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3 episodes with jeff first
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
Introducing Craig Newmark! Craig Newmark Philanthropies Supports Palomacy! Capitol riot: Jan. 6 committee demands records from Facebook, Twitter, Google. House Committee Investigating January 6th Capitol Invasion Goes On Social Media Fishing Expedition; Companies Should Resist. Reddit bans Covid misinformation forum after 'go dark' protest. Three hours a week: Play time's over for China's young video gamers. Google doodle: "Get vaccinated. Wear a mask. Save lives." Google, Apple Hit by First Law Threatening Dominance Over App-Store Payments. Google's new Pixel 5A ad spoofs Apple with humorous ode to the headphone jack. Google Pixel 6 and Pixel 6 Pro Launching October 28th. Hands-on with the Samsung Galaxy Z Flip 3. Google's New AI Photo Upscaling Tech is Jaw-Dropping. Australian powers to spy on cybercrime suspects given green light. Five Big Problems with Canada's Proposed Regulatory Framework for "Harmful Online Content" Amazon quietly building live audio business. Telegram uncaps live stream viewers as part of big version 8.0 update. Amazon now running 164 flights a day to deliver stock in the US. Amazon's answer to driver shortage: Hire pot smokers. Google Calendar will break down how much of your work is spent in meetings. Automate your whole day with the Assistant's new Daylong Routines. Google Assistant rolling out a new trigger that starts routines when dismissing an alarm. Here's how Google Assistant's upcoming 'Quick phrases' will let you skip 'Hey Google'. Google adds shipping and return labels to product listings in search and shopping tool. Google rolling out first Pixel Buds A-Series firmware update to fix volume bug. German publisher Axel Springer to acquire U.S. news website Politico for over $1 billion. 'I guess I'm having a go at killing it': Salman Rushdie to bypass print and publish next book on Substack. Happy birthday, Linux: From a bedroom project to billions of devices in 30 years. Google developing its own CPUs for Chromebook laptops. Picks: Leo - Google Colaboratory Stacey - Donate blood if you can! Jeff - First full image of 'new Vermeer' with uncovered Cupid released by Dresden museum Ant - I sold two NFTs! Hosts: Leo Laporte, Jeff Jarvis, Stacey Higginbotham, and Ant Pruitt Guest: Craig Newmark Download or subscribe to this show at https://twit.tv/shows/this-week-in-google. Get episodes ad-free with Club TWiT at https://twit.tv/clubtwit Sponsor: twit.cachefly.com
This week Introverted Intuition are joined by artist, songwriter, and creative James Worthy to discuss the trials and tribulations he has experienced as an established artist, learning how to be financially literate through experience, why having a killer instinct is a necessary mindset to have when maneuvering towards your dreams, his upcoming album as well as much MUCH more. INDULGEFollow our guest @kingjamesworthy on both Twitter and Instagram Introvertedpod.com for all MERCH, INQUIRES, and INFORMATION about the show. Jeff First book pre order link https://www.amazon.com/Avenue-Personal-Dictionary-Jeff-Kelly-ebook/dp/B08QCXPQZX/ref=sr_1_2?crid=SOTU1ADCTOYN&dchild=1&keywords=the+avenue+a+personal+dictionary&qid=1613010833&sprefix=the+avenue+a+%2Caps%2C169&sr=8-2
David, Devindra, and Jeff review El Camino: A Breaking Bad Movie, a cinematic epilogue to the hit show Breaking Bad. With the original showrunner Vince Gilligan back in the director's seat, the cast debates whether El Camino lives up to the legacy of "the one who knocks." Thanks to our sponsors this week: Villains, Feals, and Native Download the Villains podcast wherever you get your podcast or listen now at http://parcast.com/villains. Become a member today by going to http://feals.com/FILMCAST and get 50% off your first order of CBD products with FREE shipping. For 20% off of your first purchase of Native deodorant, visit http://nativedeodorant.com and use FILMCAST at checkout Listen and subscribe to David’s newest podcast Culturally Relevant (https://culturallyrelevantshow.com/) . Check out Jeff Cannata’s D&D show Dungeon Run (https://www.youtube.com/channel/UC3BYmMS1F4rNWsAkCaEVhoQ) . Listen to David’s other podcasts The Sweet Smell of Succession (https://successionpodcast.com/) with Tara Ariano and Write Along (https://writealongpodcast.com/) with writer C. Robert Cargill. Listen to Devindra's podcast with Engadget (https://www.engadget.com/2019/10/07/engadget-podcast-microsoft-apple-pcs/) on all things tech. You can always e-mail us at slashfilmcast(AT)gmail(DOT)com, or call and leave a voicemail at 781-583-1993. Also, follow us on Twitter (https://twitter.com/slashfilmcast) or like us on Facebook. (https://facebook.com/slashfilmcast) Shownotes (All timestamps are approximate only) What we’ve been watching (~2:00) David - Living Undocumented, Jeff - First 2 episodes of Goliath S3 Devindra - Primal Feature (~16:30) El Camino: A Breaking Bad Movie Spoilers (~50:00) Credits: Our music sometimes comes from the work of Adam Warrock (http://www.adamwarrock.com/) . You can download our theme song here. (http://www.adamwarrock.com/?p=3174) Our Slashfilmcourt music comes from SMHMUSIC.com (http://smhmusic.com/) . Our spoiler bumper comes from filmmaker Kyle Hillinger. (https://m.youtube.com/kylehillinger) This episode was edited by Beidi Z. (https://www.adamscostudio.com/) If you’d like advertise with us or sponsor us, please e-mail slashfilmcast@gmail.com. Contact us at our voicemail number: 781-583-1993 You can donate and support the /Filmcast by going to slashfilm.com (http://slashfilm.com/) , clicking on the /Filmcast tab, and clicking on the sidebar “Donate” links! Thanks to all our donors this week!
