 2 for some classic findings with chlamydial infections. Jeff: When testing for chlamydia, nucleic acid amplification is the test of choice as it has the highest sensitivity, 92% when tested from a first-catch urine sample vs. 97% from a vaginal sample. While these numbers are similar, and you’re gut may be to forego the pelvic exam, consider the pelvic exam to aid in the diagnosis of PID and to evaluate for cervicovaginal lesions or other concomitant stds. Nachi: Similarly, in men, the test of choice is also a nucleic acid amplification test, with a first catch urine preferred over a urethral swab. Jeff: And lastly, nucleic acid amplification is also the test of choice from rectal and oropharyngeal samples, though you need to check with your lab first as nucleic acid amplification is not technically cleared by the FDA for this indication. Nachi: Treatment for chlamydia is simple, 1g of azithromycin, or doxycycline 100 mg BID x 7 days. Fluoroquinolones are a second line treatment modality. Jeff: In pregnant women, chlamydia can lead to ectopic pregnancy, premature rupture of membranes, and premature delivery. The single 1g azithromycin dose is also safe and effective with amox 500 mg TID x 7 days as a second line. Pregnant women undergoing treatment should have a documented test-of cure 3-4 weeks after treatment. Nachi: Next up, we have gonorrhoeae, the gram-negative diplococci. Gonorrhea is the second most commonly reported STD, affecting 0.8% of women and 0.6% of men, with over 500,000 reported cases in 2017. Jeff: Gonorrhea attaches to epithelial cells, altering the surface structures leading to penetration, proliferation and eventual systemic dissemination. Nachi: Though some may be asymptomatic, women often present with cervicitis, vaginal pruritis, mucopurulent discharge, and a friable cervical mucosa, along with dysuria, frequency, pelvic pain and abnormal vaginal bleeding. Jeff: Men often present with epididymitis, urethritis, along with dysuria and mucopurulent discharge. Proctitis, pharyngitis, and conjunctivitis are all possible complications. Nachi: In it’s disseminated form, gonorrhea can lead to purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: In both men and women the test of choice for gonorrhea again is NAAT, with endocervical samples being preferred to urine samples due to higher sensitivity. In men, urethral and first catch urine samples have a sensitivity and specificity of greater than 97%. Nachi: And as with chlamydial samples, the FDA has not approved gonorrhea NAAT for rectal and oropharyngeal samples, but most labs are able to process these samples. Jeff: Yeah, definitely check before you go swabbing samples that cannot be run. Lastly, in regards to testing, though it won’t likely change your management in the moment, the CDC does recommend a gonococcal culture in cases of confirmed or suspected treatment failure Nachi: It’s also worth noting that although NAAT can be used in children, but culture is additionally preferred in all settings due to legal ramifications of sexual abuse. Jeff: It pains me just to think about how awful that is. Ugh. Moving on to treatment: when treating gonorrhea, the current recommendation is to treat both with cefitriaxone and azithro. 250 mg IM is the preferred dose, up from just 125 mg IM which was preferred dose two decades ago along with 1g of azithro. Nachi: And if ceftriaxone IM cannot be administered easily, 400 mg PO cefixime is the second line treatment of choice. If there is a documented cephalosporin allergy, PO gemifloxacin or gentamycin may be used. And for those with an azithomycin intolerance, a 7 day course of doxycycline may be substituted instead. Jeff: In pregnant women, gonococcal infections are associated with chorioamnionitis, premature rupture of membranes, preterm birth, low birth weight, and spontaneous abortions. Pregnant woman therefore should be treated with both ceftriaxone and azithro in the same manner as their non pregnant counterparts. Nachi: There is also one quick controversy to discuss here. Jeff: oh yeah, go on… Nachi: The CDC currently recommends the IM dose of ceftriaxone, not IV. And this is because of the depot effect. However, it’s unclear if this effect is in fact true, as IM and IV ceftriaxone levels measured in blood 24 hours later are similar. So if the patient has an IV already, should we just give the ceftriaxone IV instead of IM? Jeff: I think it is probably okay, but I’ll wait for a bit more research. For now, I would continue to stick with the CDC recommendation of IM as the correct route. Nachi: And with the continuing rise of STD’s and the public health and economic burden we are describing here, I think the IM route, which is known to be effective, should still be used -- until the CDC changes their recommendations. Next up we have the great imitator/masquerader, syphilis, caused by the spirochete Treponema pallidum. LIke the other STDs we’ve discussed so far, cases of syphilis are also on the rise with over 30k cases in 2017, a 10% increase from 2016. Jeff: Syphilis is spread via direct contact between open lesions and microscopic abrasions in the mucous membranes of vagina, anus, or oropharynx. The organism then disseminates via the lymphatics and blood stream. Nachi: Infection with syphilis comes in three stages. Primary syphilis is characterized by a single, painless lesion, or chancre, which occurs about 3 weeks after inoculation. 6-8 weeks later, secondary syphilis develops. This often presents with a rash, typically on the palms and soles of the feet, or with condyloma lata, or lymphadenopathy. Jeff: Tertiary syphilis doesn’t appear until about 20 years post infection and it includes gummatous lesions and cardiac involvement including aortic disease. Nachi: Patients at any stage may go long periods without any symptoms, which is known as latent syphilis. In addition, at any stage a patient may develop neurosyphilis, which can present with strokes, altered mental status, cranial nerve dysfunction, and tabes dorsalis. Jeff: In early syphilis, dark-field examination is the definitive method of detection, though this is impractical in the ED setting. There are, instead, 2 different algorithms to follow. The CDC traditional algorithm recommends a nontreponemal test like rapid plasma reagin or RPR or the venereal disease research lab test also called VDRL, followed by confirmational treponemal test (fluoresent treponemal antibody absorption or FTA-ABS or T pallidum passive agglutination also called TP-PA). More recently there has been a shift to the reverse sequence, with screening with a treponemal assay followed by a confirmatory nontreponemal assay. Nachi: The reason for the change is that there is an increased availability of rapid treponemal assays. And where available, the reverse sequence offers increased throughput and the ability to detect early primary syphilis better. The CDC, however, still recommends the traditional testing pathway -- that is nontreponemal tests first like RPR or VDRL, followed by treponemal tests like FTA-ABS or TP-PA. The article also notes that emergency clinicians should rely on clinical manifestations in addition to serologic testing, when determining whether to treat for syphilis. Jeff: For neurosyphilis, the CSF-VDRL test is highly specific but poorly sensitive. In cases of a negative CSF-VDRL but still with high clinical suspicion, consider a CSF FTA-ABS test, which has lower sensitivity, but is also highly specific and may catch the diagnosis. Nachi: Treatment for primary, secondary, and early latent syphilis is with 2.4 million units of Penicillin G IM. For ocular and neurosyphilis, treatment is with 18-24 million units of pen G IV every 4 hours or continuously for 10-14 days. In patients who have a penicillin allergy, skin testing and desensitization should be attempted rather than azithromycin due to concerns for resistance. Jeff: For pregnant women, PCN is the only proven therapy. Interestingly, there is some evidence to suggest that a second IM dose may be beneficial in treating primary and secondary syphilis in pregnancy though data are limited. Nachi: We also have to mention the Jarisch-Herxheimer reaction before moving on. This is a syndrome of fevers, chills, headache, myalgias, tachycardia, flushing and hypotension following high dose PCN treatment due to a massive release of endotoxins when the bacteria die. This typically occurs in the first 12 hours but can occur up to 24 hours after treatment. Treatment is supportive. Concern of this reaction should never delay PCN treatment!! Jeff: The next condition to discuss is Bacterial vaginosis, or BV, which, interestingly, is not always an STD. It is therefore critically important to choose your words wisely when speaking with a patient who has BV. Nachi: That is an important point that is worth repeating. BV is not always an STD. So what is BV? BV occurs when there is a decrease or absence of lactobacilli that help maintain the acidic pH of the vagina leading to an overgrowth of Gardnerella, bacteroides, ureaplasma and mycoplasma. BV does not occur in those who have never had intercourse and it may increase the risk of other STDs and HIV. Jeff: 50% of women with BV are asymptomatic, while the others will have a thin, grayish-white, homogeneous vaginal discharge with a fishy smell, along with pruritis. Nachi: To diagnose BV, most use the amsel criteria, which requires 3 of following 4: 1) a thin, milky, homogeneous vaginal discharge, 2) the release of a fishy odor before or after the addition of potassium hydroxide, 3) a vaginal pH > 4.5, and 4) the presence of clue cells in the vaginal fluid. These criteria are 90% sensitive and 77% specific, with clue cells being the most reliable predictor. Jeff: And for those of us without immediately available microscopy, you can make the diagnosis based on characteristic vaginal discharge alone. Treat with metronidazole, 500 mg BID for 7 days, metronidazole gel, or an intravaginal applicator for 5 days, with the intravagainal applicator being better tolerated than the oral equivalent Nachi: BV in pregnancy increases risk of preterm birth, chorioamnionitis, postpartum endometriitis and postcesarean wound infections. Pregnant patients are treated the same as nonpregnant or with 400 mg of clindamycin BID x 7 days. Jeff: Always nice when there is really only one treatment regimen across the board. And that will be a general theme for treatment options in pregnancy with a few exceptions. Nachi: Next up we have Granuloma inguinale, or donovanosis, which is caused by Klebsiella granulomatis. Jeff: Granuloma inguinale is endemic to India, the Caribbean, central australia, and southern africa. It is rarely diagnosed in the US. Nachi: Granuloma inguinale presents with highly vascular, ulcerative lesions on the genitals or perineum. They are typically painless and bleed easily. If disseminated, Granuloma inguinale can lead to intra-abdominal organ and bone lesions and elephantiasis-like swelling of the external genitalia. Jeff: Granuloma inguinale can can be diagnosed by microscopy from the surface debris of purulent ulcers. Nachi: Once you have the diagnosis, the CDC recommends treatment with azithromycin for at least 3 weeks and until all lesions have resolved. Jeff: Next we have lymphogramuloma venereum or LGV. Nachi: LGV is a C. Trachomatis infection of the lymphatics and lymph nodes. This is predominantly a disease of the tropics and subtropical areas of the world. Jeff: On exam, in the primary stage, you would expect a small, painless papule, pustule, nodule or ulcer on the coronal sulcus of the penis or on the posterior forchette, vulva, or cervix of women. The primary stage eventually progresses to the secondary stage, which is characterized by unilateral lymphadenopathy with fluctuant, painful lymph nodes known as buboes. Nachi: Check out figure 11 for a great classic image of the “groove sign” which is involvement of both the inguinal and femoral lymph nodes, and is seen in 15-20% of cases. And actually even more common than the groove sign is a presentation with proctitis. Jeff: Testing for LGV should be based on high clinical suspicion, and NAAT should be performed on a sample from the primary ulcer base or from aspirate from a bubo. Nachi: Treatment for LGV is with doxycycline 100 mg BID x 21 days. Jeff: So, to summarize, for LGV, remember painful lymphadenopathy, especially in those with proctitis. Treat with doxy. Nachi: Next we have Mycoplasma genitalium, which causes nongonococcal urethritis in men and mucopurulent cervicitis and PID in women. Jeff: Unfortunately, there is no diagnostic test for M. genitalium, and it should be considered clinically, especially in the setting of recurrent urethritis. Nachi: Treat with azithro, but not 1g x 1. Instead, M. Genitalium should be treated with a course of azithro, with 500 mg on day 1 followed by 250 mg daily for 4 days. Moxifloxacin is an alternative. Jeff: Simple enough. Moving on to everybody’s favorite, genital herpes. Nachi: umm, I’m not sure sure anybody would call herpes their favorite. Why would you even say that? Jeff: i don’t know, seemed natural at the time… Regardless, primary genital herpes is caused by either HSV1 or HSV2. Though only an estimate, and likely an underestimate at that, it is estimated that at least 1 in 6 people in the US between 14 and 49 have genital herpes. Nachi: That’s much higher than I would have thought. Jeff: Patients usually contract oral herpes from HSV-1 due to nonsexual contact with saliva and genital herpes due to sexual contact with an infected person. Nachi: Keep in mind, however, that HSV1 can and will also cause genital infections if spread via oral sex. Jeff: Localized symptoms include pain, itching, dysuria, and lymphadenopathy and systemic symptoms include fever, headache, and malaise. In women, look for herpetic vesicles on the external genitalia along with tender ulcers in areas of rupture, see figure 12 for a characteristic image. Nachi: Though symptoms tend to be more severe in woman, men may present with vesicles on the glans penis, penile shaft, scrotum, perianal area, and rectum or even with dysuria and penile discharge. Jeff: HSV1 and 2 infections also have the ability to recur, though recurrences tend to become less frequent and severe over time. Nachi: It’s noteworthy that there is also a direct correlation between stress levels and the severity of an HSV outbreak. Jeff: Herpes can be diagnosed by viral culture of an unroofed vesicle or by NAAT. PCR based assays can also differentiate between HSV1 and HSV2 Nachi: While there is no cure, antivirals may help prevent and shorten outbreaks. Ideally you should begin treatment within 72 hours of lesion appearance. Treat with acyclovir, valacyclovir, or famciclovir. In addition, don't forget about adjuncts like analgesia, sitz bathes, and urinary catheter placement for severe dysuria. Jeff: HSV can also be vertically transmitted from mother to child so in pregnancy, treat with acyclovir 400 mg 3x/day for 7 days or valacyclovir Nachi: And because transmission is so easy, babies born to mothers with active lesions should be delivered by cesarean section. Jeff: Let’s move on to human papillomavirus, or HPV. There are over 100 types of HPV with 40 being transmitted through skin to skin contact, typically via vaginal and anal intercourse. Nachi: Most infections are asymptomatic and clear within 2 years. Jeff: Right, but one of the main reasons this is such a big deal is that HPV types 16 and 18 are oncogenic strains and can lead to cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers. Amazingly, HPV is responsible for more than 95% of the cervical cancers in women. Nachi: Hence the importance of the new vaccine series that most young adults and children are now opting for. Vaccination should occur in women through age 26 or men through age 21 if not previously vaccinated. Jeff: Critically important to take advantage of a vaccine that can prevent cancer! Nachi: And though not as important in terms of health consequences, just be aware that HPV 6 and 11 may lead to anogenital warts, known as condyloma acuminata. Jeff: In terms of exam findings, as you just mentioned, most infections are asymptomatic and self-limited. If symptoms do develop, HPV typically causes those cauliflower like or white plaque like growths lesions on the external genitalia, perineum, and perianal skin. Nachi: For testing, there is a limited role in the ED. Diagnosis should be made by visual inspection, followed eventually by a biopsy. Jeff: And just like the biopsy, which is unlikely to be done in the emergency department, most treatment is also not ED based. Treatment options include cryotherapy, immune-based therapy, and surgical excision, which has both the highest success rates and lowest recurrence. Nachi: Next up, we have trichomoniasis. Jeff:Trichomoniasis is a single-celled, flagellated, anaerobic protozoa, that directly damages the epithelium, causing microulcerations in the vagina, urethra, and paraurethral glands. Nachi: With an estimated 3.7 million infected people in the US, this is something you’re also bound to see. Jeff: Risk factors include recent or current incarceration, IV drug use, and co-infection with BV. Nachi: Note the common theme here - co infection. It’s very common for patients to have more than one STD, so make sure not to anchor when you think you’ve nailed the diagnosis. Jeff: On exam the majority of both women and men are asymptomatic. In women, you may find a purulent, frothy vaginal discharge, vaginal odor, vulvovaginal irritation, itching, dyspareunia, and dysuria Nachi: And don’t forget about the classic colpitis macularis, or the strawberry cervix. Though this is frequently taught and stressed, it’s actually only seen in 2-5% of infected women. Jeff: But to be fair, a strawberry cervix and frothy vagianl discharge together have a specificity of 99% for trich, which is really not bad. Nachi: While many EDs sadly aren’t blessed with a wet mount, the wet mount has the advantage of being simple, convenient, and generally low cost. Jeff: While all of that is true regarding the wet mount, it’s no longer first line, again with NAAT being preferred, as it’s highly sensitive, approaching 100%. Nachi: And for those of us who don’t have access to NAAT, there are also antigen-detecting tests which don’t perform quite as well, but they are much more sensitive than the traditional wet mount. Jeff: Treatment for trichomoniasis is with oral metronidazole, 2g in a single oral dose a or 500 mg twice a day for 7 days. Alternatively, the more expensive tinidazole, 2g for 1 dose, is actually superior according to the most recent evidence. Nachi: For pregnant patients, trichomoniasis is unfortunately associated with premature delivery and premature rupture of membranes, with no improvement following treatment. Still, patients should be tested and treated, preferentially with metronidazole, to relieve symptoms and prevent partner spread. Jeff: We have two more special populations to discuss in this month’s issue - those in correctional facilities and sexual partner treatment. If you are lucky enough to be involved in treating those in correctional facilities, keep in mind that rates of gonorrhea, chlamydia, syphilis, and trichomoniasis are higher in persons in both juvenile and adult detention facilities than the general public. Nachi: In general for patients in correctional facilities, maintain a lower threshold for just about everything. This is just an at-risk population. Jeff: Let’s move on to sexual partners, and expedited partner therapy or EPT. Nachi: Once you’ve diagnosed a patient with an STD, you can also provide a prescription or medication to the patient to give to their partner or partners. Jeff: This practice is critically important to stop partners from unknowingly spreading the STD further which is a real problem. Unless prohibited by law, emergency clinicians should routinely offer EPT to patients with chlamydia, gonorrhea, or trichomoniasis. To see your states’ current status, the CDC maintains a list of the status in all 50 states. Nachi: In terms of specific partner therapies, for chlamydia, EPT can be accomplished with a single 1g dose of azithromycin or doxycyclin 100 mg bid for 7 days. Consider concurrent treatment for gonococcal infection also. Jeff: For Gonorrhea, EPT includes a single oral dose of 400 mg of cefixime and a 1g oral dose of azithromycin. Nachi: For EPT for syphilis, unfortunately the partner has to present to the ED for a single IM injection of penicillin G. While this does place a burden on the partner, it opens up an opportunity for additional serologic testing and possibly treatment of his or her partners as well. Jeff: Routine EPT for those with BV is not recommend as the data shows that partner treatment does not affect rates of relapse or recurrence. Nachi: For genital herpes, you should counsel patients and their partners that they should abstain from sexual activities when there are lesions or prodromal symptoms. Make sure to refer partners for evaluation as well. Jeff: Since there isn’t much data on HPV partner notification, for now, encourage patients to be open with their partners so they may seek treatment as well. Nachi: And lastly, for Trichomoniasis, EPT includes 2 g of metronidazole or 500 mg BID for 7 days or that single 2g dose of tinidazole. Jeff: In general, it is always better to have the partner present to a physician for diagnosis and treatment, but EPT is an option when that seems unlikely or impossible. Nachi: Also, when possible be sure to inquire about drug allergies and provide some guidelines on ER presentation for allergic reactions. Jeff: So that wraps up EPT. Let’s discuss disposition. Though most will end up going home, a few may require IV medications, such as those with severe HSV, disseminated gonococcus, and neurosyphilis. Nachi: Admission should also be strongly considered in those who are pregnant or with concern for complications. Those with severe nausea, vomiting, high fever, the inability to tolerate oral antibiotics, and those failing oral antibiotics should also be considered for admission. Jeff: But if your patient doesn’t meet those criteria, as most will not, and they are headed home, stress the importance of follow up. Especially for those with gonorrhea and chlamydia, for whom a test of cure after completion of their medication is recommended. This is even more important for pregnant women. Nachi: Chlamydia, gonorrhea, HIV, and syphilis are among the many infectious diseases that require mandatory reporting. Definitely familiarize yourself with your states’ reporting laws, as most of these patients will be headed home and you’ll want to make sure you don’t miss your chance to prevent further spread. Jeff: Perfect, so that’s it for this month’s issue. Let’s close out with some high yield points and clinical pearls. Nachi: STDs are under recognized by patients and healthcare professionals. They can often present with minimal or no symptoms and are passed unknowingly to partners. Jeff: STD’s can have devastating effects during pregnancy on the fetus. Treat these patients aggressively in the ER. Nachi: The rising rate of STD’s continues to be an economic burden on the U.S. healthcare system. Jeff: Patients can present with multiple STD’s concurrently. Avoid premature diagnostic closure and consider multiple simultaneous processes. Nachi: Urinary tract infections and STD’s can present similarly. Be sure to do a pelvic exam to avoid misdiagnosis. For the exam, always have a chaperone present. Jeff: Acute unilateral epididymitis is most commonly a result of chlamydia in men under the age of 35. Nachi: Chlamydia is the most common bacterial STD. The diagnostic test of choice is nucleic acid amplification testing (NAAT). Treat with azithromycin or doxycycline. Jeff: Gonorrhea is the second most common STD. The diagnostic test of choice here is again NAAT. Treat with ceftriaxone and azithromycin. Nachi: Gonorrhea can lead to disseminated infection such as purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: Syphilis has a wide variety of presentations over three stages. For concern of early syphilis, send RPR or VDRL for nontreponemal testing as well as an FTA-ABS or TP-PA for treponemal testing. Nachi: Tertiary syphilis can present with gummatous lesions or aortic disease many years after the primary syphilis infection. Jeff: At any stage of syphilis, the central nervous system can become infected, leading to neurosyphilis. Nachi: Bacterial vaginosis presents with a white, frothy, malodorous vaginal discharge. Treat with metronidazole. Jeff: Genital herpes is caused by HSV-1 or HSV-2. Diagnosis can often be made clinically. If sending a sample for testing, be aware that viral shedding is intermittent, so you may have a falsely negative result. Antivirals can help prevent or shorten outbreaks and decrease transmission. Nachi: Lymphogranuloma Venereum presents with small, painless papules, nodules, or ulcers. Groove sign is present in only 15%-20% of cases. Jeff: Consider Fitz-Hugh-Curtis syndrome in your differential for a sexually active patient with right upper quadrant pain. Nachi: Offer expedited partner therapy to all patients with STD’s to prevent further spread Jeff: So that wraps up Episode 27 - STDs in the ED! Incredibly high yield topic with lots of pearls. Nachi: As always, 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 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 any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: I’ll repeat that, since saving money is important. APPs, use the promotion code APP4 at checkout to receive 50% off on your subscription. Speaking of PAs - for those of you attending the SEMPA conference in just a few weeks, make sure to check out the EB Medicine Booth, #302 for lots of good stuff. For those of you not attending the conference, just be jealous that your colleagues are hanging out in New Orleans. Nachi: And the address for this month’s credit is ebmedicine.net/E0419, 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! Most Important References 3. