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TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff ` For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations,...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations, print...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations, print...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations, print...
TRANSLATION MENU: LOOK UPPER RIGHT BELOW THE SOCIAL MEDIA ICONS. IT OFFERS EVERY LANGUAGE AVAILABLE AROUND THE WORLD! ALSO, SOCIAL MEDIA AND PRINT ICONS ARE AT THE BOTTOM OF THIS POST! Sixteen years on the streets, living and working with the people of China, Jeff For donations, print...
https://amzn.to/30Aj94S (Buy When on Amazon) Connect with https://www.jeffwellen.com/ (Jeff) For help, resources, and community support, please join the https://www.facebook.com/groups/thebusinessoffatherhood (Business of Fatherhood Facebook group) to dive deeper into the topics here on the podcast. Apply for a free coaching call at benkilloy.com Follow me https://www.instagram.com/ben_killoy/?hl=en (@ben_killoy) on Instagram to submit questions you have on fatherhood. Be sure to subscribe on Apple, Google, Spotify, Amazon, or wherever you get your podcasts. And feel free to drop me an email at ben@benkilloy.com Heads Up: My episodes may contain affiliate links! If you buy something through one of those links, you won't pay a penny more, but we'll get a small commission, which helps keep the lights on. Thanks! Heads Up: My episodes may contain affiliate links! If you buy something through one of those links, you won't pay a penny more, but we'll get a small commission, which helps keep the lights on. Thanks!
Today... we talk MUSHROOMS! We're going to discuss nutritional, medicinal, and psychedelic mushrooms in this podcast with one of the very first people to bring mushrooms into the supplement market, back in 1989! Here's some more about Jeff: For over 50 years, Jeff has been on the cutting edge of growing, cultivating, and researching mushrooms. As the President and founder of Nammex, Jeff was the first to offer a complete line of Certified Organic mushroom extracts to the US nutritional supplement industry. Back in the 70's he worked on a commercial mushroom farm in Olympia, Washington, and spent the next few years climbing up the toadstool to become a production manager, responsible for the cultivation of over 2 million pounds of Agaricus mushrooms yearly! Jeff is focused on educating people in mushroom identification, ethnomycology, and mushroom cultivation, and showing everyone the power of mushrooms! Check out his companies at www.nammex.com and www.realmushrooms.com Head over to http://buylegion.com/boomboom enter code boom boom at checkout to save 20%, start earning loyalty points, and supplementing with the top supplement company on the market. Check out https://eattoevolve.us/ and enter code BOOM20 to save 20% on your meals (always fresh, never frozen - delivered right to your door). Apply for our World Renowned Coaching Program, RIGHT HERE. Join The Tailored Trainer (TCM's Membership Site) to gain full access to daily programming and a private coaching forum for guidance. Learn more at: https://tailoredcoachingmethod.com/tailored-trainer/ OR download some free sample programs at: https://tailoredtrainer.securechkout.com/samples Remember to join our private FB community, RIGHT HERE. ASK BOOM-BOOM YOUR QUESTION HERE ---- Timestamps: 4:20 - How did Jeff get started studying mushrooms 6:30 - Different of mushrooms 15:55 - What mushrooms are edible and what each mushroom does 34:40 - Medicinal side of mushrooms 42:10 - Mycelium 50:35 - Where should mushrooms be grown 53:10 - Where you can find Jeff and all of his content 58:40 - Psychedelic Mushrooms ----- Apply For Coaching: bit.ly/Coaching-App Get Your Free Copy of The Nutrition Hierarchy, HERE Learn How We Coach: Read This Case Study Article Top 4 Episodes: - Nutritional Periodization - Nutrition FAQ - Training FAQ - My Story ---- You can get access to ALL of our content in one place, now: www.tailoredcoachingmethod.com/links/ Check out all of our e-books by visiting www.tailoredcoachingmethod.com/products/ Tailored Coaching Method Coaching Info: www.tailoredcoachingmethod.com/online-coaching/ ---- Social Links: Blog – www.tailoredcoachingmethod.com Facebook - www.facebook.com/tailoredcoachingmethod Instagram -https://www.instagram.com/tailoredcoachingmethod/ YouTube - https://www.youtube.com/user/BoomBoomPerformance Email – info@tailoredcoachingmethod.com As Featured on: Huffington Post, Bodybuilding.com, The PTDC, Dr. John Rusin, Muscle For Life, HLHL, iN3, OPEX Fitness and More…
Without question, the last several months have accelerated ecommerce adoption and drastically changed consumer behavior. The entire sales lifecycle from finding a prospect to closing the deal has been turned upside down. Now two key obstacles lie in the path of ecommerce leaders… The first is the more obvious, more discussed problem: How do you operationally and technically need to change to meet your customers' evolving needs? The second key obstacle is not as often addressed, but is equally as important: How do you then communicate to your customers that even in these changing times, you are equipped and ready to meet their new needs? The binding and laminating business doesn’t sound like it would be ripe with insights into answers to both of these questions, but Jeff McRitchie, the VP of eCommerce at Spiral, is here to prove that assumption wrong. Jeff has nearly two decades of experience in the ecommerce and digital space. Just last year, his own company, MyBinding.com, was acquired by Spiral, where he now helps lead ecommerce operations. On this episode of Up Next in Commerce, Jeff explains what it has been like merging his ecommerce business with a more traditional binding company. He shares some of the challenges he faced along the way, and what methods and strategies he’s leaned into to find success. Jeff also discusses tips for building out a winning SEO and content strategy, and how ecommerce is playing a larger role across the entire business, including in customer acquisition and content marketing. Main Takeaways: The Merge: When a primarily ecommerce company merges with a larger more traditional business, there are a lot of balls in the air to create a cohesive and efficient system. Most of the adjustments have to be made on the side of the acquiring company, which needs to learn how to compete in a digital marketplace. That means that education has to be a priority both internally and externally. Use Their Words: Every industry has jargon and industry-speak. It’s easy to fall into the trap of using that language throughout your platforms and channels. Instead, you have to meet customers where they are with their own language, and use the words and phrases they use. This will ensure that your customers feel like you are speaking directly to them and it also helps create more longtail SEO opportunities. Content For Now that Pays Off Later: Some of the most-viewed content you create might be consumed after a customer makes a purchase. On the surface, that might make it seem like content-creation is not a good customer acquisition strategy. On the contrary, it’s actually a critical long-term strategy in the sense that good, useful content is critical for brand awareness and building trust, which customers will remember when they need to buy in the future. For an in-depth look at this episode, check out the full transcript below. Quotes have been edited for clarity and length. --- Up Next in Commerce is brought to you by Salesforce Commerce Cloud. Respond quickly to changing customer needs with flexible Ecommerce connected to marketing, sales, and service. Deliver intelligent commerce experiences your customers can trust, across every channel. Together, we’re ready for what’s next in commerce. Learn more at salesforce.com/commerce --- Transcript: Stephanie: Welcome to another episode of Up Next In Commerce. This is your host, Stephanie Postles. Today on the show, we have Jeff McRitchie, the VP of Ecommerce at Spiral Binding, My Binding and Binding 101. Jeff welcome. Jeff: Thank you. Stephanie: Thanks for coming on the show. I was excited when I was looking through Spiral's background. It looked like you guys started in 1932. Is that right? Jeff: Yeah. I mean, we've been around for a long time. Stephanie: Yeah. I think that'll make for a really fun conversation because I'm sure that the company and you have seen a lot of transformation over the years, so that'll be fun to dive into later. Jeff: For sure. Stephanie: Tell me a bit about Spiral. What is it? How do I think about what you guys do? Jeff: So Spiral is really a company and we've built ourselves around helping people to bind presentations and proposals. We do a little bit of laminating. We do a little bit of other things, but really we focus a lot on binding. We sell the equipment and the supplies for people to be able to bind presentations, proposals, books and training materials. Those are probably the primary things that come out of it. Jeff: We're a niche player in the office products market is one way to think about it. We're an interesting a hybrid of a company because we sell a little bit in B2B, a lot in B2B, a lot in B2C or B2B to C sort of space. Then we also have some really interesting national account sort of business as well. Kind of a little bit of an evolving company, we're a manufacturer and a distributor at the same time. We have lots of different faces which presents some really cool challenges from the standpoint of being in a digital transformation or Ecommerce role. Stephanie: Okay cool. So how long have you been at the company for? Jeff: My story is interesting, actually I'm co founder of a company called My Binding about 17 years ago. Last year we sold to Spiral. I've been with Spiral for just over a year now in this sort of digital transformation role but with My Binding, which was more of a pure play Ecommerce space. We grew and we were the largest sort of binding Ecommerce player in the market. Then all of a sudden we joined forces essentially with Spiral, which was the largest sort of B2B player in the market. Now we're one force together going after the binding and laminating market. Stephanie: Oh, interesting. What was that process like where you had your own company, you guys were selling online and then joining a company that maybe wasn't doing as much of that. What was that process like when it came to incorporating your company into an existing older company? Jeff: There's definitely some upsides. Suddenly you have increased purchasing power, you have more access to talent and capital. Those were amazing things, but the integration side of things is tough. Jeff: I mean, you're trying to merge systems and figure out how everything works together and learn the language of a new company. Some of that stuff is not as easy as it should be, as well as trying to figure out where exactly are they on the landscape of digital transformation and how do you navigate that when... We were pretty much an Ecommerce or digital first organization. That wasn't really their background. Now we're figuring out how do we be both? That's a pretty big challenge actually. Stephanie: Yeah. That sounds really difficult. What does the customer journey look like for Spiral or what did it look like compared to My Binding? Jeff: I guess the best way to think about it would be that in a B2B, B2C sort of Ecommerce experience, we were really building our business around a large number of transactions with a large number of customers, essentially small transactions to a large number of customers. On the more traditional B2B model, the traditional side of the Spiral business would have been around a small number of transactions to really big customers. Which is pretty typical when you look at this idea of traditional B2B and more like an Ecommerce B2B sort of experience. At least a B2B, to C sort of experience. Jeff: That was the really interesting thing is that we were dealing with customers from all over the country that in almost every industry that you can imagine, but most of them were rather small and we are filling specific needs for those customers. That was fine. On the spiral side you were looking and saying, hey, they had deep relationships. Relationships that went back decades, in many cases, with organizations where they were the supplier of choice. They had complex contracts and all those kinds of things. That was never really part of the Ecommerce world. Trying to figure out how do you merge those two together to get the best of both. It's not easy, but it's really fun actually. Stephanie: Yeah. I can imagine it takes a lot of training for their existing customers who are used to those contracts and used to things being done a certain way. How are you maybe going about training the customers who are used to doing things the old way to be like, Hey, we actually can do this online usually. Jeff: Slowly. Stephanie: Any lessons there that someone can take away if they're going through the same thing right now within their org? Jeff: You don't have to do it all at once. Our approach is really to allow customers to interact with us the way they want to interact with us by giving them better options. Really the priorities for this past year have been to try to integrate systems and then upgrade our footprint so that we can allow the company to put its best foot forward. Really starting with the E-comm side and getting everybody on the same platform and then tied into the same systems. Jeff: Now we're actually probably just a couple of months away from launching our brand new B2B E-com experience for the traditional spiral customers. Essentially we have been allowing them to continue to exist and deal with the company in the way that they used to while improving the experience and then bringing the platform up for the entire organization. One of the things about especially B2B commerce is that it gets really complicated as you tie in lots and lots of systems and a lot of interesting rules. Jeff: Customers want to deal with you in the way that they want to deal with you. What we've found is that we have to build specific experiences for our different customer types. That's the approach that we've been taking. I think that's a good approach from the standpoint of, you're not trying to force everybody into the same sort of experience because not everybody wants to deal with it in the same way. As a large organization that sort of deals with these sort of different challenges, we have to answer questions, like, do you display pricing on the front end of your website or is it a login only experience? Jeff: What pricing do you show people or what price pricing do people get and how do you control that and how do you manage that and how do you make sure that that experience is personalized for individuals? Then there's the age old question, which is really challenging in an organization that has multi channels and that is, how do you deal with the channel conflict? Whose customer is that? I guess it depends on who you would ask because everybody thinks that the customer is theirs. Yet ultimately the customer needs to deal with the organization in a way that the customer feels the most comfortable, not in the way that the organization feels most comfortable. Stephanie: Yeah. That makes sense. What kind of legacy or what things did the legacy customers get hung up on the most when you guys are making this transition and trying to show them that a new platform's coming? Is there similar themes of things that they're like, oh, I don't feel comfortable with that, or, I don't want to move because of this? Jeff: I think when it comes to customers, most customers want technology. I mean, they become comfortable. I think that they don't want to lose functionality. That's been probably one of the hardest things is that even if that functionality wasn't the best, they become comfortable with it and they don't really want to lose that. Yes they do want a best in class experience. One of the hard things that we all have to deal with in Ecommerce right now is that the bar has been raised. Jeff: There are people who want more and more features in terms of their online shopping experience. What you find is that you need to be able to roll these things out, but you need to make sure that it doesn't make things harder on those customers, especially long time corporate customers. They are really dependent on these things working smoothly and easily. That's actually one of the hardest challenges in this process has been, okay, well, we've done a lot of cool things for customers over the years. One off, you build a feature on the website just for that one customer. Jeff: Well, trying to then redo that and not lose a substantial amount of functionality for specific customers, especially large customers that you have these really deep relationships with, that's pretty tough. Stephanie: I was actually going to ask that next, when you mentioned that you were personalizing the experience for certain customers to make them feel more comfortable or hearing what they want and trying to incorporate that into the platform, how do you go about picking out what things you should maybe personalize or give to the customer without going down a worm hole of having a personal experience for every customer? Jeff: Ultimately, we're taking an approach of first saying, what's the best in class experience that we could build. What are the things that are going to be the best for all of the customers and then looking and saying, "Hey, can we in our roadmap put in the flexibility to accommodate for these many things that customers have asked for?" Jeff: How could we build this in such a way that we can add that on or this on? I'm not sure that we always nail it just from the standpoint of... It's pretty tough to keep everybody happy. But we're taking the approach of, hey, we can make it substantially better for everybody. It may not be perfect, but it should be a dramatic enough improvement that they'll recognize that we have their best interest in mind. Stephanie: It seems like some of those requests might also fit other customers as well or it might be something where they're like, oh, I actually wanted that and never thought to ask. It could be helpful when it comes to product development on your side, like technology development. Jeff: Yeah, totally. We had a really good team that we used to build out stuff and we're able to iterate fairly quickly. That's the good news because sometimes we miss something and so... But as long as you can respond fairly quickly to a customer's need, it gives you an opportunity to serve them better and to communicate. But the other really important part of this is really getting the account managers and your sales people involved in this process so you get some really good feedback because one of the challenges that we face at least is that sometimes as the E-com department and on the technology side, you don't always get raw feedback. Jeff: Maybe the stuff you're hearing is from the people who are yelling the loudest, not necessarily from the people who are trying to help you. You're not necessarily hearing about the features that are going to make the biggest difference for most number of users. Stephanie: That makes sense. With this whole re-platforming and new tech stack that you're going to be launching what pieces of tech are you most excited about showing to the customer or bringing online that maybe wasn't there before? Jeff: For us it's really about an enhanced user experience. We kind of been a little bit on the old school side on the traditional B2B piece of it. This gives us the ability to provide a really much better experience end to end in terms of transacting with us. Some of the things that we're aiming for, that are harder than I was thinking they would be, would be real time freight quoting. When you're a B2B company and you've got a distribution network across the country, and you're trying to figure out how much that pallet is going to cost to go to this customer. You think, hey that should be super easy. That's like in the Ecommerce world, until you start to realize, well, it's really important that you get that right. You have to first know where all that's going to ship from. Jeff: One of the biggest things is a really deep integration with our ERP so we can understand where the inventory resides and then how much it weighs and the sizes and all those kinds of things so that we can do that on the fly. Because right now we do an add back type thing. We'll tell you what the freight is later. Customers don't like that. Especially not in the Ecommerce world. Getting that upfront, same with sales tax calculation. Right now, a lot of that's done on the backend and people want to know upfront. That means building a system that has management for resale certificates and all of those pieces. Jeff: I need to understand where are you exempted, where you not exempted and what are you exempt from and all of those kinds of things so that I can quote you and tell you what the sales tax is going to be upfront before you place your order. That's another piece of it that we're excited about. Requisition list is another one where people will have their own custom price list in the system where they can quickly order. We're building a system where they can upload an Excel file with all of their items that they want so they can do quick ordering and quick reordering. Jeff: I guess those would be a few of the systems. Like a quote management system to allow people to request pricing on items and then for us to respond to them live and track that inside of our system is another one that we're building. Those are all areas where we're saying, hey, this could really enhance the user's journey and make it a lot easier for them to do business with us. Stephanie: That's great. Yeah that sounds like some great changes. Have you had any customers trying out the platform as beta testers and have you seen any difference when it comes to average order value or anything? Jeff: We're not quite there yet. We finished design and we're in the midst of development at the moment. I would say that that's going to be one of those steps prior to launch. Will be first to have sort of sales associates and account managers jump into the platform and test it for themselves and then to really get especially key customers in the system testing, and then also giving us feedback. What do they love? What did they not like and how can we make it better for them? That's on the roadmap before launch to be able to say, "Hey is this better for you?" It's funny because on a traditional B2C Ecommerce launch, you'd be focusing so much on the front end. Jeff: Like, the My Account pages are taking just as much time for this site because that's where our customers are living. They want to use the search, but they really want to use the my account pages. They know what they want, and they need to be able to quickly reorder it. They need to be able to see their orders. They need to be able to have the ability to upload those requisition lists. It's a little bit of a twist but getting them, especially into those my account pages so that they can spend some serious time understanding their accounts and telling us what they like or what they don't like is going to be really important for the launch process. Stephanie: Yeah. That's really interesting about focusing on my account page and how much time they're spending there. I'm sure that things like product suggestions or also bots might be very important on that page to help showcase items that maybe they wouldn't otherwise buy when they're just quickly uploading something or just reordering. Are you guys experimenting with some of the suggestion features? Jeff: Most definitely. Yeah. That's part of the vision is to try to figure out and say, okay, we have these deep relationships with customers and they buy specific sets of products. How can we expand to purchasing a product set? How do we get them and introduce them to complimentary products and show them the right pricing and the right place so that they can say, "Hey, I should totally add that on." That's something that I should consider. It's an interesting challenge for us because we have different personas or groups of people that we're dealing with. Jeff: On one hand we're dealing with dealers and they're really reselling product. You're trying to show them maybe categories of product, where do they need to expand because they're buying for specific purposes. Then you have end users and those end users you might want to show them a different size or a different color. We're experimenting with what the best algorithm is that we can use to show them the right products and then also in the right places too. Stephanie: That's great. What tests are you most excited about that you're pitching to everyone right now and some people maybe aren't sure about? Jeff: I'm actually most excited right now about the lead gen side of our business. Stephanie: Tell me more about that. Jeff: When you start to think about what the power of Ecommerce is for a B2B organization. Ecommerce can really become the engine that powers the acquisition efforts of a company. Especially because we can get in front of hundreds of thousands of customers a month, whereas the traditional B2B sales force might only touch hundreds of customers per month. Maybe thousands, but definitely not hundreds of thousands. Jeff: The idea of... What does it take for us to build a really cool robust system to not only bring these leads in but then to try to figure out how do I score these leads and then not only take them and turn them into an immediate sale, but to determine which ones of these really can be turned into those more traditional B2B accounts that we have these deep relationships with that are going to buy from us for years to come, many tens of thousands of dollars, right? Jeff: The really exciting part to me is looking at it and saying, okay we are on the Ecommerce side, on the B2B2C Ecommerce piece of it. We almost have too many leads. We get so much traffic that comes in. So then how do you figure out, take all those leads and build a really robust system where you can make sure that they're getting exactly what they need, and you're closing as many sales as you can, but then how do you figure out a way to pass those accounts up, the right accounts to the right people so that you can build them into a much larger long term sustainable program. Jeff: For us, that means building a really cool inbound sales team that makes sure that we take care of those leads and that we foster them and do all the things that we need to do, but then building an outbound sales team as well that's going to go in and then say, "Hey, let's take these leads and take them to the next level." Then also figuring out a system for passing accounts up and down inside of the organization. You really want to be able to pass a lead up or a customer up that has substantial potential to be either a national account or what we'll call an enterprise level account. Jeff: But you also want the reciprocity of getting those accounts back or the smaller accounts back from the team. I will say that no one wants to give up that account. That's a big challenge inside of an organization when you're trying to say, "Hey, I'll give you some, you give me some." The way usually ends up being is someone... Everyone wants to receive, no one wants to give. But the system only really works if you can give the best to the... But then also that you can receive quality back. For instance, handing back to the E-com team, only the accounts that don't do any business, isn't really a win. Jeff: You really want your enterprise salespeople focused on enterprise level accounts. We're having to sort of wrestle through what does that look like in terms of structure. I don't know that we really have it all figured out yet, but it's a cool idea. Stephanie: I'm guessing there's a way to automate that and create rules. So it, like you said, can go up or down depending on certain criteria from when they're coming in. How are you all thinking about automating that process? So it's maybe less of a salespeople having to give and take and whatnot, and more like, Oh, this is automatically routed to you based on these metrics. Jeff: That's exactly what we're doing. We're exploring machine learning and big data to try to figure out a really good way of scoring customers because using that scoring, you can figure out how to pass customers up. Then a set of rules as well that says if these customers aren't of a certain size or if they have this kind of profile, they really belong in this group. But it's an interesting challenge from trying to figure out where do you get all this data from, and then how do you process it? We're exploring different options right now in terms of what that might look like and how we can best approach that without spending a ton of money before we bet that it actually works. Stephanie: Yeah. That's really cool. So outside of the prospect giving that information, what kind of things are you looking into right now to find the information to help with that scoring process? Jeff: It's actually challenging. You have certain pieces of information that are given to you which you have usually a name and an address. Their email address usually has a domain associated with it, especially in B2B. So you can pull a lot of information from that and you can start to sort your domain, your customers by domain. But really we're looking and saying, okay, well we do know the purchase history. The idea then is, okay, if you were to sort all your customers out, you can sort them on a scale of, let's say a one, two, three. You can say my best customers spend the most money with me. My worst customers spend the least amount of money with me, but that really misses part of the point. Jeff: You almost need to add a second access to this, which is really about customer potential. When it comes to customer potential, we're looking at the idea of what would it take for us to add some big data to this? To understand the size of their company and the profile of the company that they come from, or the industry that they come from as well, because the industry can be really important to us. But then the other side of it is also looking at what they purchased. Like for instance, people who purchase specific equipment or supplies, they're going to have a much higher lifetime value with us because those are proprietary or have maybe a really good pull through rate. Jeff: For instance, it may not be that it's a proprietary supply, but when you buy that machine, you have to go through a lot of supplies to make it worthwhile. You look at the data and you say, okay, that customer has a huge amount of potential. Not because of the amount that they bought from us, but because of what they bought or who they are, the company that they work for or their position. We're looking at the possibility of maybe even extending that into some of the databases out there that help you understand whether people are in market and what their roles are as well. Jeff: Because when you're dealing with B2B, you're not really selling all the time to the company, you're selling to a person inside of the company and that person has a role. You have to figure out, okay, well what role do they play in this picture? That helps us to sort them into personas. If you're dealing with a really small number of accounts, you can figure this out, but we have to automate it because it's not really feasible to do that in a one off basis. Stephanie: Yeah, definitely seems like you're going to need a whole entire data or business operations team who can build those rules out for you and have dashboards. That seems like a big project, but well worth it. Earlier, you mentioned that you guys have more traffic than you know what to do with and lots of leads coming in. Of course my first question is how are you getting this traffic? How are you acquiring potential customers? Jeff: Sure. I mean... We're in a niche industry, right? So that's part of it. We've been around for a really long time. Because of that, at least... Spiral has been around 80 years, My Binding for almost 20 on the web. As you start to look at that, we created a massive amount of content. Thousands of videos and pages. We really have in a lot of ways, the best websites in our sort of space and industry. Because of that, people are finding us to solve problems. What you find is that we built out these websites and either through SEO or through paid search we're driving a ton of traffic to the websites because they convert and that makes a ton of sense. Jeff: We're essentially... We have all of this content and it's really designed around this idea of how do we solve these problems for customers? We can drive more and more of that content. The website deals with a certain number of those sort of leads and converts on its own. The challenge for us tends to be, what do you do with the people that are maybe a little higher in the funnel? You're now talking about making sure they have a really awesome call center that is going to be able to answer those questions. Live chat is really big. We've extended our live chat hours all the way to midnight which is unheard of in the B2B space. Jeff: I want somebody there to talk to somebody if they have questions about products. Especially really big products. We're experimenting with the idea of doing triggers for live chat. We did that and that was really successful for us. We turned on the trigger and said, with the idea of if I walk into a store, somebody says, "Hey, how can I help you?" We did that on the Ecommerce site and we had massive numbers of people that were engaging with us. But the surprise to us was that many of those people were actually much higher in the funnel than we were used to dealing with. Jeff: In other words, they were now engaging with us and they weren't ready to buy. They were in the research space and they had lots of questions. Which is really cool but it just changes the model a little bit and you all of a sudden have to figure out how do I step up for that? How do I make sure that I have the right person to answer those questions? That's part of it. Driving the leads really comes to how do you acquire traffic on scale? Really good high quality traffic for the site. Then the question is, well, what can you do with it? Driving the traffic is really exciting from a standpoint of it doesn't have to be done in one way but you have to be maybe a little bit creative to do it because you really are trying to get in front of people that have problems rather than... Jeff: At least in our space, you don't come to a binding website unless you have a problem that the binding website can solve. It's not exactly an impulse purchase. You're going to show up and you're not going to just browse around. I wonder what kind of binding machines they carry. You probably are on a mission to solve some sort of problem. Right. Whether that's like your bosses told you that you need to buy a binding machine or you need to upgrade the way that your reports or presentations are going to look, or you have a deadline of Friday and you need to get these reports out for the annual meeting. Jeff: These are all sort of really common sort of scenarios and so then the question is, will this product work for my specific needs? That's a question that our customers are constantly asking. Building to that has been a really great sort of acquisition model for us to build around the idea that every customer that comes to us comes to us with a problem that we can solve for them, and then figuring out how do you work backwards to that? What problems could we solve? Then as you start to get creative with that and build massive amounts of content, that content lives out there forever. That's been really a big part of our success, is really the longevity but also the content generation sort of machine that we've built over the years. Stephanie: How has your content... What is the style now today? Is it only educational? Is it humorous and how has it evolved over time? Jeff: We've tried a lot of things over the years. We've tried to be funny. I think we think we're funny sometimes. We've tried a bunch of different things. We've tried to be really educational. It was really hard to figure out the ROI of that. What we've really... If you were to look at our content, we do a lot of content that is really close to the bottom of the funnel, but that would be really helpful. We go with that sort of helpful thing as well as deep. So the idea of building out a really robust and large set of content over the years about products. Jeff: We spend a lot of time making sure that we have all of the details about the product, even to the point where our competitors come to our sites to look up products because they don't have as good of information as we do. That's one piece of the content side of things for us. We have a lot of how to videos. We did a bunch of experimenting around the videos. We found that the videos that people really cared about would basically answer a couple of quick questions. But mostly it was, will this product work for me? How does this thing work? Jeff: We made a whole series of those videos, almost five thousand of them that are really around the idea of how does this product work and a quick demonstration essentially. Usually around a minute long that takes the product out of the box, show someone how to use it. Those really work well for us because they show a customer generally what are they looking for. A lot of customers they want to see what it looks like or they have a machine already and they want to say, "Is that's the thing that works with my machine.? They don't understand our language. Those videos have worked really well for us as well. Stephanie: That's great. Are there any surprising pieces of content that you didn't think would work that did, or surprising sources of customer acquisition that you wouldn't have looked into before? Jeff: We've had a few blog articles that have found traction in the world and the