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!
Jeff is a cop, nurse, medic, and isn't stopping in his pursuit to upgrading his career. He shares his insight on what tradesmen could benefit from cpr and tourniquet training.
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)
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!
Episode #75 we flying high First Class Canna high!!! Orange High School homie Jeff cruises thru to the GPS studio and we go back in time, thanks to our sponsors for helping out with that too. Jeff lets us know how, and why he started his first cannabis company First Class Canna. He also drops knowledge on the legal ways of opening a cannabis company in Cali. Stay tuned to find out how racist my foot high school coach was back in the day and how low-key that I'm a miracle baby......#takeashowerwhitepower@GeorgePcomedy@SideDickEddie@FirstClassCanna@_thatonex
Episode #75 we flying high First Class Canna high!!! Orange High School homie Jeff cruises thru to the GPS studio and we go back in time, thanks to our sponsors for helping out with that too. Jeff lets us know how, and why he started his first cannabis company First Class Canna. He also drops knowledge on the legal ways of opening a cannabis company in Cali. Stay tuned to find out how racist my foot high school coach was back in the day and how low-key that I'm a miracle baby...... #takeashowerwhitepower @GeorgePcomedy @SideDickEddie @FirstClassCanna @_thatonex
When it comes to buying internet businesses, is it better to buy big or buy small? Today we are chatting with Jeff Hunt of Own Optimize. Jeff has one of the largest web business portfolios we have come across here at Quiet Light. Through close to 60 transactions, he has owned a total of nearly 500 websites. These days Jeff spends his time working on his websites and educating others on how to buy internet businesses. After a career with IBM in the services business, a move overseas led Jeff to the internet where he started a real estate website. Despite a tech background, he didn't really know anything about websites when he started out. Soon he learned that buying them was much easier than making them and started to build his portfolio. Today we talk to him all about what to focus on once a website catches your interest. Episode Highlights: Start off on the right foot at the very beginning of the process. When buying a site, what you're really looking to buy is a quality website that you can grow and automate. Jeff's range of investment is typically sites valued at $50,000 and under. Of course Jeff experienced failure, 8 out of 10 of his sites didn't make it. He admits to being guilty of chasing too many things at once. Success for Jeff has come from a combination of buying and building. Making a smaller purchase is not always for financial reasons, it can be for a new buyer to explore whether or not they even like the business. When a buyer starts small they get an opportunity to learn the transaction process. Smaller websites can carry more risk. They may not have had enough time to grow. With large sites, you still have some leverage even if you come across hard times. Owning larger sites that garner larger revenue allow buyers to afford to hire a team. Before a purchase, study the heath of the business; the historical data, the ratios, and the percentages of cost that make up the total cost. The seller should have found the key to attracting new buyers and that knowledge can be passed onto the buyer. The buyer needs to really understand the business model and hone the process that the seller has achieved. Transcription: Mark: Joe, How are you? Joe: I'm good Mark, how you doing today? Mark: Good, good! I got to talk to another member from Rhodium Weekend, which is one of those events that we talk about a lot on this podcast, to talk to Jeff Hunt. Joe: I know. Jeff Hunt's a good guy. I think he's bought four hundred (400) businesses in his lifetime. Mark: Websites, a lot of these– yeah it's about forty (40) or fifty (50) transactions that he's done, so mostly some 50,000 dollar transactions. Joe: Pause, I said four hundred (400). Am I completely wrong? Mark: No, you're not completely wrong at all. So forty (40), fifty (50) transactions but whole of about 400 to 500 websites at all. Joe: Okay, got it! Mark: Yeah, can you imagine trying to manage that many sites? Joe: Absolutely not! –trouble doing my job here at Quiet Light that is an immense amount! Mark: Yeah, I know everyone recognizes you as a slacker. Joe: (laughs) Mark: So anyways, he's bought a lot of businesses, he's bought a lot of sites and he has a lot of experience on that. Now he's teaching people, he's got the website investor– the book that he wrote. And he talks about developing systems to buy sites, successfully. And he talks a lot about some of the mistakes he made along the way. What we talk about some due diligence, but also about this ongoing question: Is it better to buy small or buy big? Now what was better for you, what's– could've helped you avoid risk more and how's that changed from the years. He's got a lot of insights into due diligence that were fascinating and honestly, the interviews I've done, I kind of wish we would flip this one around because towards the interview, absolutely, really going to miss some good topics. Joe: It's interesting that the subject of should I buy a million dollar business for– or ten– how many thousand dollar businesses always comes up. And all we can do is thought from own experience and on what other people like Jeff have done. And I think, I've had Kevin Peterson on the upsell buying portfolio SAS business as he said– I think we've quoted him that it– it takes the same amount of work to run a million dollar business as it does a hundred thousand dollar