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr- 03):1-137. (Expert guidelines/systematic review) 5. Torrone E, Papp J, Weinstock H. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years- -United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838. (Expert guideline/systematic review) 98. Schillinger JA, Gorwitz R, Rietmeijer C, et al. The expedited partner therapy continuum: a conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 Suppl 1):S63-S75. (Systematic review; 42 articles) 103. Centers for Disease Control and Prevention. 2018 National Notifiable Conditions (Historical). National Notifiable Diseases Surveillance System (NNDSS). Accessed March 10, 2019. (CDC website) 105. Carter MW, Wu H, Cohen S, et al. Linkage and referral to HIV and other medical and social services: a focused literature review for sexually transmitted disease prevention and control programs. Sex Transm Dis. 2016;43(2 Suppl 1):S76-S82. (Systematic review; 33 studies)
Show Notes 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, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss. Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively. Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations. Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria. Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma. Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode. Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo. Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients. Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%. Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma... Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall. Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries. Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal. Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately, either from direct impact or when the heart becomes compressed between the sternum and the spine. Delayed rupture can occur secondary to an inflammatory reaction. This is more likely in patients with a prior healed or repaired septal defects. Nachi: Valvular injuries, like septal injuries, are rare. Left sided valvular damage is more common and carries a higher mortality risk. In order, the aortic valve is more commonly injured followed by the mitral valve then tricuspid valve, and finally the pulmonic valve. Remember that valvular damage can be due to papillary muscle rupture or damage to the chordae tendineae. Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Jeff: Next on the ddx are coronary artery injuries, which include lacerations, dissections, aneurysms, thrombosis, and even MI secondary to increased sympathetic activity and platelet activity after trauma. In one review, dissection was the most commonly uncovered pathology, occurring 71% of the time, followed by thrombosis, which occured only 7% of the time. The LAD is the most commonly injured artery followed by the RCA. Nachi: Pericardial injury, including pericarditis, effusion, tamponade, and rarely rupture, is also certainly on the differential. Jeff: In terms of dysrhythmias, sinus tachycardia is the most common dysrhythmia, with other rhythms, including PVC / PAC / and afib being found only 1-6% of the time. Nachi: And while conduction blocks are rare, a RBBB is the most commonly noted, followed by a 1st degree AVB. Jeff: Though also rare, commotio cordis deserves it’s own section as its the second most common cause of death in athletes < 18 who are victims of blunt trauma. Though only studied in swine models, it’s hypothesized that the impact to the chest wall during T-wave upstroke can precipitate v-fib. Nachi: Aortic root injuries usually occur at the insertion of the ligamentum arteriosum and isthmus. Such injuries typically result in aortic insufficiency. Jeff: And the last pathology on the differential requiring special attention is a myocardial contusion. Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes. Nachi: Certainly a pretty broad differential… before moving on to the work up, Jeff why don’t you get us started with prehospital care? Jeff: Prehospital management should focus on rapid identification and stabilization of life threatening injuries with expeditious transport as longer prehospital times have been associated with increased mortality in trauma. Immediate transport to a Level I trauma center should be the highest priority for those with suspected blunt cardiac injury. Nachi: In terms of who specifically should be transporting the patient, a Cochrane review evaluated the utility of ALS vs BLS transport in trauma. There is reasonably good data to support BLS over ALS, even when controlling for trauma severity. Moreover, when airway management is needed, advanced airway techniques by ALS crews were associated with decreased odds of survival. Regardless of who is there, the message is the same: focus not on interventions, but instead on rapid transport. Jeff: And if it does happen to be an ALS transport crew, without delaying transport, pain management with fentanyl is both safe and reasonable and preferred over morphine. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. Nachi: And if the prehospital team is lucky enough, or maybe unlucky enough, i don’t know, to have a credentialed provider who can perform ultrasound for those suspected of having a blunt cardiac injury, the general prehospital data on ultrasound is sparse. As of now, it’s difficult to conclude if prehospital US improves care for trauma patients. Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made. Nachi: Right, and I think that just reinforces the main point here: there may be a role, we just don’t have the data to support it at this time. Jeff: Great, let’s move onto ED care, beginning with the H&P. Nachi: On history, make sure to elucidate if there is any chest pain, and if it’s onset was before or after the traumatic event. In addition, make sure to ask about dyspnea, fatigue, palpitations, and lightheadedness. Jeff: And don’t forget to get the crash details from the EMS crew before they depart! As a side note, for anyone taking oral boards in a few months, don’t forget to ask the EMS crew for the details!!! Nachi: A definite must for oral boards and for your clinical practice. Jeff: In terms of the physical, tachycardia is the most common abnormality in blunt cardiac injury. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. But don’t be reassured by normal vitals, especially in the young, who may be compensating well despite being quite ill. Nachi: Fully undress the patient to appropriately inspect and percuss the chest wall - looking for signs of previous cardiac surgeries or pacemaker placement, as well as to auscultate for new murmurs which may be a sign of valvular injury. Jeff: Similarly, as concomitant injuries are common, inspect the abdomen, looking for ecchymosis patterns, which often accompany blunt cardiac injury. Nachi: Pretty standard stuff. Let’s move on to diagnostic testing. Jeff: Lab testing should include a CBC, BMP, coags, troponin, lactate, and T&S. In one retrospective analysis, an elevated troponin and a lactate over 2.5 were predictors of mortality. Nachi: Additionally, in patients with chest trauma, a troponin > 1.05 was associated with a greater risk for dysrhythmias and LV dysfunction. Jeff: And it likely goes without saying, but an EKG is a must on all trauma patients with suspicion for blunt cardiac injury in accordance with the EAST guidelines. New EKG findings requires admission for monitoring. Unfortunately, on the flip side, an ECG cannot be used to rule out blunt cardiac injury. Nachi: Diving a bit deeper into the data, in a prospective study of 333 patients with blunt thoracic trauma, serial EKG and troponins at 0, 4, and 8 hours post injury had a sensitivity and specificity of 100% and 71%, respectively. However, of those with abnormal findings, all but one had them on initial testing, leading to a negative predictive value of 98%. Jeff: Well that’s an impressive NPV and has huge implications, especially in the era of heavily monitored lengths of stay... Nachi: Definitely. In terms of radiography, a chest x-ray should be obtained as rib fractures, hemopneumothorax, and mediastinal free air are all things you wouldn't want to miss and are also associated with blunt cardiac injury. Jeff: Keep in mind, however, that the chest x-ray should not be seen as a test for pericardial fluid as up to 200 mL of fluid can be contained in the pericardial space and remain undetectable by chest radiograph. Nachi: Which is why you’ll have to turn to our good friend the ultrasound, for more useful data. The data is strong that in the hands of trained Emergency Clinicians, when parasternal, apical, and subcostal views are obtained, US has an accuracy of 97.5% for pericardial effusion. Jeff: Not only is US accurate, it’s also quick. In one RCT, the FAST exam reduced the time from arrival in the ED to operative care by 64% in the setting of trauma. Nachi: That’s impressive -- for expediting patient care and for managing ED flow. Jeff: Exactly. The authors do note however that hemopericardium is a rare finding, so, while not the focus of this article, the real utility of the FAST exam may be in its expanded form, the eFAST, in which a rapid bedside ultrasonographic lung exam for pneumothorax is included, as this can lead to immediate changes in management. Nachi: And assuming you do your FAST or eFAST and have no management changing findings, CT will often be your next test. Jeff: Yeah, EKG-gated multidetector CT can easily diagnose myocardial rupture, pneumopericardium, pericardial rupture, hemopericardium, coronary artery insult, ventricular septal defects and even valvular dysfunction. Unfortunately, CT does not perform well for the evaluation of myocardial contusions. Nachi: This is all well and good, and certainly accurate, but let’s not forget that hemodynamically unstable trauma patients, like those with myocardial rupture, need to be in the operating room, not the CT scanner. Jeff: An important point that should not be understated. Nachi: And the last major testing modality to discuss is the echocardiogram. Jeff: The echo is a fantastic test for detecting focal cardiac dysfunction often see with cardiac contusions, hemopericardium, and valve disruption. Nachi: And it’s worth noting that transthoracic is enough, as transesophageal, despite the better images, hasn’t been shown to change management. TEE should be saved for those in whom a optimal TTE study isn’t feasible. Jeff: Great point. And one last quick note on echo: in terms of guidelines, the EAST guidelines from 2012 specifically recommend an echo in hemodynamically unstable patients or those with a persistent new dysrhythmia without other sources of ongoing hemorrhage or neurologic etiology of instability. Nachi: Perfect, so that wraps up testing and imaging for our blunt cardiac injury patient. Let’s move on to treatment. Jeff: In terms of initial resuscitation, there is an ever increasing body of literature to support blood transfusion over crystalloid in patients requiring volume expansion in trauma. There are no specific guidelines for transfusion in the setting of blunt cardiac injury, so stick to your standard trauma protocols. Nachi: It is worth noting, though, that there is literature outside of trauma for those with pericardial effusions, suggesting that those with a SBP < 100 have substantial benefit from volume expansion. So keep this in mind if your clinical suspicion is high and your trauma patient has a soft but not truly shocky blood pressure. Jeff: Operative management, specifically ED thoracotomy is a heavily debated topic, and it’s next on our list to discuss. Nachi: The 2015 EAST guidelines conditionally recommend ED thoracotomy for moribund patients with signs of life. The Western Trauma Association broadens the ED thoracotomy window a bit to include anyone with no signs of life but less than 10 minutes of CPR. The latter also recommend ED thoracotomy in those with refractory shock. Jeff: Though few studies exist on the topic, in one study of 187 patients, cardiac motion on US was 100% sensitive for predicting survivors. Nachi: Not great data, but it does support one's decision to stop any further work up should there be no cardiac activity, which is important, because the decision to pursue an ED thoracotomy is not an easy one. Jeff: And lastly, emergent pericardiocentesis may be another option in an unstable patient when definitive operative management is not possible. But do note that pericardiocentesis is only a temporizing measure, and not definitive for cardiac tamponade. Nachi: Treatment for dysrhythmias is standard, treat in accordance with standard ACLS protocols, as formal randomized trials on prophylaxis and treatment in the setting of blunt cardiac injury do not exist. Jeff: Seems reasonable enough. And in the very rare setting of an MI after blunt cardiac injury, you should involve cardiology, cardiothoracic surgery, and trauma to help make important management decisions. Data is, again, lacking, but the patient likely needs percutaneous angiography for appropriate diagnosis and potentially further intervention. Definitely hold off on ASA and likely nitroglycerin, at least until significant bleeding has been ruled out. Nachi: Yup, no style points for giving aspirin to a bleeding trauma patient. Speaking of medications, the last treatment modality to discuss here is pain control. Pain management is essential with chest injuries, as appropriate pain management has been shown to reduce mortality in pulmonary related complications. Jeff: And in line with every acute pain consult note I’ve ever come across, a multimodal approach utilizing opioids and nonopioids is recommended. Nachi: Perfect, so that sums up treatment, next we have one special circumstance to discuss: sternal fractures. Cardiac contusions are found in 1.8-2.4% of patients with sternal fractures, almost all of which were seen on CT and not XR according to the NEXUS chest CT study. Of these patients, only 2 deaths occured, both due to cardiac causes. Thus, in patients with isolated sternal fractures, negative trops, ekg, and negative cxr - the patient can likely be discharged from the ED, as long as their pain is well-controlled. Jeff: And let’s talk controversies for this issue. We only have one to discuss: MRI. Nachi: The fact that MRI produces awesome images is not controversial, see figure 3. It’s role, however, is. In accordance with EAST guidelines, MRI may be most useful in differentiating acute ischemia from blunt cardiac injury in those with abnormal ECGs, elevated enzymes, or abnormal echos. It’s use in the hyperacute evaluation, however, is limited, in large part owing to the length of time required to complete an MRI Jeff: What a time to be alive that we even have to say that MRIs may not have a hyperacute role in trauma - absolutely crazy... Nachi: Moving on to disposition: any patient with aortic, pericardial, or myocardial injury and hemodynamic instability needs operative evaluation and likely intervention, so do not hesitate to get the consults coming or the helicopter in the air should such a patient arrive at your non-trauma center. Jeff: And in those that are hemodynamically stable, with either a positive ECG or a positive trop, they should be monitored on telemetry. There is no clear answer as to how long, but numerous studies suggest a 24 hour period of observation is sufficient. For those with persistent ekg abnormalities or rising trops - this is precisely when you will want to pursue echocardiography. Nachi: And if there are positive EKG findings AND a rising trop, they should be admitted to a step down unit or ICU as well -- as ⅔ of them will develop myocardial dysfunction. Similarly, those with hemodynamic instability but no active traumatic bleeding source - they too should be admitted to the ICU for a STAT echo and serial enzymes. Jeff: But in the vast majority of patients, those that are hemodynamically stable with negative serial EKGs and serial tropinins, they can effectively be ruled out for significant BCI after an 8 hour ED observation period, as we mentioned earlier with a sensitivity approaching 100%! Nachi: Though there are, of course, exceptions to this rule, like those with low physiologic reserve, mobility or functional issues, or complex social situations, which may need to be assessed on a more case-by-case basis. Jeff: Let’s wrap up this episode with some key points and clinical pearls. Cardiac wall rupture is the most devastating form of Blunt Cardiac Injury. The sealing of a ruptured wall may lead to a pseudoaneurysm and delayed tamponade. Trauma to the coronary arteries may lead to a myocardial infarction. The left anterior descending artery is most commonly affected. The most common arrhythmia associated with blunt cardiac injury is sinus tachycardia. RBBB is the most commonly associated conduction block. Commotio cordis is the second most common cause of death in athletes under the age of 18. Early defibrillation is linked to better outcomes. Antiplatelet agents like aspirin should be avoided in blunt cardiac injury until significant hemorrhage has been ruled out. An EKG should be obtained in all patients with suspected blunt cardiac injury. However, an EKG alone does not rule out blunt cardiac injury. Serial EKG and serial troponin testing at hours 0, 4, and 8 have a sensitivity approaching 100% for blunt cardiac injury. An elevated lactate level or troponin is associated with increased mortality in blunt cardiac injury. Perform a FAST exam to assess for pericardial effusions. FAST exams are associated with a significant reduction in transfer time to an operating room. Obtain a chest X-ray in all patients in whom you have concern for blunt cardiac injury. Note that the pericardium is poorly compliant and pericardial fluid might not be detected on chest X-ray. Transesophageal echocardiogram should be considered when an optimal transthoracic study cannot be achieved. CT is used routinely in evaluating blunt chest trauma but know that it does not evaluate cardiac contusions well. In acute evaluation, MRI is generally a less useful imaging modality given the long imaging time. There is evidence to suggest that a patient with an isolated sternal fracture and negative biomarkers and negative EKG findings can be safely discharged from the ED if pain is well-controlled. Trauma to the aorta, pericardium, or myocardium is associated with severe hemodynamic instability. These patients need surgical evaluation emergently. Hemodynamically stable patients with a positive troponin test or with new EKG abnormalities should be observed for cardiac monitoring. Nachi: So that wraps up Episode 26 on Blunt Cardiac Injury! Jeff: 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 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 any images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Nachi: It’s also worth mentioning for current subscribers that the website has recently undergone a major rehaul and update. The new site is easier to use on mobile browsers, has better search functionality, mobile-friendly CME testing, and quick access to the digest and podcast. Jeff: And as those of us in the north east say goodbye to the snow for the year, it’s time to start thinking about the summer and maybe start planning for the Clinical Decision Making conference in sunny Ponta Vedra Beach, Fl. The conference will run from June 27th to June 30th this year with a pre-conference workshop on June 26th. Nachi: And the address for this month’s credit is ebmedicine.net/E0319, so head over there to get your CME credit. As always, the [DING SOUND] 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! Most Important References 7.* Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline) 22.* Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70. (Review article) 23.* El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008;35(2):127-133. (Review article) 27.* Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012;30(4):545-555. (Review article) 34.* Berk WA. ECG findings in nonpenetrating chest trauma: a review. J Emerg Med. 1987;5(3):209-215. (Review article) 64.* Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. (Prospective; 333 patients) 73.* Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. (Randomized controlled trial; 262 patients)
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!