web that I wasn't really anticipating. We've written a lot of content over the years. Most of the blog articles get a little bit of traffic. They're like evergreen content, little bit of traffic over a long period of time. But occasionally we'll end up with one like... Something about how to laminate without a laminator. Stephanie: That's a good one. Jeff: Amazingly, there's a lot of people that look up that and I was shocked. It consistently drives more traffic than almost any other blog article for us. Which is odd. I'm not sure it drives a ton of business because they don't want to buy a laminator, but if you think about it, there's a whole segment of people that have maybe problems that we don't traditionally associate with our business. That would be one thing and then the other piece would be the language piece. Jeff: It's always surprising when I discover that the language that we use internally for our business doesn't match the language of the customer. An example would be we talk about binding covers all the time because we're in the world of binding. A lot of people they just talk about card stock. In the paper world, the card stock doesn't even exist. It's not a thing. People will talk about it. It's cover weight paper. Index weight paper. Card stock is like this sort of crafting term. Yet it's sort of taken on a vocabulary of its own in the world. Jeff: When people search for binding covers, often they'll use that word. That's always surprising to me as well. There's a whole list of those things where people basically they choose to use their own words to describe things. Now you're trying to figure out how do I technically be accurate about this product but really use their language? Because if you don't use their language, then you're not going to show up in search for this stuff and they're not going to feel comfortable with it. Stephanie: That's a really good reminder, especially with generational shifts that the new consumer might be using completely different language than what you're used to. How are you exploring what that language might be? I mean, especially a company that has been around since the thirties, how are they figuring out, oh, this is what they call it now, this is what the kids are saying these days? Jeff: Probably the easiest thing for us is to look through our search results and especially the no results found once because often it's those things. When people are typing in stuff in the search bar and nothing's popping up. You look at that and you're like oh... A smart merchandiser, someone who understands your products really well, they start to make those connections and they're like, oh, wait a second. That's what they mean. Obviously a lot of that like spelling mistakes and things like that. You can fix those in your search engine but when you start to look at it, you start to see sometimes patterns. That's one of the easiest ones. Jeff: The other two that are really helpful for us would be Google autosuggest. Just start typing things in Google and then figure out what Google thinks that you should add to the end of it. All of a sudden you realize, okay, maybe people are searching for maybe a slightly different side of things than we thought they were. Then the other one would be Amazon. Amazon, their product terms are awful. Yet they sell so much. Why? Because they tie into language. They have usually products that have all these different words in the titles that you would never imagine. Jeff: As you start to look at products that are really successful on the marketplaces, you can start to realize, okay, well maybe they're onto something there. They've managed to call out even the most important attributes of that product in a very search centric sort of model or they have really been able to hone in on maybe key words that we weren't thinking of when we've been building this out. Especially because often you start with whatever... A point of reference would be the manufacturer's title. It becomes quite difficult sometimes to sort of detach from that, but Amazon detaches automatically because they let people come up with their own titles for stuff. Jeff: Usually it's the sort of ecosystem that will change the title to try to optimize. Sometimes when you find really successful products that you're realizing, Oh, maybe people do care about that. Stephanie: I love that. That's really good tips to remember about, finding those keywords and how to discover them because yeah, I think even longterm key words would probably be really good for your industry. I'm thinking, how would I Google something like that? I would probably be like how to create a hard cover book for my presentation or something really long winded like that. It's a really good reminder about the keywords importance. Jeff: Then obviously you have your paid search stuff too. You can look and see in your paid search accounts, you can say, okay, what keywords are actually driving? If it was a broad or a modified broad match keyword, you're going to start to dig in and you can say, oh, it actually matched on this keyword and it drove a sale. Again, driving back and saying, okay, what am I driving sales on? It tends to be a really good place to start discovery as well. The only thing, the problem with that is that you might be so far off that you're missing the boat completely. That's where it takes a really good merchandisers to sort of nail that stuff down. Stephanie: I also think it was interesting earlier when you were talking about how to laminate without a laminator and thinking about selling something through saying, oh yeah, you don't need to buy through us. Here's how you do it because I'm sure a lot of people, like you said, are searching for stuff like that or how to fax without a fax machine. I know I've searched that quite a bit, but making fun of it and you might actually be able to convert someone who's like, Oh, I actually just do need a laminator to do this, but having a humorous video around that. Jeff: Yeah. As well as maybe they decide that they want to buy some cold laminating pouches. The idea is, if you can be really helpful in the long term, going back to that idea of video. We've done a lot of videos over the years. We understand that many, many, many times people use our videos post-purchase not pre-purchase. People are going to the video to figure out how does this thing that I already bought work. Well, that doesn't really help us but it does help us in the long term. Jeff: As you look at it and say, it's not going to win us the sale today, but it will win us brand awareness. It does potentially when you do supply sales. Because we're a very supply driven sort of space. If you think about it, if you buy a binding machine, you got to buy some supplies for it. Longterm, we want to have an awareness and be in front of customers so they understand who we are when it comes time to buy the supplies that they need. Stephanie: Just like you said, it's really important to continue to stay in front of that customer so they come to you to buy supplies and remember you guys. How do you go about doing that and keeping a customer retained? Because it seems like it would be easier with these legacy customers who are maybe in these year or three year long contracts. Now when you're moving towards Ecommerce and they can hop around really quickly, it seems like you wouldn't be able to retain customers as easily. So how do you go about staying in front of them? Jeff: I mean, there's a lot to that, the question. To give you maybe a general overview of our thoughts is a big part of our business and something that's really important to us. Especially on the E-com side of things, it really starts with delivering a really awesome experience upfront. So you need to be able to help them find what they need and then deliver it to them in a really reasonable timeframe or meet their deadline. All that kind of stuff. To have the product in stock and all of those kinds of pieces. That's actually harder said than done when you deal with a really large niche category. Jeff: That's the beginning piece of it. Once you've given them that positive experience, or if they've had a negative experience, you use your customer service to basically earn a customer for life. That's actually the motto of our customer service group. Earn a customer for life. As you look at this idea, you say, okay, well, we now have a shot at their business longterm. Now the challenge for us is, okay, what's the best way to reach them? The easiest way is email. We have a ton of automation in our emails. We send emails based upon what you've purchased with replenishment. We send life cycle campaigns based upon... Welcome to the store anniversaries campaigns, and then also best customer campaigns, win back campaigns and reactivation campaigns. Jeff: We have all these automations that go out. They're really helpful. We also have sales that go out on a weekly basis that keep people engaged and keep things front of mind for them. You combine all of that on the email side, but then you recognize that that maybe only gets you half the customers. The question becomes... Because there's a bunch that are opted out in the B2B space, it's really hard on deliverability to get into the inbox. More and more people are using advanced filtering programs to prevent spam from getting through to their employees. Jeff: As you look at that, you say, okay, well, email only takes you so far. So then what do you do? The real question is, back to that conversation we had earlier about lead scoring, how do you determine your best customers or your best potential customers and make sure that you get somebody to call them? To send them a personal email which are easier to get into their inbox or to find another way of touching them. For us right now, the two other ways of touching them that we're sort of exploring, one would be SMS and then another would be direct mail. We're kind of in the process of exploring a test on SMS. Jeff: I'm not too sure how we feel about it, honestly. We have to figure out how our customers feel about it, just from the standpoint of as you look at customers giving their personal cell phones for business purchases and getting text messages. But you think about it, that's a great way to get in front of people and stay in front of them as long as you're going to be super, highly relevant. Then the other piece of it that we do a little bit of would be on that retargeting side of things. If you don't know who that customer is exactly, or don't have their ability to email them, you can at least sort of [inaudible] do it, make sure you're sending or placing ads more frequently into their feeds on different platforms through retargeting. Stephanie: That makes sense. It seems from, especially in SMS perspective, it seems like the only angle you can go about is being helpful. Like oh, you probably are running out of supplies, order now. I don't know, you can get a discount or something. It seems like there's not too many ways for B2B companies to use texting without the customer being like, "Oh, I don't want to be thinking about work right now." Unless it's a trigger for them to be like, "Oh, I need to reorder this or else we're not going to have it on the day." Is that true or are you seeing other avenues? Jeff: Well, the first step would be to be helpful with order cycle. For instance, think about what Amazon has done with allowing you to get a text when the item is delivered. Which is a big problem for a bunch of our customers, especially in pandemic, but even outside of that. It might be delivered to a central desk or to the shipping and receiving area of their company like an alert. Alerts are a pretty good option for us to sort of get our toe in the water a little bit and to stay active. Then yes, something that's personalized. Jeff: Then also, what we're struggling with is what is the best time of day to do this? Probably don't want to send it to them in the middle of their evening. They're disconnected from work, but you also need to make sure that... It's got to be time adjusted for the time that they're in and they also really needs to be followed in their workday probably. Those are some of the things that we're sort of figuring out and testing right now and saying how is this going? Then what's also the most appropriate way to collect where people don't sort of get freaked out. Because it's one of those things, do you want to get text messages from your binding company? I don't know. You got to ask it in an appropriate way. Stephanie: Yeah. That's a really good reminder. All right. We have a couple minutes left and I want to jump into a quick lightning round brought to you by Salesforce Commerce Cloud. This is where I'm going to ask you a question and you have a minute or less to answer. Jeff, are you ready? Jeff: Okay. I'm ready. Stephanie: I'm going to start with the hard one first for you because I feel like you're in a game right now. I got to keep it going. What one thing will have the biggest impact on Ecommerce in the next year? Jeff: Well, I think obviously it's COVID. It's pushing people online in completely new ways. It's shifting customer expectations around a whole bunch of different things. It's ruined the Amazon two day expectation, which I don't mind, but it's also shifted the way that people shop, where they're shopping, how they're shopping, and even their mentality. I don't know that we even really totally understand how it's affected everybody yet because everybody's still sort of in this scrambling mode. But ultimately I think as this shakes out, it's going to change the landscape of how we market, but it's also going to change the landscape of how our customers interact with us. Stephanie: I like that. What one piece of advice would you give a new Ecommerce entrepreneur? Jeff: I would probably say stick with solving the customer's problems. I know that tends to be a B2B thing, but it's not really a B2B thing. If you think about it, I need the right sweater for me. Really be customer centric. That becomes really cliche and that's why I go to the idea of solving a problem. You got to think about what sort of value proposition are you offering to this customer that's unique, that is going to allow them to accomplish something that they wanted to accomplish when they came to your site. Jeff: I think by focusing and being really focused on the customer problem, I think you can build out really awesome experiences, and then that deep understanding of your customer will take you really far. Stephanie: That's a good one. What is your favorite day in the office? I'm trying to imagine what a binding company feels like. What's your favorite day in the office feel like? Jeff: I mean, most of my days are pretty full of meetings. A day without meetings would be an awesome day in the office. Stephanie: That's a lot of people. Jeff: I think so. In the world of the binding company, a day in the office doesn't look all that much different than a day in a normal office. It might be a little bit like an episode of the office. Stephanie: That's what I had in my mind honestly. Jeff: Yeah. It's like paper company. There is a little bit of aspects of that, but I mean, we're just like any other company. We're a retailer, we're a distributor. We deal with customers all day long. I would say the other thing, the best day in the office is the day that you have customers that love you and that are just heaping praises, especially on the customer service people and your salespeople. When you have customers who are just singing your praises, those are great days. Stephanie: Yep. That's awesome. I'm glad you mentioned the office and I didn't have to. If you were to have a podcast, what would it be about and who would your first guest be? Jeff: That's a tough one. If I were to have a podcast. I am super passionate about entrepreneurship. I'd probably do an entrepreneurship sort of a podcast about starting a business, growing a business, and the creativity that goes around that. If I could get anybody on the show, I would probably pick an entrepreneur. Maybe I pick the person from lemonade stand or one of those organizations that's really making a big impact on starting up entrepreneurs with kids. That's something that I really love. Stephanie: Yep. I like that. Brings back the memories of my parents make me [inaudible] my neighbor's yard for 25 cents which is well below market. Jeff: I think you could make at least 50 cents for that now. Stephanie: I think so too. All right Jeff, this was very interesting, such a good conversation. So many good tid bits that people can actually use from this interview. Where can people find out more about you and Spiral? Jeff: Sure. You can definitely visit one of our websites. We've got SpiralBinding.com. We have MyBinding.com and Binding101.com. You can find me on LinkedIn as well. Shoot me a message and ask me to connect and I'd love to meet you. Stephanie: Awesome. Thanks so much for joining Jeff. Jeff: You're welcome. Thank you.
Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. Nachi: For our regular listeners, you probably noticed a lapse in recent episodes as we pulled away from our usual monthly releases. Jeff: With both of us having increasing demands on our time -- myself with business school and the busiest 21 month old in the world and Nachi with yet another entrepreneurial endeavor on the horizon -- we decided that it would be best to pass the podcast on to another host, so EMplify can continue to create and deliver the high quality materials that you deserve. Nachi: We have obviously really enjoyed creating this podcast and working closely with EB Medicine to produce it. We are deeply appreciative of you, our listeners, and your wonderful feedback and comments over the years. Without you, there would be no point in us working so hard on this. Jeff: And keep the feedback coming as we hand the reins to Dr. Sam Ashoo as the new host of EMplify. Dr. Ashoo is an Emergency Physician based out of Tallahassee Florida with a keen interest in informatics who has been featured on several other podcasts you may have heard. We can’t think of a better person to take over for EMplify. I’m sure you’ll really like him and the content he produces. Well, with that, let’s get started on our final scheduled episode of EMplify! Nachi: As we are just about to see one of the busiest travel days of the year, that would be the Wednesday before Thanksgiving, we thought there would be no better time to discuss the September 2019 issue of EMP: Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls. Jeff: This was a fantastic issue, thanks to the hard work by Drs. DeLaney and Greene, both of the University of Alabama Birmingham School of Medicine. Thanks as well to the peer editors, Dr. Knight, and Dr. Hill of the University of Cincinnati. Nachi: And I think you have a bit of a disclosure for this month... Show More v Jeff: Well, this is a first! Finally at the point in my career where I can announce a disclosure, though it’s more of a potential conflict of interest than an actual disclosure, but certainly still worth noting. I currently spend some of my time working for STAT-MD - which is an airline consultation service run by the Center for Emergency Medicine and UPMC. Though I’m certainly a junior member of the team, in some sense, I’ve responded nearly 500 inflight emergencies over the last two years. Nachi: And this definitely places you are in a particularly nice position to share some information with our listeners this month, and I’ll have some questions scattered throughout the episode for you too. Jeff: Sounds great, so let’s dive in, starting with what I think is the most important point - qualified, active, licensed, and sober providers should volunteer to assist in the event of a medical emergency rather than decline out of fear of medicolegal concerns. Nachi: I couldn’t agree more, so let me reiterate, please trust the evidence. And volunteer to help should you hear the call. We’ll get to this in a bit but there is little medicolegal concern and you owe it to the sick passenger to help. Jeff: So what are the chances you are called - well, they are not particularly high, but certainly not negligible either. In 2019, of the 4 billion passengers expected to fly, there will be an estimated 60,000 medical emergencies. That means there will be about 1 emergency per every 604 flights. Nachi: So, I fly about 4 times a month for work. At 4 times per month, over the next 12 years I can expect about one medical emergency. Already excited! Let’s start with some physiology. Cabin pressurization varies, but is typically equivalent to an altitude of 8000 feet. Jeff: And this has a huge effect, in one study of healthy volunteers, this change in pressure resulted in a 4-10 point decrease in oxygen saturation and a 35 point drop in arterial oxygen partial pressure from 95 mm Hg to 60. Nachi: In another study of healthy volunteers on a long haul flight, this change caused 7% of passengers to report symptoms consistent with acute altitude illness. Jeff: Due to the principles of Boyle’s law, decreased cabin pressure also causes expansion of gases within anatomical spaces in the body such as the eye, GI tract, sinuses, middle ear, etc. This expansion can potentially threaten surrounding structures. Nachi: So there must be guidelines for those recent post-op for flying - right? Jeff: There certainly are, but I don’t think we need to get into the weeds on this one since nobody listening will likely be doing pre-flight screenings. I think one thing to remember here, is that though cabins are pressurized to several thousand feet, they CAN be pressurized even further if necessary. The airlines don’t do this because it takes a tremendous quantity of fuel to do so, but if pressurization will defer a diversion, this option may peak their interest. Though an anecdote, the only time I’ve ever suggested it is on a flight from someone recent post-op eye surgery who went blind midflight. We pressurized the cabin from 8000 to 4000 and then finally to sea level and his vision returned. Pretty cool stuff. But getting back to the text, next we have air quality. Only 50% of inflight air is recirculated, all of the flow is compartmentalized between sections of rows, and all the air is run through a HEPA filter. The authors note that the air is actually comparable to that of an operating room. Nachi: Then why are people always getting sick after flying…? Jeff: Well it’s hard to prove, but experts believe that most post flight respiratory illnesses are likely caused by exposure to fomites on high-risk surfaces of airplanes and in airports - like the trays on the seat back. Nachi: Interesting. Jeff: It’s also worth noting that the air is quite dry, though this is unlikely to produce any clinically significant events. Most of the dehydration that occurs is more likely due to inadequate water intake and excess caffeine and alcohol consumption depending on the time of day. Nachi: Don’t judge. Even though it may be 8 am, some of our night shift locums friends may prefer an airport cocktail after a long week away. Jeff: Oh I’m definitely not judging, facts only over here. Anyway, let’s move on to a little epidemiology. Nachi: Syncope and cardiac events account for a large proportion of in-flight emergencies, with cardiac events accounting for the largest percentage of diversions. Jeff: Gi, endocrine and respiratory emergencies follow syncope and cardiac events, with specific percentages varying based on which study you look at. Nachi: Thankfully obstetric emergencies are relatively rare, accounting for less than 0.1% of all emergencies. Jeff: Trauma and substance abuse related complaints have also been reported, but represent only a small percentage of inflight emergencies. Nachi: I think that covers the main pathologies you may encounter. Next we should touch upon the actual responders. Physicians reportedly respond 44% of the time, followed by nurses at 20% and EMS providers at about 4%. Interestingly, despite physicians being there only 44% of the time, they were involved in the care for over 70% of diversions. Jeff: It might seem crazy, but that’s definitely my experience. Many physicians, especially non-ED physicians are not familiar with caring for the acutely ill. Additionally, most physicians are very uncomfortable actually witnessing someone syncopize and then immediately checking vitals and finding the passenger to be bradycardic and hypotensive as is the case with many patients immediately after a vasovagal syncopal episode. I cannot tell you how many times we get called by pilots considering diversion based on a physician’s request only to have the symptoms completely resolve in just 10 minutes. Be patient, this is a common in flight pathology. Nachi: Your experience has not failed you - data from your own group showed that 31% of cases resolved before arrival. Even in cases where EMS was requested, patients were only transported 37% of the time and of those, only 8% were actually admitted for further work up. Death is also a very rare phenomenon, occurring in only 0.3% of cases. Jeff: Alright, so let’s move onto the actual logistics of responding. Each airline has its own protocols and policies with respect to medical responders - some will require credentials, others may not. In some instances, you may be the first responder, in others, the flight crew may have already been in contact with their ground based medical control. Nachi: In terms of supplies, the FAA requires an emergency medical kit and an AED on all commercial flights. These kits cannot be opened without direction from a medical professional on the ground or on board. Jeff: And while airlines may add additional drugs at their discretion, the FAA mandates certain supplies. You can remember these supplies by thinking of the 5 A’s - asthma, allergy, altered mental status, ACS, and ACLS. The 5 As should help you remember the bronchodilators, epinephrine, antihistamine, dextrose, nitroglycerine, aspirin, and lidocaine as the one antiarrhythmic available. Of course, there are also gloves, an IV start kit, and a few other basic supplies. Nachi: AEDs are also required and have been since 2001 and amazingly when a shock was delivered in flight, 40% survived to hospital discharge with a good outcome. Jeff: Just as on the ground, shockable rhythms do well with good BLS care. And lastly, airlines also have a portable oxygen tank in addition to the emergency oxygen that is stored in the event of cabin depressurization. The exact quantity varies, but portable cylinders are certainly available. Nachi: So next we have to talk about a topic that I’m sure many of you have wondered about - what are the medico-legal risks of intervening? Jeff: As with most incidents of concern over medico-legal risk, we really just shouldn’t be too concerned over the potential legal ramifications. Though we’ll get into specifics, the short answer is that you should definitely volunteer your services - there are lots of protections in place with a paucity of case reports of legal actions against medical volunteers who volunteers in flight. Nachi: Perhaps most importantly, remember that ultimately the captain is in charge and you are functioning in a strict advisory capacity. Remember that most airlines can handle most emergencies with their ground based medical control, their typical staff, and predefined protocols - you are an added bonus. Jeff: For many ED providers, functioning as a consultant will be unfamiliar. Nachi: If I’m a consultant, I’m going to demand a WBC before seeing the patient, as I’m fairly certain that’s rule number 1 in consultant school... Jeff: It’s actually rule #12, now get out of your seat and come see the patient…. But back to medicolegal issues. In the US, health care professions are protected by the good Samaritan law and the 1998 federal aviation medical assistance act. Nachi: The Good Samaritan law provides legal protection to medical providers who perform their services in response to medical emergencies outside of the hospital. The exact verbiage of the law differs from state to state, but all 50 states have some version of it in their legislation. Jeff: Similarly the aviation medical assistance act applies to “medically qualified individuals and offers broad medico-legal protection to the airlines in the event that a medical volunteer is accused of malpractice as well as to medical providers who respond to an in-flight emergency.” Nachi: More specifically, the act states that “...an individual shall not be liable for damages arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.” Jeff: That’s a bit of a mouth full to get out. But basically, you need to remember that the AMAA protects you from everything shy of gross negligence. Because of this, there have been no reports to date of a medical professional falling below that standard. Nachi: There is one caveat to all of this though: don’t forget about your own mental status - for example if you have taken any sleeping aids or had any alcoholic drinks. Though this may not preclude you completely from rendering care, do so only with extreme caution. Jeff: And I don’t think we were clear enough about this up front. Up until this point we have mostly talked about US based flights. Flights run by International airlines are a somewhat different ball game for a number of reasons. First, medication kits will vary widely. Many will carry medications similar to those mandated by the FDA, but there certainly is no international standard. Next, the availability of ground based medical consultation is similarly widely variable, with many in the middle east contracting for this service and almost no airlines in Africa offering such services. Nachi: And lastly, with respect to legal risk - the international laws also vary widely. According to French law, for example, a French physician who does not volunteer may be committing willful negligence. Similar laws exist in Germany, Australia, and Canada. However proving you were there and refused to provide care would be quite difficult. And lastly, it’s unclear how to determine which countries’ laws apply when - for example, is it the sending country’s laws, the receiving country’s laws, or the country whose airspace you are currently in? Jeff: All excellent points. Next, we are moving to my favorite topic of the article - diversion. This is a tremendously complicated topic and I think the authors handled it quite well. Remember, the decision to divert is multifactorial and you are only there to communicate your medical opinion about the passenger - leave the decision for diversion up to the flight crew. I cannot stress this enough. Getting on the radio with the pilot and ground based medical control and demanding a diversion is often very unhelpful and simply not the right approach and can really be quite costly. Nachi: All of this is so interesting. I can’t believe you do this and divert planes.... Can you go into a bit more detail about everything the pilot considers when they are deciding to divert? Jeff: So there’s quite a bit, but I can touch on some of the main considerations. First, you have to consider the medical needs of the passenger - can he or she be temporized to get to the destination? Is there a suitable airport for diversion with an accessible local hospital with the required resources? Logistically, you need to find an airport that can not only safely accommodate the plane you are on but also one in which the airline can refuel and guarantee that the passengers and crew are safe. Remember, if you are on an A380, there are only so many airports with runways long enough for a safe landing. Fun fact: planes also take off heavy - with tons of fuel that will be burned prior to landing. Say you were to take off from London, bound for the US. To turn around and land back at London Heathrow, you may have to literally dump thousands of gallons of fuel to get the plane to a safe weight for landing. Alternatively, you may have to fly in circles for some time to burn fuel off in planes that cannot dump. A heavy landing necessitates a thorough maintenance overhaul of the landing gear and can cost the airlines not only money but significant time, which is equally as valuable. Nachi: Speaking of cost - while exact costs are unknown, one airline estimates that the cost can be as high as $600,000 - we are not dealing with small numbers here... Jeff: No definitely not. That’s why it’s so frustrating when medical volunteers demand the plane divert without talking through the medical scenario with the crew and ground based control - often temporizing measures are adequate. Nachi: And we alluded to this earlier - Physicians advise diversion more frequently at 9% of the time followed by EMS providers and nurses. When the airlines are left to their own means, they divert at rates roughly half that - just 5% of the time. At half a million dollars for some diversions, and an overall very low level of morbidity and mortality, a 50% reduction amounts to massive savings for possibly no clinical difference. Jeff: I can’t stress this enough - you are a consultant, helping the captain and the ground based medical control to come to most appropriate plan of action. When your advice causes the airlines to deviate from their standard protocols, that’s where they potentially run into trouble. Nachi: There are just two controversies to discuss this month and I actually think they are extremely pertinent. The first one relates to using personal medication or medications from other passengers. Given the relative paucity of medications in most airline medical kits, it may occur to you that someone else may have a helpful medication on board. While there is no strict rule against this, it could result in an increased level of scrutiny if there is an adverse event. So consider this a last resort. Jeff: The next controversy to discuss is the issue of gifts. There is a widespread belief that accepting gifts from the airlines would void legal protections. To date, there is ample airline-based data to suggest that medical providers’ legal protections are not negated in the event that the airlines wanted to reward a medical volunteer. Additionally, there are no reported cases of providers losing legal protection for receiving compensation for their services in flight. Nachi: Interestingly, some international carriers even offer points or other bonuses for registering as a medical volunteer. While I’m hesitant to call this controversy a myth, it seems like there isn’t much evidence to support it. Jeff: Agreed, don’t expect a gift, but if you do receive one, you can keep it and enjoy it without concern for your legal protections. Nachi: Alright so that wraps up the new material for this special edition of EMplify - let’s close out with some key points and clinical pearls. Jeff: Aircraft cabins are typically pressurized to about 8000 ft, resulting in a 4-10 point drop in oxygen saturation in healthy adults as well myalgias, fatigue, and generalized discomfort on long haul flights. Nachi: Only 50% of the cabin air is recirculated. When recirculated, it is subjected to HEPA filtration, which is adequate to prevent infection by airborne pathogens but not the infectious respiratory viruses, which are spread by droplets. Jeff: Dehydration on long flights is likely due to inadequate water intake and the increased use of diuretics such as caffeine and alcohol. Nachi: There is about 1 in-flight emergency per 11,000 passengers or 1 in 604 flights. Syncope and cardiac events are most common followed by GI, respiratory, and neurologic events. Jeff: Most in-flight emergencies are minor. When EMS is requested upon arrival, roughly 1/3rd are transported and less than 10% are admitted, with mortality estimated at 0.3% of cases. Nachi: AEDs are required on all US-based flights. Jeff: Airlines have a limited supply of supplemental oxygen for use in medical emergencies in addition to that provided to the entire plane in the event the cabin becomes depressurized Nachi: All US airlines have some form of ground-based medical assistance. Ultimately any decisions are the responsibility of the pilot in command – medical volunteers function in a strictly advisory capacity. Jeff: Medical volunteers are protected by both the Good Samaritan law and the 1998 Aviation Medical Assistance Act. Nachi: The Aviation Medical Assistance Act protects medically qualified individuals, unless they are guilty of gross negligence or willful misconduct. Jeff: International laws and protections vary widely. In some European countries, for a physician to not offer their services during an in-flight emergency may constitute willful negligence. Nachi: The decision to divert is multifactorial and can cost as much as $600,000 in some circumstances. Jeff: When physicians and EMS providers respond to in-flight emergencies, diversion rates are nearly double that of when the airlines work solely with their ground based support, increasing diversion events from 5% to 9%. Nachi: It is largely a myth that accepting any gift or payment after responding to an in-flight emergency would void your legal protections; the AMAA has no language regarding compensation and to date there are no such reported cases of lost legal protection. Jeff: And that’s the end of this months episode of EMplify: Assisting With Air Travel Medical Emergencies. This also marks the end of our run as your hosts. Over the past 3 years, we’ve thoroughly enjoyed hosting EMplify and having the unique opportunity to share high quality evidence based medicine with you all. As health care continues to move towards a quality over quantity paradigm, understanding evidence based practice will be increasingly more important. Nachi: We thank you all for giving us your ears and your time to help hone your clinical practice. Naturally, a big thanks also goes out to all of the contrubutors to Emergency Medicine Practice -- authors, peer reviewers, and of course the kind and thoughtful staff at EB Medicine. Jeff: We have no doubt that Dr. Ashoo, who will be taking over, will keep you on the edge of your seat as he brings new material to you. Couldn’t be more excited to have him as our successor. Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: The [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net.
Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours. Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin. Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage! Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!! Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first... Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function. Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year. Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone. Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure. Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin. Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications. Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin. Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin. Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently. Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin. Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine. Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism. Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding. Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies. Jeff: First up is CT. There are no clear cut guidelines here, so Drs. Maher and Taub had to rely on observational studies and expert opinion. Remember, most standard guidelines and tools, like the canadian and nexus criteria, are less accurate in anticoagulated patients, so they shouldn’t be applied. Instead, most studies recommend a low threshold for head imaging, even with minor trauma, in the setting of DOAC use. Nachi: That is so important that it’s worth repeating. Definitely have a low threshold to CT the head for even minor head trauma patients on DOACs. Basically, if you’re on anticoagulation, and you made it to the ED for anything remotely related to your head, you probably win a spin. Jeff: I suspect you are not alone with that stance... There is, however, much more debate about the utility of follow up imaging and admission after a NEGATIVE scan. Nachi: Wait, is that a thing I should routinely be doing? Jeff: Well there’s not great data here, but in one observational study of 1180 patients on either antiplatelet or anticoagulant therapy, a half a percent of them had positive findings 12 hours later, and importantly none required surgical intervention. Nachi: Certainly reassuring. And for those with positive initial imaging, the authors recommend repeat imaging within 4-6 hours in consultation with neurosurgical services or even earlier in cases of unexpected clinical decline. Jeff: Interestingly, though only a small retrospective study of 156 patients, one study found markedly reduced mortality, 4.9% vs 20.8% in those on DOACs vs warfarin with traumatic intracranial hemorrhage. Nachi: Hmm that actually surprises me a bit with the ease of reversibility of warfarin. Jeff: And we’ll get to that in a few minutes. But next we should talk about ultrasound. As always with trauma, guidelines recommend a FAST exam in the setting of blunt abdominal trauma. The only thing to be aware of here is that you should have an increased index of suspicion for bleeding, especially in hidden sites like the retroperitoneum. Nachi: And just as with traumatic head bleeds, a small observational study of those with blunt abdominal trauma found 8% vs 30% mortality for those on DOACs vs warfarin, respectively. Jeff: That is simply shocking! Let’s also talk lab studies. Hemoglobin and platelet counts should be obtained as part of the standard trauma work up. Assessing renal function via creatinine is also important, especially for those on agents which are renally excreted. Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. DOAC levels may be indicated in certain specific situations, such as while treating life-threatening bleeding, development of venous thromboembolism despite compliance with DOAC therapy, and treating patients at risk for bleeding because of an overdose. Jeff: In terms of those who require surgery while on a DOAC - if urgent or emergent, the DOAC will need to be empirically reversed. For all others, the recommendation is to wait a half life or even multiple half-lives, if possible, in lieu of level testing. Nachi: Coagulation tests are up next. Routine PT and PTT levels do not help assess DOACs, as abnormalities on either test can suggest the presence of a DOAC, but the values should not be interpreted as reliable measures of either therapeutic or supratherapeutic clinical anticoagulant effect. Jeff: Dabigatran may cause prolongation of both the PT and the PTT, but the overall correlation is poor. In addition, FXa inhibitors may elevate PT in a weakly concentration dependent manner, but this may only be helpful if anti-fXa levels are unavailable. Nachi: Which is a perfect segway into our next test - anti-factor Xa level activity. Direct measurements of the anti-Fxa effect demonstrates a strong linear correlation with plasma concentrations of these agents, but the anticoagulant effect does not necessarily follow the same linear fashion. Jeff: Some labs may even have an anti-FXa effect measurement calibrated specifically to the factor 10a inhibitors. Nachi: While measuring thrombin time is not routinely recommended, the result of thrombin time or dilute thrombin time does correlate well with dabigatran concentrations across normal ranges. Jeff: And lastly, we have the Ecarin clotting time. Ecarin is an enzyme that cleaves prothrombin to an active intermediate that can be inhibited by dabigatran in the same way as thrombin. The ECT is useful for measuring dabigatran concentration - it’s not useful for testing for FXa inhibitors. A normal ECT value could be used to exclude the presence of dabigatran. Nachi: So I think that rounds out testing. Let’s move into the treatment section. Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Tourniquet application, direct pressure, endoscopy for GI bleeds, etc... should all be used as needed. And most importantly, for airway bleeding, pericardial bleeding, CNS bleeding, and those with hemodynamic instability or overt bleeding, those with a 2 point drop in their hemoglobin, and those requiring 2 or more units of pRBC - they all should be considered to have serious, life threatening bleeds. This patient population definitely requires reversal agents, which we’re getting to in a minute. Nachi: A type and screen should also be sent with the plan to follow standard transfusion guidelines, with the goal of a hemoglobin level of 7, understanding that in the setting of an active bleed, the hemoglobin level will not truly be representative. Jeff: Interestingly, in the overdose literature that’s out there, bleeding episodes appear to be rare - occurring in just 5% of DOAC overdose cases. Nachi: Finally, onto the section we’ve all been waiting for. Let’s talk specific reversal agents. Praxbind is up first. Jeff: Idarucizumab or Praxbind, is the reversal agent of choice for dabigatran (which is also called pradaxa). According to data from the RE-LY trial, it reverses dabigatran up to the 99th percentile of levels measured in the trial. Nachi: And praxbind should be given in two 2.5 g IV boluses 15 minutes apart to completely reverse the effects of dabigatran. Jeff: As you would expect given this data, guidelines for DOAC reversal recommend it in major life-threatening bleeding events for patients on dabigatran. Nachi: Next up is recombinant coagulation factor Xa (brand name Andexxa), which was approved in 2018 for the FXa inhibitors. This recombinant factor has a decoy receptor for the FXa agents, thus eliminating their anticoagulant effects. Jeff: Recombinant factor Xa is given in either high or low dose infusions. High dose infusions for those on rivaroxaban doses of >10 mg or apixaban doses >5 mg within the last 8 hours and for unknown doses and unknown time of administration. Low dose infusions should be used for those with smaller doses within the last 8 hours or for last doses taken beyond 8 hours. Nachi: In one trial of 352 patients, recombinant factor Xa given as an IV bolus and 2 hour infusion was highly effective at normalizing anti-FXa levels. 82% of the assessed patients at 12 hours achieved hemostasis, but there were also thrombotic events in 10% of the patients at 30 days. Jeff: And reported thrombotic events aren’t the only downside. Though the literature isn’t clear, there may be limited use of recombinant factor Xa outside of the time of the continuous infusion, and even worse, there may be rebound of anti-Fxa levels and anticoagulant effect. And lastly, the cost is SUBSTANTIAL. Nachi: Is there really a cost threshold for stopping life threatening bleeding…? Jeff: Touche, but that means we need to save it for specific times and consider other options out there. Since this has only been around for a year or so, let’s let the literature play out on this too... Nachi: And that perfectly takes us into our next topic, which is nonspecific reversal agents, starting with prothrombin complex concentrate, also called PCC. Jeff: PCC is FDA approved for rapid reversal of vitamin K antagonist-related hemorrhagic events and is now being used off label for DOAC reversal. Nachi: PCC comes in 3 and 4 factor varieties. 3-factor PCC contains factors 2, 9, 10 and trace amounts of factor 7. 4 factor PCC contains factors 2, 9 10, as well as purified factor 7 and proteins C and S. Jeff: Both also contain trace amounts of heparin so can’t be given to someone with a history of HIT. Nachi: PCC works by overwhelming the inhibitor agent by increasing the concentration of upstream clotting factors. It has been shown, in healthy volunteers, to normalize PT abnormalities and bleeding times, and to achieve effective bleeding control in patients on rivaroxaban, apixaban, and edoxaban with major bleeding events. Jeff: In small studies looking at various end points, 4 factor PCC has been shown to be superior to 3 factor PCC. Nachi: Currently it’s given via weight-based dosing, but there is interest in studying a fixed-dose to decrease both time to medication administration and cost of reversal. Jeff: Guidelines currently recommend 4F PCC over 3F PCC, if available, for the management of factor Xa inhibitor induced bleeding, with studies showing an effectiveness of nearly 70%. As a result, 4F PCC has become an agent of choice for rapid reversal of FXa inhibitors during major bleeding events. Nachi: Next we have activated PCC (trade name FEIBA). This is essentially 4Factor PCC with a modified factor 7. Though traditionally saved for bleeding reversal in hemophiliacs, aPCC is now being studied in DOAC induced bleeding. Though early studies are promising, aPCC should not be used over 4factor PCC routinely as of now but may be used if 4Factor PCC is not available. Jeff: Next we have recombinant factor 7a (trade name novoseven). This works by activating factors 9 and 10 resulting in rapid increase in thrombin. Studies have shown that it may reverse the effect of dabigatran, at the expense of increased risk of thrombosis. As such, it should not be used as long as other agents are available. Nachi: Fresh Frozen Plasma is the last agent to discuss in this section. Not a lot to say here - FFP is not recommended for reversal of any of the DOACs. It may be given as a part of of a balanced massive transfusion resuscitation, but otherwise, at this time, there doesn’t seem to be a clear role. Jeff: Let’s move on to adjunct therapies, of which we have 3 to discuss. Nachi: First is activated charcoal. Only weak evidence exists here - but, according to expert recommendations, there may be a role for DOAC ingestions within 2 hours of presentations. Jeff: Perhaps more useful than charcoal is our next adjunct - tranexamic acid or TXA. TXA is a synthetic lysine analogue with antifibrinolytic activity through reversible binding of plasmin. CRASH-2 is the main trial to know here. CRASH-2 demonstrated reduced mortality if given within 3 hours in trauma patients. There is very limited data with respect to TXA and DOACs specifically, so continue to administer TXA as part of your standard trauma protocol without modification if the patient is on a DOAC, as it’s likely helpful based on what data we have. Nachi: Next is vitamin K - there is no data to support routine use of vitamin K in those taking DOACs - save that for those on vitamin K antagonists. Jeff: Also, worth mentioning here is the importance of hematology input in developing hospital-wide protocols for reversal agents, especially if availability of certain agents is limited. Nachi: Let’s talk about some special circumstances and populations as they relate to DOACs. Patients with mechanical heart valves were excluded from the major DOAC trials. And of note, a trial of dabigatran in mechanical valve patients was stopped early because of bleeding and thromboembolic events. As such, the American College of Cardiology state that DOACs are reasonable for afib with native valve disease. Jeff: DOACs should be used with caution for pregnant, breastfeeding, and pediatric patients. A case series of 233 pregnancies that occurred among patients on a DOAC reported high rates of miscarriage. Nachi: Patients with renal impairment are particularly concerning as all DOACs are dependent to some degree on renal elimination. Current guidelines from the Anticoagulation Forum recommend avoiding dabigatran and rivaroxaban for patients with CrCL < 30 and avoiding edoxaban and betrixaban for patients with CrCl < 15. Jeff: A 2017 Cochrane review noted similar efficacy without increased risk of major bleeding when using DOACs in those with egfr > 30 (that’s ckd3b or better) when compared to patients with normal renal function and limited evidence for safety below this estimated GFR. Nachi: Of course, dosing with renal impairment will be different. We won’t go into the details of that here as you will probably discuss this directly with your pharmacist. Jeff: We should mention, however, that reversal of the anticoagulant in the setting of renal impairment for your major bleeding patient is exactly the same as we already outlined. Nachi: Let’s move on to some controversies and cutting-edge topics. The first one is a pretty big topic and that is treatment for ischemic stroke patients taking DOACs. Jeff: Safety and efficacy of tPA or endovascular therapy for patients on DOACs continues to be debated. Current guidelines do not recommend tPA if the last DOAC dose was within the past 48 hours, unless lab testing specific to these agents shows normal results. Nachi: Specifically, the American Heart Association suggests that INR and PTT be normal in all cases. ECT and TT should be tested for dabigatran. And calibrated anti-FXa level testing be normal for FXa inhibitors. Jeff: The AHA registry actually included 251 patients who received tpa while on DOACs, which along with cohort analysis of 26 ROCKET-AF trial patients, suggest the risk of intracranial hemorrhage is similar to patients on warfarin with INR < 1.7 and to patients not on any anticoagulation who received tpa. However, given the retrospective nature of this data, we cannot exclude the possibility of increased risk of adverse events with tpa given to patients on DOACs. Nachi: Endovascular thrombectomy also has not been studied in large numbers for patients on DOACs. Current recommendations are to discuss with your stroke team. IV lysis or endovascular thrombectomy may be considered for select patients on DOACs. Always include the patient and family in shared decision making here. Jeff: There are also some scoring systems for bleeding risk to discuss briefly. The HAS-BLED has been used to determine bleeding risk in afib patients taking warfarin. The ORBIT score was validated in a cohort that included patients on DOACs and is similarly easy to use, and notably does not require INR values. Nachi: There is also the ABC score which has demonstrated slightly better prediction characteristics for bleeding risk, but it requires high-sensitivity troponin, limiting its practical use. Jeff: We won’t say more about the scoring tools here, but would recommend that you head over to MD Calc, where you can find them and use them in your practice. Nachi: Let’s also comment on the practicality of hemodialysis for removal of the DOACs. Multiple small case series have shown successful removal of dabigatran, given its small size and low protein binding. On the other hand, the FXa inhibitors are less amenable to removal in this way because of their higher protein binding. Jeff: Worth mentioning here also - dialysis catheters if placed should be in compressible areas in case bleeding occurs. The role of hemodialysis for overdose may be limited now that the specific reversal agent, praxbind, exists. Nachi: In terms of cutting-edge tests, we have viscoelastic testing like thromboelastography and rotational thromboelastometry. Several studies have examined the utility of viscoelastic testing to detect presence of DOACs with varying results. Prolongation of clotting times here does appear to correlate with concentration, but these tests haven’t emerged as a gold standard yet. Jeff: Also, for cutting edge, we should mention ciraparantag. And if you’ve been listening patiently and just thinking to yourself why can’t there be one reversal agent to reverse everything, this may be the solution. Ciraparantag (or aripazine) is a universal anticoagulant reversal agent that may have a role in all DOACs and heparins. It binds and inactivates all of these agents and it doesn’t appear to have a procoagulant effect. Nachi: Clinical trials for ciraparantag have shown rapid and durable reversal of edoxaban, but further trials and FDA approval are still needed. Jeff: We’ve covered a ton of material so far. As we near the end of this episode, let’s talk disposition. Nachi: First, we have those already on DOACs - I think it goes without saying that any patient who receives pharmacological reversal of coagulopathy for major bleeding needs to be admitted, likely to the ICU. Jeff: Next we have those that we are considering starting a DOAC, for example in someone with newly diagnosed VTE, or patients with an appropriate CHADS-VASC with newly diagnosed non-valvular afib. Nachi: With respect to venous thromboembolism, both dabigatran and edoxaban require a 5 day bridge with heparin, whereas apixaban and rivaroxaban do not. The latter is not only easier on the patient but also offers potential cost savings with low risk of hemorrhagic complications. Jeff: For patients with newly diagnosed DVT / PE, both the American and British Thoracic Society, as well as ACEP, recommend using either the pulmonary embolism severity index, aka PESI, or the simplified PESI or the Hestia criteria to risk stratify patients with PE. The low risk group is potentially appropriate for discharge home on anticoagulation. This strategy reduces hospital days and costs with otherwise similar outcomes - total win all around. Nachi: Definitely a great opportunity for some shared decision making since data here is fairly sparse. This is also a great place to have institutional policies, which could support this practice and also ensure rapid outpatient follow up. Jeff: If you are going to consider ED discharge after starting a DOAC - there isn’t great data supporting one over another. You’ll have to consider patient insurance, cost, dosing schedules, and patient / caregiver preferences. Vitamin K antagonists should also be discussed as there is lots of data to support their safety outcomes, not to mention that they are often far cheaper…. As an interesting aside - I recently diagnosed a DVT/PE in an Amish gentleman who came to the ED by horse - that was some complicated decision making with respect to balancing the potentially prohibitive cost of DOACs with the massive inconvenience of frequently checking INRs after a 5 mile horseback ride into town... Nachi: Nice opportunity for shared decision making… Jeff: Lastly, we have those patients who are higher risk for bleeding. Though I’d personally be quite uneasy in this population, if you are to start a DOAC, consider apixaban or edoxaban, which likely have lower risk of major bleeding. Nachi: So that’s it for the new material for this month’s issue. Certainly, an important topic as the frequency of DOAC use continues to rise given their clear advantages for both patients and providers. However, despite their outpatient ease of use, it definitely complicates our lives in the ED with no easy way to evaluate their anticoagulant effect and costly reversal options. Hopefully all our hospitals have developed or will soon develop guidelines for both managing ongoing bleeding with reversal agents and for collaborative discharges with appropriate follow up resources for those we send home on a DOAC. Jeff: Absolutely. Let’s wrap up with some the highest yield points and clinical pearls Nachi: Dabigatran works by direct thrombin inhibition, whereas rivaroxaban, apixaban, edoxaban, and betrixaban all work by Factor Xa inhibition. Jeff: The DOACs have a much shorter half-life than warfarin. Nachi: Prehospital care providers should ask all patients about their use of anticoagulants. Jeff: Have a low threshold to order a head CT in patients with mild head trauma if they are on DOACs. Nachi: For positive head CT findings or high suspicion of significant injury, order a repeat head CT in 4 to 6 hours and discuss with neurosurgery. Jeff: Have a lower threshold to conduct a FAST exam for blunt abdominal trauma patients on DOACs. Nachi: Assessment of renal function is important with regards to all DOACs. Jeff: While actual plasma concentrations of DOACs can be measured, these do not correspond to bleeding outcomes and should not be ordered routinely. Nachi: The DOACs may cause mild prolongation of PT and PTT. Jeff: Idarucizumab (Praxbind®) is an antibody to dabigatran. For dabigatran reversal, administer two 2.5g IV boluses 15 minutes apart. Reversal is rapid and does not cause prothrombotic effects. Nachi: Recombinant FXa can be used to reverse the FXa inhibitors. This works as a decoy receptor for the FXa agents. Jeff: Vitamin K and FFP are not recommended for reversal of DOACs. Nachi: Consider activated charcoal to remove DOACs ingested within the last two hours in the setting of life-threatening hemorrhages in patient’s on DOACs. Jeff: Hemodialysis can effectively remove dabigatran, but this is not true for the FXa inhibitors. Nachi: 4F-PCC has been shown to be effective in reversing the effects of the FXa inhibitors. This is thought to be due to overwhelming the inhibitor agent by increased concentrations of upstream clotting factors. Jeff: tPA is contraindicated in acute ischemic stroke if a DOAC dose was administered within the last 48 hours, unless certain laboratory testing criteria are met. Nachi: Emergency clinicians should consider initiating DOACs in the ED for patients with new onset nonvalvular atrial fibrillation, DVT, or PE that is in a low-risk group. Jeff: So that wraps up Episode 31! Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: And the address for this month’s cme credit is www.ebmedicine.net/E0819, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month!