business in some cases actually takes less because it's more established. And Jeff bought forty to– 5400 smaller sites, right? Mark: That's right. And we talked about that. I do think that running-a-large of business is often less work And I wrote an article on this, years ago, We have not been blogging for almost a year now because we've been focusing on the podcast but I did right an article on this rad. I went into the data actually to take a look at: What are the average number of hours that people are working on smaller sites versus larger sites. And what is the average number of staff and how does that correlate with revenues. Really some fascinating data in there, so excited. I got to transcend you deep dive there. So all in to that much show notes, anyone wants to do some further reading. But larger sites, they're often less work. And in some ways, that's risky because there's– you have more cash flow and we talked about that. If you have a business that's– that has twenty (20) thousand dollars of revenue and you lose a key client or you lose a key-traffic source when things get cut in half, you don't have but ten (10) thousand. Joe: Absolutely! That's why, just to say it so people hear it that the– the multiple's evaluation on these jump when your discretionary earnings is up that million dollar mark, you're going to jump significantly in terms of the over-all value not– obviously because of numbers but because the multiple actually jumps too, from a– let's say from a three (3) to four (4) for an instance. Mark: Yeah and I was talking to a potential client the other day who has a business who– it's multi-million dollars of revenue but the earnings are starting to have troubles and he said, “Would anyone buy this?”. And I explained to him that if a business has millions of dollars in revenue, even if it's struggling from an earning stand point, yeah, that's going to really negatively affect the business but this is probably still is soluble. But if you have a business that makes five (5) or ten (10) thousand dollars a year in gross revenues and isn't making any money probably not going to be sold. An orgs couldn't be very difficult to sell for anything of value, so can newly certain size? It's just more flexibility on the part of a buyer. Joe: Yeah! But Jeff has a different model in system and he's buying lots of smaller one's so he's doing something very, very right. Different than your blog couple of years ago, talked about so be real interesting series got to say. Mark: Yep, let's get to it. Alright, hey Jeff! Thanks for joining me. Jeff: Hey, it's great to be here, Mark. Mark: I know we know each other from a mutual group that were both part of. And people who have listened to the podcast before will be familiar with this group, at least you've heard of it before, and that's Rhodium Weekend. You and I have attended it from the past some years, right? Jeff: Yeah, love–met a lot of fantastic people–Rhodium is a good– as you know, it's a group of people either buying, or have already bought in to operate online businesses so it's kind of really unique crowd and be part of it. Mark: Yeah, if anybody wants an introduction 0:05:43.3 let me know, I'd be more than happy and of course, Chuck will surely be able to provide that as well. Chuck Mullins who works at Quiet Light Brokerage, introduced me to Rhodium. And really– Chris had actually stopped me, but really Chuck encouraged me to go. And it's been a good investment of our time and place. It's good group and I met you there few years ago. We talked at the conference and we've seen each other at conferences since then. I think the last time we met in person was Afilias somewhat last summer. Jeff: Yeah! That's right! And I met Chuck there I think the first time at Rhodium and I formed a number of partnerships there so it's a great group of people, it's your (0:06:22.0) way around the business that were in. Mark: Alright! So, let's start getting into little bit in the– as our listeners know, we usually love our guests introduce themselves. So if you want just give, just kind of quick background on who you are and what you do, that'll be really helpful. Jeff: Okay. Well, you know, I maybe one of your older guest– I don't know but if the white here kind of gets it away a little bit, I'm in my fifty's and I'm still on the website business so… Mark: Oh, my! Jeff: Kind of funny like the bunch together that we hangout or they're a little bit younger than I am but I give them a run through their money. I actually started out in the corporate world. Probably like a lot of people buy websites and I had a crew with IBM and I was in middle managements. I had a pretty lardge organization, people who were in to service this business. So, big companies with give us their I.T. departments to run so I had development organization, infrastructure guys, and a lot. And how to buy a budget of about twenty five (25) million dollars, at that time. It's kind of funny that even though I was kind of that technical business, I didn't know anything about the internet at all. And so my first introduction to the internet was actually I started a real estate business. So I moved overseas, left IBM, moved overseas, I started this real estate business and I realized it needed a website. And so, I kind of just dove in and I learned out to do all the websites, staff and crew website for this business. And then after that , I– you know, my eyes kind of got opened to the side of the all. Starting website really hard and so I started looking at as ways to buy them. And I started buying websites and over the last ten years I actually– I've done probably fifty (50) or sixty (60) transactions and about something like three hundred (300) websites, actually probably closed to the five now but while