It’s time for Toby Mathis and Jeff Webb of Anderson Advisors to answer your questions about taxes, the IRS, and much more. Do you have a tax question for them? Submit it to Webinar@andersonadvisors.com. Highlights/Topics: What is Nexus? Why do I care? Nexus is a state’s right to tax your income; different types (tax and physical), state laws, and throwback rule - how they affect you Does IRS reimburse me for corporate expenses? Misconception about reimbursement from the client’s company or IRS; IRS doesn’t give you money, but let’s you write it off How do I qualify for a real estate professional status? Requires 750 hours as #1 use of personal professional time; know importance of passive activity loss and logging time What are self-dealing rules for non-profits, IRAs, QRPs? Particular entities can’t interact with a disqualified person - can’t sell them anything; but self-dealing exceptions exist Am I dealer or investor? What’s the difference? Investor is passively involved, dealer is actively buying/selling real estate; can depend on the intent and timeframe Why set up an LLC that does flipping as a C or S Corp instead of a partnership? Because it’s taxed as ordinary income and subject to self-employment tax What is UBIT? Unrelated business income tax is when a plan/non-profit isn’t doing what it’s set up to do; can have passive activity until it competes with active businesses I hold rental property in a self-directed IRA. What can I do? There’s things you can/can’t do, especially add value to a property, so find a property manager and IRA custodian My wife’s previous employer’s stock options were exercised and have peaked. If we cash in, what’ll be the tax consequences/burden? Long-term capital gain and opportunity zone I’m helping a friend with a crowdfunding project. What are tax consequences with no deductions? Does he pay tax on donated money? No tax for less than $15,000 per donor How to aggregate all properties? Disadvantages? Election form that your print with your tax return to identify properties; doesn’t free up large losses tied up If real estate investing part time, are you considered a part-time investor? You’d be a part-time investor, not real estate professional; determining factor is to document time How do I get the 501(c)(3) tax-exempt? Use the 1023 application How do you create an LLC in an IRA? IRA custodian enters into a contract with a company to create an LLC, or set up a 401(k) to roll the IRA into it without a custodian Investing in LLC for holding rental property. How do you avail to a 1031 exchange? Need a 1031 exchange facilitator and LLC must buy or sell the next property within 180 days If I receive social security benefits at 62 and not currently employed, but do receive interest income. Will it affect my SS benefits? Can be isolated into its own taxable entity My wife and I are the only shareholders and both take a ⅓ salary. Is that the right amount? You should take a ⅓ of the net profit as salary instead How do you put an LLC on hold? Do nothing with it or pay the state; file non-activity return Will real estate holding LLC taxes partnership qualify for 20% pass-through deduction? Yes, if not triple net property For all questions/answers discussed, sign up to be a Platinum member to view the replay! Resources Anderson Advisors Tax and Asset Prevention Event Toby Mathis Anderson Advisors U.S. Supreme Court Reverses Long Standing Law On Collection Of Sales Taxes Northwest Energetic Services LLC vs. California Franchise Tax Board Throwback Rule SALT Limit After 24 years, wealthy inventor gets his day in tax court – and wins 10 Tax Deductions That Will Disappear Next Year Passive Activity Losses - Real Estate Tax Tips Real Estate Professional Status - Becoming More Important - Very Hard To Prove Acts of self-dealing by private foundation Unrelated Business Income Tax Opportunity Zones Frequently Asked Questions About Form 1099-INT | Internal Revenue Service Exemption Requirements - 501(c)(3) Organizations Form 1023 Taxbot MileIQ Tax Cuts and Jobs Act, Provision 11 011 Section 199A - Qualified Business Income Deduction FAQs Full Episode Transcript Toby: Alright, welcome to Tax Tuesday, this is Toby Mathis joined by our tax manager Jeff Webb. Jeff: How do you do? Toby: We're going to get jumping on here. We're just going to jump right in. no time like the present to just get business done. So first off, happy Tuesday. Second off, let's jump into a bunch of questions that are giving us a steady feed from folks even before we got started. I'm sure I'll be more happy than to answer your questions. I also got emails in from folks that I may be trying to make sure I answer all of those and we'll just make sure that we're getting through each and every question to the extent humanly possible within this hour. So the first one is, what is Nexus and why do I care. Second one is going to be, does the IRS reimburse me for my corporate expenses. Third one is, how do I qualify for real estate professionals, technically real estate professional status. What are self doing rules for nonprofits in QRPs. I'm going to throw in IRAs in there as well. Am I a dealer or an investor, what difference does it make. Those are the ones that we're going to hit one after the other in succession. I'm making sure that we're getting through these. So the first one is, what is nexus and why do I care. Jeff, do you want to hit tax nexus because there's different types of nexus. There's physical presence for lawsuits and there's tax nexus for taxation. I'm going to have Jeff hit the tax and then I'll touch base on the physical nexus. Jeff: So when we're talking about tax nexus what we're primarily talking about is a state's right to tax you on your income. For example, you may live in Nevada, have a rental property in California. California has a right to tax any income on that property because you're doing business within California. There are different roles, there have been numerous cases on nexus. Toby: Most recently, our Supreme Court reversed a physical presence test that the error that Amazon, everybody that was an online retailer use to avoid state sales tax and that was just changed. Jeff: Yeah, on that one in particular the Supreme Court as Toby said, gave the states the right to tax online sales in their states. The thing is, the states now have to write tax walls to accomplish this. Most of the states don't have anything that accomplishes this. Toby: A lot of times, ignorance is bliss. People would avoid sales tax like for example, I live in Washington, Florida, Oregon and avoid the sales tax and they ignored Washington's use tax. A lot of states have this. You don't pay sales tax and you go someplace where there is no sales tax, you still owe sales tax on it but they call it use tax because you brought the physical item into your state and you never paid sales tax on it. So then they would say, "Aha." And the really interesting thing – there were actually some interesting cases that were popping up from the nexus, ones that came out of Washington, was Northwest Energetic Services too and that was a case in California where they tried to tax an organization that was registered to do business there that didn't actually do any business in California but they wanted to tax its worldwide revenue. The franchise tax board of the board of equalization lost that one and they had a few others but what you'll find is that this is a continuously active in generating area of tax law and we tend to fall into the category of ask for forgiveness not for permission all the time because if you ask a state whether you should be paying tax, they will gladly say yes even if it's not a legitimate tax. They'll tell you that you have to pay it even though it's made to be unconstitutional, unlawful, you fill in the blank. Even if you don't owe it, they'll oftentimes just answer, "Yes, of course you should." They can't actually be giving you any tax advice anyway so it's the wrong party to be asking. I'm sure Jeff you get to deal with that more than I do. Jeff: Yeah, in a state like California, it used to be an old joke for the CPA's that you could be flying over the state of California, make enough business phone call and California would want to so you have nexus and we can now tax you. They're also a state that's very difficult to leave if you're a resident. We had a case where somebody, NBA player for the Sacramento Kings was traded to Seattle Sonics and moved there. Toby: Yeah, now the Oklahoma City Thunder, I was there when they move, horrible. Jeff: The state of California wanted to say, "No, you're still resident of California, we're still going to be taxing you because you got friends here and you have club ownership, some relationships. California in particular is very tenacious with Nexus. Toby: Yeah, so you're going to see things evolving over the next few years since the Supreme Court decision was literally this last, I think it was just months ago or end of the year last year. You're going to see the states trying to fill in the blanks. So you have some states for example in drop shipping, Pennsylvania would tax you if you drop ship out of their state where it used to not be, other states did before. We were talking earlier before the webinar, Jeff and I were talking about what is like a claw back. Jeff: Yeah, it's called a throwback rule that says if your sales into a state that doesn't have taxes then where it got shipped from can tax instead. Toby: Somebody's asked, what are the worst three states for nexus. It really depends on what you're doing, but I would say just off the top of my head probably New York, Connecticut and California. They're pretty heinous. Look at the states that just filed a lawsuit against the federal government under the SALT limitation which is the State and Local Tax Limitation. You'll see I think there was four states Maryland was one of them, where they try to hit you with so many different taxes. It's not just business, it's on your personal as well. It's just for nexus, for a person, it's really easy to figure out, "Hey, where do you live?" Because when I say it's easy, it can be difficult if you have two residences that you spend time with equally. They're going to add up things like how much utility you use, where your driver's license is. Where your kids go to school, where your vehicles are registered, you're going to look at those types of things. There's Hyatt v. Commissioner Case or what was it, Hyatt versus board of equalization I think is actually what it was. Where a gentleman moved to Nevada and the California franchise tax board sent agents to Nevada they climbed to his garage and break into his apartment to prove that he was actually residing more in California than he was in Nevada because his tax bill would've been so great and when they got caught, they said they're immune. Our Supreme Court and Scully I remember the opinion was scathing on them saying, "No, you're immune in your jurisdiction. When you cross the state lines, don't expect any immunity." They just harassed that poor guy. They were climbing around his house. So let's just narrow it down though. You asked a question what is nexus. There's two sides, there's tax nexus and then there's physical nexus. In the physical nexus again where you reside, it's pretty easy. If you live there, then you have a physical nexus in that state, it's where you have a house. In the business it's no different. In a business, you have to decide where it's going to have its main presence and the courts have held having a bare office and nothing more isn't going to be sufficient. You actually have to do something there. That's when you actually have to have a physical office space. We use virtual office where it's doing more than just maintaining a registered agent. There we're actually giving conference facilities, phone answering, we'll do document prep and things like that for the governance of the company so the company can actually have a physical presence. The reason that you do that is to make sure it has a home. So if somebody's coming after one of its shareholders or members, one of its owners that it does not draw that entity into the state where they're located. So, if I have owners in a company and I have my company set up in Wyoming and they sue me in Nevada and they sue somebody else in Texas and somebody else in Florida, you don't have a choice between the Nevada, Texas and Florida where the shareholder or where the members of the LLC are located, they would actually have to go to Wyoming where the actual entity is located. That's what you're trying to do. So if Anderson does my meeting notes, that's why that's important. We're not talking about Canadian, US the nexus pass. I could tell you a fun one. We had a client that just got nailed by California. It's actually under the FBAR which is Foreign Bank Account Regulations. They had some interest on a bank account that was there for a condo they had in Whistler and they sold the condo in Whistler and they didn't report, I think it was like $70 or $76 worth of interest. Jeff do you know these off the top of your head? How much the penalty is? Jeff: No. Toby: If the IRS catches you, it's 50% of the account balance per year. But if you go under amnesty which they have taken an amnesty was a $38,000 fine which they paid for that $76. Canada is still offshore. Anyway, so what is nexus and why do I care. It gets a little convoluted but the reason you care is you don't want to draw your company into your state, you want to make it very difficult for somebody to get a hold of your assets if they're coming after you. From a tax standpoint, it matters because we want to keep our business activities to the extent possible in the lowest taxing jurisdiction as humanly possible. So that's that one. Jeff this is one of your favorites, I know. Does the IRS reimburse me for my corporate expenses? Jeff: Of course they do. IRS is really giving out money. We get this question more often than you would think. I think it's a misconception that clients are being told that their companies can reimburse them for certain expenses which will reduce our taxes and sometimes the clients are hearing IRS is going to reimburse us. The only time you get back money from IRS is if you pay money into IRS for taxes and you don't owe them any tax or maybe overpaid them. Toby: Yeah. IRS is a policing agency. Your taxes when you pay it, they don't even go to the IRS, it goes to the US treasury. So the IRS is merely, pay my boss, is all they are. So they don't give any money out whatsoever so the IRS does not reimburse you for your corporate expenses. What the IRS does is it enforced the laws which is the United States code and issues regulations interpreting that code and is basically the enforcement arm for the US department of treasury. What ends up happening for corporation is they're allowed to reimburse shareholders many expenses that are not included on the shareholder's personal tax returns. So it sometimes seems like they're giving you money when in all reality, they're allowing you to not pay tax on your expenses which is always the battle because there's lots of rules out there that say things are not deductible. Nothing more telling them what we just had happened in this tax change where they eliminated all miscellaneous itemized deductions. All of them are gone in case you've been sleeping. In 2018, you do not get to write them off anymore. Jeff: Now that's your union dues, your tax preparation fees. Toby: Any unreimbursed business expense if you're a teacher and you're providing stuff for your classroom, you don't get to write it off. Jeff: If you're paying substantial amounts to your broker for advisory fees. Toby: That's a huge one. We're going to see that one come back and bite people in their touché. Jeff: That's no longer deductible. Toby: So it's horrible. So no, the IRS does not reimburse you for your corporate expenses. Your corporation reimburses you for your corporate expenses and the IRS lets you write it off. How do I qualify for real estate professional status. Jeff do you want to play with this one or do you want me to handle it? Jeff: I'll do a little and then you can correct me. So real estate professional has a hours commitment. I believe it's 750 hours a year. Toby: So it's a minimum of 750 hours. There's a second part to that too, you know that. Jeff: And the 750 hours can be earned by you or your spouse. What's your second one? Toby: The second one is it has to be the number one use of your personal professional time. Jeff: Oh, correct. Toby: The way I always explain this is if you did 1001 hours doing bicycle repair and you did 1000 hours of real estate, you do not qualify as a real estate professional. But if it's reversed and you did 1000 hours of bicycle repair you did 1001 hours of real estate activities, then you do. And the reason this is important is because ordinarily, your real estate expenses are offset your real estate income and you can only take losses from real estate. In other words, the excess depreciation, or repairs, or whatever, your losses are limited to $3000 a year against your other active income. So that's called the passive activity loss rule. Jeff: $25,000. Toby: If you materially participate and then you have $100,000 to $150,000 scale up. There's some little nuances which don't bring your head with. At the end of the day, there are restrictions on taking passive activity loss. Real estate professional status removes that restriction. The other thing that's really important about real estate professional status is it is per property. So if you have three properties, you'd have to meet it for each of the three unless you elect to aggregate all your properties on your tax return. We have seen this missed by accountants who don't do real estate. They don't aggregate and there are actually cases on the book where people had to fight and they literally had tons of properties they easily met the 750 if you aggregate it but their accountants miss the aggregation election. Jeff: And the sum of 750 hours is not just for your rental properties. Toby: Any real estate. Jeff: Any real estate activity. Toby: Yeah. Jeff was actually right when he said your spouse could qualify, either you or your spouse if you're filing jointly. Jeff: So if you have a full time job and you're getting a W2, I can guarantee you that you will not legally qualify. Under audit, you're going to lose. However, if you have a full time job and your wife does not or your husband does not, they can qualify to be that real estate professional. Toby: We had a fun one. A good friend of ours and a colleague in Georgia was making somewhere between $2 million and $3 million a year in his professional practice. His wife qualified as a real estate professional and he quite literally bought enough commercial property and did something called cost segregation where you're rapidly depreciating it where he generated enough loss off the real estate to offset his income. The IRS audited it, he is self represented because he knew the rule. It withheld, he stood up. His wife just did their real estate activities and he did their practice and at the end of the day, she met the requirement for the real estate professional status and the rule is pretty straightforward. IRS didn’t like the outcome but that's not their job. So they picked a fight and lost the audit which is not uncommon. All right, so how do I qualify for a real estate professional. Keep a log of your time and make sure that you're aggregating all of your real estate activities. Even if it's for a closely held company, it's still going to match, it's still going to work. Next one, what are the self dealing rules for nonprofits in QRPs. I'm going to add in there IRAs as well since when we talk about a qualified retirement plan, we're really talking about 401K and 401A. This is going to dovetail in with one of our other questions that came in off the internet as well. But here's how it works. If you are in a particular type of entity where it says you cannot interact and engage in business with a disqualified person, you could not sell them a $1 million building for $1. It is an absolute prohibition against self dealing. The most important first step is determining whether or not you're within one of those rules. Then if you are, then you look and say are there any exceptions to that rule. So for nonprofits, nonprofits are going to fall into broad categories foundations, private foundations are one. These are nonprofits that aggregate money and give money to other nonprofits, they don't do anything. And in that one, you have an absolute bar from self dealing. The next one is an operating nonprofit that is doing something and in that case, you just have to use arm's length transactions. So we look at that, that's our step number one. So let's go back to the first one, private foundations then you look and say, are there any exceptions. The only exception is reasonable compensation, it can always be reasonably compensated. But other than that, no more transactions. So for nonprofits 501(c)(3) you can enter into transactions as long as it's an operating nonprofit. It can give you benefits, it can pay you and it can engage in sales and other transactions between you and the agencies so long as they are arm's length. And the way you make sure it is arm's length is you have non-interested parties looking at it saying, "Hey, that looks okay to me." somebody who doesn't have a dog in the fight. Now we go to QRPs and IRAs. In either one of those, you have absolute prohibitions against self dealing with disqualified parties and disqualified parties are lineal descendants which would be grandparents, children and their spouses, great children and their spouses. It does not include your siblings. So what's interesting is you could actually engage in transactions with your IRA for example, loan money to your brother. You cannot loan money to your mother. You could not loan money to your kids or your grandkids, you could not do a second on their house, you could not do anything between the company. You could not buy a house from them. That is an absolute bar that's called, disqualified party. Jeff: The way I kind of look at it as to whether you may be violating self dealing rules is, are you benefitting from a transaction between you and the nonprofit or the QRP or the IRA. That's really what they're out to prevent. And unfortunately the rules are pretty severe for violations of the self dealing. Toby: If you self-deal, you're just going to disqualify your IRA. If you're using a QRP and you're using a 401K, then we have different rules, and in that particular case, it would just disqualify the money that you actually were utilizing. Their far more lenient. Jeff: I had a client who had a QRP, it was actually defined benefit plan, who had a required minimum distribution to make and the plan was not funded at the time. The client had to make a loan to the QRP, which is a self-dealing but unfortunately there's an exception for that that one was quickly repaid. There was no profit or interest earned on it. Toby: Was it within the 60 days? Jeff: I believe it was within 60 days. Toby: There's some more fun stuff. Then we go into the 401Ks and this is where you get into people acting on behalf of the company. I know that