In today's podcast Mason chats to Jeff Chilton. Jeff has been working in the medicinal mushroom industry since 1973 and is an absolute specialist in his field. Jeff is the founder of Nammex, the leading supplier of organic mushroom extracts in the world today. With over 40 years of mushroom growing experience, Jeff was one of the first people to bring mushroom extracts to the North American market. All you medicinal mushroom nerds out there make sure you catch this episode, Jeff is a deep reservoir of knowledge and insight! The gents wax lyrical over: The ins and outs of mushroom harvesting. The difference between products made from mushroom mycelium as opposed to their fruiting body. Cordyceps Cs-4. The inferior nature of grain grown medicinal mushroom products. The nature of the medicinal mushroom industry at large, and what to look out for in regards to quality and authenticity. Following your passion in business. Retaining your integrity in the mushroom industry. Polysaccharides and betaglucans. China as a superior source Who is Jeff Chilton ? Resources Q: How Can I Support The SuperFeast Podcast? A: Tell all your friends and family and share online! We’d also love it if you could subscribe and review this podcast on iTunes. Or check us out on Stitcher :)! Plus we're on Spotify and Soundcloud! Check Out The Transcript Here: Time to talk tonic herbalism people. Maybe some medicinal mushrooms and philosophy for longevity, so pour yourself a tonic and get ready to get super human, baby. Let's start the show! Mason: Hello everybody. Welcome back to the podcast. Got one that, I've been really looking forward to doing this interview. Jeff Chilton, I'll go into a little breakdown now, rather than just jumping ahead to why I'm really into his work. He's been in the mushroom industry since 1973. When it comes to mushroom cultivation, back then, he was really pioneering. Especially, a lot of the mushrooms that we have available today via cultivation in the west. Mason: He had a lot to do with the developing the manufacturing of those. Then in 1989, switched over to the manufacturing of medicinal mushroom extract, so he's OG in this medicinal mushroom world. There was no real trending back then. And I, like him, we met two years ago at a herbal symposium in Oregon. That's when I really ... super aware of him and just how he was just via just his own integrity and just educating the market. Mason: He became this internal watchdog of the industry. Just in the sense of just calling out real bad practices that are going on in the medicinal mushroom industry, and still today, and educating people, so you can spot a product on the market which is telling fibs, and really doesn't have the good stuff that we have all come to know and love about medicinal mushrooms. Mason: So NAMMEX is his company, also Real Mushrooms, and I love the fact that we can sit down as colleagues, offering medicinal mushrooms, having more at it from the Taoist perspective and Jeff just rocking gin that specialization of mushrooms and especially being such an originator of the entire industry. I really love to be able to sit down, talk with him and ask him about the history, especially he's really been shining in educating people about the difference between growing medicinal mushrooms on wood and on mycelium. And we dive into nuances of that. Mason: Basically we talk about the industry and we talk about setting up relationships in China and just how amazing it is to be able to source really incredible, the most high quality mushrooms that you're gonna be able to get in the world outside of a wild cultivated situation. Where we are talking about medicinal qualities. Getting those from China and being able to educate people about the beauty of getting them from China. We talk a little bit about that. Mason: Also what it's taken for us to develop the relationships with growers and farmers and so I think you'll find it really interesting hearing me from 2011, Jeff from 1989 really navigating the difference in our stories. As well we go into organic because Jeff has pioneered in getting the first certified organic mushroom supplement in the US which is really amazing. We go a little bit into that, I share my two cents on where I see organic is at. More so the reason why I like Jeff is because he's not like most companies that just think the be all and end all is paying for this little sticker, jumping through a couple of hurdles and getting the sticker on your product. Mason: But what we call going beyond organic. And Jeff does that with the organic certification and I share my two cents on where I'm at with that whole thing. But mostly just how much I love that he's non-stop out there educating people. Not just trying to flog a product, not just trying to grow this crazy big business. But I think that's kind of inevitably happening, it's just a nice slow growth of a business. Because it has a lot of trust and it has a lot of consistency in its messaging. And we talk a lot about that and have a lot of laughs and get a couple of stories about the history of the mushroom kingdom and those mushroom people back in the day. We talk about mushroom conferences and a bunch of other things. I think you'll really enjoy it, I hope as much as I did, here's Jeff Chilton from NAMMAX. Mason: Jeff, thanks for joining me, man. Jeff: Hey Mason, thanks a lot for having me. Mason: Absolute pleasure, so remind me where are you again in the world? Jeff: I am in British Columbia, Canada. I like on Vancouver Island out on the West Coast. You and I are actually connected by the Pacific Ocean. Mason: Vancouver Island especially, for some reason that just keeps on calling in. I keep on having friends, awesome friends and now you. You're waiting there. And I'm like "What is the pull?" Jeff: Yeah. You have gotta come. Definitely come in our summer time because otherwise you'll just be hit by all of those things you don't like, which is rain and all the rest. Mason: Well, it brings mushrooms, yeah? Jeff: It's true. Mason: When is it really on for you there? What months is it on for mushroom harvesting? Jeff: Mushroom season is really going strong in October. First couple weeks in November still happening but then things cool off too much then it slows down and there's nothing happening. We get rains in August, which really primes things then in the last couple weeks in September we could see things starting to pop up. Mason: All right, I love it. October, that sounds good to me. Let's dive in a little bit because we met maybe we were chatting it must've been two years ago. Jeff: At the American Herbalist Guild Conference in Oregon, which was just awesome. Mason: That was amazing, I mean, we were in Silverton? Is that right? Jeff: Silverton, exactly, yeah, that's where we were. Mason: But apparently not the witch one. No, I think that's on the other side. Tony was looking at Silverton but that's where all the witches were. Jeff: Oh, ah Mason: That's a different Silverton. I can't remember the name of the hotel but their grounds rolling in and the ginkgo trees, big ginkgo trees as well lining it. And then all the herbalists who came and did their herb walks were just frothing at how much they were able to go and show everyone how to forage, how to identify. Because the array of herbs there was incredible. That place is designed. Jeff: It was absolutely designed. It was a huge property and they put in all sorts of different plants, herbs and different kinds of trees. It was a beautiful venue there are a great place to have that. Even on the Saturday night when they had a band playing and everybody was dancing. I had a great time. Mason: That's so good, yeah. I imagine that place gets a lot of herbal symposiums going through it. And man, the best thing, the fig tree was kicking. Did you get up there and face on the fig then, during that symposium? That was the best part of it. Right next to the pine. Jeff: Oh my goodness, no. I hardly had a chance to get outside which is back to my place where I was staying on the grounds and then down to the venue. But I was locked into my booth most of the time and talking to people. And then in the evenings it was nice. It was a fun thing. And I know you said you had a chance to get to hear Christopher Hobbs while you were there. That had to have been really great because I always enjoy seeing Chris. I know he was really busy in fact, funny thing was Chris told me, he said "God, I'm sorry I didn't spend more time with you. I ran into an old girlfriend." Mason: Oh, right, I'm happy for him. Jeff: Me too. Mason: You're like, 100%, I can't contend with that. So '86 Hobbs wrote the book. Were you aware when his book 'Medicinal Mushrooms' came out, because when was NAMMAX first created? Jeff: I started the business in 1989. I'm trying to remember whether I knew Chris at that point in time or not, but he was part of the whole herbal industry, so to speak, and Herbalist Guild and all of that back then. I wasn't nearly as much in touch with herbalists until I started my company. Before that it was just pretty much just mushroom people and all the people that were in the mushroom world over here. There are a lot of them. Mushrooms really happening. Long before the herbal industry figured it out and got wind of it.Chris was one of the first because he was an herbalist but also was interested in fungi. So that was really cool. Mason: Yeah, I think he studied and formally became a mycologist as well. Jeff: Well, no, he was a botanist, definitely a trained botanist and a history orf botany in his family. Herbalists and things like that. And now he went on and he got a PhD in molecular genetics. Mason: Okay, he's going down that route. I like that book because he was really able to balance the mystical aspects of the mushroom herbal kingdom especially and then dive deep down into the science. It's something that only him and Steven Hardliner. Steven is the master at going down deep, molecular how a particular compound is interacting with a particular viral passade. And then blowing into full throttle Earth poetry in the next paragraph. It's a real gift. Going back to the 80s, you were running with the mushroom clique in America. Yeah, tell us the story. Jeff: The thing was in the 70s... Well, first of all in the late 60s magic mushrooms were really great interest. That was one of the things that I was really studying at university. I had this interested in mushrooms in the 60s and I reading all about a man named Gordon Wasson. Are you familiar with Gordon Wasson? Mason: Just the name and loosely, but not really. Jeff: Yeah, so Gord Wasson was a New York banker with a Russian wife. He learned about mushrooms being used deep in the mountains of Mexico by Curanderez and went down there in the 50s and spent the next five summers down there. He classified a whole bunch of different psilocybes during that period because he took a French mycologist with him. And so, five summers. But he basically opened up this whole world of Look! Still today after thousands of years there are people in the world that are still using these psychoactive mushrooms in their healing practices. Man, that was a mindblower. Jeff: So I was reading Watson and other people that were involved in that and they had published these books that were incredible books. I mean Watson went on to publish a book called 'Soma: Divine Mushroom of Immortality.' He published that in 1968. Jeff: Then somebody came along a man named John Allegro came and published a book called 'Sacred Mushroom and the Cross,' which talked about mushrooms in early Christianity. So, Mason, listen, think about it for a second. In 1968 two books are published. One says that a mushroom is at the root of Christianity. The other one says a mushroom is at the root of the Hindu religion. Jeff: And then all of a sudden from there it just... You get going forward and you find that mushrooms, you see symbols of them and you start to hear stories about them used through all sorts of different groups throughout history. Pre-history actually, because as that came out people started looking and discovering this. That was really part of my study in university because I was studying anthropology. And mycology on the side. Jeff: Going into the 70s in Olympia, Washington where I lived and worked on this big mushroom farm there was a whole core of people that were interested in mushrooms. It was an amazing group of people. Paul Stamos is one of those people. Ultimately he and I wrote the book called 'The Mushroom Cultivator' in 1983. We even had a group. We had four people, Paul and I and two other people, where we had four different mushroom conferences. These conferences were so ... You would have enjoyed it so much. We had people there that were speaking about how to identify mushrooms. I was speaking on cultivation of mushrooms, speaking on the anthropological aspect of mushrooms. We had great people there speaking. There was Andre Wyle was at our conferences. And it was just a great time had by everybody, right? You can imagine. All these mushroom people coming together. 200 people coming together for a weekend. Amazing. Mason: So good. I mean, it's different, you got this original crew, there's always something special when you've got the original crew. Jeff: Yeah. Mason: There's a medicinal mushroom symposium every year that moves around the world. It was in Colombia a couple of years ago and then in Italy. Do you know that one? Jeff: You're actually talking about the International Medicinal Mushroom -- Mason: Conference? Jeff: Society IMMS and you know what? And that was more of a scientific group that was formed much later. I know the principles of the group. It started somewhere around 1999. They're having a conference in China on the 18th of September this year. You should come. I'm gonna be over there at this conference. I know lots of other people are gonna be there as well. It's gonna be an interesting time. I'm gonna be giving a paper there, which will be fun. There will be lots of other people too. I don't know what time of year you go to China. Mason: Yeah, I go in September. I think this year we've got our staff retreat in September. I'm gonna check the dates, but otherwise I've been wanting to get along anyway. I've been trying to revolve it around going to Wudang mountain and doing some Taoist training as well. This is where I've been tossing up this year, what time to get over there. But that sounds a bit serendipitous. Jeff: Yeah, well, the conference is I believe the 18th to the 22nd of September. That's normally kind of early for us. We like to go over more in November. We go every year. November's really harvest time for a lot of mushrooms like Shiitake, Maitaki, Wood ear. A little bit later is Hericium, Lion's mane. In September it's the Reishi harvest. Mason: Yeah, Reishi harvest is normally for us in September. Where's your Lion's mane growing? Which region? Jeff: It's growing in Fujian province. Mason: Okay. Ours is a little bit earlier, in September as well. In Heilongjiang. In the northeast. Jeff: Okay, yeah, because in Fujian province it is late, late November when it's quite cold. It's back to the mountains, quite cold. Maybe up in Heilongjiang it's colder in there right? Mason: It's chilly. Jeff: (laughs) Mason: That's spoken like a true Australian. Jeff: Let's fly in and start up north there and step off. I just can't wait to get to Yunan province. Mason: (laughs) Jeff: I can't wait to get down into that tropical vibe. Although, nothing beats that crisp air. Jeff: Well that's good. I'm at that point where -- I don't know when your periods of this business growth have been -- but I've been real head down, bum up in the business. Not really been in that space of upgrading my information. Of course, I'm always reading and everything, doing all these things. I feel like that's like, you're at a point in your business where you are traveling around and you're educated. You're back at that point where you're free to go and educate and then go and educate yourself non-stop, constantly, which is really nice. I'm nearly back there. Jeff: Yeah, you know what it's like. We are so swamped right now. We've got so much demand for the product right now. We're growing and over the past two years we've hired four people, two people for lab and another person for regulatory and, can you imagine, we've got one person that's strictly regulatory affairs and deals with all the paperwork that we have to deal with. The paperwork is really monumental. We get forms from companies that are 220 questions! Mason: Companies that you're doing business with and they wanna know, looking at purity or is it you getting stocked with them that they want all those questions answered? Jeff: No, they qualify their suppliers. And so this is all about GMPs for the most part and how your product is manufactured. They want to know that everything is according to the GMP, quality, and the standard operating procedures and all the rest. Mason: I think that's where Real Mushrooms. Was it your son that created Real Mushrooms? Jeff: Real Mushrooms, yeah. Sky created Real Mushrooms in 2015 as part of NAMMAX so it's just one division of the company. He runs Real Mushrooms as well as other things because he's in training to allow me to go fishing and he can stay and do all the work. Mason: Great. NAMMAX is providing more providing bulk for people that are putting it into products and stuff? Jeff: We're a business to business. We sell the raw materials and then Real Mushrooms is retail products and mostly sold online. Maybe getting it into the stores at some point, but right now an online business. But we're business to business where we sell to companies that then put the raw materials out under their own brand. Mason: Does NAMMAX do... I'm increasingly aware because I think NAMMAX... we get a lot of people asking at SuperFeast but we don't really specialize in that B2B space. But one thing I want to talk a little bit about later is a lot of people who, like NAMMAX has bridged it and made it really accessible. Especially with you and the middlemen not having to deal straight with trying to... I'm still appreciating, it took me quite a few years but you'd know the in's and out's beyond what it's like developing relationships, critiquing, getting the authenticity on the testing. Also developing a relationship based on integrity and qualifying on that level takes so long. I feel like NAMMAX has really made it possible. Mason: I know a lot of people in Australia who are like "Ah, great, I can just go and NAMMAX can just do it all for me." Which is really great, because there's a lot of people. I like it because there's a lot of people jumping onto the bandwagon, and Australia has got this nice buffer. We don't have too much shit here, which is really good. And that's something that's nice for me to be able to say about my competitors as well. Australian community doesn't need to be as wary, I think, as the U.S. world because the U.S. is a bit...I didn't realize it's a shit fight. I know talking to you a lot back in the day, I don't think I presented that I was from SuperFeast. We were just talking about mushrooms and I was just learning a bunch off you and learning about your history. Mason: As a company when I started out it was an absolute no-brainer that we weren't gonna use fillers, that I wasn't going to be using mycelium product myself. We'll talk about that, it has its place. Of course, growing on good-quality wood. In Australia we're just small companies. I started in Mum's spare room getting products for me and Mum. Then talking to you I was like... and then reading your blogs and really falling off the back of it just like that. Wow, because you actually really inspired me after that talk going, "Well of course, I do talk about the fact that we don't use fillers and we don't grow on grains." And all these kinds of things, but it was getting to that point I didn't realize people really needed to know the in's and out's of your product and be able to ... Mason: After seeing what happened in America with how much trickery there is and the percentages of polysaccharides there is, lets' go into it a little bit now. You've been watching it and been the internal watchdog of the industry, which I really like. When did that first start cropping up? When did people start jumping on the mushroom bandwagon and fibbing about the levels of polysaccharides and active ingredients? Jeff: The interesting thing was that having been in the supplement industry since 1989, the key thing for me was that I was a mushroom grower by trade. So i spent ten years as a commercial mushroom grower on a very big, big farm. Not a hobbyist growing in my basement or a closet or something like this. A commercial mushroom grower, large farm. Millions of pounds of mushrooms every year. So I knew how it all worked, I knew the economics of it all. I realized back in the late 90s, for example. Or even the early 90s that you couldn't actually produce mushrooms in North America and turn them into a supplement, because it's a dry powder it's not a fresh product. Once you dry that thing out it's 90% water you gonna get ten times as much money for that pound of mushrooms. It doesn't work in the supplement world. Jeff: That's where going to China and I went to farms, I went to factories, I went to research institutes, I went to conferences. The 90s was just amazing to see what was going on. I went north to south, east to west. Yunan province all the way up to Jilin province. It was all over China seeing this industry and seeing the research. One of the things, you talked a bit earlier about quality how do you know. Here I am visiting these companies going to all of these conferences. I'm having people coming up to me all the time saying, "Will you buy my product? Here it is." And they just show me a brown powder and I'm just like, it's a brown powder, I don't know what it is! How can I really know what that is. And then getting to know companies and people that were genuine and you could go to their factories and see what they were doing. Especially if they were only producing mushroom products and then building the relationships to that. Jeff: Then I turned around and back in the United States here are these companies that come along and they start to produce mycelium on sterile grain. The worst part about it is they sell it as a mushroom. Mason: Some people might not know what, so, we're talking about the fact, which you alluded to, which I completely agree with, that the only way to make a viable super high-quality product that's a powder is doing it in China. Based on the fact that, say you have 10 or 20 kilos worth of raw product that's gonna then give you a kilo of the powdered product in the end, it's not viable in the U.S. so to make it viable in the U.S., the way it generally works is that it's grown on a grain substrate, like rice, brown rice, oats, this kind of thing. Jeff: Yeah, and the thing is, what people need to understand is that a mushroom is just one part of this fungal organism. So the other parts would be a spore, the spore germinates in to a fine filament, those filaments come together, they create mycelium, which is the actual body of the fungus. Which normally if you're out there hunting mushrooms you never see that because it's in the ground or it's in the wood. So most people are unaware of that. But that mycelial network amasses nutrients. When the conditions are right it produces the mushroom. That's what we see because up it comes and it's like "Wow, look at that thing there!" And then that matures, it produces spores, and then we have a complete life cycle. Jeff: The interesting part, Mason, is that growing mycelium, which is the vegetative part of this organism, on sterile grain as a mushroom grower, what that is and what that was developed as mushroom spawn. Which is like the seed that is used to grow mushrooms. Because mushrooms don't have seeds they have spores. You don't plant spores when you grow mushrooms, you plant live mycelium. The mushroom growing world, what they developed is "Okay, we'll take that live mycelium and we'll put it onto some kind of a carrier. Then that carrier we can spread into our compost or whatever it was that they're growing their mushrooms in. If you take a gallon of grain, you've got maybe thousands of grains in there you coat that with mycelium, and then you take those thousands of grains and you can mix them into a big pile of straw or compost or something. Each one of those mycelium grows off of and it grows into this thing. So that myceliated grain actually was developed in the 1930s as mushroom spawn or essentially seed to grow mushroom. Jeff: It's an easy process, it's done in a lab and people in the United States, we can't grow mushrooms. Why don't we just take that process, we'll grow out the mycelium. Mycelium in and of itself it's got beneficial properties because it is a fungal hyphae that has beta glucans in its cell walls. If you grow it in a certain way like in liquid or something it can produce certain medicinal compounds. But when you grow it on grain and then you don't separate it out from the grain at the end of the process you end up with mostly grain powder. That's what companies started to do. They started to grow the mycelium on grain. At the end of the process they would dry it -- just like you're drying a mushroom, but -- they'd dry it, they would grind it to a powder. No mushroom there at all. No mushroom, it's just myceliated grain, and it's mostly the grain powder. Finally, the worst part about it is then they call it mushroom when they sell it. Mason: I definitely know I've been surprised, because my first trip to the States I went and bought all the different brands. I was floored by some of the grainy non-mushroom powder that I was buying. That was like white powder, it's in your face. Jeff: Yeah, white powder and you taste it and you're like, "How's it supposed to taste like mushroom? It tastes kind of like flour." Mason: Yeah, it's like flour, sawdust. So are there companies doing a mycelial growth that are more on the ethical spectrum, that they're not doing a full grain wash and that they're growing on a particular grain that they're able to separate out a lot of the mycelium? I know that a lot of the mycelium is embodied grain. That's just a reality that you're not gonna be able to get rid of. But I'm trying to play that... is that possible in your experience? Jeff: In China they grow mycelium in large tanks of liquid. Mason: Like Cs-4 Cordycep, yeah. Jeff: Yeah, Cs-4 Cordyceps. They've been doing that for 50 years. But the thing is that it takes a lot of money to put in a big facility that can grow and these tanks are huge and you have to have a steam generator. It's a big investment but to actually grow out the mycelium on sterilized grain does not take a lot of money, it doesn't take a lot of expertise. It's a very simple process. Anybody can do it. In my book that I published in 1983, it tells you how to manufacture mycelium on grain at home in your kitchen. It's not difficult so it's very easy and ultimately, the stuff is so cheap to produce. And these people are selling it as mushroom and making a fortune doing it. It's really immoral in my opinion, and unethical. And especially if you're calling it mushroom. Mason: I think because we sometimes maybe look at the market and what we subconsciously are looking for when we want a mushroom and most of the studies have been on if you're like... Most of the time we're looking for a fruiting body. That's the mushroom. It's the unspoken that we know that we're talking about is the fruiting body there? And I guess there are some companies that have been quite averse or trying to sign typically validate the mycelium. When I was first kicking around all this there were people going "Look, just have it all. Have the fruiting body, have the mycelium, have all these..." and I very quickly, before I had a company was like "Mmm, no." I'm not in this to justify a particular aspect of the market or go for ease. I'm in it personally, and especially in the beginning, being a dreadful romantic, trying to connect to a herbal system, particularly Taoist tonic herbalism for me. Jeff: Exactly. The people who grow those products and they say "Oh, we want to have all parts of this. We want to have the spore, we want to have the mushroom, we want to have the mycelium." It's like they say "It's full spectrum." Well, the problem is that they leave out the fact that (A) there is no mushroom in it, and (B) the grain! How can it be a full spectrum product if they've got all of this grain in the product? That's what they don't like to talk about. They don't like to talk about the fact that it's mostly grain and all of this other stuff about "Oh, you know, the fruit body's in there and the spore's in there." Absolutely not. It's really a lot of smoke and mirrors. Jeff: That's what's so hard to take is that when there are people out there actually espousing that and claiming that they've got a full spectrum product when in fact it doesn't take much in the way of analysis to prove what they do and they don't have. We've run analysis and what's really interesting is if you analyze it, for example, with a proximate analysis, which is proteins, carbohydrates, fats, ash, minerals. Those products line up perfectly with the grain they're grown on. Mason: Are there exceptions to that? Jeff: No. All of these products and there, it's the myceliated grain products. If it's grown on brown rice it lines up with brown rice. If it's grown on oats it lines up with oats. Literally the two lines run together. The way I like to think about it too is I talk to people and I tell them what they're growing is tempeh. And they say what tempeh is, it is cooked soybeans with fungal mycelium grown on it. If you look at that tempeh and it's all white that's the mycelium but if you look at tempeh and you cut it open you can see it's mostly the soybeans. And if you were to dry it out, look, Mason, mycelium is 90% water. Just like a mushroom. The soybeans are 50% water. When you dry that tempeh out the mycelium just goes "Fffft!" Just tell me, where's the mycelium? And you've got all of these dried soybeans and you're like, well, it's mostly dried soybeans, that product. Mason: I'm sure you get it a