it does ring, big groups like networks of websites that did some more functions than those kind of things. So– Then along the way, I kind of wanted to leverage some of my assets. One of my assets was just– I have been doing this for a while and you know, having my fingers and all kinds of online businesses and different business models across all the sites. And so I wrote a book called The Website Ambassador and then I've done courses on website investing and some networking like at Rhodium and other places and stuff. I really enjoyed this– I just love– I really love almost everything about online businesses. And just the lifestyle part of it but really like the analytical part of it, the marketing component and operations component. Component is just– is just low fun. So that's my story. Mark: So– I'm sorry, you said three hundred (300) and four hundred (400) websites in total? Maybe more? Jeff: Yeah! Like one of my purchases is something like two hundred and fifty (250) websites that were– I can't even read the domain names. They were German and French. And there were these affiliate websites selling Amazon FiliA products and to Amazon Germany and Amazon France. And I ran with those for couple of years some of them died off and then I sold them. Mark: Oh, okay. How in the world do you begin to even manage that many sites? Jeff: Yeah, well–you know, that's one of the many mistakes that I've made I think in the course of my website career is buying too many and chasing too many ideas that looks really interesting like– it's probably happen to you. Maybe it hasn't happen to you though like I see these things and I think “Woah! That's a very unique business modeling and that's really cool. I like to learn more about it and pick it up. Like uncharmed by those particular sites, actually those who're kind of template sites and so there was a lot of automation. There were programs that could make the same update to, ten's, twenty. Sometimes more sites at a time. So that's how we managed them. Mark: Okay, That makes a little bit more sense. Now when you say that you've been buying all these websites, we don't have to talk specific dollar amounts but who are we talking about larger sites, smaller sites, what's the range that you really been investing in. Jeff: Well I've bought in– again maybe this is something I would do differently for starting over again but most of my sites for sub- fifty thousand dollars only handful of that amount, just a lot of them as like mentioned. And I've done kind of a combination of buying and then building and typically for me the cycle's ban or buy something that I don't really know that much about like I started out with Google news approved sites and merely day so I bought a dozen different news site over time but then after a while after a year or two into that, I really understood that news business borrowed so it was very easy for me to actually create my own news websites and then go from there and I've done some more things. For example Mozilla site– so one of the reasons that we buy is because were learning something, were picking up. Were kind of learning from something that's already working. And then later on if you want to add to it by building from scratch, that's kind of a logical sequence for me. Mark: Yeah, alright, let's dive in to that topic a little bit because we get that–this question a lot from potential buyers, especially first time buyers. People that might become mean and in. They know that they want to get in to the website business or some sort of online business, they're coming from the corporate business world like you did and they might have good enough money to do a larger deal but their wonder, is that the right thing to do? And I think you might have touched a viewpoints here which might be interesting. let's talk about, specifically, let's just start with the benefits, binds small to start. You've done a lot of bind small sites and smaller sites. What were some of the big benefits that you've gotten from that and then maybe later on we can move in to some of the drawbacks from that. Jeff: Okay, yeah! That sounds great! And one of the first things that I say when I get that question by big or small is: Whatever you buy, it needs to be a good quality so it needs to be something that's very stable no matter how big or small it is. So, kind of get to your specific question, what are the benefits of buying small, first the obvious one is that you're risking less capital and for many people, that's important, especially when they don't have that experience that leads to the confidence to something bigger. So that's kind of important. And many people are running to ask me that question and it doesn't even matter what their capacity is. Some of them have a capacity in capital to buy very very large websites, multi-million dollar websites. They still don't want to do it. They want to spend five (5) thousand or twenty five (25) thousand or something like that and the reason is because it gives them the, yeah. One of the things that they think about necessarily is they don't even know what it's like to be a website owner. So it isn't just the risk of the money but they're not even sure that they'll enjoy the– be and stay which is being the owner and upper of your website. So that's one thing that binds small can do. Kind of give them a taste, what it's like. And then secondly it gives them an exercise of the transaction process. That's as you know, the transaction process is quite different from very small sites than from a large one but at least they're going through the steps of– during the evaluation, looking, evaluating, waiting, executing a transaction, setting up the accounts, perhaps hiring the team, and all of those kinds of stuff. And then some basic