there were some questions, that were already posed in the chat feature here. You're not supposed to be getting any personal benefit or using those funds at all when you have an IRA or a 401K. In an IRA, it's much more severe because you have a custodian. So if a renter for example is paying you money and they pay it to you individually, technically you have a violation of the self dealing rules because you just received money. Even if you go ahead and put it right back in the IRA, you're going to have an issue because technically you weren't supposed to receive the money, the custodian was supposed to be receiving the money. So you should actually have rental money going to your custodian if you’re using an IRA. If you’re using a 401K or 401A, which the profit sharing plan or 401K, then you are the trustee and you're able to accept the money and endorse it right into the account and make sure that the money goes to the right place. IRA's are a little more difficult. To get around this, a lot of people with IRA's will set up an LLC which you can be the manager of. Actually, the IRA is technically the member— you're in non compensated role and we have to make sure that the LLC agreement says that if we drafted it, then we make sure that we're putting in the non-prohibitionals. You cannot personally benefit from these activities. It has to all go back to the retirement plan. People will do the LLC and they will be all right, now I can go ahead and accept the funds through the LLC, that's how they do with an IRA. If you're doing with the 401K, we're going to suggest that you still set up an LLC anytime you have real estate, just because we don't want the liability to flow through to you. But there, now, you don't need the custodian. You could technically do it inside the 401K directly though you should still have the LLC and it's the same scenario where you're able to accept the proceeds. That's not going to be a technical violation because you're acting on behalf of the plan. And that is not a violation of the self dealing rules. So the biggest takeaway from all this, is that you can act on behalf of the plan. The second a just qualified person starts to get personal benefit, you have violated the rules and if it's an IRA, the whole thing is violating—considered a taxable event, which should be that 10% penalty plus income tax on it for the entire amount if it's at 401K or 401A, it would just be the portion that you violated. We tend to be very bullish on using 401Ks and 401A's, profit sharing plans around here also known as QRP. And this is why, because they're far more forgiving and they have a less moving pieces. I hope that explains that. We're going to have—I know there's a couple more questions that are in here, that are going to be relevant to this section as well. Let me jump on to something. The questions, this is something you can ask detailed questions via our email. I will answer them, Jeff or Tony, whoever's from the tax department here. We will answer these on the tax Tuesday. We will also more likely be responding back out to you directly as well because we want to make sure you get your questions answered, but just jot down that address, webinar@andersonadvisors.com and feel free to shoot them in. Since our last one, Tax Tuesday, we had a couple of questions and I want to go through these. Number one was from Karen out of Alaska, "I have a revocable trust in Alaska that owns and sells real property, does the trust to pay income taxes on the profit or does the profit end up on my personal tax return? Is it taxed at the same rate as everything else? So the most important word she used in her question was revocable, because trust come in two flavors, revocable are irrevocable. If they're irrevocable, then we have two choices, we don't have to worry about the irrevocable.. Since it's revocable, it's a grand tour trust is ignored, it's you, for tax purposes until your dead. So you're good, sorry, sometimes I'm blunt. So if you're buying and selling real estate, real property it's taxed no differently than if you're on the real property. Now here's the rub, it also gives you know asset protection. So revocable trust is giving you know asset protection with that real property, so I would really strongly suggest that the revocable trust actually be the owner of an LLC that is buying and selling the real estate and depending on how quickly you are turning this, will depend on whether that say, S or a C-Corp., if it's a flip versus if it is a long-term holds, then we just put it as an LLC. It would either be disregarded or taxed as a partnership. We want it to flow under our return. Those are kind of our choices. There was a question, I don't know if I got to that. I'm going to skip back to our slides. There's something about—Am I a dealer or an investor? So I want to make sure that I'm getting this one right here. Because this is relevant to one of these questions. A dealer and an investor is something that we talk about in real estate, you want to hit on this? Jeff: No, you're doing fine. Toby: An investor is someone who's passively involved, a dealer is somebody who is actively buying and selling real estate. So if you buy real estate with the intent to hold it for its long term appreciation cash flow, then you are an investor. If you buy real estate with the intent to sell it, then you are a dealer. The easiest way to conceptualize this is if I am an investor, I am passive. If I am a dealer, then I am a supermarket with inventory. And I'm putting my real estate on a shelf and it's constantly for sale. Just like at your grocery store, it may take a couple years for something to sell. I'm just imagining the items that are on the shelf. Jeff: Your durable goods. Toby: Right, so you sell something, I used to do liquidation. We would grab all the expired items we would sell them but let's say, it doesn't matter how long you held them. A lot of people think, well if I held it over a year, I can't be a dealer. That's not the case, we actually have cases on the book where they held it over 10 years. What matters is what your intent was when you buy it. And the difference it makes is active income versus passive income. The difference is an investor can 1031 exchange and defer all other taxes. An investor can get long-term capital gains, an investor can do installment sales, an investor can spread out the tax liability over a long period of time. Whereas a dealer is active. It's subject to social security taxes, it's taxable immediately even if you don't receive the money. It is active ordinary income, it's no difference than I just sold that box of Cheerios on the shelf that I've been waiting to sell. It makes a huge difference. Dealer activity we're going to isolate inside of an S-Corp or a C-Corp. Investor activity, we're going to make sure it flows on your personal return either by using a disregarded LLC or a partnership LLC, one of the two. Jeff: Intent has really made a difference in a couple of cases. One, where somebody bought a property that they go allow their child to live in, something end up happening then they sold it after a short time. They were considered to be an investor not a dealer. Toby: It doesn't even matter. It does not matter whether you ever rented it, there's plenty of cases where somebody tried to rent it and they were going to use it as a long term hold and then things change and they sold it. Just know that if you buy or sell within a year, the presumption is going to be that you're a dealer. If you hold for over a year, the presumption is going to be that you're an investor but it's not a guarantee. We're going to get back to these questions. How does Flip LLC income flow into S-Corp and then what will be distributions of the seller? So, we talked a little bit about this last week but I'm going to go and we're going to hit this. When you set up an LLC, it doesn't exist to the IRS. So when you say how does the Flip LLC flow into S-Corp, it doesn't. A Flip LLC is an S-Corp if you elect to have it be treated that way with the IRS. The income is just going into an S-Corp. Then you have to decide what your salary will be because if you know anything about an escort S-Corp, you want to make sure you pay yourself a reasonable salary if it's making money. The rule of thumb to use is, one third of your net income should be paid out as salary. That's just a rule of thumb but it's all in all reality the IRS has this funky test where you're supposed to say, "Hey, what would it be? What could it be paid?" they never tell us exactly. So I'll just say this, pay a third, don't worry about it. If you get too much money, if you start making over $300,000, then we're going to have a chat but where you're going to be on our radar anyway, we're going to be making sure you're paying a reasonable salary anyway. The reason this is important is because the salary is subject to old age death and survivors in Medicare also known as FICA or social security and the distributions are not. So what you would do is you'd be cutting your social security tax by about two thirds if you did it that way. I hope that explains it. So it makes its money and it pays it out. We do need to make sure that if you're flipping, that the money goes into the LLC. Jeff: A quick comment on distributions on an S-Corporation. Distributions are typically the money that's already been taxed are in you're just pulling the cash out. What you don't want to do is go out and get a bank loan in S-Corporation and take distributions from that for several reasons. One, you don't have basis in those distributions. Two, it gets into the whole finance distribution issues and things of that nature. So you really only want to be pulling money out of the company that you’ve already been taxed on. Toby: Fair enough and then if you don't pull any money out of an LLC that's taxed as an S-Corp, you don't technically have to pay yourself a salary. You just let it sit in there and keep growing which your accountant is not going to tell you because they don't know that. The reason I know that is because I have spoken to probably 100 accountants that missed that one. It says, why do you want the LLC that does flipping set up as an S-Corp or C-Corp instead of a partnership? Mark, we were just talking about that because it's taxed as ordinary income as subject to self employment tax. So the reason we want that in an SRC is so that you do not get classified as a dealer because then all of your real estate is dealer real estate and you could lose all your long-term capital gains, you to lose your 1031, you could lose your installment sale. So we want it to be a separate taxpayer from you so the IRS notes clearly who the investor is and who the dealers is and then you can reduce the amount of tax hit by using the S-Corp that will reduce your self-employment tax significantly, if you add a 401K to it, you could eliminate your tax or defer it out into the future. If you use a C-Corp, then depending on what your expenses are, we can also eliminate all your tax or at least reduce it significantly. So that's why we use that. All right, we have a whole bunch of questions to go through so I'll go through this. What is UBIT and UBITA. UBIT is unrelated business income tax and the easiest way to understand this is when you have a tax deferred entity or tax, it's not actually a tax rates, it can be tax rate if it's a Roth but when you have a qualified plan or a nonprofit and it is not doing what it's set up to do, so let's say in an IRA or a 401K or a 401A, or a nonprofit, they're all set up to do certain things. They're allowed to have a passive activity which is rents, royalties, dividends, interest, even capital gains and it can have those and you don’t have to worry about it at all. But once it starts competing with other businesses, active businesses, now you have an issue and that's what's called—let's say that you have these ordinary businesses. Then they would be taxed, generally speaking it's going to be the highest rate at 37% I believe is what it's going to be as kind of a disincentive to engage in traditional businesses inside those exempt organizations. The easiest way to look at this, let's say you set up an IRA and it runs a mini mart, you're going to pay tax on those profits just like anybody else would. The exception is if that IRA owns a corporation that does not pay out the profits directly. It would have to own C-Corp and then it would only receive dividends and then those are considered passive. So it gets funny and a little bit difficult. The other one is let's say you set up a nonprofit, that's for—what's a good one? Helping Vet and then it sets up a pizza business on the side and starts competing, it buys a bunch a Domino's franchises. It's going to pay tax on the Domino's franchise. It doesn't get a big huge competitive advantage selling pizzas because it's a nonprofit. It would have to be for its charitable purpose and that's UBIT. Jeff: One place we see a lot is like hospitals, they're usually tax exempt but they may have a gift shop which they have to pay the business income tax on because it's not directly supporting them but it is a business. Toby: But you're allowed to do that for like what is it, Salvation Army and some these other thrift stores. They'll let you have one for a church and whatnot. If it's ancillary, if it's completely ancillary and it's just being used like thrift stores I think are one of the few exceptions, gift shop absolutely, you're head to head. Here's another one and I think that this may be what Diane was looking at, it's debt financed income. What that is, is if I'm using the leverage, then there's an exception for IRA's where it cannot use loans to generate income, it's considered an unrelated debt financed income. It will be taxable That is not the case for 401Ks and for 401As, which is what—if you've ever been to one of our events, you hear us railing on the idea that if you are going to finance real estate, real estate is considered passive and it's considered okay not UBIT. The only way you make it taxable is if you leverage it inside of an IRA, so don't do that. If you're going to leverage it, make sure your rolling that IRA into a 401K or profit sharing plan which is the 401A. So there, that's my two cents. I figure that maybe they had a funky—UBITA, I have no idea what that is, but it looks neat. I think they were probably referring to get financed income, since those things usually go side by side. All right, we have a ton of questions that have been posed and this is so much fun, we have like literally a jillion questions, if that's the number. All right, so here's the first one, if I cash out refinance or borrow an equity loan from my primary residence, use the money to do private lending by rental property, can I deduct the interest expense as an investment expense beyond $750,000 amount? They're throwing some things in here. This is actually a really long question, I'm giving you the thumbnail sketch of it. Hey guys email those types of questions in, because nobody's going to be out to follow this, but here's what here's what they're saying, we now have a restriction on your mortgage interest, it's $750,000. If you borrow on your house, and by the way it's $750,000 now, if you had a loan on it up to $1 million, you're grandfathered in, if those prior to what was it, 12/15/2017, you're good or if you got your long before April 15th and you already started the process before December 15, don't you make my head hurt. Long and short of it is, let's say $750,000, but your house is worth $1.5 million. You borrow money out of your house. You will not be writing that off personally, you are capped at $750,000 and that's on your schedule A. Whether or not you're getting any benefit out of that is to be seen because you have your standard deduction. I imagine it's going to be above the standard deduction if you're borrowing up to $750,000. Let's just say we have our $750,000 and we borrowed an extra $500,000, it can't go on your schedule A, but it can go someplace else. The someplace else would be, for example, if I put it into my schedule E, because I'm using it to buy rental property. Then I can use the income of the rental property and I can use the interest being paid as a separate expense, it's just going on a different tax form. The other route that you can go is, if I give that $500,000 and I loan it to a corporation and the corporation re-loans, in the words the corporation is going out loaning its money out and it's reimbursing my interest, then in all reality the loan is really to the corp, and I'm not getting any tax benefit but the corporation is reducing its income by reimbursing me the right to use basically my line of credit. This is no different than if you do this with your credit card. It's reimbursing you, so you make no money on it, but you don't pay tax on it, it such a fancy work around. That's number one. Next question, I hold rental property in a self directed IRA. I do tenant screening, manage the rental, hire vendors to do the repair work and I don't physically work on the house. Good, because you can't physically work on the house, you can do everything else, you can hire, do screening. I would actually have a property manager on it. All income expenses come and goes to the same self directed IRA account, hopefully that's with the custodian or you have an LLC, disregarded to the IRA. Somebody asked this, the IRA custodian sets up the LLC, you can't do it. You shouldn't be going out and doing it yourself, paying your money, you should actually have the IRA do it to keep it clean. Is it allowed? Yes, some people say, "If only I don't work on the house myself, that's okay," and they're correct. Some people say, even screening, collecting rent is not allowed, can you please clarify? You should not receive the money, the IRA should receive the money, you can direct you to the custodian though. You can even get the check and hand it to the custodian, forward it to the custodian, whatever, as long as what you're doing is not adding value to the property. That's the big no, no. Don't go get a paint brush and start painting the house because you're increasing the value to your personal efforts. Next question, my wife's previous employer stock options were exercised and we feel have peaked, cost basis 132, market value 280, if we cash in, what will be the tax consequences and how can we reduce the tax burden? We need to pull the trigger shortly. Aziz, this is you, there's two ways you can do this. First off, you're going to end up with long term capital gains, so it's not horrible. Secondly, there's something called an opportunity zone which just enacted at the end of the year and the just published out all these zones. If you reinvest the money in a opportunity zone, you defer to the tax. In the opportunity zones, there's tons of them. It's any neighborhood that is considered—that needs public support and there's a laundry list. I would actually encourage you to go Google, opportunity zone, tax and you'll find a big old list. But the communities in your area that are typically low to moderate income house. If you took your entire amount of increase, so let's say that we have $150,000 of taxable capital gains, you could buy $150,000 of opportunity zone properties and pay zero tax. Now, the question is, what happens when I sell? So there's holding periods and the minimum holding period, I believe, is you're going to be looking at five years, where then you're going to not have to pay tax on 15%, I'm going off of memory. So you'll have to excuse me if I'm not spot on, but it's 15% then it jumps up. At 10 years, the entire $150,000 is no longer taxable. And I believe that you're not going to be paying tax on the gain in the opportunity zone, it's kind of a two pronged, are you familiar with that one, Jeff? Jeff: Somewhat, I know that you replaced the old enterprise some number of years back. Toby: Something to look at, but would be it. The last way to avoid tax is give them, before you exercise it, is give that to your non-profit, if you have one and you would get a $280,000 deduction. And then the nonprofit can sell it zero tax. You'd get a monster tax and you could have these too, you could say, "Hey, I really need to offset a bunch of the tax, so I'm going to make a contribution," it doesn't matter what your basis is, it only matters, the fair market value of those assets and if you transferred let's say $140,000, half of it, let's see transferred $140,000 worth of stock, you would get $140,000 tax deduction and it can offset your income up to 60%. In either case, if you're pretty confident that we can mitigate or eliminate that tax bill if you wanted to. If you keep it out of state, somebody says, if you keep it as state for 36 months, can it be avoided? I am helping a friend with crowdfunding project and due to medical needs, we'll need a large sum, maybe $100 million what would his tax consequences be if he has no deductions? Does he have to pay tax on donated money? Fred, generally speaking, if you're getting these little gifts, as long as they're less than $15,000 there's no tax and when I say $15,000 that's per donor. So if I do a crowdfunding and everybody gives $100, there's no tax to the recipient. So go ahead and raise them a bunch of money. Jeff: Keep in mind when you're doing this crowdfunding, if you're contributing to a crowd funding, it is a gift, it's not a donation. Toby: And it's not a tax deductible donation. In 2017, I sold a rental house and took a $40,000 note. In 2017, I received $944 in interest but have not issued a 1099-INT. I did report the amount on my personal 2017. What should my next step be? Wait until 2019 or file now. So he's the one who holds the note, he was paid interest. What do you have to say? Jeff: This is kind of a darn if you do and darn if you don't. There is a penalty for not issuing the 1099. You did the right thing by reporting the amount of interest. However, there's a penalty for not following the 1099. There's a penalty for filing them late. Toby: What's the penalty like? Jeff: I think it's $50 or $75. I think it's $50 up to $99. Toby: So what you're saying is do it next year? Jeff: I didn’t hear anything. Toby: Hey do it next year unless they start digging in. I've had that, we actually went through a super audit here once and they went through every—they let you fix it. So I just wouldn't do it. I would just do it next year and say, "Hey, oops." How to aggregate all properties. What are the disadvantages to doing. You file an aggregation election, is it a form or you just check in the box? Jeff: It's an election. It prints out a form with your tax return. It says exactly what properties or investments you're aggregating together. The only real disadvantage is. Once you aggregated these properties, let's say you have two houses and one has significant passive losses. When you become a real estate professional, those passive losses gets stuck in there. Normally they get freed up when you sell that property but once you aggregator properties, it's all considered one property. So it doesn't free up those if you have a large losses tied up, it doesn't free them up until you get rid of all your aggregated properties. Toby: Cool. Nicely put. Are the purchase and sale of mortgage notes considered real estate