lot as well. Yours, there's obviously a few brands in the U.S. becoming more aware of the others. I didn't go looking for them but as you move into a market. SuperFeast, I spoke to you about it the other day. We've got so many people ... like [inaudible 00:29:50] story. I've realized in business a lot of the time it's like, same with you, I like the people. I like the unique stories. People are like "Bring SuperFeast over, there's no one doing that like what you're doing over there!" I like, yeah. Jeff: (laughs) Mason: And it's the same. When you're upfront about the nuances although there's a lot of companies doing medicinal mushrooms like yourself and Taoist herbs like us, medicinal mushrooms. There's nuances there and the sourcing and there's nuances in the story. What I like is, which is going to get to the polysaccharide claim, and the full spectrum claim for the people growing the mycelium. Because people are in an egoic, competitive make money mentality a lot of the time. They think they have to be everything to everyone. Versus just being very upfront. I'm always quite upfront, I don't really look at that. I don't try and standardize color or anything in any way. I don't try and standardize the constituents. I don't even sell on the percentages of constituents. I don't focus on it. I'll move more in that direction because more and more people want to be satiated. I can say yes, we test for percentages of the active ingredients to ensure that they're in alignment with the Chinese cornucopia and ensure that they're actually active. And all that kind of stuff. Mason: But going over into the States now and hearing about all these other brands and I'm with you whenever it's growing on grain I can't get behind it. Not to be disrespectful, and I'm always trying to be really amicable in my talks. There's a place for it, but less and less can I find that place. Jeff: And I understand what you're saying too because if a person is genuine. For example the herbalists, who are at an American Herbal AHG conference. These are people that want to provide good products, they want to provide a body of knowledge to help people. That's who you wanna be, that's who I wanna be. I'm not in this to make a lot of money. I'm not in this to build some big company and go Oh, gee, isn't this great? Because I'm selling $20 million a year of this or that. That does not excite me at all. That has no meaning for me. What has meaning for me is that I'm producing a quality product that I've been working on for years and I can tell you the product is what I say it is and I want it to help you. I want you to be able to take this product and feel confidence that you're getting what the Chinese have used in traditional Chinese medicine for thousands of years. That's what I want. Jeff: I don't want to sell you something that is not what it really is and is a placebo and expect you to buy the product from me and I walk away going "I'm managing this great at my company. I'm making so much money and it's wonderful." No, I'm sorry, that's not me. I'm not interested. Those people turn me off. It's like the difference between being in a group of people that really understand mushrooms or herbs and being in a group of people that are just talking business and numbers and all that kind of stuff. And I don't give a shit about that. Mason: Yeah. I think it's interesting. Watching your business I can see in the beginning it probably would've started out that everyone knew Jeff and knew your level of integrity and how you just wanted a good product. In that little circle it was like 'Great, we'll just go and get Jeff's product.' Then as you grow I think what you've done really well ... just to put it as an example of why I'm bringing this up, we're getting to this point where we're growing as a company where it's beyond Mason at the markets and everyone knows that Mason has the badass tonic herbs. Or people are coming along to the talks and all the health clique. We've started emerging. Mason: I think you would've gone through this years ago when you emerged beyond the health clique. And it's very dramatically people aren't associating directly with you or the founder, it's the company. They don't even know or care who the founder is and therefore you need to have these things in place. We're getting to the point where everyone who's a SuperFeast customer is just like, "Yeah, we don't even care about organic, we know what you guys are doing," and we're going on that old philosophy and we're documenting that and there's all those other checks in place like independent testing for pesticides and metals and all that in place and available. Mason: But it's getting to that point now where the people on the very outside... I still don't know if we're really gonna shift because I still personally don't care and I don't change my company for perception's sake. But you can see Wow, that organic would be really, really useful for those people on the outside. Or the testing to know what percentage of what's going on inside and being able to present that. I think we'll move in that direction. I think you've done that really well and really maintained the trust in the brand of course, and in yourself. But maintaining you there as the one that's rolling this along and not then just relying, you know, the organic certification or the percentages. Mason: I think that's what I find really commendable, because most people then they rest on their laurels. Once they change over into, not standardizing but testing for minimum constituents like beta-glucans or organic. they then rest on that. Whereas that means nothing to me at all. Being able to talk to you I'm like, Yeah, because organic, I don't know what your take on that. I know there's some terrible organic products out there. Just the fact that we know we can go organic there's five different companies we can go to, so you just go and find the company that suits you. We can go with the company that's the hardest to jump through. Mason: I won't go into the details of what's going on, why we're probably not going to go in that direction. For us there's so many little micro-farms that we're being nimble with whom we're working with. When we're beyond mushrooms we've got a lot of other herbs going on. We need to cut that farm out if they need to move on and do something else and we'll go and we've got that team to go around and constantly go and find these people. So every time we want to nimbly adapt and go down a different direction when someone's doing a little more traditionally than the other person, all right, get the organic certify up. Or lie, which is what I think a lot of people are doing. They get the organic certification, then when they change up those little farmers, because we're dealing with independent farmers as well, not a company that can provide the organic certification. I don't know why I went on that rant. So that's why we're not going on down that route. Mason: It's something I see. I know there's a bunch of companies who are coming to NAMMAX, which I think is just been so good for the Australian industry. For people to know that they're very quickly going to be introducing a really good quality. You can tick off the organic but I hate it when it's just organic that they are going for and not just an incredible product with a story behind it as well. So I really commend you for offering that out. Jeff: I've always really believed in chemical-free food. Organic is more than just chemical-free it's how it's grown. When you're growing out of soil it's building the soil and not just depleting it. For me organics is a holistic way of looking at things. I've always considered that to be very important and I support that type of agriculture no matter what it is. A lot of these companies that are producing myceliated grain, they're organically certified! Jeff: It doesn't necessarily mean that it's going to be a great product. These companies have what I call all sorts of merit badges. 'We're big and we're organic, we're kosher, we're this, we're that,' which ultimately means nothing at all. There's a lot more to it than just that. The one thing I really like about what you're doing too is that you're introducing the philosophy of it and that's something that you really believe in. That to me is important and that's what people look at. They look at who's behind the company and what that person has to say, is that person ethical, righteous, person or not. You're not up there as a smooth talking business salesman or anything like that, right? Mason: You should see me try and sell something I don't like. I'm a bumbling mess. I think I told you that back in the markets people used to say god-made...you could sell ice to the Eskimos. But I'm terrible if I'm not talking about herbs or philosophy behind it. Jeff: That's because you're doing something you believe in. That's where everybody should be. Not everybody has that opportunity, but if you can have that opportunity. I was lucky enough that I followed my passion and I didn't do that because I wanted to be rich. I did it because I loved it. I always say to people, if you really like to do something, whatever it is, just do it. Follow your passion. Maybe you're going to be poor for a long time. Make something that you feel good about. Mason: Honestly, and I really mean it not just because you're on the podcast talking it up or trying to flatter you. But when I met you, you had a happy disposition to be in business that long. In the beginning I was trying to escape the business side of things. Quite scared about having a business and not coming out the other end alive. You have a sunny disposition and you still have control of your company and the standards and you're still educating about the same thing that you're educating, of course it's evolved, but you were educating about beforehand. And there's something that I've learned a bit about in that. There's something humbling and nice about not being in that pursuit for aggressive growth while still growing at a nice, sustainable rate. But staying true to what you were doing in the first place. I educate about basics of herbalism and medicinal mushrooms in the beginning and then I'll move on and doing other things. The more I go along the more I want to settle back into doing what I did all along. Mason: I've got a weird thing about going back to the organic, I'll almost shy away from something if it's organic because I see it as a marketing ploy a lot of the time. And I think it is a lot of the time. With little things. When growing Lion's mane there's a lot of people who will use organic fungicide because they don't pick when they're watering out to the Lion's mane. I like to use this example because we don't have a plastic covering, it's just a straw and a hut to keep it nice and dark and it gets watered. That's the only part that gets watered. And one of the things I talked about in the beginning with Lion's mane, I just heard about it through the grapevine, that fungicide is needed if you're watering straw a lot of the time in order to, all right, we know why fungus grows. But found someone who wasn't doing that and found people who were doing organic Lion's mane who were using organic fungicide on the huts. Little things like that they get me so dejected about the marketing ploy behind it. But I think you're the one organic product that I would be over the moon to use. Mason: And the other example is Ron Teeguarden. I think we talked about him. He was such a rogue in the industry herbally. You were telling me about the acupuncture when he was offering acupuncture because he's a barefoot herbalist and all the acupuncture's guilds are like "Screw you, you need to be regulated." And he's like "Hey." Jeff: I know, it might've been somebody when you were in LA but it wasn't me. I don't know Ron that well. He's been around a long time. He's done his own thing, he's not out at the shows or anything like that. He's very well-known and in a sense he's been the herbalist to the stars. He's in Los Angeles, right? A lot of people in Los Angeles that are into herbal medicine and living properly in term of what they eat and things like that. They would go to Ron and Ron has one of the very first herb bars where you can walk in and have this type of a drink or that type of a drink. He was really in it very early and doing stuff that nobody else was. He was an outlier in that sense. I don't think he really needed to go into the industry proper. He's done a little more now that before. He didn't have to. Mason: He, on the level of sourcing philosophy. I bumped into him years ago. I was at that place where I was starting to grow, people are asking why I'm getting my herbs from China and people asking me if I'm organic and all these kinds of things. I want to keep on doubling down on my philosophy, what I'm doing here. One thing that I drew from yourself as well and then be proactive and educating the market. Not in pushing your own product, just generally being happy about the market being educated as well. And Ron was like...In fact I talked with him for about five minutes. More or less he was like "Listen, if you have that spark," I remember, "do not deviate from that sourcing philosophy." And it really stuck with me and from that day I did. I doubled down and I was not going to try and... I'm going to continue to not worry about what's going on and just do me. It's a lot of fun. I was at Dragon Herbs Tonic Bar about three weeks ago. I frequent the Hollywood one when I'm in L.A. Mason: Before we go too far off the mycelium grown, one of the things you've really educated, not only the market, but businesses in the market around medicinal mushrooms in the market, is how to identify a true polysaccharide read on medicinal mushrooms. Rather than people including 60% polysaccharides or even 30%, yet when you go down into the class of beta-glucan it's actually been tested you've been hoodwinked and they've gone dry from age or whatever. Can you talk a little bit about that? Jeff: This is something in the herbal industry too that you learn right away, and I learned it back in the 90s, was that so many herbal extracts, when you make the extract they oftentimes need some kind of a stabilizer. Otherwise they can get gummy, they can jut come together if it's a powder. Putting a carrier with a lot of extracts was pretty common. What happened was sometimes companies would cheat a little bit. The next thing you know instead of 10% carrier it was 50% carrier or 80% carrier. And they're not revealing that to anybody. You think you're getting an herbal extract, not just mushroom extract, an herbal extract and it ends up being mostly maltodextrin or dextrose or something like that, and they're not telling you, then it is really deceptive. So there's a lot of companies that were doing that in the industry. Jeff: As I went along, the whole time that I'm working with people in China I'm like, "Look, I want extracts where we aren't using any carriers. It has to be made in a certain way," because I'm looking for the pure essence. In traditional Chinese medicine they take the herbs and they throw it in a pot and they boil it up and pour it out and "Here, drink this!" There's no carriers in there. Mason: That's right, not sliding agents. Jeff: That's right. If you have to put something in a capsule you've got 150 milligrams of different types of fillers and binders and flow agents. Putting it into a pouch is so nice because then you don't have to put those things in with it. It's just the pure herb. Early on in the 90s everybody's testing for polysaccharides and nobody's testing for beta-glucans. And beta-glucan is a polysaccharide. Unfortunately all these carriers are polysaccharides too. A lot of people can hide that from you that you've got carriers on their product. No, no, we don't use carriers, it's 100% mushrooms, stuff like that. That's where with any kind of supplier you have to build up a level of trust. Like I say, they show you a brown powder and say. "Here's our product, it's shiitake mushroom extract. Isn't it great?" You can test it. Jeff: This is the thing, Mason, it's not like you can take a mushroom product other than a reishi extract, consume it, and then a few hours later or a day later go, "Wow, yeah! Did I ever get a kick out of that!" No, it doesn't work that way. You can organoleptically, I can taste the shiitake extract and I can tell you yeah, that's definitely essence of shiitake. Or with reishi it's so bitter I can taste all those bitter notes in that reishi extract, that is an awesome extract. Jeff: I used to give a reishi extract to a friend of mine who was a deep herbalist making his own liquid extracts and a big business ultimately. He'd taste some of my extracts in the beginning and he'd go, "Not bad, but it tastes a little bit burnt." And I'm like, "Oh shit." When it was dried it was maybe in the oven a little longer, and he could pick up on it. I thought that tastes pretty good. That was in the early days when I didn't know any better. I thought it's great and high triterpenes and all this. He'd go "Yeah, it tastes a little bit burnt." Those kind of things teach you a little bit about, okay, how's it made. Let me tell you, in the 90s the facilities that were making herbal extracts were nasty. They were old facilities Mason: Not too much GMP regulation back in those days. Jeff: It wasn't like stainless steel everywhere, no. Everywhere was dark from all the herbs they'd been cooking for who knows how many years. Now all that's been torn down and you see nothing but brand new factories in China. Everything is stainless steel and it's beautiful and there's none of that anymore. But back then, actually, it wasn't until we got the megazyme test and I started using that. And that was in 2012 or 2013. Up until that point I thought, well, the polysaccharide number was high, that's great. Then we starting testing the products and that's where we really pulled back the curtain. My main supplier, awesome! The test results we got from that. Beta-glucan and alpha-glucan and the alpha-glucan, that was where any of the carriers were revealed. Jeff: And then another company that was supplying me with some products, only a few, not many, fortunately. And was swearing up and down they never used any carrier. Jesus, their alpha-glucan level was way up there. I was shocked and really upset because I thought their product was good because occasionally I'd test it for polysaccharides it was 50-60% and I was thinking, great product. I could taste it, it tasted okay. Nothing but mushrooms they were producing. But here they were. They were putting them on a carrier and telling me they weren't. That's the kind of thing that you face when you're over there. Jeff: How do you qualify these products? You can go to the factory. They can show you around, you can look at all the mushrooms in their warehouse, you can look at them cooking these things up, the final products. They don't show you the bags and bags of maltodextrin that are hidden back in the warehouse somewhere that they're using as a carrier for the liquid extract. That literally pulled back the curtain and I went and confronted that with them. They claim no. Finally they actually admitted it and I'm like, okay, see you later. I'm not buying another product from you because you lied to me. Fortunately it was a secondary supplier. They weren't my main supplier at all, but I needed a secondary supplier. I visited them and it was all mushrooms that they were doing and they were in the heart of mushroom country and it was nothing but mushroom. Yet they had all these carriers in there. I was really upset not only with them but with myself because I got taken in by it too. And that's what you have to do. Jeff: Look, Mason, have you ever been at Ali Baba and looked at all the mushroom products being sold? Mason: It's always funny, and as you know, everyone's jumping onto the bandwagon right now. You can see people trawling through Ali Baba going "Oh, just tell me which one is awesome." I haven't been in there in a long time. I got curious, to be honest. I think we were in the office having afternoon drinks and seeing what was on Ali Baba. It is insane. Jeff: It's totally insane. So many companies selling mushroom extracts. Sometimes they're selling at prices where you're like, "No, wait a minute, you can't sell me that extract for $20 for a 10:1 extract. That's impossible. You load it up with starch, that's quite possible, right? That's where analysis, for me, has been very helpful. Especially the beta-glucan analysis because that gives me that alpha-glucan which is the whole carrier. That's what unmasked all of those myceliated grain products. There's definitely a place for analysis. There's also a place for getting to know the grower. I don't believe in organic pesticides. I don't give a shit. Don't use whatever it is, you have to grow this. I know it's more difficult but you have to grow this without sprays and all that. Jeff: The thing about China is that when you're traveling through China and I've been back in the mountains in all these different places and you go back and you look down and this little valley and here's this beautiful rice fields down there and you're going "Oh, isn't it great, back here. Everything's idyllic." And then you see somebody walking through the rice field and they've got a backpack sprayer. And they're going along spraying chemicals on this rice crop. I'm like, "Ugh, shit. Really? Do you have to do that?" And I think to myself, even the smallest growers out there are using some chemicals. That's where I'm like... And I want to be sure. And that's where we test and test to make sure that everything is staying on track because these things can slip in. Somebody can cheat. You have to ride herd on the whole thing. Otherwise it can slip right through your fingers. Jeff: That's been good for me in the sense of having an organic product that has meant that we put these constraints on the people that we work with. We say look if your product shows one of these things in there I'm sorry we're not selling it. If you and if you shipped it over to us and we find it in there after you've done the testing that's all good and we find it in there it goes the landfill I'm sorry, we can't sell it. That has been a really good quality, that's how we keep that quality up. In that sense I kind of believe in it all and think it's important. It helps us keep the product a little bit more real. Mason: As you say said there's all these things that can go by... even though it is organic, you can get organic pesticides and all this kind of stuff. I have taken your product and of course I really love it. You know that you're going to go that extra mile with it. It's a trip around it, there's a stigma around China is isn't that whole thing polluted? Jeff: Well, that's the other side of it right now, Mason. People are so afraid of anything coming out of China that this gives them a little bit more confidence in it. They can say what they want about organic and all but we've got pesticide tests that can demonstrate what it is and of course the always have to do heavy metals and micros and all of that. Mason: Alpha-toxins Jeff: For us, especially as a raw material supplier to companies large and small we have to be able to give them confidence because you know they're selling a Chinese product that they buy from us and lot of people are just like you know when it comes to China it's like no no no no it's like not going to do it so I have to talk to a lot of people. And I say, well, hey look. There's products in the United States that are absolutely full of chemicals. So it doesn't matter where it's grown. It matters where it's grown but it's not this country or that country. You can grow good, clean products anywhere in the world if you're doing it properly. Mason: It's so good. Of course people are realizing that the ultimate Chinese herbs and medicinal mushrooms are going to be coming out of China. I really like how it's still dominating and making it really easy for people to get One thing that's organic and Two very quickly have all those things to provide so enough people are going to be able to go, Oh, okay, so it's from China and we can trust it. That's something that makes it really easy, because people are going to jump on the mushroom bandwagon. We found it as well, a similar thing. People want to come, they're like okay, tell us about Chins. Okay, tested three times for pesticides before it comes to market, each batch. Plus here in Australia the TGA facility and heavy metals and alpha-toxins and microbes. At some point people go "Hmm, shit, okay." And testing of the water. And when we can going and doing radiation testing in the areas. And then going live and seeing pictures of you at your reishi farm is magic. Mason: When I was going live around China going, you know we're still going up while we're outside the mountains going to the fields where the eucommia bark trees were grown or up in Yunnan. Just drove five hours in the middle of nowhere to get to the poria farm, where there's wild pine and people are going "Holy shit! Look at that land! The land of the dragon. It's calling me. It's real." All of a sudden popping that thing that first of all, yes, you just need to be vigilant, that's absolutely number one. I've only changed suppliers once. In the beginning I found someone I had really enjoyed their product. And then what I've decided was one of my areas in going forth is I need someone that could absolutely school me. If I'm requesting things and they weren't able to "bang" school me on that immediately, then I'm not going to be able to do business. Mason: And it got to this point where I was confirming no municipal water. Only springs, only well water. Only creek water in the area. Nothing from the tap every touching the crops. At one point "Okay, sometimes that's a bit hard." I was like "All right, I'm gonna change now." That's when I started going down that route and ended up... developing relationships, developing a friendship first, understanding the intent behind the philosophy behind the business, understanding who owns the business that you're going to be dealing with and what their motives are and what their history is. These are the things where people don't realize what goes into it. People go "Can you tell me your supplier?" And you're like Jeff: (laughs) Mason: At this point it's not about me being scared about you having access to that supplier but so much has gone into this relationship. It's not just about finding someone and sourcing off them. Although, it's nice and easy to do that. If I was beginning right now I'd love to be buying just from suppliers on NAMMAX because it's cool. All the certificates, all the independents, and then all the years of vetting and tweaking that leads to this point where trust is inevitable and you become even more switched on to what to look for if anything ever comes up. If anything slips or changes you know the questions to ask and where the slip in quality could possibly be. And large ways you know how to put things in place that would stop that from ever happening to begin with. It's an interesting industry. Jeff: We go there every year and we'll do an audit. We'll visit farms, the factory we'll be sure we confer with our partners to make sure everything is good. This year we're at the point where we're hiring someone to be on the ground in China that will do a lot of checking and stuff for us on a regular basis. More regular than us going over there once a year. It's gotten to a point where we really need that coverage of somebody right there that we can say "Can you go out to this farm or this factory?" Also, communications because sometimes communications... although some of our partners speak English but some of them not so well and then they have to use a go-between and that's not always the best. So we're gonna have somebody now that's right there in China and can do that for us. Can you imagine going to China and traveling around without having somebody with you to help you through the liaise and talk? Mason: I have the best intentions of getting my Mandarin up to scratch and as soon as I'm out of it, it all slips out of my head. I haven't fully entered into that poetic language realm. The language is sticking. Can you speak Chinese? Jeff: No, I speak Spanish, but Sky's learning Chinese. He has three classes a week, an hour each class with a Chinese speaker he does it over Zoom or something like that. He's very diligent about it. We get over there. He's speaking with them in Chinese and they love it. He's learning more, but unless you actually go and live somewhere for a while it's always tough. I've been thinking about it. You go over and spend two weeks, three weeks, whatever, then you leave. That's nothing in terms of really getting in and learning a language. That's swimming on the surface. Mason: I gotta get onto it because I'm gonna do some Taoist training there. Jeff: Yeah, that'd be really cool. You're young enough that you still can do that. I'm way beyond doing anything like that. Mason: Come on, they'd love you up in the temple. Jeff: Not only that, where I love to be is in Patagonia Mason: Dude, that's the other place my heart lies, down in Patagonia. I want to become an old Argentinian man. I want to become a cowboy. Jeff: Exactly, I know where we can get some horses, Mason, so let me know. Mason: All right, that's it. That's on. China this year, maybe Patagonia next year. Jeff: Yeah, two years ago Andrea and I went out and spent the day with, we had a gaucho that took us out. We went all over this one area. It was a hot day too. We were on horseback the whole time, cruising through, very slow. Slow living at its best, right? Mason: Yeah, that's it. Drinking, eating a lot of meat, drinking a lot of yerba mate. Jeff: Yeah, when you're on a horse you're not going to go very fast. You're going to cruise along. It's life in the slow lane. Mason: I love it. So before we finish up is there anything that is coming up now that's exciting you about educating people about this market and about this industry with medicinal mushrooms? Jeff: People really still need a lot of education with mushroom. Part of what I do too which I really like is I talk about the nutritional value of mushrooms. My thing too is eat mushrooms. I think mushrooms may be the missing link in terms of food. A lot of people are like, fungus, never eat it, right? And I'm like, "Dude, you've gotta get on and eat mushrooms, it's a fabulous food. They've got great benefits, you get medicinal benefits as well as nutritional benefits." That's the key for me, I'm pushing that really hard when I talk to people, saying "No, it's a fabulous food." And in China they have this whole thing of food is medicine. Jeff: That's in Ancient Greece too. Food as your medicine. Everything that you take into your body should be something that is beneficial. And medicine as a very loose way in terms of it's feeding you and keeping you healthy. And that's what we should all be thinking about. What we consume is keeping us healthy and we should look at our food as that. That's providing me with all of these benefits. I say if you want a supplement, you feel you need more, that's great. You can supplement. But definitely use mushrooms for food. That's a big category for me. Jeff: As a mushroom grower, can you imagine? I'm working on an agaricus farm. For ten years every day I'm going in I'm going through the rooms and each room ultimately is producing 20,000 pounds of mushrooms. There's mushrooms everywhere around me growing and I'm stoked. I love this. I've got mushrooms that I'm eating all the time. I've even got small beds of mushrooms that I bring stuff home and I'm growing them in my house because it's so interesting to me. The farm I was on it wasn't just an agaricus, we had a scientist that was growing shiitake and maikitake and oyster mushrooms. Back in the 70s when those weren't even on the markets anywhere. And I had access to these mushrooms. Besides the wild mushrooms that we were navigating. I'm like, make them part of your diet because it's a wonderful food. Jeff: That's my message to people is this is a forgotten food, bring it home. Mason: I love it so much. Thanks for reaching out, I really appreciate you reaching out and having you on here. It's not only do I admire you as a person, admire what you've done and your business. I spoke to you a little bit about it. I like talking to the other people who are perceived competitors. There's so much room in this market and everyone's doing their own thing and has their own story. This whole red ocean we have to fight over a scrap of people who are going to be buying mushrooms and not focusing on educating together is absolutely ridiculous. It's always awesome to meet people who trail-blazed that attitude in the industry. Calling out people that are bullshitting and then coming together and educating together and getting the world healthy together in our little way. There's something really nice about that that makes it possible to be in business for so much time, for so long, see so much shit yet still have such a positive attitude about it. Jeff: That's absolutely right. I really love what you're doing too and I love the whole Taoist part of what you're taking to people and bringing to people. That philosophy is really awesome. That's what brings something really unique. When I hear you talking about mushrooms up around, what's the lake up there in the mountains? Mason: Mumbai Jeff: Yeah, that was so cool and you're hanging out there, talking about the mushrooms really excited about it all. That is really special. I love your energy, Mason, I'm really happy that we've been able to get together and have these meet-ups, speak and let's carry it on, let's keep doing it and stay in touch for sure. Mason: Absolutely. We'll get some videos in another podcast together, 100%. I'll go check out these dates, see if I can swing a Jeff: I'll send you the info on it so that you can check it out. If you can come you'll have a ball because there's gonna be lots of mushroom peop