things that if you've never been on the website business, you've never done before like giving hosting setup and domain ownership and some of those basic things. So that's kind of the value. And the other thing is that, whereas the dynamics and management of large versus small can be quite different some of the basics in terms of the actual business models behind the sites are actually quite similar. So the content website monetized by advertising is very similar too. Whether it's big or small. Just the mechanism and process you put around that are different. So if you're unfamiliar with the business model, you can pick up some familiarity from buying a smaller site. Mark: So, you said that I think it's a key point here, and that is bind for education. And bind small for education is something that you've done quite a bit, in where you bought, you've learned in this industry a net shore, a style of online business. And I've been able to use that as an education, they will build your own as well. I talked to buyers a lot about their first purchase and an advice to buy smaller if they want to get that education set, understanding that, can you talk about that a little bit more how you've used buying small to be able to learn more about the nature, about the business style? Jeff: Yeah, that's excellent accredit in general sense education and one of the ways that we educate our self is through relationships and at working and so really, the important part when you buy a site is the relationship that you have with the seller and those have been valuable to me. I meet so many really , really instructional, educational relationships, from sellers who– and that starts with setting at the relationship– setting off at the right flow with the relationship at the very very beginning on the process. But many of the sites I bought I got really good coaching, I have relationships to this day with people that I bought sites from eight (8) years ago who were entrepreneurs, they figured something out. Most– as you know, most business is fail. Very high percentage of business is fail, off line or online. And even at higher percentage of online business is fail, been off. And I think it's just because more people try at the online business but when you have any site that's been around for a while and it's kind of built up a following and so on, is one that hasn't fail or at least not yet. And so the entrepreneurs who're able to do that and figure that out, a lot of times, they know things that you want to know from them so the key thing is actually learning what has been built, what the process is, that they use to attract customers and we'll probably talk more about that later. I hope we could. Mark: Yeah, I'll get you to talk about whatever you think will be worth talking about. I do want to talk a little bit about the differences though on bind big versus small. You mentioned in there one of the benefits to bind small is you're obviously risking what's capital. And I would completely agree with that. I mean, it's pretty obvious, if you're buying a million dollar site to buy in a ten (10) thousand dollar site, there's significantly less at stake. When I tell buyers to buy small, initially, often times I'd tell them that and say, you know, be prepared for a little bit higher risk profile. And in my experience in– feel free to disagree with this , that's in my experience buying small often comes with a little higher level of risk. I know you said you have to buy quality. What's been your experience as far as the quality businesses that you bought in this small range? Jeff: I totally agree with you and the reason that buying small carries more risk is because most smaller websites don't have the same age. They don't have the same momentum they haven't necessarily withstood the test of time. And what that really means is, in the internet business they change really fast so new competitors enter the space, there's changes in technology, changes in software, and most importantly there's changes unlike the big players like Facebook, Google and the like. And they're making policy changes and all those things, so when you buy a smaller site, in most cases, they may be successful, cause they're flying under a radar of sorts and they haven't been around long enough to see the change from desktop to mobile or from easily making Facebook ad purchases to a more competitive environment, faced to capture all those things, so as a result, the lower in sites is almost always more risky. Now obviously, you can mitigate the risk the longer you look but sometimes it takes a really long time to find the site that's– that has true stability. That's still kind of that low end so, yeah, that's right. So my experience with that, that answers a specific question is that I've failed a lot of times. Probably, my early sites that I bought, I bet you eight (8) out of ten (10) just didn't make it. Either they didn't pay for themselves and some of them might've made almost no money, most of them made some money but not nearly what I wanted and then they kind of take her off. It's hard. Mark: I found as well what larger sites having that extra cushion more discretionary earnings and more revenue, gives you a lot more ability to, not to make a mistake and absorb it. With the small site, if it's only generating twenty (20), thirty (30) thousand dollar per year, if it loses a major source of traffic, all of a sudden that twenty (20), thirty (30) thousand will go down to five (5). And now, all of a sudden you're questioning why I'm even doing this anymore. Where, you were as a few–you have a business's doing five hundred (500) thousand dollars a year and discretionary earnings and it gets hit hard. You're still probably making six (6) figures and have some leverage