for real estate professional status I'm assuming. Jeff: This is my gut feeling, I would say no. it's more of a lending, more of an investment in the notes. Toby: Depends on whether you're ending up with the properties. It depends on what your intent is and if your intent is just to buy and sell mortgage notes, then you're dealing with lending. In order to be real estate, it's really got to be focused in on the purchase and sale of real estate. Jeff: So we kind of run into the same thing with construction companies and such that they meet the test for certain things but not for other test. There are some input to it so real estate broker is kind of the same thing. Toby: Here's the thing, so this is Dean. Dean, if I am in your shoes, I am documenting the time I'm spending in real estate. so even though I may be going after a note, if the reason that you're going after the note is with the intent that possibly end up with that property and you do the research and you can back it up, then you add it into the real estate column as far as your time and you aggregate all your time. The only time this is going to come up is if somebody audits you in goes through all of your records that thoroughly which is rare that that happens. But let's say that it does, then you're the one who's tracking all of your expenses and your time. Then it would be up to the IRS to sit there and say, "Hey, that was actually for the mortgage." and so the old adage is pigs get fat, hogs get slaughtered. You don't take all of it but you aggregate that a little bit. Jeff: Can I bring up a pet peeve? I hear on the radio frequently about all these auditors that IRS has hired and they haven't had a real hiring since 2010. Toby: They're so toast right now. Jeff: The last big hiring they did most recently was to deal with Obamacare for that audit purposes. But really, they're dealing with almost a skeleton crew anymore. Toby: We just got proposed tax forms for 2018. We don't even know, we just had proposed regulations issued on the tax changes two weeks ago, three weeks ago. They're way behind the eight ball and sometimes we put ourselves in a disadvantage. Don't be crazy about it, but you can be pretty aggressive and especially if it's the truth. If what you're spending your time on is real estate, count it towards real estate. So if you're doing real estate investing part time, can you be considered a part time investor? Yeah, you'd be a part time investor but you wouldn't be a real estate professional. So the biggest important thing and this is for Darlene and Ken, is to document your time and if you go over 750 hours and it's more than you spend than anything else, then you're going to be a real estate professional. Otherwise, you're just an investor, unless you are buying properties to sell. So when you say investing, that means you're going to hold on to them, you're letting them depreciate a little bit but you get the cash flow. Does time spent lending money on real estate for real estate qualifiers and real estate professional. No investing, didn’t we just answer that one? It depends on your real intent of investing in the note. A lot of people are buying notes to end up with a real estate in which case then I'd say probably. Jeff: No, what if she's gap funding? Toby: If you're gap funding then I would say no, then you're lending. So you really have to take a look at the totality of the circumstances. I wish I could say yes or no. what we want is a yes and there's a way to get there. So it's making sure that you're documenting things to support your position. We could dig into that a little bit more, if you want to shoot us the email then let us dig into it. Then the next tax Tuesday, I can answer that one and Jeff can answer that one with a little bit of research behind it. Nexus question, "I'm a resident in California, I'm moving to Arizona. I plan to keep a single family rental in California. The California houses and the land trust is owned by Wyoming LLC, does California have the right to tax my pension income after I move in addition to my income in California rental." Shelly the answer is, it depends on where the rental was earned and whether you're taking out over a 10 year period then the answer is, no. and my guess is that you're going to be a big no. They will be able to tax technically the rental income that is being derived from California but for the most part, that's going to be zero. Jeff: A really important number to remember when you have a property in more than one state is 183. That's typically the number of days you need to spend in a state to be a resident in that state. Toby: "How do I get the 501(c)(3) tax exempt?" Marie, that’s the 1023 application. Yes, it's the 1023 application. So with a nonprofit, I always look at these things in threes, we file with the state which is a corporation. We document it to make sure there's no shareholders which is for private parties, and then we file with the feds and we're telling them we want to be an exempted organization and that exemption is done via 1023. So we go through that process. When we set them up, we set up about 3,000 of them successfully. "How do you create an LLC and an IRA?" Darlene and Ken, what you do is you have the IRA custodian internal contract with a company like us and we create the LLC, or we set up a 401K, roll the IRA into it and then we'd let you do it so you don't need a custodian. "Is this recorded and will a replay be sent out?" Robin, it's made available to anybody who's platinum and then I'm cutting out a bunch of the Q&As and will throw them all over the internet. The recording, yes we record them. Join platinum, it's fun. "If I sell a partial note to a family member from my QRP, is that disqualified?" it depends on the type of family members. When they're your kids, yes. If it's to a brother or sister, no. then you can do it. When you make a contribution and that's just the whole disqualified person argument we had earlier. So you can always ask again, ask the question specific to your situation, we'll give you a very specific answer. But just know that if you sell a partial note out of your QRP, it depends on the relationship of the family member. If it's lineal, you have a problem. Which means kids, parents, grandparents you have a problem. If it's horizontal, siblings, not a problem. If it's the spouses of the disqualified person, you're going to have a problem. "Investing in LLC for holding rental property, how does one avail to a 1031 exchange?" Here's how it works, so I'm not going to worry about this. The 1031 exchange, you have to have a 1031 exchange facilitator. The LLC has to buy the next property. So you sell one and buy one within 180 days and there's some other roles in there about when you identify it or you do a reverse exchange where you buy the replacement property then sell the other property within 180 days. But neither cases, in the name of the LLC, you don't have to do anything else. "I should be able to still qualify as an investor and still be active in real estate by investing more than 750 hours." yes, but in actually is a full time job. So if you have a full time job as a real estate professional, then you're good. But remember, your activity as a real estate investor has to exceed your activities of any other profit making activity. So if you work and you work 1,500 hours, even if you did 1400 hours as real estate, you are not a real estate professional, still below that 1,500. Investment in LLC for holding rental property, how does or somebody asked that. If you in invest funds to have an equity in a project, oh my god, this one's going to kill me, built by someone else, I'm trying to think what this is. So you're investing funds for a piece of an LLC in which you are passive and they are a builder, are you a dealer? So Judith, no, you are a passive investor in an active business, is what you are. I see what you're saying, what she's asking is, "Hey, I have Bob the builder come up to me and says, 'Hey, we're going to build this big apartment complex, we're going to develop and everything. You put in $100,000 everybody else puts on $100,000.'" You are passive. You are not considered the dealer. Here's a fun one, did you already read this one? Jeff: No, I haven’t read this one. Toby: Okay, I am planning to receive social security benefits at 62, and currently not employed. I do private lending to real estate investors through promissory notes. So I do receive interest income in the amount of $40,000 to $50,000. Will this affect my social security benefits? At what point to social security benefits are taxable? So Joe, the answer is that there are certain types of income that are exempt from calculations, social security, Jeff you know off the top of your head? Jeff: If you're receiving earned income and that's all social securities could ever know about, so we're talking about self employment income, W-2 wages, that's going to affect your social security benefits. Toby: But if you're just receiving interest income, is it going to affect it? Jeff: Well, here's the thing, if you're in the business of lending money, we would typically set you up as a business, either on schedule C or through an S-Corp or something. That interest you receive wouldn't be, interest income, it would be business income. You'd be able to deduct certain expenses from that income… Toby: We got to look at it, because usually you're going to want to be treated as active, in this particular case you're not going to outdo yourself. Jeff: The downside of this is, any money, any net income you have from this business of lending money is going to affect security until you're 65, or 67, full retirement age. Toby: Joe, the answer is, we may one isolated into its own taxable entity, so that it doesn't affect you. We may. Jeff: I kind of feel like this would be in a great place for an S-Corporation. It's not earning income flowing through to them. Toby: Would he have to take a salary? Jeff: Yeah there we go. Toby: I'm going to take a look. Joe, that's a great question, could you submit it to the webinars at Anderson Advisors, so we can research it. In that way we can hit it in two weeks, to get you a much more thoroughly research, because you're asking a very complicated question. That’s just not going to be at the top of our head. We're going to make sure that we don't step on a landmine. Jeff: So the answer's, maybe. Toby: My wife and I are the only shareholders and we both take a one third salary. No, you should take about one third of the net profit as salary, total between the owners. So greater than 2% shareholders or you and your spouse, so you could each take, I'll throw numbers out, let's say you made $100,000, you could each take up to $18,500. If you're under 50 and immediately dump it into a 401K and not pay any tax. So, "Hey we like that." We have a medical coding business, perfect, yeah, so that's when we want to take a look at. "This is so much fun, really appreciate it," I hope that's not sarcastic, Al. "I opened a couple of LLC, I'm going to use to purchase flipping, can I put them on hold until I do? Do I have to do tax returns?" It all depends on what you're doing with those, the answer is, yes you could put them on ice. "Thanks for the answer on UBIT." Diane, no problem. See we actually do answer questions here. "What are the legal benefits of incorporating in Puerto Rico, if any compared to Nevada?" If you live there, I think they give you 4% tax rate, but you actually have to reside there. There's legal benefits, not really any, other than the tax benefits and the fact of the matter is Puerto Rico has Spanish law, which means they could probably take your company from you. But you can still go down there and Jeff… Jeff: Well, I mean, there are certain industries that have great tax benefits pharmaceutical companies was always a big one. Some of those old laws have sunsetted but might be a good opportunity. Toby: Cool, look at all these questions. All right, some people are saying nice things, great. I like nice things better than, "You guys are jerks." In 2017, I was self employed under my LLC, I have not filed my taxes yet and not considering retirement. Would I still be able to do that? What is best options?" Casey, are you under—self employment under my LLC. So it depends on whether—it was an S-Corp. Did you file an extension because you would be able to do a retirement plan either a sub-IRA or if you already had the 401K then you can make a contribution from the company for it. It would either be a 401A or a 401K. or sub-IRA, I think those are going to be your... Jeff: And if you do extension, you have 11 days to get it done. Toby: Yeah, you have 11 days. Casey, get off your butt. All right, Brian wants advice with the start up pre revenue, he is offering 10% stock, "Not sure I want ownership that subject to capital calls, expectation, potential—is it better to take an offshore [inaudible 01:06:53] until there's more value in the company?" It really depends, so Clark, nice to see you. Awesome. I know Clark's brother very well, studs, nice family. All right, friends, if I was going to have a piece, the whole thing is, if I'm putting money into an endeavor, it's going to be, "What am I going to get out?" It would really depend on the agreement, I don't want to be subject to having to put more money in, nor do I want my interest necessarily being diluted by somebody who is. So one of the one of the ways you can do it, is sometimes do it is a convertible note where you loan the money, so you know you can at least get it back, but it's convertible into equity at the fair market value at that time. You guys can actually agreed to this ahead of time. So that if you decide you want to contribute it, you see they're doing what you want but then you convert it into equity. Otherwise it just remains a note that they pay you on. Clark, that's probably the route I would go. Jeff: But the assumption here is, this is a C-Corporation he's talking about. Toby: I don't even care… Jeff: Well if it's an S-Corporation that we wouldn’t be able to have all these secondary notes and stuff. Toby: If it's an S, I could so convert it. Jeff: Could you? Toby: Yep. Jeff: As long as it converts into the same… Toby: Yep. The risk is I don't want to have a convertible debt to anything other than an individual that would qualify for S.. Jeff: Okay. Toby: But I don't see S-Corps raising money this way. It's almost always C-Corps with partnerships. So the ones that I've been personally involved in, we did three levels of financing this exact way with Vegas Tax fund. That's the little Tony Hseih group and they dumped a bunch of money to a company called Role Tech. You can look them up online, because we exited that wanted with the sale to Brunswick. In a way they did all their money was purely—that was a C-Corp, but it was purely through convertible notes. All right, "What are the best tools you can recommend for tracking time mileage and expenses for real estate investors? My desire to be paperless and get everything out…" People use Taxbot for mileage, it's mileage IQ, MileIQ, I think it's the one that I use, but if you're tracking time, it's just using—sometimes is just using your calendar or spreadsheet. Let's see, "Is full time realtor, a real estate professional?" Chances are, you're going to aggregate and all that. "I understand and agree." I'm not sure I understand that. "I executed a 1031 exchange where trust all the owned property, sold it, and took title of the up leg property in the trust using 1031 exchange. But now I want to transfer up leg property into an LLC." Diane, there is no time restriction that you have to hold it as long as you are the one and still the end beneficiary. If you extend loan through an LLC owned by Roth IRA, they want to transfer, sell the remainder, but then season it out to a lower interest rate. Can Roth continue to receive the full payment from the borrower and the relay the portion?" Yes, as lines is non-convertible, same as you do in an S-Corp. "Is the answer the same best self administer S 401K? So what they're asking is," If you extend a loan through—we're just going to call it the Roth IRA, because the LLC looks right into it from a tax standpoint. And then you sell the remainder of that then season notes. So you start collecting and then you sell the note because it's doing really well and you say, "Hey does anybody want to pay me for this?" I know a guy that that's what he does. He puts the notes together and he sells his notes out and so he can get the money to go to another one and he aggregates them altogether, they call it flying in flocks. The lenders flock together and together they do a loan and he sells his portion. Yeah, you could sell it and then you can continue to receive it and keep a portion of it. the only issue you have is if it's a convertible note then you wouldn’t want to do a convertible note because boom, that Roth IRA depending on the type of entity if it's an S-Corp you'd kill the S-Corp's status of it. How do you put an LLC on hold? You get quite literally do nothing with it or you just pay the state and then you file a non activity return. You say it's not doing anything. So you're allowed to do that or you just do nothing. Which is what I tend to do. It just depends on your state. If there's not much penalty then I just kind of sit it and then two years later I might reactivate it. Will real estate holding LLC taxes partnership qualify for the 20% passed through deduction? Yes, it will. Here's the deal, as long as it's not triple net property. What she's asking is, "Hey, I have a whole bunch of LLCs and they all receive rental income and there's a net income amount." let's say it comes through with $50,000 there's something called a 199A deduction that was enacted by the 2017 tax cut and jobs act. And it gives you a 20% deduction off that amount or 20% of your taxable income whichever one is less/ but if you earn over a certain amount so for individuals it's over, $100,575 if it's a married couple it's $315,000 which is going to make your head hurt I'm going to suffer memory here. Then you scale up and then you have a new test it's 50% of the W2 income that's being paid on that particular busine
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 back with our old routine – no special guests. Nachi: Don’t sound so sad about it! Jeremy was great last month, and he’s definitely paved the way for more special guests in upcoming episodes. Jeff: You’re right. But this month’s episode is special in its own way - we’ll be tackling Electrical Injuries in the emergency department - from low and high voltage injuries to the more extreme and rare lightning related injuries. Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions. Jeff: I hate to digress so early and drop a cliché, “let’s start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly. Nachi: This month’s print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O’Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively. Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month’s team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review. Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes. Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare. Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards. Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it’s necessary. There are a couple of terms we need to define to help us understand the pathologies we’ll be discussing. Those terms are: current, amperes, voltage, and resistance. Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it’s measured in amperes. Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC. Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm’s Law here. Voltage = current x resistance. Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact. Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury. Jeff: Definitely adding insult to injury right there. With respect to the tissue resistance, that amount varies widely depending on the type of tissue. Dry skin has high resistance, far greater than wet or lacerated skin. And the skin’s resistance breaks down as it absorbs more energy. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat have the highest resistance. In between nerve and bone or fat, we have blood and vascular tissue, which have low resistance, and muscle and the viscera which have a slightly higher resistance. Nachi: Understanding the resistances will help you anticipate the types of injuries you are treating, since current will tend to follow the path of least resistance. In high resistance tissues, most of the energy is lost as heat, causing coagulation necrosis. These concepts also explain why you may have deeper injuries beyond what can be visualized on the surface. Jeff: And not only does the resistance play a role, but so too does the amount and type of current. AC, which is often found in standard home and office settings, but can also be found in high voltage transmission lines, usually affects the electrically sensitive tissues like nerve and muscle. DC has a higher let-go threshold and does not cause as much sensation. It also requires more amperage to cause v-fib. DC is often found in batteries, car and computer electrical systems, some high voltage transmission lines, and capacitors. Nachi: Voltage has a twofold effect on tissues. The first mechanism is through electroporation, which is direct damage to cell membranes by high voltage. The second is by overcoming the resistance of body tissues and intervening objects such as clothes or water. You’re probably familiar with this concept when you see high voltages arcing through the air without direct contact with the actual electrical source, leading to diffuse burns. Jeff: As voltage increases, the resistance of dry skin is -- not surprisingly -- reduced, leading to worse injuries. Nachi: And for this reason, the US Department of Energy has set 600 Volts as the cutoff for low vs high voltage electrical exposure. Jeff: It is absolutely critical that we also mention and then re-mention throughout this episode, that those with electrical injuries often have multisystem injuries due to not only the thermal injury, electrical damage to electrically sensitive tissue, but also mechanical trauma. Injuries are not uncommon both from forceful pulling away from the source or a subsequent fall if one occurs. Nachi: That’s a great point which we’ll return to soon, as it plays an important role in destination selection. But before we get there, let’s review the common clinical manifestations of electrical injuries. Jeff: First up is – the cutaneous injuries. Most electrical injuries present with burns to the skin. Low voltage exposures typically cause superficial burns at the entry and exit sites, whereas high voltage exposures cause larger, deeper burns that may require skin grafting, debridement, and even amputation. Nachi: High voltage injuries can also travel through the sub-q tissue leading to extensive burns to deep structures despite what appears to be relatively uninjured skin. In addition, high voltage injuries can also result in superficial burns to large areas secondary to flash injury. Jeff: Electrical injuries can also lead to musculoskeletal injuries via either thermal or mechanical means. Thermal injury can lead to muscle breakdown, rhabdo, myonecrosis, edema, and in worse cases, compartment syndrome. In the bones, it can lead to osteonecrosis and periosteal burns. Nachi: In terms of mechanical injury – electrical injury often leads to forceful muscular contraction and falls. In 2 retrospective studies, 11% of patients with high voltage exposures also had traumatic injuries. Jeff: While not nearly as common, the rarer cardiovascular injuries are certainly up there as the most feared. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Common arrhythmias include AV block, bundle branch blocks, a fib, QT prolongation and even ventricular arrhythmias, including both v-fib and v-tach, both of which typically occur immediately after the injury. Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged cardiac monitoring – however several well-designed observational studies, including 1000s of patients, have demonstrated no such evidence. Jeff: It’s also worth noting that ST elevation MIs have also been reported, however this is usually due to coronary artery vasospasm rather than acute arterial occlusion. Nachi: Respiratory injuries are somewhat less common. Acute respiratory failure usually occurs secondary to electrical injury-induced cardiac arrest. Thoracic tetany can cause paralysis of respiratory muscles. Late findings of respiratory injury including pulmonary effusions, pneumonitis, pneumonia, and even PE. The electrical resistance of lung tissue is relatively high, which may account for why pulmonary injury is less common. Jeff: Vascular injuries include coagulation necrosis as well as thrombosis. In addition, those with severe burns are at increased risk of DVT, especially in those who are immobilized. In at least one study, the incidence of DVT in hospitalized burn patients was as high as 23%. That’s -- high. Nachi: Neurologic complaints are far more common as nerve tissue is highly conductive. While the most common injury from an electric shock is loss of consciousness, other common neurologic insults include weakness, paresthesias, and difficulty concentrating. Jeff: And if the entry and exit sites traverse the spinal cord – this also puts the patient at risk for spinal cord lesions. Specifically with respect to high voltage injuries – these victims are at risk for posterior cord syndrome. In addition, depression, pain, anxiety, mood swings, and cognitive difficulties have all been commonly described. Nachi: Rounding out our discussion of electrical injuries, visceral injuries are rather rare, with bowel perforation being the most common. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. Jeff: Perfect. I think that more or less rounds out an overview of organ specific electrical injuries. Let’s talk about prehospital care for these patients -- a broad topic in this case. As always, the first, and most important step in prehospital care is protecting oneself from the electrical exposure if the electrical source is still live. Nachi: In cases of high voltage injuries from power lines or transformers or whatever oddity the patient has come across, it may even be necessary to wait for word from the local electrical authority prior to initiating care. Remember, the last thing you want to do is become a victim yourself. Jeff: For those whose electrical injury resulted in cardiac arrest, follow your standard ACLS guidelines. These aren’t your standard arrest patients though, they typically have many fewer comorbidities – so CPR tends to be more successful. Nachi: Intubation should also be considered especially early in those with facial or neck burns, as risk of airway loss is high. Jeff: And as we mentioned previously, concurrent trauma and therefore traumatic injuries is very common, especially with high voltage injuries, so patients with electrical injuries require a complete survey and not just a brief examination of their obvious injuries. Nachi: When determining destination, trauma takes priority over burn, so patients with significant trauma or those who are obtunded or unconscious should be transported to an appropriate trauma center rather than a burn center if those sites are different. Jeff: Let’s move on to evaluation in the emergency department. As always, it’s ABC and IV, O2, monitor first with early airway management in those with head and neck burns being a top priority. After that, complete your primary and secondary surveys per ATLS guidelines. Nachi: During your survey, make sure the patient is entirely undressed and all constricting items, like jewelry is removed. Jeff: Next, make sure that all patients with high voltage injuries have an EKG and continuous cardiac monitoring. Those with low voltage injuries and a normal EKG do not require monitoring. Nachi: Additionally, for those with severe electrical injuries, an IV should be placed and fluid resuscitation should begin. Fluid requirements will likely be higher than those predicted by the parkland formula, and you should aim for a goal of maintaining urine output of 1-1.5 ml/kg/h. Jeff: With your initial stabilization underway, you can begin to gather a more thorough history either from bystanders or EMS if they are still present. Try to ascertain whether the current was AC or DC, and whether it was high or low voltage. Don’t forget to ask about the setting of the injury as this may point to other concurrent traumatic injuries, that may in fact take precedence during your work up. Nachi: Moving on to the physical exam. As mentioned previously, disrobe the patient and complete a primary and secondary survey. Jeff: If the patient has clear entry and exit wounds, the path through the body may become apparent and offer clues about what injuries to expect. Nachi: A single exam will not suffice for electrical injury patients. All patients with serious electrical injuries will require serial exams to evaluate for vascular compromise and compartment syndrome. Jeff: So that wraps up the physical, let’s move onto diagnostic studies. Nachi: First off -- I know we’ve said it, but it’s definitely worth reiterating. All patients presenting with a history of an electric shock require an EKG Jeff: In those with a low voltage injury without syncope and a normal EKG, you don’t routinely need cardiac monitoring. However, in the setting of high voltage injuries, the data is less clear. Based on current literature, the authors recommend overnight monitoring for at least 8 hours for all high voltage injuries. Nachi: While no routine labs work is required for minor injuries, those with more serious injuries require a cbc, cmp, CK, CK-MB, and urinalysis. Jeff: The CK is clearly for rhabdo, but interestingly, a CK-MB greater than 80 ng/mL is actually predictive of limb amputation. Oh and don’t forget that urine pregnancy test when appropriate. Nachi: In terms of imaging, you’ll have to let your history guide your diagnostic studies. Perform a FAST exam to screen for intra-abdominal pathology for anyone with concern for concurrent trauma. Keep a low threshold to XR or CT any potentially injured body region. Jeff: Real quick – in case you missed it – ultrasound sneaks in again. Maybe I should reconsider and do an US fellowship – seems like that’s where the money is at - well maybe not money but still. Let’s move on to treatment. Nachi: In those with minor injuries like small burns and a low voltage exposure – if they have a normal EKG and no other symptoms, these patients require analgesia only. Give return precautions and have them follow up with their PCP or a burn center. Jeff: In those with more severe injuries, as we mentioned before, but we’ll stress again, protect the patient’s airway early especially if you are considering transfer and have any concerns. In one study, delays in intubation was associated with a high risk of a difficult airway. Always make sure you have not only your tool of choice but also all of your backup airway devices ready as all deeper airway injuries may not be apparent externally. Nachi: Fluid resuscitation with isotonic fluids is the standard -- again -- with a goal urine output of 1-1.5 ml/kg/h. Jeff: Address pain with analgesia – likely in the form of opiates – and don’t be surprised if large doses are needed. Nachi: Dress burned areas with an antibiotic dressing and update the patient’s tetanus if needed. While there is ongoing debate about the role of prophylactic antibiotics, best evidence at this point recommends against them. We talked about thermal burns in Epsiode 13 also, so go back and listen there for more... Jeff: There is also a range of practice variation with respect to early surgical exploration of the burned limb with severe injuries. At this time, however, the best current evidence supports a conservative approach. Nachi: Serial exams and watch and wait it is. . We have some interesting special populations to discuss this month. First up, as is often the case, the kids. Jeff: Young children are sadly more likely to present with orofacial burns due to, well, everything ending up in their mouth. And since many of our listeners are likely in boards study mode – why don’t you fill us in on the latest evidence with respect to labial artery bleeding. Nachi: Sure – . There is up to a 24% risk of labial artery bleeding and primary tooth damage with oral electrical injuries. Although there isn’t a clear consensus, current evidence supports early ENT consultation and a strong consideration for admission and observation for delayed bleeding. Jeff: Keep in mind though, that labial artery bleeding is often delayed and has been reported as far as 2 weeks out from the initial insult. Nachi: Moral of the story: don’t put electrical cords in or anywhere near your mouth. Next, we have pregnant patients. Case reports of pregnant patients suffering electrical injuries have described fetal arrhythmias, ischemic brain injury, and fetal demise. For this reason, those that are past the age of fetal viability should have fetal monitoring after experiencing an electric shock. Jeff: If not already done, an ultrasound should be obtained as well and a two week follow up ultrasound will be needed. Nachi: We’re switching gears a bit with this next special population – those injured by an electrical control device or taser. Jeff: Tasers typically deliver an initial 50,000 volt shock, with a variable number of additional shocks following that. Nachi: Most taser injuries are thankfully direct traumatic effects of the darts or indirect trauma from subsequent falls. Jeff: While there are case reports of taser induced v fib, the validity of taser induced arrhythmias remains questionable due to confounders such as underlying disease and previously agitated states like excited delirium Nachi: Basically, [DING SOUND} those with taser injuries should be approached as any standard trauma patient would be, with the addition of an EKG for all of these patients. Jeff: The next special population --- the one I’m sure you’ve all been waiting patiently for -- is lightning strike victims. Lightening carries a voltage in the millions with amperage in the thousands, but with an incredibly short exposure time. Because of this, lightening causes injuries in a number of different ways. Nachi: First, because it’s often raining when lightning strikes, wet skin may cause the energy to stay on the skin in what is known as a flashover effect. Jeff: Similarly and not surprisingly, burns are common after a lightning strike. Lichtenberg figures are superficial skin changes that resemble bare tree branches and are pathognomonic for lightning injury. Thankfully, these usually disappear within a few weeks without intervention. Nachi: Next, the rapid expansion of the air around the strike can lead to a concussive blast and a variety of traumatic injuries including ocular and otologic injury like TM rupture which occurs in up to two thirds of cases. Jeff: An ophthalmologic consult should be obtained in most, if not all of these cases. Nachi: Making matters worse, lightning can also travel through electric wiring and plumbing to cause a shock to a person indoors nearby the strike! Jeff: And like we mentioned earlier, just as was the case with my fellow Pittsburgher or ‘Yinzer. Nachi: Yinzer? Jeff: Forget about it, it’s just what Pittsburghers call themselves for some reason or another - but we’re still talking lightning. Cardiac complications including death, contusion and vasospasm have all been reported secondary to lightning injury. But don’t lose hope – in fact – you should gain hope as these patients have a much higher than typical survival rates. Nachi: From the neurologic standpoint – it’s a bit more complicated. CNS dysfunction may be immediate or delayed and can range from strokes to spinal cord injuries. Cerebral salt wasting syndrome, peripheral nerve lesions, spinal cord fracture, and cerebral hemorrhages have all been described. An MRI may be required to elucidate the true diagnosis. Jeff: Clearly victims of lighting strikes are complex and, for that reason, among many others, the American College of Surgeons recommends that victims of lightning strikes be transferred to a burn center for a comprehensive eval. Nachi: Let’s touch upon any other details regarding disposition. Jeff: Those with low voltage exposures, a normal EKG and minimal injury may be discharged home with PCP follow up and strict return precautions. Nachi: High voltage injuries on the other hand require admission to a burn center and the involvement of a burn surgeon, even if it involves transferring the patient. Jeff: And remember, trauma takes precedence over burn and those with traumatic injuries or the possibility of traumatic injuries should be evaluated at a trauma center. Don’t forget to take the airway early if there is any concern, and consider transporting via air as the services of a critical care transport team may be required. Nachi: That wraps up Episode 22, but let’s go over some key points and clinical pearls. During evaluation, consider multisystem injuries due to not only the thermal injury and electrical damage to electrically sensitive tissue, but also mechanical trauma. Thermal injury can lead to muscle breakdown, rhabdomyolysis, myonecrosis, edema, compartment syndrome, osteonecrosis, and even periosteal burns. Mechanical injury can be a result of forceful muscular contractions, and trauma can manifest as fractures, dislocations, and significant muscular injuries. Electrical injuries due to grasping an electric source can induce tetanic muscle contractions and therefore the inability to let go, increasing the duration of contact and extent of injury. Current tends to follow the path of least resistance, which explains why you might have deeper injuries beyond what can be visualized in the surface. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat, on the other hand, have the highest resistance to electrical injury. High voltage injuries place patients at risk for spinal injuries, most notably posterior cord syndrome. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. All patients with electrical injury require an EKG. Low voltage injuries with a normal presenting EKG do not always require cardiac monitoring. High voltage injuries require cardiac monitoring for at least 8 hours. Intubation should be considered early in patients with facial or neck burns, as risk of airway loss is high. Make sure to have airway adjuncts and back up equipment at bedside, as deeper airway injuries may not be obvious upon external exam. For severe injuries, target a urine output rate of 1-1.5 mL/kg/hr. All patients with serious electrical injuries require serial exams to evaluate for vascular compromise and compartment syndrome. Address pain with analgesia. Larger than expected doses may be needed. Dress burned areas with an antibiotic dressing and update the patient’s tetanus if required. For pediatric patients with oral electric injuries from biting on a cord, consult ENT early and consider admission for observation of delayed arterial bleeding. Pregnant patients who are past the age of fetal viability should have fetal monitoring and ultrasound after experiencing an electric shock. Tympanic membrane rupture is a commonly noted blast injury after a lightning strike. Cardiac resuscitation should follow ACLS guidelines and is more likely to be successful than your tyipcal cardiac arrest patient as the patient population is typically younger and without significant comorbidities. When determining destination, trauma centers take priority over burn centers if those sites are different. So that wraps up episode 22 - managing electrical injury in the emergency department. 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 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. And the address for this month’s credit is ebmedicine.net/E1118, 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!
Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. 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 and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found in the greatest quantities. The neuropsychiatric and addictive properties of cannabis are due primarily to the delta-9-THC. Jeff: THC and other cannabis derivatives work through the endocannabinoid system and other neuroregulators. The endogenous cannabinoid system has 4 components: (1) endogenous endocannabinoids, (2) receptors, (3) degradation enzymes, and (4) transport mechanisms. Nachi: There are two endogenous endocannabinoids to know about: anandamide (AEA) and 2-arachidonoyl-glycerol. Jeff: Cannabinoid receptors are broadly dispersed through the central nervous system, and to a lesser degree, also to other organ systems. Nachi: Because CB receptors are concentrated within the central nervous system, they exert the majority of their effects on the neuropsychiatric systems. And -- yes that’s a double ding -- the cannabinoid 1 (or CB1) receptor is most responsible for cannabis-induced neuropsychiatric effects. Jeff: Interestingly, the anti-emetic effects and possible palliative properties of cannabis derivatives are thought to be secondary to the inhibitory effects on serotonin receptors and the excitatory effects on the transient receptor potential vanilloid 1 (or TRPV1). More on TRPV1 later... Nachi: So far we have been talking about cannabinoids from the cannabis plant, but with cannabis being illegal in many states, there has been a growing emergence of synthetic cannabinoids. Synthetics were initially developed in the 1980s largely for research purposes. Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests. Nachi: You may be familiar with some of the street names for synthetics -- like spice, K2, scooby snacks, black mamba, kush, and kronic. These can often be purchased over the internet or through specialty smoke shops. Jeff: Scooby Snacks, what a fantastic name, mooovingggg on… Synthetic cannabinoids often have greater affinity for the CB1 receptor than naturally occurring cannabinoids -- and synthetics can produce 100 times the effect. As a result, the presenting symptoms with synthetic intoxication can be difficult to differentiate from crystal meth or bath salt abuse. Nachi: Manufacturers sometimes use solvents and other contaminants. Clusters of toxic ingestions and deaths have occurred. Emergency clinicians need to be aware of this and should report suspicious events immediately. Jeff: For more on synthetic intoxications in the ED, be sure to take a look at the recent May 2018 issue of Pediatric Emergency Medicine Practice on Synthetic Drug Intoxication in Children if you haven’t already read it. Also, just a quick FYI - If you’re not a current subscriber to Pediatric Emergency Medicine Practice, we’re giving away a free copy of the issue specifically for our listeners. Just head over to ebmedicine.net/drugs for the PDF of the issue. Nachi: A free issue for our listeners, that’s nice! Let’s move on to a discussion about current indications for cannabinoids. So, there is no clear consensus on these indications, but there is some research of varying quality that supports the treatment of some chronically debilitating diseases with cannabinoids. Jeff: A systematic review and meta-analysis from 2015 found low-quality evidence to support cannabis therapy for appetite suppression in HIV and aids patients; moderate-quality evidence for treatment of chronic pain and spasticity; and also moderate quality evidence for some chronic debilitating diseases. Nachi: While talking about evidence-based medicine here, another review by the National Academies of Science, Engineering, and Medicine on possible associations between cannabis and cancers arising in the lungs, head, and neck, or testicles -- showed no statistically significant associations exist. Jeff: So in case that wasn’t clear - the overall evidence to support cannabis therapy, in general, is weak. Also, be aware that there are various formulations of cannabis that allow for different routes of administration. We’re talking oils, tinctures, teas, extracts, edibles like candies and baked goods, parenteral formulations, eye solutions, intranasal, sublingual, transmucosal, tablets, sprays, skin patches, topical creams, rectal suppositories, and capsules -- just to name, a few. Nachi: A few! That seems pretty complete to me. Basically, any way you can imagine, it seems like a route of administration has been explored. But of importance, these formulations have different absorption times -- as you might expect. The shortest duration to peak plasma levels of delta-9-THC is through the inhalation route, which can produce effects within 3 minutes. On the longer end, rectal cannabis administration can take up to 8 hours to reach peak plasma concentrations. Jeff: Let’s talk about some of the clinical findings and systemic effects associated with cannabis use. First up is the link between cannabis use and stroke or TIA. Cannabis users who smoked at least once weekly had a 3.3 times higher risk of stroke or TIA. Nachi: And there is moderate quality evidence that this link may be dose-dependent. Larger amounts of cannabis use lead to cerebral vasospasm and a reduction in cerebral blood flow. Jeff: In terms of psychiatric effects, several low-to-moderate quality studies have shown statistically significant associations between psychosis and self-reported cannabis use. Some association between high potency cannabis or synthetic cannabinoid use with new-onset psychosis or relapse in previous psychiatric disorders has also been found. Lastly, there is weak data supporting a correlation between cannabis use and depression. Nachi: From a cardiovascular standpoint, cannabis use is associated with increased resting heart rate, hypertension, and decreases in the anginal threshold for patients with chronic stable angina. A 2001 study described an augmented risk of myocardial infarction within the first hour of cannabis use and found an almost 5-fold increase in those who reported smoking cannabis at least weekly when compared to those who smoked monthly or less. Jeff: Dysrhythmias, qt prolongation, av blocks, myocarditis, and sudden death have all been reported with cannabinoids. Nachi: In terms of pulmonary effects, these are not really related to cannabis use directly, but rather the smoke inhalation and combustion materials of synthetic cannabinoids. Effects from chronic use can be seen. Jeff: Renally speaking, acute kidney injury and rhabdomyolysis are associated with synthetic