My guest on today’s show is a Staff Operations Engineer from Zendesk. He describes himself as a Linux systems geek with a passion for making systems serve great content. And he is recognized as an expert in metrics and monitoring, about which speaks, as well as a featured panellist for the MonitoringScale Live community panel. EPISODE DESCRIPTION: Phil’s guest on today’s show is Jeff Pierce. He has been working in the industry since 2003 when he started Coldflare Internet Services. Later, he moved into systems administration working for several firms. Jeff then changed direction a bit, taking up a role as a senior systems engineer for Apple in 2011. Then again when he started work as a DevOps Engineer for Krux Digital and a Senior DevOps Engineer for Change.org. After a few years working as a software and infrastructure engineer, he is now Staff Operations Engineer for Zendesk. He specializes in automating large clusters of Linux systems. Metrics and monitoring are his other passions. He is an expert in this field and regularly speaks on this subject. Jeff was also a featured panelist for the MontoringScale Live community panel. KEY TAKEAWAYS: (00.49) – Can I ask you to tell us more about the metrics and monitoring that you focus on and speak about? Jeff starts by pointing out the only way to do effective system administration is to have access to good software data. You need that data to be gathered automatically. Over the years, Jeff has focused on making sure companies are able to collect the data they need to be able to scale things and optimize what they are doing. (1.26) – So, you are following the principle – if you can’t measure it you can’t improve it. Jeff agrees but explains that it is a little more than that. He says if you can’t see what your system and software are doing, you are already broken. You just don’t know it yet. (1.44) – Can you please share a unique career tip with the I.T. Career Energizer audience? Jeff’s advice is not to share your salary with your new employer. This is because they will simply offer you a percentage over what you already earn. If you want to make sure that you are paid the market rate, keep your salary history to yourself. Let it be known that you want to be paid a certain percentage over the market rate and let them negotiate from there. In fact, in the US in Massachusetts employers are no longer allowed to ask future employees how much they earn. The authorities are recognizing that being able to do this gives firms a huge amount of power over prospective employees. Continuing to base what they pay on what previous employers is only making pay gaps worse. (4.16) – Can you tell us about your worst career moment? And what you learned from that experience. Interestingly, the experience Jeff shares turned out to be a combination of the best and the worst moment of his career. It happened when he was working for the petition site change.org. They help campaign groups and people to put pressure on government and corporations, using petitions, to literally drive change. About four years ago they were involved in using petitions to stop the dog eating festival in Yulin, China. The data involved was huge. So much so that it uncovered a bug in their Galera MariaDB Cluster. The error caused every node to go into data protection mode. When all your nodes go down like that you do not have a cluster anymore. Instead, you end up with four separate servers. In their case, there was also a fifth arbitral process in place to break ties. The nature of the problem meant that their 4th server was serving virtually the whole site while they worked on the bug. Fighting to keep the site online at a time when they were getting four times more traffic than normal was a challenge. There were other issues too. On the one hand, existing on a few hours sleep and working in a highly stressed environment, was awful. For any engineer that time spent fire-fighting keeping the system going knowing that you could not fix it yet, for five straight days, was a nightmare scenario. But, it was also one of the best times. The strength of the team he was working with shone through. Plus, he learned a huge amount from getting the system into working order. That learning carried on for weeks after as they forensically examined what had happened. He delved into areas of the system and technologies he had barely touched before. (11.12) – What was your best career moment? Deploying the first piece of code he had a hand in writing into production was a real highlight for Jeff. He had just moved from the ops side to DevOps, so he knew it had the potential to make a big difference and help a lot of people because they were able to make it Open Source. For change.org having the ability to store the stats in Cassandra was very helpful. It is a no sequel database format, which means that it is highly scalable. Exactly what they needed, at the time, although now they have moved on to using DataDog. But, when Jeff wrote and deployed the code it was a step change. At this point, Jeff reminds the audience of the value of Open Sourcing something you wrote in terms of energizing your IT career. Being able to do this demonstrtes to a prospective employer that you are good at what you do. So, good that you are confident enough to put your work out there so others can use it. To this day, Jeff mentions it to hiring managers. They are still impressed by it. Coming up with a fresh idea and being able to take it to the point where it is available for general use proves you have a good skill set. Learning code is a lot like learning how to play the guitar. At first, you can only play one chord and you struggle with that. You think you are never going to get it. But, you persist and practice your chords. Before you know it you can play a song. (19.38) – What excites you about the future of the IT industry and careers? To use a cliché “software is eating the world.” It is everywhere, which is really exciting because the possibilities are endless. Now, anyone can easily put a product out on the internet using the products Amazon provides. When Jeff was working in the field of systems administration you had one manager for every 50 servers minimum. Now AWS and Google Cloud are available, one person can manage huge scalable systems. Nowadays, nobody asks you what is the biggest environment you have managed? They just want to know that you are familiar enough with the software so you can run the system. Of course, this shift means that you do not need as many system administrators. But, fortunately, these days, as one door closes, others open up. No matter how smart the devices and tech are, end users will always need some sort of support. The robots that are used to automate tasks still need to be maintained. There will always be a geek working in the background. There are still plenty of opportunities for those who want to get involved in the industry. The list of possibilities is endless, which is also exciting. (23.34) – Phil comments on that the fact it is impossible to predict what will happen next. Jeff agrees this is exciting. Ten years ago he thought Linux branded zones which are sometimes called Solaris Containers would be huge. But, Docker came along and totally changed the landscape. Set up properly, with all of the right permissions in place it is safe to give junior system admins access. Plus, you can guarantee that everything will work once it goes into production. Even more surprising was seeing the GPU becoming big again. In the IT world, you can never be sure what will happen next. (25.32) – What drew you to a career in IT? Jeff has been a computer geek since he was a kid when his dad bought him a BC286 from ComputerLand. Jeff loved using it from the start. It had a 640k ram, 10 times more than they used to get to the moon. At the time, Bill Gates said that was all the ram anyone would ever need. When it broke it was too expensive to have it repaired. So, he learned how to do it himself. He loved solving puzzles, so when he realized he could do it for a living, he leaped at the chance. Jeff is on the spectrum, so without IT, he is not sure where he would be today. Being able to work in the industry opened up the chance for him to earn good money and find work easily. (26.06) – What is the best career advice you have ever received? It came from his dad who insisted that Jeff learn a trade. He was an auto mechanic. When he could no longer physically do the work, he switched to teaching auto mechanics. Jeff did not get much formal education. But, once he realized he wanted to work in IT he approached learning how to do it and building his career as if it were a trade. From the start, he realized that he would only master it if he practiced. Repairing someone’s PC is not dissimilar to fixing someone’s car. In both situations, the person handing it over to you does not really understand how it works. So, they have to trust you to do it for them. (27.38) - Conversely, what is the worst career advice you've ever received? Someone once told Jeff to stay at least a year with each company. There will be times when things will not be working out. In that situation, staying the year just does not make sense. If you are learning something and have no problems with the work environment, by all means, stay at least a year. If not, don’t be afraid to move on. Of course, during the interview, you will find that hiring managers will ask you why you left so soon. But, there is no need to be worried about that. Just be honest. For example, they just weren’t a good fit or I was just not learning anything there. It is best to prepare a good answer prior to the interview. Jeff was fired once. At the time, he was suffering from depression and it was affecting his work. He has been hired twice since then. In both interviews, he disclosed what had happened and still landed the jobs. (29.40) – If you were to begin your IT career again, in today’s world, what would you do? Jeff says he would go to a code boot camp. Some of the brightest people Jeff has worked with have done attended coding camps like Hack Reactor and Hackbright Academy. It is a great way to get into coding. Unless you are involved in developing leading-edge technologies like AI or neural networking you don’t really need a computer science degree. For many people, it turns out to be a waste of education. Even with a first class degree in all likelihood, your first job is going to be something like working on a mobile API or website. (32.44) – What are you currently focusing on in your career? Right now, Phil is building his online presence back up by using social media. He is also planning to speak more again. But, top of his list is getting more involved in educating others. He wants to mentor more. Jeff only learned to code in 2011. So, he is still developing his DevOps skills. (34.42) – What is the number one non-technical skill that has helped you the most in your IT career? Jeff is autistic so he has had to actively learn people skills. For example, looking someone in the eye when having a conversation does not come naturally to him. In fact, he still can’t quite do it, but has learned that looking at someone’s forehead is close enough. Focusing on and honing these skills has enabled him to progress within the industry. Today, he is better than most people at things like navigating a crowd or public speaking. (37.40) - What do you do to keep your own IT career energized? Jeff finds taking on side projects keeps him energized. Often it is his non-IT interests that determine what he does next. For example, he is currently learning C# because that is what the Unity game engine uses. This feeds into his desire to start his own video games company. He is a big gaming fan and is especially proud of being listed on Marvel Heroes as a member of the senior technical operations staff. He does not like sitting on his laurels. Constantly challenging himself keeps him interested and energized. (41.37) - What do you do in your spare time away from technology? Jeff plays the guitar and bass. He used to play in a punk band, but now mostly creates and records as a solo artist. Jeff is also a big video game fan who enjoys role-playing and strategy games. (43.07) – Phil asks Jeff to share a final piece of career advice with the audience. Get a mentor, someone who can guide you and help you to work out what to do next. He also advises the I.T. Career Energizer audience not to be afraid to apply for jobs for which they are not fully qualified. Hiring managers do not expect you to have every single skill that is on the list. Jeff’s suggestion is to apply if you meet around half of them. He has never met the full criteria asked for, yet has still been hired many times. On your application spend time explaining why you are a good fit for the job in the cover note you provide. Often, you will land yourself an interview. Thirdly, Jeff explains that effective networking is key when it comes to developing a successful IT career. When you are looking for work, often, your network will introduce you to people who are hiring. BEST MOMENTS: (1.36) JEFF – "If you can’t see what your system and software are doing, you are already broken. You just don’t know it yet." (2.11) JEFF – "Never share your salary history with a new employer. Instead, ask for the market rate plus a percentage." (15.18) JEFF – "When you’re passionate about a project you do your best work." (21.58) JEFF – "End users always need technical support, no matter how smart the devices get." (22.27) JEFF – "You will always need the geek behind the scenes." (28.48) JEFF – "Don't stay in a situation that isn't good for you or for the company you are working for." (32.04) JEFF – "For the programming side of the industry, code school is one of the best ways to get your foot in the door. " (39.48) JEFF – "Don't get comfortable, keep seeking out something harder.” CONTACT JEFF: Twitter: https://twitter.com/Th3Technomancer LinkedIn: https://www.linkedin.com/in/jeffrpierce/ Website: https://almostinteresting.net
Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)
The guys talk about having more books than shelf space and also their upcoming 24th anniversary. Will reviews An Easter Promise by A E Ryecart. Jeff reviews Play It Again by Aidan Wayne. Jeff interviews Hank Edwards and Deanna Wadsworth about their collaboration, Murder Most Lovely, the first in the Lacetown Murder Mysteries series. They talk about how they came up with the book, their process for co-writing and what’s still to come in the series. We also find out what’s coming up for each of them in 2019. Complete shownotes for episode 186 along with a transcript of the interview are at BigGayFictionPodcast.com. Here’s the text of this week’s book reviews: An Easter Promise by AE Ryecart. Reviewed by Will. This is the continuing story of Rory and Jack, who we first met in the holiday story, A Kiss Before Christmas. In that story, Jack finds the homeless Rory huddled on his doorstep and offers him a place to stay. As they learn more about one another, Jack asks Rory to pose as his fake boyfriend when he goes home for the holidays. An unexpectedly severe winter storm prevents them from that trip, but in the few days they’ve been together they’ve fallen in love. I read A Kiss Before Christmas last year, and I still highly recommend it. In An Easter Promise, it’s now Spring and our two heroes are finally making the trip to visit Jack’s family in his ancestral manor house in the countryside. This is a particularly nerve-wracking experience for Rory, whose childhood couldn’t have been more different than Jack’s well-heeled upbringing. Things go relatively well as Jack shows Rory around the expansive estate, but they then get frosty when Jack’s mom makes it clear that she believes that Rory is after her son’s money. Gold-digging accusations aside, as a favor to her, Rory steps in as a last-minute contestant in the Best Bake competition at the village festival. Though his brownies were obviously the best, he doesn’t win. Afterward, Jack announces that he and his culinarily gifted boyfriend are going into business together and are opening a bakery. This once again raises the suspicion that Rory is only after Jack for his money, causing a major rift in family relations. Jack tells his mom where she can stick her suspicions, and is ready to return to London, but when Rory takes the family dog for a walk, he gets lost on the moors in a sudden storm. If reading fiction set in the U.K. has taught me anything, it’s that going for a walk on the moors is always a bad idea. The family organizes a search party and journeys into the dark night to find Rory. He is eventually found, and Jack makes amends with his parents. Flash forward a few months to the opening of the bakery and the beginning of a new chapter for our romantic heroes. I really like both of the stories featuring Rory and Jack and sincerely hope that this isn’t the last that we’ll see of them. The opening of the bakery certainly presents several new story possibilities. A.E. Ryecart, if you’re reading this, I’m a fan and a series set in this world would be greatly appreciated. Play It Again by Aidan Wayne. Reviewed by Jeff. I was completely delighted by new-to-me author Aidan Wayne’s Play It Again. Part of what drew me in initially is that part of it relates to what we do here on the podcast. Dovid is a YouTuber alongside his sister Rachel. They run a channel called Don’t Look Now. Among the things they do is review eateries in Seattle for how accessible they are because Dovid is blind. They also interact with their fans, go on trips, open mystery boxes–it’s the full YouTube gambit. Over in Ireland, Sam runs a Let’s Play channel where he plays a popular videogame. Rachel and Dovid become obsessed with Sam’s channel because of his easy-going, fun delivery. Dovid calls out Sam’s channel in an episode and sends Sam’s subscriber count through the roof and when Sam contacts Dovid to thank him they end up talking frequently. Dovid and Sam are single–but as I mentioned live on opposite sides of the globe. Neither of them, quite cutely, realizes how flirty they’re being as they message each other. Initially Dovid offers Sam advice on how to manage his new subscribers and ways to grow his channel but as they move beyond that and get to know each other the realization comes that perhaps there’s more there. This isn’t the first book I’ve read that relies heavily on text messages, instant messenger, email and so on. I loved how these wove into the story. There’s a good deal of, what I’ll call, regular storytelling too, coming from both points of view. Dovid and Sam have quite a lot internal dialogue about their growing predicament. Just getting time to talk on the phone is a challenge with the nine hour difference between them. It doesn’t stop them though from being ridiculously cute and challenging themselves to let this relationship go through its formative stages without being in the same physical location. Of course, the guys have to get together and that happens when Dovid and Rachel had the chance to do a European tour, which includes Ireland. As much as Dovid and Sam questioned themselves as they did the long distance thing, the jitters ratchet up as they meet. Aidan does a great job of showing the hesitancy–from Dovid wanting everything to be perfect to Sam wondering if he’s worthy of Dovid. Sam comes from a family where he was put down a lot and Dovid goes into protector mode when Sam talks about this, which is incredibly touching and sexy. For all the exploration they did via email, the time they spend together in Ireland really made me appreciate the romance that Aidan spun even more. They’d bonded so much before, they almost fall into old married couple mode with how they try to take care of each other. Dovid is particularly mindful of Sam’s asexuality and makes sure Sam isn’t doing anything he doesn’t want to do. It’s wonderful to see two such diverse characters finding their happy. Speaking if the HEA, I’d wondered how it would manifest in a book where the two characters spend probably eighty percent of the book on separate continents. I adored how Aidan brought Sam and Dovid together. I would love to see more in this universe to know how Dovid and Sam are getting on. Besides the wonderful romance, I loved the attention to detail that Aidan put into showing the work Dovid and Rachel do on their channel. From the talk of creating Patreon campaigns to managing social media and how to interact with the audience, I enjoyed it and I don’t think it’s too much for people who don’t do this kind of thing. Another excellent detail, Dovid and Rachel receive a package from a fan in Michigan–it contained Faygo Red Pop and Mackinac Island fudge, two childhood favorites that made me smile and gave me cravings! So, in case you haven’t figured it out, I totally recommend Play it Again by Aidan Wayne. I’m also looking forward to their upcoming book, Hitting the Mark, which comes out at the end of May. This interview transcript is sponsored by Dreamspinner PressDreamspinner Press is proud to publish this week’s guests Hank Edwards and Deanna Wadsworth and their new book Murder Most Lovely. Check it out, and all the new mystery and suspense titles from your favorite authors like Amy Lane, KC Wells, Tara Lain, and Rhys Ford, just to name a few, and find a new favorite author while you’re at it. Go to dreamspinnerpress.com for everything you want in gay romance. Jeff: Welcome to the podcast, Hank Edwards and Deanna Wadsworth. Deanna: Hello. Jeff: Thanks for being here. Hank: Thanks for hosting us. Jeff: You guys have written a book together… Deanna: We did. Jeff: …which is super cool. April 30, which is the day after this comes out, you’re releasing the first book in the “Lacetown Murder Mysteries” called “Murder Most Lovely.” Tell us about this new series. What is the scoop? Deanna: Who wants to go first? Hank: Deanna? You go first. Deanna: Okay, I’ll go first. So like a year ago I went out to dinner with my husband, had some cocktails and at like 11:00 at night after having like wonderful conversations in my brain with myself because I think I’m clever, I messaged Hank, and I said, “Dude, we need to write a book together.” And he’s like, “We should.” And then we did. Hank: I might have had some cocktails that night too. I can’t remember. Deanna: You may have. Hank: Might have. Deanna: And it was, “Yeah, we should,” kind of moment. And we didn’t really know where it was going. Hank: We had no idea. Deanna: What’s that? Hank: We had no idea, like nothing. That was just the random start of things. “We should do a book.” We didn’t have an idea or anything. Deanna: It was a completely inane, “Dude, we should write a book together,” kind of moment. And then seriously, the next day, we had some conversations like, “What should it be? Superhero?” And then we just kind of like spitted ideas back and forth. And Hank was like, “We would write the fuck out of a rom-com.” Am I allowed to say fuck? Jeff: Yes, you are. We’ll put a little explicit logo on the episode and you can cuss as much as you want. Deanna: So he was like, “We would write the fuck out of a rom-com.” And I’m like, “We would.” And then we’re like, “What should it be?” And we just spitballed ideas back and forth. Like, I mean, literally, like there was probably like 30 or 40, like, things we shot back and forth at each other. And then Hank picked on two of them. And he’s like, “I love the idea of a mortician and a hairdresser.” Then we ran with it. Hank: Yeah, and we just ran with it. And it just started writing. I mean, we didn’t plan, like, “You take one chapter.” What we did was each of us wrote up a character bio and sent it to each other. And so I wrote up… Deanna: It was so great. Hank: You what? Deanna: It was so great, like blind dates for our character. Hank: It was. It was really fun. So you had Michael, right, and I had Jazz. Deanna: Yeah, you made Jazz. So tell us about Jazz. Hank: So Jazz is very sassy and very snarky. And he’s a talented hairstylist and he’s uprooted his life after separating from his husband, who is a best-selling novelist and mystery novelist. And so he’s moved to this small town on the coast of Lake Michigan in Michigan. And some Michigan love there, Jeff. Yes. Jeff: I love that. Hank: Yes, always. And so he’s starting over and he’s just trying to kind of like rebuild and he works at a fun little salon but he’s kind of, he’s 49 but he tells people he’s 41 and… Deanna: He tell’s people he’s 35, remember? Hank: And he tries that too. Deanna: He totally lies about his age. He says he’s 35. Hank: We had, our editor actually called us up and she was like, “Is this right?” Because he shouldn’t have been around back then. Jazz lies about his age. Deanna: He’s almost 50 but he says he’s 35. Hank: Right. So that’s how that started. And then she brought up Michael. Deanna: Yeah. Hank created Jazz, the hairdresser, which is funny because I actually legitimately am a hairdresser in real life. But when we were talking, Hank had said, “I’ve always wanted to write a hairdresser.” I’m like, “You take the hairdresser. Run with it.” And then I took the mortician, which sounded really great and exciting. And after dozens of Google search, Google decided that I obviously want to be a coroner and mortician and they send me casket ads, but yeah, whatever. So I created a…it was fun because Hank created Jazz, this sassy, almost-50 hairdresser who’s super sarcastic, he’s got long honey blonde hair and super stylish and wears eyeliner and he’s really sassy and he has a big potty mouth. Hank: Oh, yeah. Deanna: Oh, he does. And then I didn’t know who Hank was creating when we came upon this conversation. It was very much, “Hey, you pick your guy. I’ll pick my guy. We’ll see what happens. And I made Michael Fleishman who is a 42-year-old, very uptight, very socially awkward Jewish guy who runs the local funeral home and he’s also the county coroner to our fake county…is it Carver County? Hank: Carver County, yeah. Deanna: Carver County on Lake Michigan, which is sort of like in somewhere between, I don’t know… Hank: Like Saugatuck and… Deanna: Saugatuck and… Hank: Yeah, Muskegon. Deanna: Muskegon, somewhere, a fake county in between there and he’s the county coroner. He’s very uptight and super horny and has this like hilarious like sexual imagination but he’s really reserved and he is obsessed with mystery novels. And he goes to a bookstore in Lacetown, which is our fictional town on Lake Michigan, during