that are to be able to– may buy yourself out of this situation or fund what needs to be fixed Maybe place that better or so, there's a little bit of subordinate there. Workload as well, I mean– I've found in your website, in some sense, I found that with larger sites, sometimes that workload can actually be less because you can afford the higher people, where as with other site that's kind of on the edge. And I ran into this with my first company actually that I owned, I got it to a hundred twenty(220) thousand dollars in revenue and really I needed to hire people but I needed all the money. I was getting so– I couldn't really afford six months of that financial hit. What's been your experience with that? With dealing with casuals and maybe the freedoms that casuals would– of a large business would bring you? Jeff: My experience is exactly what you said where– and in fact I have websites right now where I'm forced to do things that I really shouldn't be doing, I should be spending my time thinking about the strategy, looking in for competition, time plotting on a road map, and in managing people on. And some sites is just aren't making enough money for me to hire someone to do that on month you have. So that's absolutely right, that when you get that, and you know– as I mentioned I– that there were intersections and that I've done everything where I sweep the floor myself, so I kind of gone the whole gimmick and certainly when you have a team then it really freeze you up to use your mind in a different way and that's a lot of fun if that's kind of where your skills are, what you want to do. So definitely not to big advantage of buying big. Mark: Alright, so you have done– how you told me at the beginning, I didn't worry about, how many transactions again, estimated? Jeff: Only sixty (60). Mark: Alright, that's a ton! I mean quite label with more or less than a thousand for ten years, that's with lots and lots of buyers and sellers. Sixty (60) percent is a lot. I'm going to put you on the spot and if you don't have an answer for this please just ignore it. I'm curious, what's one of the craziest thing that you can share that you've ran across in your process of buying sites? Jeff: Well. you know, I've ran across more than I– there's some crazy one's I've ran cross that I haven't bought. But there's several of them, one of them that I talk about in my book is– I found this site that– I had a hard time finding out what product is sold but it was insanely profitable like nine (9) percent profit margins but it was an E-commerce site. So it was a hard physical good and when I looked into it carefully, what they were selling was a urine. Laboratory processed urine for people who're trying to pass drug tests. And so they said, after I finally understood exactly what their product was, I understood why it was hard for me to understand, because they didn't want to like, advertise it too much that they had to do it enough to be on the safe side. Mark: There you go. One of the first clients I took on was selling poppy flowers and they were selling them for couple rearrangements, I may be naive. I had no idea that they were used for opium as well. And I had one person tell me, one buyer was like, “So are you okay with selling drugs?” I'm like, “What? What are you talking about?” Ends up, they were not, but there is people buying the poppies. At least my theory at probably buying the poppies thinking that they were buying drugs. They're probably just get stomach ache. Jeff: Alright, well, you know, that's interesting you bring that up because it's an example of one of the subtle eficlosures and we ran into this issues a lot in this business crossly, even for sites that you would think don't really have controversy around them. We ran into this kind of things. So it's one thing that buyers should be aware of. Mark: Let's (0:23:21.2) to that because you've got your course to write your book as well. Your course is at website investor.com? Is that right? Jeff: Yeah, ownoptimize.com is a good place right now. Mark: ownoptimize.com, Okay. Jeff: Yeah! Mark: We'll link to that in the troll notes so just go over to our website and look in the troll notes for the course, the online course. Let's talk about some of the lessons that you teach in this course. Obviously, we'll keep the best secrets for the courses. So– but, what are some of the things that you try and teach buyers who are taking your course? Jeff: Well, one of this– I don't want to over simplify and this may just sound too simple but one of the biggest mistakes I think that new buyers make is they don't just look at the graphs. And it's amazing what this simple graphs can tell you, the direction of the traffic, and the direction of the financial, those two simple things are really, really important. And a lot of times when you look at a graph, let's say twelve (12) month graph and it's– you can kin od tell visually that it's down or gently downwards sloping, but in truth it may actually be like twelve (12) or twenty (20) percent downward sloping and if you just extrapolate that into the future– I mean, business is going to be worth nothing in just a few years and so I think people tend to have an optimistic view when they look at numbers and sometimes they realize that their businesses that are losing money overtime and they feel like the moment that they buy this site, it's going to stop losing money, it's going to start– it's going to be flat or go up from there and there's no real reason to think that. So that's kind of really simple but that's a way that you can dismiss a lot of sites unless you have really specific knowledge about why it's going down and a very specific idea about how you can turn it around. Now we can talk about that way or two because a lot of