cannabinoids and have been observed in several case reports. The rhabdo is believed to be due, in part, to associated seizures, muscle tremors, and agitation. Nachi: Among metabolic abnormalities, patients can present with hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. Jeff: Orally and dentally, dry mouth is the most common finding in acute cannabis toxicity. Chronic use has also been linked to severe periodontitis. Nachi: And ophthalmologically, there is, of course, the commonly seen conjunctival injection. Cannabis has also been found to decrease intraocular pressure when used topically -- and of note, there have also been rare reports of acute angle closure glaucoma and central retinal vein occlusion. Jeff: While talking about clinical findings and systemic effects of cannabis use, we certainly need to go over cannabinoid hyperemesis syndrome (or CHS), which is -- quite simply put -- associated with frequent visits to the ED in chronic users. It presents with nausea, vomiting, and abdominal pain. Nachi: CHS is commonly misdiagnosed as cyclical vomiting syndrome. After the legalization of marijuana in Colorado, it was reported that nearly twice as many patients had presented for what was thought to be cyclical vomiting syndrome. And ironically, though cannabis has been used as an anti-emetic, chronic use can cause the opposite reaction, leading to CHS, which is typically refractory to traditional anti-emetics. Jeff: And the etiology of CHS is not well understood. Similarly, the exact criteria for CHS are poorly defined. It presents as a recurrent and relapsing disorder that can be divided into 3 phases: prodromal, hyperemetic, and recovery. Nachi: In the prodromal phase, patients complain of early morning nausea without vomiting, and they can have mild abdominal discomfort. This can last from months to years. In the hyperemetic phase, patients complain of severe, unremitting abdominal pain with repeated episodes of vomiting and retching. This is often associated with an inability to tolerate po. Jeff: The hyperemetic phase lasts 24-48 hours and can lead to dehydration, electrolyte abnormalities, and weight loss. Patients may learn to relieve symptoms by compulsively bathing in hot water. Nachi: Resolution of symptoms is seen when the patient stops using cannabis. This is during the recovery phase, which can last from days to months. But this can be short-lived if the patients begin using cannabis again. Jeff: On that note, we should also touch on cannabis withdrawal. Termination of heavy and habitual use can lead to withdrawal syndromes within 48 hours. Symptoms here include irritability, anxiety, restlessness, sleep difficulty, seizures, and aggression. Medications that can be helpful include benzodiazepines, neuroleptic agents, and quetiapine in refractory cases. Nachi: Moving on to the next sections in the article, let’s talk about differential diagnosis and prehospital care. The differential for acute cannabinoid intoxication, as you might suspect, is broad, and it includes some life-threatening processes. We won’t list them here, but be sure to think broadly before deciding on cannabis as the cause of your patient’s symptoms. Jeff: For the prehospital providers -- care here is mainly supportive. Provide airway protection as needed - gather information from the patient’s environment, looking for empty pill bottles or another empty packaging. Nachi: Let’s move on to care once in the ED. All patients who are in distress and suspected of drug ingestion should be disrobed completely and placed on a cardiac monitor. Fully assess for trauma and place an IV in the patient. Search the patient’s clothing for drugs and paraphernalia, which may help in making the diagnosis. Jeff: When getting a complete history from the patient, it may also be worthwhile to talk with any persons accompanying the patient to the ER for more information. In your history, be sure to ask about a pattern of use and possible co-ingestions. Nachi: When considering cannabis hyperemesis syndrome, a detailed history and physical exam are crucial for making the diagnosis. To differentiate between other etiologies of abdominal pain and vomiting, be sure to ask about the use of hot baths for relief, resolution of symptoms after stopping cannabis use, and the predominance of symptoms in the morning hours. Jeff: On physical exam, for cannabis intoxication, there isn’t a particular toxidrome to look for. Monitor vital signs closely, looking out for alterations in blood pressure and heart rate. A complete neurologic and mental status examination will be the key here. Nachi: Decisions for lab testing should be dependent on the patient’s presentation. Possible tests include CBC, BMP, LFT’s, lipase, cpk, ckmb, troponin, urinalysis, urine drug screening, serum tox screens (for alcohol, aspirin, and acetaminophen), and any other drug levels for medications that the patient is taking for medicinal purposes, like phenytoin or lithium levels. Jeff: One study supported point of care urine drug testing in the ED. However, know that acute cannabis intoxication can be difficult in the chronic user, as delta-9-THC will be present in urine for up to 24 days. Testing for synthetically derived cannabinoids is difficult due to changes in synthetic compounds. Nachi: Interestingly, there are a number of medications that are associated with false positive cannabinoid screenings. These include ibuprofen, pantoprazole, efavirenz, and lamotrigine. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. You’re looking for signs of ischemia, arrhythmia, and interval abnormalities. Serum and urine tox tests are not particularly helpful in the acute chest pain patient who is using synthetic marijuana. Nachi: Not surprisingly, there are no specific diagnostic imaging modalities to help diagnose cannabis or synthetic cannabinoid intoxication. But imaging may help with assessing other disease states on a patient’s differential, so stay mindful of that. Jeff: Now that we’ve talked about history, physical exam, and useful testing modalities, let’s talk about treatment for cannabis and synthetic cannabinoid toxicity… therapy is primarily focused on supportive care. Most ED visits only require a short stay. Nachi: That’s right, there are no antidotes to give for treatment here. Be sure to look for and treat dehydration, acute renal failure, and rhabdo though. In severe cases of neuropsychotropic effect, give benzodiazepines, like lorazepam, to help with control. Jeff: For GI effects, first-line treatment is traditional anti-emetics like ondansetron or metoclopramide. Recent literature and case reports have shown significant improvement with butyrophenones like haloperidol as a second-line treatment. Nachi: While talking about treating the gastrointestinal effects of cannabis toxicity, let’s also discuss methods to control cannabinoid hyperemesis syndrome. The mainstays for treatment here are actually supportive therapy and cessation of cannabis use. Jeff: And can you tell us more about why these patients crave hot showers and improve after? Is there a pathophysiology or mechanism to know about there? Nachi: There is a well-studied theory here and it relates to the TRPV1 receptor that we talked about earlier. Temperatures in excess of 109 degrees Fahrenheit, acidic conditions, and compounds found in certain foods and plants (like cannabis) activate this receptor. It’s believed that intermittent and repetitive exposure to agonists of the TRPV1 receptor leads to a persistent state of nausea and vomiting. Desensitization of the receptor happens after repeated stimulation, and repetitive topical capsaicin or hot water is believed to function as an exogenous agonist. Jeff: In any case of repetitive emesis, be sure to consider electrolyte replacement if needed. In many cases, hydration or repletion will need to happen through an IV. Proton pump inhibitors can also help in some cases where GI symptoms are a dominating complaint of the patient. Nachi: Recent literature supporting the use of haloperidol for nausea and vomiting has found that symptoms improve approx 1hr after administration. This can decrease the need for observation or admission. Jeff: Haloperidol works via dopamine 2 receptor antagonism. D2 receptors are found in high concentrations throughout the nervous system and bind with high affinity to haloperidol. The suggested starting dose is 2.5mg IV with a repeat dose of 5mg IV if needed. An RCT is underway in Canada on the use of ondansetron versus haloperidol with an estimated completion of July 2019. Nachi: Capsaicin has similarly shown promise in cannabis hyperemesis syndrome through the TRPV1 receptor as we discussed already. Currently, there are no dosing recommendations or application instructions for capsaicin. There is some evidence supporting relief within 30 to 45 minutes, and capsaicin can be applied topically to any nonmucosal surface like the abdomen, chest, or back. Jeff: So to recap -for cannabis hyperemesis syndrome, treat with anti-emetics, PPI’s, electrolyte repletion, and IV hydration as needed. As a second line treatment, consider haloperidol and topical capsaicin applied to the chest, abdomen, or back. Nachi: Let’s talk about some special populations next -- starting with Pediatrics. According to data from 2012, of the 130 million people reporting illicit drug use within their lifetime, 25% were children between 12 and 17 years of age. Jeff: And according to the national poison data system, states with marijuana use laws have seen a 30% increase in calls related to marijuana use by children. From 2010 to 2011, the number of ED visits by children aged 12 to 17 years old due to synthetic cannabinoid use also has doubled. Nachi: Many children and adults believe that synthetic cannabinoids don’t pose serious health risks, as these are not illegal to purchase. And this class of drugs is particularly attractive to adolescents since it will not readily test positive on urine drug tests. All of this is very concerning for emergency clinicians. Jeff: There have been several recent reports of myocarditis in association with marijuana use. One case resulted in death due to myocyte necrosis after an unknown amount of edible marijuana was consumed by a toddler. Nachi: Horrific! Jeff: And the exact mechanism through which the myocardial necrosis happens isn’t known. Nachi: For all children and adolescents who present to the ED with alteration in mental status, psychosis, or chest pain -- be sure to screen for cannabis or synthetic cannabinoid use. There are case reports in the pediatric literature of STEMIs seen in patients without pre-existing cardiac disease or risk factors. Jeff: Keep in mind that urine drug screens can be falsely positive from certain proton pump inhibitors, so if possible, assess a urine drug screen prior to starting a PPI in these patients. Nachi: Moving on to our next special population… pregnant women. Know that it can be difficult to the differential between hyperemesis gravidarum and cannabis hyperemesis syndrome in pregnant patients. Ask specific questions regarding marijuana use before and during the pregnancy. Jeff: It’s also worth noting that cannabis is known to cause adverse outcomes on babies such as low birth weight and more frequent perinatal ICU placement. Nachi: Let’s move on to the final major section of the article, which is on the legal status of cannabis and cannabinoids. Much of the controversy surrounding cannabis for medicinal use relates to the absence of quality evidence. More research is needed to evaluate potential public health risks posed by variations in quality and potency, potential impact to our healthcare system, and ability to legislate for synthetic cannabinoids. Jeff: Though marijuana and all whole-plant derivatives are schedules I controlled substances, there are a few cannabinoid-based drugs approved by the FDA for medicinal purposes -- with lower schedule designations. Dronabinol is a schedule III drug derived synthetically from delta-9-THC. It’s used in chemotherapy-induced nausea/vomiting, as well as anorexia and weight loss from AIDS/cancer. Nachi: Nabilone, a schedule II synthetic variant of THC, has been approved in the treatment of aids-related anorexia and chemotherapy-induced nausea also. Jeff: Nabiximols, a plant-derived cannabinoid, has been approved in Europe and Canada for multiple sclerosis induced spasticity and cancer-related pain. Nabiximols are not yet approved in the US. Nachi: And lastly, we should mention cannabidiol, which is a schedule I controlled substance approved for treatment of seizures with 2 rare diseases -- Lennox-gastaut syndrome and dravet syndrome. Compared with placebo alone cannabidiol and other medications have shown efficacy in lowering the rate of seizures for these diseases. Jeff: Lots of interesting stuff to look out for there in cannabinoid-related medications. Alright, on to disposition - Nachi: Most patients who present with uncomplicated acute cannabis or synthetic cannabinoid intoxication can be observed until clinically sober. Discharge home should be in the care of a sober family member or friend. Make sure that the patient knows not to operate vehicles or heavy machinery under the influence of drugs. Counsel them on drug abuse also. Jeff: In more rare situations, patients will require admission. Consider this particularly for patients who have end-organ damage, rhabdomyolysis, acute renal failure -- evidence of cardiovascular, cerebrovascular, or ophthalmologic insults -- intractable vomiting, or acute psychosis. Nachi: And for cannabinoid hyperemesis syndrome, patients may require admission for IV hydration and electrolyte correction. Once the patient is tolerating PO and lab derangements have been corrected, they can be discharged. Jeff: Let’s wrap up the episode with key points and clinical pearls… N: Marijuana is the most commonly used illicit substance in the US. States that have legalized marijuana for medical and recreational purposes are showing increased rates of marijuana abuse and dependence. J: When concerned with drug intoxication, search your patient’s clothing for drugs and paraphernalia on arrival. N: The neuropsychiatric and addictive properties of cannabis are due primarily to delta-9-THC. J: Synthetic cannabinoids have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designations as well as routine urine drug screening tests. N: Manufacturers of synthetic cannabinoids sometimes use solvents and other contaminants, which have caused clusters of toxic ingestions and death. J: The shortest duration to peak plasma levels of delta-9-THC is through the inhalational route. Effects can be seen within 3 minutes. N: Cannabis users who smoke at least once weekly can have a 3.3 times higher risk of stroke or TIA. J: The risk of myocardial infarction is increased within the first hour of use, and there is an almost 5-fold increase for individuals who smoke at least once per week. N: Acute kidney injury and rhabdomyolysis have been noted with synthetic cannabinoid use in several case reports. J: Cannabis intoxication is associated with many metabolic abnormalities like hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. N: Cannabis hyperemesis syndrome, which presents with abdominal pain and vomiting, is associated with frequent visits to the ED in chronic users. J: The mainstay for treatment of cannabis hyperemesis syndrome is supportive therapies and cessation of cannabis use. N: Patients with cannabis hyperemesis syndrome crave hot showers because of activation of the TRPV1 receptor. J: Topical capsaicin may also help in the treatment of cannabis hyperemesis syndrome through activation of the TRPV1 receptors. N: Haloperidol at 2.5mg IV may help in refractory vomiting associated with cannabis hyperemesis syndrome. J: Many children and adults do not believe synthetic cannabinoids pose serious health issues as the they are not illegal to purchase. This is incorrect. N: Most patients with acute uncomplicated cannabis intoxication can be observed and discharged. Admit if there are any signs of end organ damage, intractable vomiting, or acute psychosis. Jeff: So that wraps up the August 2018 episode of Emplify. Nachi: For those of you looking for CME - the address for this months credit is ebmedicine.net/E0818, so head over there right away to get the credit you deserve. Remember that the you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. See you next time! Most Important References 5. * Kim HS, Monte AA. Colorado cannabis legalization and its effect on emergency care. Ann Emerg Med. 2016;68(1):71-75. (Literature review; 21 studies)7. * Baron EP. Comprehensive review of medicinal marijuana, cannabinoids, and therapeutic implications in medicine and headache: What a long strange trip it’s been …. Headache. 2015;55(6):885-916. (Review)9. * Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456-2473. (Retrospective chart review; 4 cases)64. * Tournebize J, Gibaja V, Kahn JP. Acute effects of synthetic cannabinoids: update 2015. Subst Abus. 2016:1-23. (Systematic review; 46 articles, 114 patients)83. * Wallace EA, Andrews SE, Garmany CL, et al. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. South Med J. 2011;104(9):659-664. (Review)
Highlights: War Comes to U.S. Shore! 100 Years Ago This Week: German U-boats on the Eastern seaboard | @01:30 War In The Sky: First American Ace | @07:30 A million men in France - Mike Shuster | @`12:30 Machine gunners at Chateau Thierry - Dr. Edward Lengel | @16:45 Commission Armistice Centennial Plans - Meredith Carr | @21:10 CBS News Radio at Pershing Park - Chas Henry | @27:15 WWI at the Smithsonian National Air & Space Museum - Dr. Peter Jakab | @29:50 New Mexico in WWI - Jeff Laudermilk | @36:10 100C /100M: Hawaii’s Memorial Natatorium - Donna Ching | @43:00 Centennial in Social Media - Katherine Akey | @51:25----more---- Opening Welcome to World War 1 centennial News - episode #75 - It’s about WW1 THEN - what was happening 100 years ago this week - and it’s about WW1 NOW - news and updates about the centennial and the commemoration. This week: Mike Schuster updates us on the fighting fronts around the world Ed Lengel tells the story of the machine gunners at Chateau Thierry Meredith Carr gives us a preview of commemorative events planned for the upcoming centennial of the Armistice Dr. Peter Jakab [jay-cub] introduces us to the WW1 programming at the National Air and Space Museum Jeff Lowdermilk joins us fromthe New Mexico WW1 Centennial Commission Donna Ching shares the 100 cities/100 memorials project in Honolulu Katherine Akey highlights the commemoration of world war one in social media And a whole lot more on WW1 Centennial News -- a weekly podcast brought to you by the U.S. World War I Centennial Commission, the Pritzker Military Museum and Library and the Starr foundation. I’m Theo Mayer - the Chief Technologist for the Commission and your host. Welcome to the show. [MUSIC] Preface [MUSIC TRANSITION] As we screened the stories running 100 years ago this week, in the NY times and the Official Bulletin, the government’s War Gazette - a major US domestic theme took front and center. The germans were trying to bring the war to our shore! U-boats were cruising off our eastern seaboard, threatening our merchant shipping and sinking ships. Though the loss of life was minimum, the psychological effects were powerful… and the media was speaking to it. With that as a setup, we are going to jump into our Centennial TIme Machine and go back 100 years ago this week in the War that changed the world! [SOUND EFFECT] [TRANSITION] World War One THEN 100 Years Ago [SOUND EFFECT] From the front page of the Official Bulletin - published by George Creel’s Committee for Public Information... Dateline: Monday, June 3, 1918 Headline: three American ships sunk off New Jersey coast by enemy submarines Crews are rescued And the stories reads: Secretary of the Navy Josephus Daniels authorizes the following statement: The Navy department has been informed that three American schooners have been sunk off this coast by enemy submarines. The secretary’s statement closed with: “The Navy department is taking the necessary steps to safeguard the shipping along the coast.” The next day in the Bulletin [SOUND EFFECT] Dateline Tuesday, June 4, 1918 Headline: Navy announces - now five US ships sunk by submarines off Atlantic Coast One life known lost Steamship Carolina not heard from since reported under fire of U-boat Sunday afternoon. Oil tanker among the vessels reported lost. Later in the same issue of the Bulletin there is a first person account of the attack. It is an account of how these attacks went throughout the week - Headline: Steamer Bristol chased by submarine after picking up Schooner Cole's crew; latter saw the second steamship sunk And the story reads: the captain of the Bristol reported: "on June 2 at 4:30 PM, I cited a lifeboat with 11 men, the crew of the American schooner Edward H Cole, The Cole having been sunk by a submarine at 3:30 PM about 50 miles south east of Barnegat light." "the crew of the Cole say the submarine was about 200 feet long and was armed with two 6 inch guns. About 3 PM the Cole sighted the submarine on the starboard bow about 2000 yards away. He circled around and came up their port side. The submarine commander told the captain and crew to get in their boats, saying that he was going to sink the vessel. He then came aboard and examined the ships papers, and at the same time gave the captain 7 1/2 minutes to leave the ship. About 15 minutes after the crew got away from the Cole it sank. Four bombs had been placed on the vessel, two on each side, and some were placed about the deck. The submarine stayed until the crew rowed to the northwest." One hour later, when we were about 4 miles from the submarine, another steamship appeared close up to the submarine, which fired five times before she altered her course". On Wednesday another front page story in the bulletin [SOUND EFFECT] Dateline Wednesday, June 5, 1918 Headline: US destroyers stops U-boat attack on French steamer Off Maryland coast Warship also takes on board man from the Edward Bayard, bombed and sinking. Another story in the same issue lists 11 US ships reported to navy as sunk by submarines… The article goes on to read off the names of the ships the smallest of which was a 436 tons, schooner and the largest a steamship at 7200 tons. From the NY times: [SOUND EFFECT] Headline: TEXEL sunk, 36 survivors landed Former Dutch steamer attacked by a U-boat 60 miles from the city Fired without warning Shrapnel rained on deck, men reach Atlantic City lighthouse in small boats And the story reads: 36 survivors of the steamer TEXEL, a former Dutch ship which recently had been operated by the United States shipping board, was sunk without warning, 60 miles off New York Harbor, Sunday afternoon at 4:21 p.m., The crew landed at a nearby lighthouse, just before midnight. A cargo of 42,000 tons of sugar, valued at $20 a ton was lost. The total loss was more than $2 million. The stories go on throughout the week and beyond with many articles providing first hand accounts of the attacks - many times, in attacking the unarmed merchant ships, the U-boats would fire warnings from guns, come aboard, examine papers, get the crews to abandon ship and blow them up with bombs rather than wasting torpedoes. If the ships were armed or fought back - the submarines would stand off and torpedo them. The general loss of life was not large, but the disruption to shipping in our eastern seaboard was profound. We have posted a lot of our research links for you in the podcast notes. The most compelling are the many first person accounts of the attacks - as the Germans bring the war to our shore -- 100 years ago this week in the war that changed the world. Other naval stories https://timesmachine.nytimes.com/timesmachine/1918/06/06/102706915.