a literary festival to meet his favorite also author, Russell Withingham, which happens to be Jazz’s husband. They’re separated but they’re not divorced yet. Hank: And that’s the meet-cute. Jeff: Wow. Hank: I know, right? Deanna: Total rom-com, meet and greet during the rain under an umbrella, cute scene. Until Jazz gets his little…I mean, he really worries Michael thinks he’s a bitchy queen and he kind of is. He’s totally the queen. Hank: He’s really fun to write. Deanna: It’s so fun. Jeff: So when you got these characters who are obviously really opposite to each other, you could just hear it in the bios, what was it like to mash them together? Hank: Oh, man. Jeff: Sparks had to have flown off the pages. Hank: Oh, yes, right away. It was really fun. The first chapter is their meet-cute. And we had…I mean, we do a lot of like editing, right? So we’ll write the first pass and we’ll talk about it. We message a lot during the day and stuff like that, talk about where we want to go with things. And then we use Google Docs to write together. Yeah, so that was a lot of fun to just see the whole creation of it and like set up that setting and understand how they were going to meet and how that was going to go and how Michael would be so taken with Jazz at first sight. It was really fun. Deanna: Totally. Like, “Oh, you’re so handsome. Why is he talking to me?” Hank: That’s really fun. Jeff: And of course you’ve got the mystery element in this too. So rom-com mystery, which trying to think, I haven’t necessarily seen that kind of combo a lot because there’s straight up romantic suspense, of course. And then there’s like cozy mystery and maybe this ekes a little towards that with the rom-com–iness. But did you know that this was going to be like something to go for? Or did you just like mash these two elements together and say, “This thing…” Deanna: We thought about doing like a film noir concept, like a 1940s film. But see, that’s the thing. Like when Hank and I started writing, we didn’t have a direction. We were very much open to anything. And it was sort of like he created Jazz, I created Michael. We knew we wanted a murder. We knew we wanted it to be like… Hank: We wanted a murder. The murder got pretty gruesome too. I was really shocked. Deanna: Yeah, we wanted some things but then as we began to write it, it began to have elements of a real murder. So like our sheriff is blustering and funny. And Michael has his kitty cat, the little Mr. Pickles. Hank: Mr. Pickles. Deanna: Mr. Pickles, the fat, black-and-white kitty, which my dog is growling at right now. Jeff: Which we should note, for the people who may not be watching the video, Deanna just held up this stuffed kitty. And you’re going to be giving these away at GRL in a few months. Deanna: Yes, we have a few couple. So like when we created the story, I guess maybe other people with their writing collaborations might be different than we were. But Hank and I were not in a competition with each other. We were not like…we just knew we were going to have fun because we like each other and we know each other personally. And we were just like, “Let’s have fun with this.” And there was no like obsessive competition with like, “I don’t like the storyline.” Or, “I like this.” It was just sort of like, “What do you want to do? Okay, that sounds fun.” And we both ran with it. And we ended up developing this city on Lake Michigan and this little town and these little side characters. Jeff: Let’s talk about the mystery side of it. Who is dead? Deanna: Oh, yes, the mystery side of it. That’s right. So I’ll talk and then I’ll let Hank talk because I’ve been blabbering too long. So we decided we wanted it to be, like, film noir idea. And then it became like a legitimate murder mystery where there is a dead body and it’s gruesome and it’s creepy and it’s sad. And there’s like some crazy shit happening. And there’s like cops that need to come in. And there’s like a real mystery. And there’s actually a couple side mysteries that are happening over the book arc of the next two novels, novel two of which we will be submitting in the morning. We would have submitted it today but I’m being a typo psycho. I am. I’m a typo psycho. Hank: She’s finding a lot of good stuff, though. I like the changes. So, yeah. So the murder actually got more gruesome than I was anticipating. We were like, “Let’s go.” “Wait, do we want to go?” “Yeah, let’s do it. Let’s do it.” So it’s…do we want to say who it is? I mean, it happens early on. So I don’t think it’s a spoiler, right? Deanna: Oh, I don’t know. Why don’t we just talk about how creepy the murder is. Hank: Okay, we’ll just leave it just like that. Deanna: Not who is murdered. Hank: Someone’s murdered and maybe their hands are missing. Deanna: Or chopped off. Jeff: Oh, wow. Hank: So, yeah, that’s kind of… Jeff: That’s more gruesome than I expect in a rom-com. Hank: I know. Jeff: I’ll say that. Deanna: Oh, wait ’till you hear about the serial killer. Wait, that was a spoiler. I didn’t say it. Hank: But in the first book… Jeff: Is that a spoiler that we’re leaving in or a spoiler that we’re taking out? Deanna: We’re leaving it in but we’re not gonna respond about it. Jeff: Fair enough. Hank: That’s right. Jeff: A little breaking news there for the podcast that we will not do follow-up questions on. You were saying, Hank, on this murder. Hank: So yeah, so it was gruesome. And then there’s the discovery. But Michael is kind of, you know, he can’t help but be a little excited about it because it’s his first murder because he’s a small town, county coroner. And the only… Deanna: He’s not only a mortician. He’s the county coroner too. Hank: Right. So it’s up to him now to, like, investigate it. He’s never had a murder like this. He’s had a murder but they knew the victim and the attacker. So this is completely new for him. And he reads murder like mystery novels, so he’s really excited about it. So he’s, like, starting to play, like, detective. And then the sheriff is kind of, you know, like all blustering and yelling at him like, “Fleishman. Dilworth.” You know, that’s Jazz’s last name, Jazz Dilworth and he like calls everybody their last name and yells at them. And they’re always a suspect, so, “Don’t leave town.” Deanna: Everyone is a suspect until Musgrave says they’re not a suspect. Hank: “Don’t leave town.” Yeah. Sheriff Musgrave. Jeff: So if I understood correctly, you kind of just created this on the fly. Hank: Yep. Deanna: Totally. Jeff: For both the romance and the mystery? Deanna: Totally. Jeff: How did that play out in like the day-to-day writing? Because I can’t even like imagine having co-written something that there wasn’t more of a plan to it. Hank [softly]: I know! Deanna: How did it go? Hank: Actually it went smoother than I expected. Deanna: It was so much fun. Hank: Yeah. And it was a lot of fun because we chatted a lot on Facebook Messenger. And we’d text and we call each other now and then. We’d have conversations, phone conversations, and we’d plan out where we wanted things to go. And then one of us would say, “Okay, I’ll do this and then you can write that.” And then we just kind of took it. And then it was really fun because like you’d go through and you’d read…you know, how you like read through what you’ve written and it’s somebody else has written something new and you’re like, “Wow, this is like a whole new story.” Like you don’t know what you’re reading, you don’t know anything of what to expect. So it was really fun. Deanna: So awesome because, like, first, I gotta say, writing with Hank Edwards has been a pleasure. Because not only is he a great writer and like stupid funny, like so funny, I can’t even tell you how many times he writes something and I’m just like…laughing. But he and I are not…we’re not competitive individuals. We’re not like jumping into this, like, “Well, this is what I want. This is what I want.” It was so easy, where it was just like we just…Hank created Jazz and then Jazz has this profile that we went with. I created Michael and we had this profile we went with. He and I created an exterior mystery that happened to them. But because he created such a good profile and I just created such a strong profile, both of us knew who Michael and who Jazz were. And then it was like, “Well, Michael wouldn’t do that,” or, “Jazz wouldn’t say that.” And we didn’t like try to, like, undermine the other person. I don’t know. I just feel really blessed. I love you. I just feel blessed to be able to write a story with someone who is so easy and so fun and our sense of humor is both very similar and darkly twisted and inappropriate, like we both knew when our editor was gonna go, “Mm-mm. No.” Hank: I told her several times, I’m like, “This is gonna get cut out and you put it in and it’s gonna get cut out. I’m telling you right now.” And she’s like, “I want to leave it in.” I’m like, “Okay, but it’s gonna get cut.” And it did. Deanna: And I’m like, “They’re not gonna let us use the C-word.” And he’s like, “Maybe they will.” No, they didn’t. But it was so much…I don’t know. It was just one of those things that were really easy because Hank is so fun to work with. It was just easy. I mean, not that writing and editing is easy. But even as we went through the process, there would be scenes…we each knew where the scene was going to go. We knew what scene was going to happen next. And if it was…because our work…he’s very typical 9:00 to 5:00 work schedule, Monday through Friday, and I am Wednesday through Saturday, noon to 8:00, those four days. So like he would do all the stuff Wednesday through Saturday and then I’d open it up on Sunday, and then I’d do all the stuff Sunday to Tuesday. And then it wasn’t like we were fixing or changing each other’s work. It was like, “Oh, that’s a great scene.” And then I would add to it. And then he would take my scene and add to it. And it was just like layering and layering cool stuff with what was already funny. So it was like I knew what I was writing on Tuesday. I wrote this whole scene. And then Hank would write the next scene. And when I would get a chance to read on Thursday, he was like, “Oh, what am I going to read? I know what’s gonna happen but how is it gonna happen?” And he is so funny. So funny. And, I mean, it was just so great writing together. Jeff: So, Hank, for you, what’s kind of your side of that story as you’re like going through and doing your part on the book on your days? Hank: So it was a lot of fun. Like Deanna said, because I’ve been writing during my lunch hours at work, so like Monday through Friday I’d have like an hour and I usually go and I hide somewhere at the building and I’ll, like, be able to focus and write. And it was really fun to go through Google Docs and be able to accept all those changes because we always do the suggestions, right, so like the track changes so we can see what each other has done. And it’s always so much fun to see. It looks like, you know, like Deanna said, it’s like, “Oh,” it’s like a little present. You know, like, “There’s something new.” And I go through. But then seeing how she did the layering, I was talking to my husband, Fred, and I was like, you know, it’s like I’m picking up such good ideas about how to layer emotion in. Deanna is awesome at doing that and like pulling out the emotions in a scene and like digging in deeper where it needs to be. You know, that’s something that I’ve always kind of like, you know, I’m always like, “Write the action. Write the action. Write the action.” Deanna: But that’s what I love about his writing because he will write action that conveys emotion, whereas I would have written a long, drawn-out emotional monologue. And somehow the two just worked so great. I think. Hank: We are a good blend together like that. So, yeah, it’s really funny and she’s funny and really darkly funny. So it’s been a lot of fun because there’s some stuff where I like write something dark and funny and then, you know, you get the comment. It’s always fun to get that comment like, “LOL. Oh, my God.” And so then like all of a sudden like further down the page, she’s added somebody I’m like, “Oh, my God, you did not just write that.” So it’s really funny. Deanna: We’re so wrong. We’re so wrong, we’re so right, Hank. Hank: Yes. Jeff: Well, I really like the organic method it sounds like you guys had. Because like my brain can’t even begin to process trying to co-write without a plan. But I’ve heard other people do that and it works out great. What, as you got the draft done, what was the revision and also, I guess, making the book seem like it had one voice? What was that like? So was it like two different people at work? Deanna: Can I respond to this? Hank: Of course. Deanna: Okay, so, Hank would send me…well, it was in Google Docs. So we would get scenes together. So I feel like the way it went before anyone else read anything or we got any feedback from editors, from beta readers, or whatever, it was like we had our strong characters decided who they were and what they were and what the mystery was. And he would write a scene and then I would get it and I’m like, “Oh, it’s a good scene. I love where it’s going. Maybe…” Okay, so like I’m not going to give a spoiler, but there’s a scene at the end of Book 1 where the murderer is caught and our two heroes are like in this epic battle fighting them, like the murderer, right? Okay. So Hank writes that scene and I’m like, “Ah,” and then I go in and I add some fighting, some struggling, and maybe a little dialogue. Hank comes back in, he adds a little more dialogue. He remembers that the gun is on the other side of the room. Whatever the detail is, we both keep adding layers. And I think it comes back to the point that we’re both so invested in our characters and we weren’t, like, competing to try to be the better person. And I think that’s a lot of it. I mean, I think you can’t co-write a book together if you’re competitive or need center of attention. Hank and I just had so much fun. It would be like, “Oh, yeah. Add that, add that.” And he’s just like “Oh, my God. We’re great. That’s great. You shot him. Oh, I didn’t expect to shoot him. Let’s do that.” Whatever it was and we kept adding these layers and it became so much fun. But in the end, when we would get a scene and it was completed, we would…each of us would go back and read through the whole manuscript and be like, “Oh, we missed that detail.” And Hank would send that to me. And I’d be like, “Oh, yeah, that’s right. I forgot about that.” And he would add it. Or I would like, even today, we’re actually like one day off submitting Book 2. We were going to submit it today but I am like typo crazy. So I sent the manuscript to my Kindle so I could find any misspellings and typos. And I was like, “Oh, my God. We have a scene where Michael and Jazz are sitting in Michael’s living room with the TV. And in Book 1, he only has a TV in his bedroom. What are we going to do?” And Hank is like, “That’s cool. Good for catching that.” And I feel like that’s kind of how we’ve been like we’ll catch something and go. “Oh, I’m glad you caught that.” Hank: Yeah. But to your point, Jeff, you said like about planning and writing off the cuff, so the first book, I think, Deanna, you can tell me if I’m wrong. But the first book was really, I mean, it wasn’t easy because writing is hard but it was easier. Book 2, it was more of a struggle I think with writing it. Deanna: Book 2 was more of a struggle. Hank: And we had a lot going on. So we have like an overarching mystery, we have another, like, contained mystery. Deanna: Yes. Hank: So we’ve talked about it and we’re like Book 3, we really need to plan it out more. We’re gonna… Like once we let this book to get out a little bit, we’re going to like start planning Book 3 and then really like… Deanna: We need a serious luncheon with some planning. Hank: Yeah, so, absolutely. Deanna: Book 1 was very organic and natural. And Book 2, I mean, you’ll probably agree, Hank, I think we fell in love with our side characters so much we got distracted with all these sides stories. Even our editor was like, “Why are you talking about that and that?” We’re like… Hank: “Because we like them.” Deanna: So we had to cut a lot of scenes and really focus back on the romance, on book 2. Jeff: DVD extras, deleted scenes. Hank: DVD extras, exactly. Jeff: But let’s talk about those side characters a little bit because there’s a whole paragraph of the blurb for Book 1 that details the side characters. Michael’s sassy assistant, Kitty, the grumpy Sheriff Musgrave, Russell’s creepy PR rep, Norbert, Michael’s grandfather who likes his Manhattans strong and his women saucy. And of course, who we’ve already met, Mr. Pickles Furryton the Third. Hank: Yes. Mm-hmm. Jeff: So did you guys split those up in the same way that you took Jazz, Hank, and Deanna took Michael? Or did these get created on the fly as you needed them? Deanna: They were on the fly. Hank: Yeah. Deanna: We just like… Hank: We just do, kind of. Yeah. Deanna: I think I came up with Mr. Pickles Furryton the Third and Hank created Sheriff Musgrave. Because I think when we were talking, Sheriff Musgrave was actually like an old man and Hank made him this whole, like, Ron Perlman kind of character. Hank: Yes. Very Ron Perlman. Deanna: He has a lot of attitude. And Kitty, I don’t know where she came from. Hank: You created Kitty. Deanna: Did I? Okay, because I imagine her. Do you watch “Blue Blood” with Tom Selleck? Jeff: I have not. Deanna: Oh, anyways. His secretary is this voluptuous like blonde chick and I pictured her. And I don’t know who created Grandpa. Hank: I think we both did. Deanna: You had Steve. Hank: Oh, yeah, the handyman. Deanna: We both made Ezra. Hank: The apprentice. Deanna: I don’t know anything about them. That’s not a spoiler at all. Jeff: That’s very impressive to just kind of create on the fly like that. Two people pantsing would make my head explode, but. Hank: It was insane. I don’t know how we managed to do it but… Jeff: I think you had fun with it all the more. Hank: …we had really good feedback from the editor. Deanna: We did have so much fun, Jeff. Hank: Yeah. Deanna: I don’t know how lucky I am. Like a year ago, I sent him a drunk text message that we should write a book together. And we have had the best year. Jeff: Had it even crossed your minds before the drunk text to do this in some, like, other random moment? Deanna: No. Hank: Never ever really even talked about it? I mean, we see each other GRL. She comes up for Ferndale Pride because she lives about an hour and a half away from me. Deanna: I’m northwest Ohio, he’s southwest Michigan, so we’ve done some pride festivals together. But in all freaking honesty, the whiskey made me do it, Jeff. I literally texted him, “Hey, full disclosure, I’ve been drinking. We should write a book together.” I do believe, Hank, that was the quote. Hank: Pretty much. Yeah. Deanna: And he was like, “We would write the fuck out of a rom-com.” And I was like, “We would.” And then we ran with it. And then that’s that. It was just, like, all fun. Jeff: And it’s interesting that you’re evolving in Book 2 and probably in Book 3 too. You had the fun moment. Now you kind of have to make everything keep tying together in the next two books. Hank: Yes. It’s all got to come together now for the third book. Yeah. Jeff: Because that’s like, yeah, when you have all that tied together stuff, because I’ve been reading a lot of romantic suspense lately where it’s like something that arcs across a trilogy or whatever, and it’s like…it’s exciting. Hank: Right. Deanna: Yeah. Book 2 is tentatively called “Murder Most Deserving,” and it was a lot harder to write than the first book. Hank: Yeah. Jeff: As fun though, I hope? Hank: Oh, yeah. Deanna: Oh yeah, just as fun, but there were moments I feel like we both checked out. And we’ve had this conversation. We know that we checked out because we had decided on a storyline for Michael and Jazz. And then we were like, “This doesn’t feel right.” Because it’s not your book, it also belongs to someone else, you don’t just say, “Oh, that storyline can’t happen,” because two of you decided together so you keep going with it. And then there’s moments where we had to talk and we’re like…where I was like, “I don’t like this.” And he’s like, “Yeah, I don’t like it either.” And I thought I said I didn’t like it. I’m like, “Maybe you said you didn’t like it. But I didn’t really expect you didn’t like it and I don’t know why we didn’t like it. And I don’t even know why we’re doing it.” And it was like we had…I mean, there was like, there was a couple of moments like that on the story. And there was also like we said in the beginning, we love our side characters too much. And we gave them a lot of screen time they did not deserve, even though we love them. So we had to distract and take a lot of stuff out. Not that we wanted to take it out but it was like why is this thing here? No one cares… Hank: Right. Deanna: …except us. So it was a little different. Like we created this wonderful world and in Book 2 we kind of just went crazy. We, like, went crazy with the Cheez Whiz. It’s like, “I love Sheriff Musgrave. I love Missy.” And we just wrote all these scenes and we’re like… And part of that I will say is my fault because I sent a lot of scenes to Hank before we even plotted the book. I was like, “I wrote this funny scene I’m going to send you.” And he’s like, “I love it.” And we wrote it. Hank: And I was like opening emails from Oprah. “And you get a storyline, and you get a storyline.” Deanna: Totally. Jeff: Maybe these could become short stories for these characters if you can’t get them into the book. Hank: That’s great. Jeff: So take a moment to brag on each other. And outside of working on this book, what do you like about each other’s work? Hank: I’ll go. Jeff: Hank first. Hank: All right. I love Deanna’s depth of characters. So her books, I think the first one I read of yours was “The Legend of Sleepy Hollow.” And I was like, “Oh, Ichabod. Oh, you naughty boy.” But then I can’t remember in what order then I read them but like “Easy Ryder,” I love that book. That is an awesome book. And I love the time period and I love the characters and I just love all of it and the discovery. That’s a road trip, another…you love the road trip books. Deanna: Apparently. Hank: Apparently. And then “Wrecked” is awesome. It’s really good. But she has a way of just like, you know, pulling up those emotions and really getting into the romance of it and doing an awesome job with it and having the characters. And then the conflict is organic, it’s not, like, fabricated. And it all blends together. She’s got a really good sense of story. Jeff: Nice. Deanna: That’s so sweet. I feel like, Hank, your dialogue sells your story. You could write a whole book on just dialogue with nothing else and people would buy it and laugh. You’re hilarious and your dialogue is great. And I feel like our styles mesh well because I do write more… I like to write a lot of the internal monologue and the emotion. But I’ll tell you an example, and this is a semi-spoiler in Book 2. But this is what I love about Hank’s writing. Okay. I’m not gonna tell too much of the story but there is a scene where something really shocking happens for our character, Jazz, the hairdresser. And the scene is in Jazz’s point of view. You’ll know what I’m talking about in a second. So the scene is in Jazz’s point of view and then Michael, our mortician, bursts through the door. And everyone is like, “How did you get here?” And he’s like, “I ran here.” And that sounds like simplistic but the emotional intensity of why Michael would run five blocks to the salon where Jazz works on a mere phone call just conveys so much intensity with three words, “I ran here.” And that’s what I love about Hank’s writing. I mean, I write the long emotional, internal monologue. And Hank writes that same intense emotional monologue in three words, “I ran here.” And I think, I mean, I’ve always…that’s what I love about his books. But I feel like those two things complement each other in our writing. Like I like to write the long drawn out emotional and he writes that same scene in three words, “I ran here.” And that’s why I love writing with him. Jeff: Cool. They’re hearting each other for those people not watching the video right now. Jeff: So you mentioned three towns…three towns, no, three books in the “Lacetown” series are planned. Do you foresee life in the universe beyond those three since you’re having such a good time? Deanna: Yeah. Hank: We talked about it. We’ve discussed it, yeah. We’ve got the trilogy planned and then we’ll see what happens with it. Deanna: We have at least two in our head. Jeff: That’s cool. Deanna: Beyond the three. Jeff: Now what about separately? What’s coming up next outside of the “Lacetown” series for you both? Hank: You have something coming up soon, Deanna. Deanna: Well, I have one thing coming up for sure and hopefully two. I also write young adult fiction just like Hank does under his…is it RG or RD? Hank: R.G. Deanna: R.G. Thomas. Hank has a young adult series under RG Thomas. And I have a young adult series, K.D. Worth, which is very different from my Deanna Wadsworth writing. It’s young adults/new adults because my characters are 19 and there are some, I don’t know, level-three sexy moments. So you can’t really…like you know people get funny about young adult that has sexy stuff in it. There’s a strong spiritual element with the main character who was trying to kill himself because of his family sending him to like one of those creepy pray-the-gay away camps. And the moment he kills himself he’s saved by a young teenage Grim Reaper, who decides that he wants to give him a second chance in life. And there’s a sassy foul-mouthed, because no one understands why Deanna would write a character like that, a sassy foul-mouthed angel who helps these boys on their journey. And that story is called “The Grim Life.” And Book 3, the final series, the final saga in that trilogy “The Lost Souls” is coming out this fall. And I’m really, really excited about that. I mean, a lot of M/M or gay romance, whatever you want to call it, authors know that young adult isn’t where the sales and money are at, sadly, but this is like a really intense…I don’t want to say pet project because that trivializes it, but it’s really a series that means more to me than almost anything I’ve ever written. Hank: Yeah. You’ve been working on these for what? Like two years now? Deanna: Yeah, four. It took me two years to write Book 3 because I just emotionally invested in it. There’s a lot of death and questioning of what goes on on the other side and where God sees your soul and all these like intensely hard questions. And to make things harder on myself, I put a school shooting in Book 3 because why not? Hank: No, why? Deanna: It’s so emotionally intense that you can’t write it. So that comes out this fall. But I’m hoping my second book in my Pride of the Caribbean Cruise series comes out which is a merman. Hank: Nice. Deanna: A merman… Hank: On a cruise. Deanna: …on a Caribbean cruise. It’s like I like to be intense or I like to be funny. I can’t be… Hank: There’s no in between, right. Jeff: Either end of the spectrum. Hank: That’s right. Deanna: That’s what I do. So that’s what’s coming out for me. Jeff: Cool. Hank: I will be working on the final book of the “Critter Catcher” series, final book for now. It’s tentatively titled “Dread of Night.” So and I’ve got about six chapters written. I’m working on a big pivotal scene also, so I need to just like…now that Book 2 has been sent off for consideration I can like, you know, kind of focus on that because I’m really bad at like jumping between projects too. Like my mind gets stuck in the other characters because while I’m working on this other I’m like, “But wait, what about…?” So, yeah. Jeff: Cool. All right. What is the… Hank: There’s other stuff to work on too but that’s the big thing coming up. Deanna: I love the “Critter Catcher” books. They’re so good. I manipulated Hank into giving me the last book when I was sick last summer. I was like, “Shouldn’t you send it to me? I know that you’re going to submit it for publishing in a month, but I’m really sick.” Hank: “I need to beta it. I’m sick.” Yeah. Deanna: Yes. I did do that. Jeff: And it worked too, right? Deanna: It worked. Hank: I did. I sent it. I was good. Deanna: And it was worth it. Jeff: So what’s the best way for readers to keep up with you guys online? Let’s start with Hank. Hank: I have a website. It’s hankedwardsbooks.com. You can also find my young adult fiction at townofsuperstition.com. And I do have those books listed on my Hank Edwards’ website just to make it easier. And then I’m on Facebook. I have a Facebook page. It’s facebook.com/hankedwardsbooks. And I really don’t use…Twitter confuses me. I get really…it’s just this noise. It’s like people yelling at each other. And so I have a Twitter account but I’m not out there much. But I am on Instagram. I usually post pictures of my cats. You know, and that’s @hankedwardsbooks as well. Jeff: Cool. And Deanna? Deanna: I’m on Facebook, deannawadsworthauthor. And Instagram, I go by @deannawads. I don’t know why I didn’t finish my last name but I don’t know. Everybody called my grandpa Wadsy. So I should have done Deanna Wadsy but I screwed that up. But I’m on those two. A little on Twitter and a little on Pinterest, all under Deanna Wadsworth. Mostly my most activity is on Instagram or my website, deannawadsworth.com. And that’s it. And you should totally read Hank’s R.G. Thomas books. It’s like Harry Potter but gay with, like, dragons. And little garden gnomes. I fricking love those books. You better write another one after we write our book. After we write our book. You’ve got to. Hank: Got it. Jeff: You’ve got your marching orders now, Hank. Hank: I do. I get them a lot. Deanna: He doesn’t have a wife, but… Hank: It’s all right. Deanna: …I’ll jump in that role. Hank: She’s my work wife. Jeff: All right. Well, this has been a blast. We will definitely link up to everything in the show notes that we’ve talked about here. And we wish you the best of success on the “Lacetown Murder Mysteries.” Hank: Thanks very much, Jeff. It’s been fun. Deanna: Thank you, Jeff.