people– that's hard to really know for sure. So then you need is just to stay away from those kinds of sites so we need to look–. So overall, key thing is you look at the graphs, if it's a stable business, you're looking for a stable business because the most important thing is– I kind of teach a risk-based methodology but for valuation and also for valuation-selection websites so for me, real core thing is you're looking for the engine for customer acquisition and you can– all kinds of sites she can evaluate, usually the successful ones. The owner, the creator, has found a way to systematically attract new clients and if it's a content site and the client is website visitor or if it's a services site, a client, whatever it is. And that process–whatever the process is, it might be toasting the Facebook every day, it might be buying Google ad words, ads, it might be just content creation regimen, it might be a product launch, philosophy on Amazon like these kinds of steps, I'd choose these kinds of products, I'd brand them in this way, I'd quadrant them in this way. And the process may be –it may not be like mind blowing in terms of what it actually is, but it might just be very consistent and perhaps complex and blast. and whatever that process is, it's that– is that engine it drives the site, that's really what you're buying because if you can get your mind around it and understand what it is that they're doing that attracts these customers consistently and then you can start envisioning how you would do that yourself and perhaps, how you would scale it, how you would tweak it to enhance it, then that's kind of the whole agree, So you want a process like that but you feel like doesn't have a hauls or gas in it, like you can see why it's working and how it's working and you get your head around that then you know the business model and then if it's historically if it's a cheap pretty solid results, consistent results, there's always going to be pivoting and changing strategies and so on but you get a model like that, that's kind of what you really want to buy, to probably grow what you're trying to buy as a buyer so that's kind of a key thing and then there's all kinds of methodology around you, valuation. We look like — there's like several dozen things you can evaluate that there's content and ownership and reasons people are selling and the financials and branding, legal aspects–all, all those kinds of things that you want to look at but the core thing is that how do they get their customers and what's the risk profile on this side. Mark: So how do you– how do you, work for– so that's really, really good advice, understanding the customer journey from beginning– from top of funnel, just awareness of the site that you're looking at down to the actual acquisition of the client. Right? How do you handle that insane environment like Amazon or were dealing with all the market places or even with– I guess with E-commerce, you do have a customer journey but have you worked much with Amazon to see how you would evaluate that? Jeff: Well, no, I don't have a lot of very specific experience with Amazon but I can tell you that– Amazon FBA is actually a very sophisticated business because there are so many elements of it and you have to do each of them quite well, actually. That's one of those cases were it's not just a simple three (3) or four (4) silver bullets and you win. It's like the people who do Amazon FBA well, do a lot of things well. They do product selection very well. Niche selection first, product selection well, then they understand the launch process like putting the right brand on their product and giving those initial reviews. And they understand the inventory process. They don't have cash problems with having generating a man and then having nothing to sell to people. Then they have to understand the operational aspects too like how do they wants making sales, how they actually get the product out and in a good way and then servicing the customers later on and answering their questions from there, just get a review and so it's really kind– it's a complex process so the– what I just said earlier about what's the engine behind it, well in that case, the engine is, are there good SOP's, is there a good team, is there like –what's kind of the new ones that has a loud– like some people, super good at branding and they're super good at that product launch process in Amazon and so that's kind of what's giving them the edge over the competition and other people were good with analytics and numbers and ratios and shipping cost, cost of good sold to whatever they're spending on customer service and all that kind of stuff. Which that's all fine but it's kind of that it's up front-end that's probably more important in Amazons like how they're interacting with the customer. Mark: Well this is why it's so important for pre-sellers to document their processes because a lot of this stuff is done almost from a skills like that is developed over years. Having those processes, documented, the stuff that you're doing on day-to-day basis helps buyers like you, Jeff or any of the buyers out there understand what's going on and try to sum it– that is as well. I want to go back about what you said about graphs because that really caught my attention. I–I'm with you on that. I love graphs. I think visualizing data, specifically the financial data is something people don't do enough. And I might geek out a little bit here, and save my finger craft that I used when I'm evaluating business myself, is year over year analysis that I like to look at both the revenue and to those gross profit. Definitely take a look at that if you're able to, if it's done on cruel basis. My discretionary earnings, it was a year-over-year because it