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/07/102707289.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706133.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/06/102706933.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/05/102706533.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706131.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/03/102705767.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/02/102704868.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/02/102704910.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/03/102705842.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/03/102705878.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706134.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706129.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706151.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706155.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706158.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/05/102706538.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/05/102706559.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/05/102706536.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/07/102707292.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/07/102707298.pdf Fighting Front https://timesmachine.nytimes.com/timesmachine/1918/06/02/102704870.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/02/102704865.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/02/102704860.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/02/102704879.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/03/102705775.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/03/102705771.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/03/102705775.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/03/102705780.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706126.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/05/102706529.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/07/102707272.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/06/102706968.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/06/102706910.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/06/102706903.pdf [MUSIC TRANSITION] War in the Sky This week for the War in the Sky 100 years ago, we can easily stay on the theme of the war at our shore with two stories and then we head overseas to pick up the action there. [SOUND EFFECT] Dateline June 5 1918 Headline: City lights out in air raid test Aviators make observations preliminary to possible darkening of the streets. Anti aircraft guns ready System of siren signals arranged to warn people of danger from the skies And the story reads: Electric signs and all lights, except street lamps and lights in dwellings, were out in the city last night in compliance with orders issued by police Commissioner and at the suggestion of the war Department, as a precaution against a possible attack by aircraft from a German submarine. While the probability of raids by aircraft from submarines is not considered to be great, officers of the Army and Navy urged that every precaution be taken. In spite of the difficulties attending such an operation, to assemble an airplane on a submarine and launch it for a raid is held to be far from impossible. [SOUND EFFECT] Dateline June 3, 1918 Headline: Aero club wants more aviators to hunt U-boats here And the story reads Extension of the airplane mail service is to give long distance flight training to American aviators to fit them for seeking out submarines which now have appeared off the coast and for bombing German cities, This was urged by the post office department today by a committee from the Aero club of America. They said that they had been informed by the military authorities that there were plenty of training planes and that the war Department was more than willing to cooperate with the postal authorities in extending the air Mail service. Meanwhile from the war in the skies over Europe: [SOUND EFFECT] Dateline June 2 1918 Headline: Campbell first Ace of America California pilot honored as well as two others who flew with Lafayette corps. Campbell Downs a fifth adversary And the story reads: The first American trained Ace has arrived. This morning Lieut. Douglas Campbell, of California, brought down his fifth Bausch plane in a fight back of our lines. Besides Campbell, America has two other cases, maj. William Thaw and Capt. Peterson, but both Thaw and Peterson got their training in the Lafayette escadrille. Campbell on the other hand, never trained with any other outfit than the Americans, and never did any air fighting before he arrived on the American front a few weeks ago. Campbell is the son of the chief astronomer of the lick Observatory, near Pasadena California. He joined the American air service after the United States entered the war and came to France and began practice flying last fall. He is 22 years old. He is the first to get the credit of being a Simon pure American Ace. In a final story from the NY times we have a front line correspondent story about the allied air superiority in France. Dateline June 7, 1918 Headline: air superiority rewon Allied bombers operate with impunity on the French battlefront "In the valley of the Savierre, our bombardment squadrons threw more than 17 tons of bombs on enemy troop concentrations." Says last nights communiqué. The New York Times correspondent today visited one of the finest aviation groups in the French army and learn a first-hand story of that exploit. In the early afternoon, the airmen were informed that a large number of Germans were assembling in the valley of the Savierre, a little river whose course is almost parallel with the front. Owing to the configuration of the ground they were sheltered from the fire of artillery and it was evident that they intended to reinforce the German move westward into the forest of Viller-cotterets. A first squadron of Bomb planes were sent out. Then a second... At first, no Germans were visible, then circling low, the air men discovered the enemy hiding in the horseshoe woods on the Eastern side of the valley. Again the German battalions were subjected to a terrible bombardment amidst trees that gave no protection. Before the decimated units could reform the first squadron had returned with a new load and once more the wood was filled with the roar of explosion. No human morale could stand such triple strain. In vain, the German officers tried to reform their panic stricken men. When the French infantry counter attacked they had an easy victory over the weakened forces that had made the advance. And those are some of the stories -- 100 years ago this week From the war in the sky! https://timesmachine.nytimes.com/timesmachine/1918/06/07/102707275.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/04/102706151.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/02/102704861.pdf https://timesmachine.nytimes.com/timesmachine/1918/06/05/102706536.pdf [SOUND EFFECT] Great War Project Let’s move on to the great war project with Mike Shuster, former NPR correspondent and curator for the Great War project blog. Mike, your post this week includes a very interesting and relatively unknown skirmish near the village of Montsec - when the US forces get thrown off a hill there for one night and the germans use that for propaganda that the American’s can’t fight. Of course that turns out quite incorrect, but things are far from rosy at this point, aren’t they Mike! That’s true Theo! The headlines this week read... [thanks Theo - The headlines read] [MIKE POST] Mike Shuster, curator for the Great War Project blog. The link to his post is in the podcast notes LINK: http://greatwarproject.org/2018/06/03/a-million-americans-now-in-france/ America Emerges: Military Stories from WW1 Now for - America Emerges: Military Stories from WWI with Dr. Edward Lengel. The Americans turn out to be fierce fighters -- despite all initial uncertainty coming from their French and British allies - and of course the German propaganda that these are not fighters. Ed’s here to tell us about how one division, the 3rd, proved their worth in battle -- Ed? [ED LENGEL] [MUSIC TRANSITION] Dr. Edward Lengel is an American military historian, author, and our segment host for America Emerges: Military Stories from WWI. There are links in the podcast notes to Ed’s post and his web sites as an author. Links:http://www.edwardlengel.com/chateau-thierry-american-machine-gunners-action-1918/ https://www.facebook.com/EdwardLengelAuthor/ http://www.edwardlengel.com/about/ [SOUND EFFECT] World War One NOW And that’s what was happening 100 Years ago this week - It is time to fast forward into the present with WW1 Centennial News NOW - [SOUND EFFECT] This part of the podcast focuses on NOW and how we are commemorating the centennial of WWI! https://militaryhistorynow.com/2018/05/27/the-war-that-changed-the-world-americas-ww1-centennial-commission-gears-up-for-a-summer-of-commemorations/ Commission News Armistice Events in 2018 with Meredith Carr With the centennial of the Armistice, only 6 months away, the US WW1 Centennial Commission is preparing for a national commemoration of this very significant moment, November 11, 2018. Of course “Armistice Day” has evolved into Veterans day, but this year, it is is marked with very special significance as the centennial of the END of WWI! Meredith Carr, the Deputy Director of the US WW1 Centennial Commission is heading up the initiative of what will happen on November 11th and we thought it would be great to have her come on the show and give us a heads up on what we can expect, both in Washington DC and around the nation… indeed maybe around the world! Meredith! Welcome to the podcast. [greetings/welcome] Meredith - I gotta go for a little insider info for the audience - Way back in 2013, Meredith used to “host” a weekly conference call for various organizations planning the WWI centennial - and that very same call evolved into this podcast! So welcome home Meredith! [comment] Let’s talk through some of the events the Commission has planned to commemorate the end of WW1 on November 11th this year-- Can you start by telling us about the event at Washington’s National cathedral? You’ve got another program that EVERYONE around the country can participate in - a bell tolling - can you tell us about that? I know it is early - and plans are just coming together and we will be having you on again over the coming months but is there anything else you can tell us about today? [Pershing park activities in planning] Meredith - thank you for joining us and giving a preview of coming attraction for the upcoming centennial of the WWI armistice. [thanks/goodbyes] Follow the links in the podcast notes to learn more about upcoming WW1 commemoration events across the country. Links: http://www.worldwar1centennial.org/ http://www.worldwar1centennial.org/index.php/participate/state-organizations/state-websites/others-pending.html http://www.worldwar1centennial.org/index.php/commemorate/event-map-system.html A Century In The Making A Century in the Making is our on-going narrative about the National World War One Memorial at Pershing Park in Washington DC. This week, CBS News radio is running a story where host Chas Henry - Himself a retired US Marine Corps Captain - did an extended interview for CBS Eye On Veterans with Commissioner Edwin Fountain, and memorial designer Joe Weishaar recorded AT pershing park. The segment will air Saturday June 9th between 6-8 pm Eastern and again Sunday June 10th between 2 and 4pm Eastern. You’ll find the interview around 34 minutes into the show and it runs for nearly 25 minutes - an interesting perspective on the Memorial not to be missed. Here is a brief introduction with Host Chas Henry. [RUN CLIP] Events Events and Programs at the National Air and Space Museum For this week’s commemoration events section - we are very pleased to welcome Dr. Peter Jakab, chief curator at the Smithsonian National Air and Space Museum in Washington, DC-- Welcome, Dr. Jakab! [welcomes/greetings] Dr. Jakab - Let me start by asking you about curation - WW1 is this incredibly important moment for flight technology -- with many planes and materials from the era lost to time! How do you approach this very complex period in aviation history? The National Air and Space Museum is hosting this wonderful exhibit called “Artist Soldiers” -- It is a great exhibit - and not particularly about flight - so how did this show end up at the National Air and Space Museum? You have an upcoming MUSICAL event called, "The Yanks Are Coming:" The Songs of World War I Could you tell us about it? Does the museum have any specific activities planned for the Armistice centennial this November? Katherine noted that the Museum has great ways for people who are not in Washington to enjoy your content - could you tell our audience a bit about how they can enjoy the museum in other ways? Dr. Jakab - Thank you so much for all the great focus you are bringing to the centennial of WWI and for coming on the podcast to tell us about it! [thank you/goodbyes] Dr. Peter Jakab is the chief curator at the Smithsonian National Air and Space Museum in Washington, DC. Learn more about the museum and its WW1 programs and exhibitions at the links in the podcast notes. Links:https://airandspace.si.edu/events/yanks-are-coming-songs-world-war-i https://airandspace.si.edu/exhibitions/artist-soldiers https://airandspace.si.edu/exhibitions/pre-1920-aviation https://airandspace.si.edu/exhibitions/legend-memory-and-great-war-air Updates from the States New Mexico This week in Updates from the States -- we’re headed to a state we don’t automatically associate with WWI --- Pershing, and Pancho Via - yes - but WWI - not so much… It’s New Mexico, the Land of Enchantment! To tell us about New Mexico and WWI is Jeff Lowdermilk, deputy chairman of the New Mexico WW1 Centennial Commission Jeff - welcome to the podcast! [greetings/welcome] Jeff -- let me start with your state and WWI - You were just 2 years old with WWI broke out! what was New Mexico like 100 years ago, and how did it participate in the war effort? Jeff.. The New Mexico WWI commission was only recently established… Can you tell us about that? What kinds of programs are the Commission planning? Well, you just recently launched the New Mexico state website at ww1cc.org/nm or ww1cc.org/newmexico - all one word - lower case -- what can people expect to find there? Jeff: As a side note - briefly - because we are almost out of time, you recently published a book; Honoring The Doughboys: Following My Grandfather’s WWI Diary, where you retraced you Grandfather journey in europe. Can you give us an overview? Where is the book available? [thanks/goodbyes] The New Mexico in WWI website can be found at ww1cc.org/newmexico - all one word - all lower case… Jeff Lowdermilk is an author and the deputy chairman of the New Mexico WW1 Centennial Commission. Learn more about the New Mexico WW1 Centennial Commission by going to their website or by following the links in the podcast notes. Link: www.ww1cc.org/newmexico http://www.worldwar1centennial.org/index.php/communicate/press-media/wwi-centennial-news/4567-five-questions-for-jeff-lowdermilk.html 100 Cities / 100 Memorials Hawaii Moving on to our 100 Cities / 100 Memorials segment about the $200,000 matching grant challenge to rescue and focus on our local WWI memorials. This week we are crossing the Pacific to Honolulu Hawaii! Now Hawaii has been in the news for week with the volcano eruptions on the Big Island - which is not, for those of you who have not been lucky enough to go there - where the capital of Honolulu is located. Hawaii was also in the news 100 years ago this week, when on June 4th, 1918 the secretary of War announced with a headline that read: HAWAIIAN NATIONAL GUARDS ADD 3,200 MEN TO ARMY Now Hawaii was not even a state yet, but a force of 3,200 men were to be added to the Army from a proclamation by President Wilson placing the Hawaiian National Guard in service Now they were not planning to send this force to France - but rather to relieve forces that the US army had stationed there - freeing them up for deployment. According to the article in the Official Bulletin - That Hawaiian force was genuinely cosmopolitan with native Hawaiians, Americans, Filipinos, Chinese-Americans, Japanese - Americans and more… After the war - Hawaii dedicated a large swimming venue as a WWI memorial - it is called the Natatorium - and here to tell us about the venue, its restoration and its designation as a WWI Centennial Memorial is Donna Ching, Vice chairman of Hawaii's World War I centennial task force. She is also vice president of the Friends of the Natatorium, a nonprofit organization dedicated to the preservation of the ocean pool known as Hawaii's 'living war memorial' Donna, Welcome to the Podcast! You know, I think most people have never thought about Hawaii and WWI - But there are really a surprising numbers of connections… underestimate Hawaii's role in WW1 - by how much would you say? Donna, can you start by telling us the history of Hawaii “Living Memorial”? QUESTION: I hear…. that you have big plans for the armistice centennial coming up on 11/11. QUESTION: Thank you Donna, for talking with us and sharing the story of Hawaii incredible living memorial! There has been a big fight going between preserving and tearing down this really beautiful venue - how’s that going? Your 100 Cities / 100 Memorials grant application was in large part built around informing your community about the importance of the venue - rather than for restoration directly. Has the designation as a National WWI Centennial Memorial helped? What’s next for the project? Donna - It’s a great story - About Hawaii, about the centennial, about the armistice and for me - most important about passion for local heritage driven by WWI - thanks for sharing it with us! [goodbyes/thank you] Donna L. Ching, Vice chairman of Hawaii's World War I centennial task force . Learn more about the 100 Cities/100 Memorials program by following the link in the podcast notes. Links: www.ww1cc.org/100cities The Buzz And that brings us to the buzz - the centennial of WW1 this week in social media with Katherine Akey - Katherine, what did you pick? Exhibits, Posters and More I want to share a couple great resources and exhibits this week! In the fall, we let you know about the Department of Homeland Security's WWI Poster Series, which highlights the historic roles of the DHS components -- to include Immigration & Naturalization Service, Customs & Border Protection, Secret Service, Coast Guard, and legacy agencies. Well, the folks at DHS have now published these great poster files on their website -- so that the public can easily access them! They’re a wonderful, free educational resource -- check them out at the link in the podcast notes. Additionally, there’s a new exhibit open at the Library of Virginia in the state’s capital, Richmond. The exhibit “"True Sons of Freedom" explores the stories of Virginia's African American soldiers who served during World War I -- and will be on view to the public through November 9, 2018. I’ve included a link to the exhibit’s website as well as to a video tour of the exhibit in the podcast notes. The exhibit’s website is a great resource for anyone who can’t quite make it to Richmond -- it include profiles of dozens of Virginian men who served. Finally -- this week included June 6th, well known as the anniversary of the WW2 landings at Normandy, D-Day. But June also marks the anniversary of some of the most bloody and intense fighting American soldiers have ever faced -- the fighting at Belleau Wood. The battle forged the modern day Marine Corps -- and you can, and should, read the article recently put out in the Washington Post and included in the podcast notes -- it highlights the fighting from 100 years ago and contextualizes its importance to the modern day. That’s it for this week in the Buzz. Link:https://www.uscis.gov/history-and-genealogy/our-history/world-war-i-centennial-commemorative-poster-series https://www.facebook.com/LibraryofVA/videos/10155505095947227/?hc_ref=ARSOicdS9Bv7HrYGe-RfUptXbIhmIpH4aJfhdl0W2mZaBr_cGrLnGos2AlwORMfTbSw http://truesons.virginiamemory.com/ https://www.washingtonpost.com/news/retropolis/wp/2018/05/31/the-battle-of-belleau-wood-was-bloody-deadly-and-forgotten-but-it-forged-a-new-marine-corps/ Outro And that wraps up episode #75 of WW1 Centennial News. Thank you so much for joining us. We also want to thank our guests... Mike Shuster, Curator for the great war project blog Dr. Edward Lengel, Military historian and author Meredith Carr, Deputy Director of the WW1 Centennial Commission Dr. Peter Jakab, Chief Curator at the National Air and Space Museum in Washington, DC Jeff Lowdermilk, deputy chairman of the New Mexico WW1 Centennial Commission Donna Ching, vice president of the Friends of the Natatorium Katherine Akey, WWI Photography specialist and line producer for the podcast Many thanks to Mac Nelsen our hard working sound editor I’m Theo Mayer your host. The US World War One Centennial Commission was created by Congress to honor, commemorate and educate about WW1. Our programs are to-- inspire a national conversation and awareness about WW1; Including this podcast! We are bringing the lessons of the 100 years ago into today's classrooms; We are helping to restore WW1 memorials in communities of all sizes across our country; and of course we are building America’s National WW1 Memorial in Washington DC. We want to thank commission’s founding sponsor the Pritzker Military Museum and Library as well as the Starr foundation for their support. The podcast can be found on our website at ww1cc.org/cn - now with our new interactive transcript feature for students, teachers, bloggers, reporters and writers. You can also access the WW1 Centennial News podcast on iTunes, Google Play, TuneIn, Podbean, Stitcher - Radio on Demand, Spotify, using your smart speaker.. By saying “Play W W One Centennial News Podcast” - and now also available on Youtube - just search for our WW1 Centennial youtube channel. Our twitter and instagram handles are both @ww1cc and we are on facebook @ww1centennial. Thank you for joining us. And don’t forget to share the stories you are hearing here today about the war that changed the world! [music] Hey - in closing we just want to welcome all our new summer interns at the US WWI Centennial Commission. Hey Gunny - we haven’t heard from you you in a long time - I hear you want to welcome the interns. That’s right you maggot - OK Intern’s listen up! Welcome to WWI Centennial BOOT CAMP - I don’t wanna see any of you trying to spit polish your tennis shoes - Got it? Dismmised So long!
© 2020-2025 Ivy Podcast Discovery LLC