soothes out some of the seasonality that you're naturally going to have in pretty much every business (0:31:12.3) has, even a little bit of seasonality. Is there a better–like a favorite approach or favorite sort of graph that you would recommend or any other piece of geo that you would look at to say, “Hey! Here's kind of a peak into the future or maybe what the drafts of help of these businesses” Jeff: First of all, I love year-over-year analysis too when you have a business that has enough historical data out there to be able to do that, and that's really, really helpful. But in terms of adding to that, for me, one of the important things is ratios and if you have a numbers degree, whether it's finance or accounting, whatever they teach you about that. But actually it's simpler than– you don't have to learn what you do in school. What it is, is your looking for things like the percentages of the cost that make up the total cost of the product or the service and a lot of times you can find problems where, for a few months, shipping was a lot of money or cost of product or cost advertising is a lot of money and then there's–and then some of those cost drop-off where the ratio changes, the percentage change radically. And for me, those are kind of– a lot of people are afraid of financial analysis in funnels but actually, we understand that what you're looking for is kind of that stability in the business and then a little– the flags or things that changes in the ratios, changes– the peaks and valleys in the chart. And is there good explanation for those peaks and valleys. Peaks and valleys are just fine. The only concern is what are the reasons behind those peaks and valleys and sometimes, for example, sellers, so they really have– they may not have any idea why they're getting more customers or any idea why they lost customers. And the big problem with that is that when you buy the site and something happens, you're not going to be able to get those customer back if you don't know the reasons for those things. So some of the tools and things that I look at. And also just say, they kind of end in the evaluation stage and stay on in due-diligence stage. One of most important tools for new buyers is to compare different sources of information, just in the content, for example, a lot of times, you'll have analytics reports then you have your ad network reports and sometimes you have bank statements, you have taxes, you have– you actually, a lot of times have a lot of different sources for very similar information and it's important to kind of compare those sources together to see if something's missing, something's kind of wack. And it kind of really helping, so in E-commerce is same thing, where a lot of times you'll have traffic and saying why I'm getting this many sales, repay-dues and then you have shopping cart software on your website, you have merchant processors who have similar data and then whatever is in half-thing in your back account and all of those things that's lying out. So , there's actually some, pretty simple tools, once your kind of aware them to take the mystique off of what're people are a little bit concerned about when they first enter business. Mark: Wow! there's– I kind of always restarted with this, rather than buy a big verse and buy a small sort of conversation that is a lot of details you get in to hear, but we are up against clock a little bit here. I think this idea of understanding the customer journey, understanding how they become customers, and the process they're involved there both can help any buyer understand how healthy a business is and how new was or how specialized they're going to have to be in their–works with that business but also potentially uncover some opportunities if there's leakage, for example in that customer journey wherein you're losing a lot of people at a certain step maybe they are taking advantage of cart abandonment technologies or maybe they don't have a good e-mail automation. Well these are opportunities that might be available for buyers. And then also this idea of looking at ratios; really, really solid advice. Jeff: Yeah, the ratios– what I will do again when I'm evaluating business is I'll look at cost of good sold– gross profits were the first things I will look at. Is that ratio staying healthy because you don't want a business where that's getting squeezed up at time or at least you need to understand that. But also you compare advertising to total revenue are you having to spend more just to keep the same revenue? Or has that owner adjusted another area so maybe they're spending more but cutting back on staff–But to make the bottom line look healthy but ,maybe lying underneath there's a few issues that you have to be aware of. Mark: I would love to sit and talk for a couple of hours because I think we could talk for a couple of hours. So, maybe what we'll do is we'll have you on again in the future and we can continue the conversation. In the meantime where can people learn more about you? Jeff: I've a website called “HeckYeah.org” and then “OwnOptimize.com” is where I'm selling my courses right now. So those are the two places. And yes Mark, I would love to– this is one of my favorite topics really is this idea. First time buyers, second, third time buyers; what are the questions that they have, which they look for and as you said, lots of things we could talk about. We're just barely scratching the surface so I'd love to come back and talk some more about it. Mark: Cool! Hey Jeff, thanks for coming on. Really appreciate you coming on and well, stay in touch. Jeff: Yeah, sounds good, great. Thanks a lot for having me. Links and Resources: Jeff's Website Jeff's Course The Website Investor
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