The guys open the show with a discussion of the Netflix original Unicorn Store. Jeff reviews Bad to the Bone by Nicki Bennett. Will reviews LaQuette’s Under His Protection. Jeff & Will interview LaQuette about Under His Protection. They find out about the story’s inspiration and how it ties into LaQuette’s other series. LaQuette also shares details on her upcoming Harlem Heat series, what got her started writing romance and details about what she does as the president for New York City’s Romance Writers of America chapter. Complete shownotes for episode 184 are at BigGayFictionPodcast.com. Book Reviews from this week: Bad to the Bone by Nicki Bennett. Reviewed by Jeff Bad to the Bone turned out to be one of those perfect Dreamspun Desires for me. I’m a sucker for second chance romance combined with friends to lovers and this one adds in a bit from the redeemed bad boy trope as well. It all combined to give me exactly the read that I needed. The story kicks off on the eve of a high school reunion taking place in a small Oklahoma town. Alex Morrison has been back in town for several years, taking over his family’s hardware store when his parents needed him to. One afternoon, while working with his sister at the store, they witness a motorcyclist pulled over and it’s soon revealed that the man is Alex’s high school bestie, Ricky Lee Jennings. Alex hasn’t heard from Ricky Lee since he was expelled and sent away to reform school. Alex regretted he didn’t defend Ricky Lee and prevent the expulsion, but he was scared he’d lose his football scholarship if he did. Sparks fly at the reunion when Ricky Lee shows up without a ticket and Alex gets him in as his guest. What unfolds over the coming weeks is the rekindling of far more than a friendship. Nicki does so much with this rather simple set up. Both characters complexity made me love this book so much. Alex is someone I wanted to wrap up in a comforting hug. He does so much for the community that he lives in between serving on the library board, working for Habitat for Humanity, helping out with the high school reunion committee, and anything else he can do to help his fellow citizens. Yet, all he can see in himself is failure from a lost college football career because of an injury, a failed marriage, and even coming back to manage his family business is something he considers a fail because he gave up his dreams of being an environmental lobbyist. Of course, what he’s done is made the decisions that are right in the moment but he can’t see that. Ricky Lee, on the other hand, subverts every stereotype the town has for him. It’s awesome to watch as people who believe they know exactly who he is after ten years begin to see who he has become. He’s far from the young man who was abused by his alcoholic father and just wanted to survive high school. As both relive their high school times and share what they are doing now, Ricky Lee and Alex are drawn back together. Alex, however, is sure this can’t be more than a fling. He’s scared of revealing himself as bisexual to the town and there’s no way Ricky Lee will move back to Oklahoma since he’s got a life in Portland. The wooing that Ricky Lee does with Alex is outstanding. I love a good date and their weekend trip to Oklahoma City is all that. They stay at a boutique hotel, go to art museums and the botanical gardens and eat delicious food. The sizzling sex made the date all the hotter. It showed Alex in vivid detail what life could be like in if he decides to make a go of it with Ricky Lee. The other depth that Nikki weaves into this book is the town Alex lives in. In particular, I liked the local pastor, who is nothing like what you might expect a southern pastor to be. He turns out to be one of Alex’s biggest supporters in being true to himself. We also see Alex’s work with the library, which is a central subplot for the story since Alex and Ricky Lee’s high school nemesis, Odell, who wants to expand his car dealership by buying the land the library sits on. The goings-on with Odell took some wonderful turns that I couldn’t have predicted and I might’ve cheered just a little when everything was revealed and [spoiler alert] Odell gets his. It’s a great ending for a high school bully. There’s a tremendous cast of supporting characters too. Alex’s sister Alana and his best friend, local police officer Samantha, a.k.a. Sam, both nudge Alex in the right direction. Ricky Lee comes to town with Crae, who he introduces as his friend and assistant although many initially think they are in a relationship. I actually wish Crae had had more screen time in the book as they were a fascinating character. Crae and Sam develop a friendship that might be more and I’d love to see a book that explores that. There are also some townsfolk who have interesting reveals to Alex along the way that were incredibly sweet. And if audio is your thing, certainly pick this one up. Colin Darcy is a new-to-me-narrator and boy did he make me swoon with his voice for Ricky Lee–deep, rumbly sexiness. If you’re looking for a great category romance with some very tropey goodness, I highly recommend Nicki Bennett’s Bad to the Bone. Under His Protection by LaQuette. Reviewed by Will. This book literally starts with a bang when one of our main characters, assistant DA Camden, is nearly blown up by a car bomb. In order to keep him safe, he’s put in protective police custody. Unfortunately, the man watching over him is the memorable one night stand he walked away from five years ago, a guy named Elisha. Sequestered away in Elisha’s Westchester house, our two heroes must come to grips with the attraction that still, after all this time, is still there. As things start to become more romantic, the situation becomes even more complicated when Elisha’s family shows up for a weekend visit. They assume that the two of them are a couple and Cam and Elijah play along since it’s too dangerous to explain why Cam is hiding out at Elijah’s house. Over the course of the weekend Cam can’t help but fall for Elisha and his wonderfully crazy family. You might think things get a little too close for comfort with are two heroes and the family all in one house. Elisha actually has a very small apartment in his attached garage. They escape there every once in a while, for some truly superduper scorching sex. The chemistry between these characters is very real and very palatable. As the weekend winds down, there’s an unfortunate kidnapping attempt by this crazy religious group and Cam sacrifices himself in order to save Elisha’s mom. Camden ends up in hospital and, unfortunately, his father arrives on the scene. Camden’s life has essentially been controlled by his father, who’s had his son’s life planned out from my birth to death. It’s essentially how Cam has lived his entire life. The expectations of his father are actually part of the reason why he walked away from Elisha five years ago. Having a sexy one night fling and living a life with an average guy like Elisha just wasn’t in the plan. After experiencing the possibility of loving a man like Elisha and realizing the wonderful possibilities of a fun and fulfilling family life, he tries to stand up to his father. Cam’s father puts a stop to everything, setting up some genuinely insurmountable roadblocks to our hero’s happiness. But Cam and Elisha are not only charismatic and sexy, but also really super smart. With the help of Elisha’s police chief friend, Cam concocts a way to outwit his father and get out from under his thumb, so he Elisha can live happily ever after. I don’t know if I can adequately find the correct words, or enough adjectives to tell you how much I loved Cam and Elisha’s story. It’s just really damn good. One of my favorites of 2019 so far! I hope it’s obvious that I really enjoyed Under His Protection by LaQuette and I highly recommend that everyone give it a read. Interview Transcript - LaQuetteWill: We are so pleased to welcome LaQuette to the show. Welcome. LaQuette: Thank you. Will: So I just spent several minutes praising and telling the entire world how much I loved "Under His Protection." Now, you've been writing for a while now, and I freely admit this is the very first book of yours that I have read, and I went absolutely bonkers for it. I love it to pieces. LaQuette: Oh, thank you. Will: Can you give us sort of an idea of where the concept for "Under His Protection" came from? LaQuette: Well, I was encouraged by Kate McMurray to submit a "Dreamspun Desires" concept. And I kind of read the submission guideline, and I really didn't think that the category section was for me, because I'm long-winded in my writing and there's this, you know, 50,000-word count, and I didn't know that I could meet that and make the story make sense. But I just felt like, you know, there's a lot of angst in my writing and a lot of heavy topics sometimes. And I didn't... You know, category can be light and, you know, it doesn't have so much angst to it, so I wasn't sure if it was actually the right fit for me. But she encouraged me to do it anyway. So I thought, "Well, if I'm gonna do it, it has to be, like, LaQuette style. It can't be, you know, the traditional map of a category. I've gotta throw, you know, everything but the kitchen sink in it." And I had this sort of, like, this Prince and Pauper sort of situation in my head, but in Brooklyn. And it worked out really well in my head anyway. I really enjoy the idea of Camden coming from this really, really posh existence, and then clashing with Elijah and his very loud and boisterous family. And, I think, putting those two people together and those two, you know, with their backgrounds and differences in their backgrounds and the differences in their, you know, perspectives in life, it really...it just made for a richer experience for me, as a writer. Will: I utterly fell in love with Camden and Elijah. I think they're two incredibly...they are exceptional heroes, and they're part of what makes this book really sing. But as I mentioned in my review just a few minutes ago, part of what, I think, what makes the story compelling and even more enjoyable is the sort of supporting cast that helps them along in their journey towards saying, "I love you." Elijah's family is amazing, every single one of them. But I was particularly struck by one of Elijah's co-workers, the police chief, who is his best friend, along with, you know, being a colleague. And what I was struck by is that at the beginning of the book, the character seemed, you know, pretty, you know, straightforward, it was a secondary character, and she was there to kind of like, you know, get the story moving along. But as we read further and get to know Camden and Elijah more and more, she becomes a much more integral part of the story. And in fact, she's pretty vital to the solution that Cam comes up towards the end. And I was really surprised to read in an interviewer just, I think, this last week it appeared online. I learned that one of the reasons that this secondary character is so well-drawn is because she's actually already had her own book. LaQuette: She's had three books, actually. Will: Can you tell us real quickly, for our listeners, can you tell us about the origin of this particular character and why you thought she would be such a good fit for Camden and Elijah's story? LaQuette: Captain Heart Searlington is a character from my "Queens of Kings" series, which is all heroine-centered. And she is this...you know, her name is Heart for a reason, because she has a huge heart, even though she really carries it under this gruff exterior. She's a badass, she's all about getting work done. And if you ever get the chance to read her books, you know, she's really out there hands-on in the street. And I felt like Elijah would need someone like that, professionally and personally, to kind of...to get him to the place where he could admit his flaws. Someone that's not... You know, he's a very...he's a large man, he's aggressive, you know, he carries a gun, so he could be a little bit intimidating for the average person. But for her, she's not afraid to tell him like it is to his face. And, you know, when you have that kind of a personality where people might not tell your truth because they find you imposing, having someone who will speak the truth to you, regardless of whatever the situation is, can be vital to you, you know, making the right choices in life. And I felt like having her there would give him that balance, because he needed some really cold truths told to him, for him to get his head together and do what he needed to do. Jeff: Was it always your intention to have the character crossover or did that just kind of manifest itself? LaQuette: Well, the precinct that they work at is sort of anytime I have a police situation, those cops show up in a book somewhere. So one, because, you know, the world is already created, so it's kind of easy for me to draw from that precinct, but it's also because my readers absolutely adore this woman. And so they're always asking for her, and this was an opportunity for her to show up and say, "Hi." And not in a way that overshadows, you know, the main story, which is Camden and Elijah, but just enough to make readers go, "Oh, my God. She's here." Jeff: It's always good to get those universe crossovers and little Easter eggs like that, for sure. LaQuette: It's true. It's very true. Will: Yeah. Now, "Under His Protection" is not your first M/M romance. LaQuette: No, it is not. Will: There's also "Love's Changes," which I believe came out in 2016? LaQuette: Yes. Will: And I wanted to ask you, what drew you to writing in this specific subgenre? I mean, along with all of your other books that are more traditional male/female romances? LaQuette: Well, one, I wholeheartedly believe that everyone deserves a happy ending. And when I wrote the "Queens of King" series, I always knew that Heart's cousin, because the characters, the protagonists in "Love's Changes" are Bryan, who is one of Heart's lieutenants, you met him, actually, in "Under His Protection," and her cousin, Justice. And so they get to have their own story. You get to see them a little bit in the "Queens of King" series, but they're more background. We know that they were having a hard time and they were broken up for some reason, but we don't know why. So they get, you know, readers... Which really surprised me because I didn't really believe that there was a lot of crossover between male-female readers and male-male readers. But people really asked me for a story for those two. Like, "When are we gonna get Justice and Bryan's story? We wanna know what happens to them and how they get back together." And so I that story was actually born out of the fact that readers requested it, and so I gave it to them. Jeff: That's very cool. You know, it's always nice to see as the M/F readers catch the male-male pairing to then want to know more. LaQuette: Yes, it was really a trip for me. I did not believe that they would want it at all. But it was very touching to write their story. I was very happy with how the story turned out. I was very happy with the fact that they get their happily ever after. And it's not...it's connected to the "Queens of Kings" series, but it's not really part of it. So the story kind of takes place outside of everything that's going on in that particular story. Jeff: Do you envision more, I guess, "Dreamspun Desires" books that happened in the universe you've created with everything that's going on so far? LaQuette: I really didn't, but I've been getting a lot of mail recently about this book. And, you know, people wanting to know what happens after this. They wanna see how Camden's family kind of blends with Elijah's family and how that's going to work. I'm like, "Dude, I'm not there. Like, I have so many other projects. I can't right now. But we'll come back to that maybe." Jeff: Just based on your review, I don't see how those families mesh. Will: Two different worlds. Most definitely, yeah. LaQuette: They really are. Jeff: Now, one of the things that I'm super excited about, having recently read about, is your new contract with Dreamspinner for "Harlem Heat." LaQuette: Yes, "Harlem Heat," so when stuff makes me mad, it also makes me really productive. So I was really kind of getting tired of hearing the "not historically accurate moniker" criticism given to African-American romance, especially historical African-American romance. And it just bothered me because it's not that those happily-ever-afters weren't possible. It's just people aren't really aware of the completed history. So a lot of thing...you know, a lot of people who think they know about African-American history, the only thing they know is slavery and Jim Crow, and that's it. And, you know, black people have been downtrodden since we were brought to this country. But that's not exactly the truth because even in all of the horror, there were still moments of triumph. And we didn't just, you know, survive, we thrived. We're still here, the proof that we're still here, you know, the proof that we had happiness at some point is that we're still here. So I decided I wanted to write about a time that was where to be black and to be gay wasn't something that you had to hide from the world. It wasn't something you had to...you had your own pocket of community. There was a celebration of it. And I wanted to speak to that. I wanted people to know that these two intersections of life existed with happy endings. Jeff: And this series, in particular, is gonna go to such an interesting time period in the U.S. when all of the Harlem Renaissance was happening. LaQuette: Yeah, so it's based on three actual people who lived during the Harlem Renaissance. So it's based on Bumpy Johnson, who was the godfather of Harlem for 30 years. It's based on Langston Hughes, who was a great contributor to the Harlem Renaissance as a poet and writer. And it's also based on Cab Calloway, who was sort of one of the most notable faces in jazz and jazz music and jazz performance at the Cotton Club. So we're gonna see... we won't be using their names, but those characters will be based off of those actual people. Will: Yeah, because it was...I think it was like mere moments after I finished reading "Under His Protection." I read about this Harlem Renaissance series that you were doing, and I like lost my mind. I was like, totally doing a happy dance. This is going to be so amazing. I know this is still far in the future. But when do you think we can expect this series? LaQuette: I don't know. And that's the God's honest truth. I'm actually currently writing, finishing up the series for Sourcebooks. And so "Harlem Heat" doesn't...I don't think I'm projected to start it until like the end of the year. So I don't know exactly when it's going to be ready. But I mean, you know, ready for the world anyway. But I think I can talk to someone about getting you a beta read...a copy for beta reading if you'd like. Jeff: Please do. Yes. Will: That would be amazing. Jeff: I imagine the research for that got to be a lot of fun to look at that period in history and figure out what parts you wanna take and use. LaQuette: It is. I mean, I was very fortunate when I was in college. When I did my undergrad in creative writing. I was very fortunate to have a professor who thought outside of the box, and he taught a class on Harlem Renaissance. That was amazing. I mean, it was so rich and filled with culture. And you know, not just the usual things that we see in mainstream history but, you know, getting really down to the nitty-gritty of it. And you know, showing you to...I'm sure that when you when you guys, as gay men, look at the history of the LGBT community, and you get to see it unfold, there's such a moment of connection there. And it's the same thing for black people when we're getting to experience our history because we don't often get to see it through mainstream lens. And so to see it and to see the information dispensed in a way that's positive and celebratory and uplifting, it changes your whole perception of yourself, of who you are and where you came from. And so I'm delighted to be able to dig back into that. I have Piper Huguley, who is a history professor at Spelman College. I believe it's Spelman. And she's also a romance writer, and she's brilliant. So she helps me with a great deal with telling me what books I need to read for this period, and where I need to look for information. But it's so much fun. It really is so much fun. Jeff: That's amazing. Let's talk origin story for a minute. How did you get started writing romance? What led you down this path? LaQuette: I didn't see me on the page. I started reading romance when I was about 16 years old. Way too young to be reading some of the stuff I was reading, but you know, hey. And by the time I was about 18, I probably went through every "Harlequin Presents" that my local library had. And every romance novel I read, it was never about a girl that looked like me, never about places where I lived. So it kind of pulled me out of the romance reading for a while because it was nice to read about those stories, but there was just something missing for me after a while. And I probably, at the time, didn't recognize that I was internalizing that these stories were basically saying, "Romance isn't for you. You don't look like this. You don't fit this mold, so romance isn't for you." And I kind of just pulled away from it. And I think after I finished my undergrad, I just wanted to relax and have some fun and I kind of got back into it. And at the time, I discovered black romance was a thing. And I discovered people like Rochelle Alers, and Brenda Jackson, and Zane. And I'm like, "Wow." Like, it became exciting again. It was refreshing. It was new and yet still very familiar because I could see myself in all of the antics that were going in these stories. I could see myself in those characters. And so I decided I wanted to do that. I wanted to create those spaces, create more stories like that so people could have those connections in reality, you know, reactions when they opened up a book and saw themselves. Jeff: Now that you are writing, what do you think the trademarks of your books are? LaQuette: I do sex and snark really well. Like, I do sarcasm really well because that's my language. It really is my language, and sex, yeah, that's so if you're gonna pick up a LaQuette book, you're going to get lots of sex and lots of sarcasm. Jeff: Did she meet those two in your book? Will: Oh, yeah. Just before we started this interview, we were talking about the possibilities of an audiobook for "Under His Protection." And whatever narrator lands this job is going to, number one, have the time of their life, because Camden and Elijah are very...the banter is very smart and very witty. But also, as you say, the sex scenes are...I'm not even sure what the correct adjective is. It's smoking hot. Yeah, you're gonna need a nice cool beverage after you listen to those scenes, for sure. LaQuette: I don't know that I could listen to that. I don't know that I could. It would be so weird for me. I don't know. I mean, I know I wrote the words, but to hear them aloud, I don't know that I could do that. Will: Exactly. Yeah. Jeff: Yeah, I know, you know, many authors can't listen to their own audio books. LaQuette: Especially those parts. Like I said, I do sex. Amy Lane told me, she was like, "You write sex in such a beautiful concrete way. Like, I just wanna have all the facts when I read your books." I'm like, "Amy, that is the sweetest and weirdest thing that anyone has ever said to me, and I love you for it." Jeff: That almost should be a blurb on the book cover or something. Will: Yeah. Yeah, definitely. Jeff: Is there anything you're reading right now that you wanna shout out to people as like a book to grab? LaQuette: Oh, I'm reading a few books. So I just finished Adriana Herrera's...the third book in this "Dreamer" series, and I can't remember the title because it's not actually out yet. I beta read for her, and it is fantastic. I mean, book one is great and I love it. It was so real to me that literally, I had to drive like two to three miles from my house just to go get Dominican food, because I was so hungry after reading book one. Will: Exactly. Yes. Yeah. LaQuette: And book three does the same thing. There's lots of cultural food. And it's part of the tapestry of how these two people connect and share their backgrounds, their experiences, their worldviews. And not to mention, she's so good at writing books that are socially conscious without making you feel like you're being talked down to or preached at, and I love her for that, for being... I don't know that I could do that the way she does it. She's so talented. And I'm also reading...I'm halfway through...I stumble with her name because I know her as Blue Sapphire, but she's now writing as Royal Blue for Dreamspinner, "Kyle's Reveal." Will: Yeah, I've heard of this book, yeah. LaQuette: And I'm halfway through it. And, you know, she's fire, like, she writes hot books. So I'm really excited. I can't wait to get to the end of this book. Will: What was the name of that book again? LaQuette: "Kyle's Reveal." Will: Okay. And that's the...please remind me, is the basketball book, is that correct? LaQuette: Yes. Will: Okay, yes. LaQuette: I mean, it's kind of dark because the protagonists have like a really dark traumatic history. But it's definitely deep and I'm loving it. So I'm really, really, really interested in getting to the end to see if I could just get a minute to stop writing and finish it, I'd be great. Will: Awesome. Jeff: It's such a hard thing balancing. LaQuette: It is. Jeff: "I wanna to finish this book." Then it's like, "I don't wanna read it too fast." LaQuette: Exactly. Jeff: Finding that balance. LaQuette: It's true. Jeff: Are there tropes or genres that you wanna tackle that you just haven't yet in your own writing? LaQuette: I don't know that there are any tropes, because I kind of...I throw a lot of different tropes in my books. Like, "Under His Protection" has second chance romance, it also has proximity, it also has sort of kind of enemies to lovers the way Elijah and Camden started out in the book. And it could sort of kind of be considered like a workplace romance being that they're both involved in different sides of law enforcement. But I don't know. I mean, I've done secret baby before and I love that. That was really fun. And I've done...the only thing I haven't done is like May-December romances. So I think maybe that might be something I'd might want to try. Jeff: Cool. I would read that. I love a good May-December. Absolutely. So beyond the writing, which obviously takes up a lot of time, you also are the president of RWANYC. So the New York City chapter of Romance Writers of America. Tell folks what that entails and what actually led you to running for office. LaQuette: I didn't wanna run. I had no intention of running because I have a lot of stuff to do. And it takes time away from the things that I'm contracted to do. But one of the things that's very important in romance that's happening right now is the fact that romance can be a very whitewashed world, meaning the protagonists that we see, the authors that get the most opportunities are white authors and white characters. And so if you're not white... and straight characters. If you're not writing that, it's difficult to get into the door, it's difficult to find the same resources, the same backing. It's almost impossible to get contracts. And so I ran for president of RWANYC because I wanted, in some way, to help change that landscape, to do some of the work necessary with publishers to try to change that. And it's a heavy task, it's a heavy burden, especially when we get, you know, over the last couple of weeks, we are still reeling from the RITA Awards, which is basically like the Grammys for romance. And every year, it's the same thing. It's a very, very white landscape, and very few authors of color are made finalist. No black woman has ever won a RITA in the 30 years that this award has been established. And people do a lot of mental acrobatics to justify why that is. So "Oh, maybe the writing is just not that good. Maybe that's why we've never had a black RITA award winner. Maybe black authors are not entering." You know, these are also questions that are ridiculous, because statistically, it's just impossible that no black woman would ever have won in 30 years. It's just impossible. And the reason it is, is because the judging pool, there's a bias there in terms of black women and black characters, not just black authors, but black characters. Because you cannot know who the author is, but you cannot...well, I don't write characters who are racially ambiguous. I'm proud of my blackness and my characters are as well. And so I don't try to hide that or trick people into reading my books, or make it so difficult for people to recognize who a person is or what their background is because I feel like that is an important thing. In real life, we don't really get to not know who people are by looking at them. So I don't do it in my books. And because of that, it's very difficult when you know, going into this, "I'm gonna submit this book, and it's not going to final," not because it's a poorly written book, not because I didn't do everything I could to make this book as good as it could be, but simply because my characters, especially my heroines are black. And that is just something that the judging pool cannot handle as of yet. So my work as president is a lot of, you know, being the champion for this cause and taking on this battle because it's not just about me succeeding, it's about any black author who was writing black characters having the ability to write and be supported by the industry. And if I can make any sort of headway in that and if I can help anyone along the way, I'll feel like I've done something positive with my life. Will: With books like yours, and with Adriana Herrera, who you mentioned not too long ago, do you think it's really just a matter of representation that can help build awareness for diversity in romance or is there something else that readers, specifically, should be doing or asking for? LaQuette: Well, specifically, yeah. I mean, readers have a lot of power. So if you're asking publishers, you know, "Why don't we have more diverse romance? Why don't we have romance where...you know, that shows basically the colors of the rainbow and all those brilliant facets of intersectionality in life, like, why don't we have that?" Because your buying dollars is what demands, what makes the demand. Because publishers will say, "We don't sell that. We don't contract black books because they don't sell." One of the things we discussed at Dreamspinner was the cover. That was an intentional choice. I was very clear with them when we sat down and talked about this project that Elijah needed to be on the cover. I would not subscribe to the ideology that a black man on the cover can't sell. And there are...I mean, we've seen in our writing community that some publishing houses have actually made this statement. I don't subscribe to that. So we talked about it. And then we talked about the fact that readership sometimes can have a bias. And sometimes they won't engage with the book if they feel like the person is the wrong color or wrong background. And I said, "I understand that, but we're still gonna work...you know, to work with me, this is how we're gonna work." And they were in agreement. I didn't have to convince them. I went in prepared to battle. And it was like, "Listen, I really need this guy to be black and I really need him to look like this." And they were like, "We agree. We agree." So we need more of that in the industry. And it starts with readers. It also starts with the gatekeepers. People reaching out and specifically looking for these things. It also, people who are gatekeepers also need to check themselves. So when you're reading a book and you're saying, "I can't connect to it. I didn't relate to it." Why aren't you relating to it? Is it that it's a poorly written book? I've gotten rejection letters that literally said, "This is a really well-written book, but I didn't relate to the character, so I'm not gonna buy it." That doesn't really make a lot of sense, right? So what was it that you didn't relate to? If you could see that it was a really well-written book, I mean, if it's that good, why not work with me in terms of editing to kind of get things right, you know, to where it would be something that you feel is that you could sell. But a lot of publishing houses out there don't have that mentality. And it's this sort of...it's insidious. It's not something, you know, you can actually like, look and see. Some people don't even notice it. They just think, "Oh, I don't read those kinds of books because I don't like them." And it's not that they don't like them, it's that they've not actually giving them the opportunity to be great. Jeff: So that is, obviously, great words for the readers. Kind of spinning it back to your RWA role, you're in such a diverse chapter there because you're in NYC. LaQuette: Yeah. Jeff: How are the authors in that particular region banding together to like help RWA move past the issues? LaQuette: Oh, well, a lot of my recent successes, because, you know, allies, colleagues like Kate McMurray and Tere Michaels, are like, "Listen, you're fabulous, and we want you to meet people who will also think you're fabulous. So come here." And that's part of the beauty of RWA, and that's why I fight so hard for diversity and inclusion within RWA, because my success, as I said, my recent success has all been attached to people pushing me in different directions to say, "This is where you need to be. This is the person you need to meet." And if you're not a part of the organization, you can't make those connections. And networking connections will get you further than anything you know, right? So when we cut off authors of color from that source, from the resources, from the networking connections, and the opportunities that are presented to people who are part of the organization, what we're doing is we're disconnecting them from publishing. And we're forcing them to be indie. And this is not an indie versus trad conversation. This is... some people cannot be anything other than indie, because trad will not give them the opportunity. They've been completely marginalized. And so that should not be. People should be able to publish however they choose to, whether they up to be an indie author or whether they decide that the trad route is for them, because, you know, different strokes for different folks. It is different, you know, depending on what your lifestyle is like. I have crazy children and I have to juggle being a mom, a writer, and everything else and try to keep sane. Being an indie author is a lot of work. It's a lot of effort on your end to make a book successful. I don't have that kind of time in my life, or that kind of energy, honestly. So being a trad author is a much better avenue for me and my situation. And if that is the only way that I can publish, but publishing will not give me the opportunities, then it's, you know, I'm losing out. And that's the purpose of RWA to sort of bridge those gaps. But I don't think we're exactly where we need to be yet. So we're still working on it. Will: Yeah, definitely. Jeff: We very much appreciate your efforts towards that, for sure. Will: Now, the Romance Writers of America National Conference is going to be in NYC this summer. LaQuette: Absolutely. Will: And I expect you're going to be there. LaQuette: Oh, yeah. I wouldn't miss it for the world. Will: Yeah, we're actually making a trip for the first time this year as well. LaQuette: Yay. Will: So hopefully we will... I know it's gonna be crazy busy. But hopefully, we're gonna get a chance to say hi in person. LaQuette: It is. Absolutely. Jeff: For sure. Now, we talked about "Harlem Heat." You mentioned a couple other things. What is on your docket for the rest of this year for releases? LaQuette: I don't think I have any other releases this year because I'm writing. So I've been very blessed in that I have landed these two major contracts with Sourcebooks and with Dreamspinner, both for series. So I'm halfway through Source's books. And I need to start on Dreamspinner's toward the end of the year. So there won't be any more releases from me. I mean, if I get a moment where I'm, you know, feeling really creative, I might try to get a novella together. But I'm not making any promises. Jeff: All right, so we'll look for a lot more in 2020, for sure. LaQuette: Yeah, 2020 is definitely...the first book for Source comes out in 2020. I don't have a release date yet. I have delivery dates for Dreamspinner, but I don't have release dates yet. So I'm thinking probably sometime toward the end of 2020, possibly, or maybe the beginning of 2021. Jeff: All right. Well, when "Harlem Heat" comes out, you definitely have an invitation to come back and talk, for sure. LaQuette: Oh, yay. Thank you. Jeff: Now what's the best way for everybody to keep up with you online? LaQuette: Oh, so you can find me on Facebook at, you know, my Facebook page, LaQuettetheAuthor. You can find me on Twitter @LaQuetteWrites, or you can find me on Instagram at la_quette, or you can email me at laquette@laquette.com, or you can go to my website laquette.com. Will: Fantastic. Jeff: She's well branded, and everything is the same. Will: Most definitely. Well, LaQuette, it was a genuine honor to have you on the show today. LaQuette: Oh, thank you. Will: We're so glad that you could take some time out of your extremely busy schedule that you can come talk to us. LaQuette: Thank you for having me. I mean, I was so excited and a little bit nervous also, to come on and talk to you guys because I've seen the show before. And I'm like, "Yay, I get to go hang out with them. I feel special." Will: Well, it is a genuine pleasure. We're so glad that you came. LaQuette: Thank you so very much for having me.
Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re moving from the trauma bay back to a more private setting, to discuss Emergency Department Diagnosis and Treatment of Sexually Transmitted Diseases. Nachi: And for those of you who follow along with the print issue and might be reading in a public place, this issue has a few images that might not be ideal for wandering eyes. Jeff: I’d say we need a “not safe for work” label on this episode, though I think we are one of the unique workplaces where this is actually quite safe. Nachi: And we’re obviously pushing for “safe” practices this month. The article was authored by Dr. Pfenning-Bass and Dr. Bridges from the University of South Carolina School of medicine. It was edited by Dr. Borhart of Georgetown University and Dr. Castellone of Eastern Connecticut Health Network. Jeff: Thanks, team for this deep dive. Nachi: STDs or STIs are incredibly common and often under recognized by both the public and health care providers. Jeff: In addition, the rates of STDs in the US continue to rise, partly due to the fact that many patients have minimal to no symptoms, leading to unknowing rapid spread and an estimated 20 million new STDs diagnosed each year. Treating these 20 million cases amounts to a whopping $16 billion dollars worth of care annually. Nachi: 20 million! Kinda scary if you step back and think about it. Jeff: Definitely, perhaps even more scary, undiagnosed and untreated STDs can lead to infertility, ectopic pregnancies, spontaneous abortions, chronic pelvic pain and chronic infections. On top of this, there is also growing antibiotic resistance, making treatment more difficult. Nachi: All the more reason we need evidence based guidelines, which our team from South Carolina has nicely laid out after reviewing 107 references dating back to 1990, as well as guidelines from the CDC and the national guideline clearinghouse. Jeff: Alright, so let’s start with some basics: pathophysiology, prehospital care, and the H&P. STDs are caused by bacteria, viruses, or parasites that are transmitted vaginally, anally, or orally during sexual contact, or passed from a mother to her baby during delivery and breastfeeding. Nachi: In terms of prehospital care, first, make sure you are practicing proper precautions and don appropriate personal protective equipment to eliminate or reduce the chance of bloodborne and infectious disease exposure. In those with concern for possible sexual assault, consider transport to facilities capable of performing these sensitive exams. Jeff: As in many of the prehospital sections we have covered -- a destination consult could be very appropriate here if you’re unsure of the assault capabilities at your closest ER. Nachi: And in such circumstances, though patient care comes first, make sure to balance medical stabilization with the need to protect evidence. Jeff: Exactly. Moving on to the ED… The history and physical should be conducted in a private setting. For the exam, have a chaperone present, whose name you can document. The “5 Ps” are a helpful starting point for your history: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. Nachi: 5 p’s, I actually haven’t heard this mnemonic before, but I like it and will certainly incorporate it into my practice. Again, the 5 p’s stand for: partners, practices, prevention of pregnancy, protection from STDs, and past STDs. After you have gathered all of your information, make sure to end with an open ended question like “Is there anything else about your sexual practices that I need to know?” Jeff: Though some of the information and even the history gathering may make you or the patient somewhat uncomfortable, it’s essential. Multiple partners, anonymous partners, and no condom use all increase the risk of multiple infections. Try to create a rapport that is comfortable and open for your patient to provide as much detail as they can. Nachi: And as with any infectious work up, tachycardia, hypotension, and fever should all raise the concern for possible sepsis. In your sepsis source differential, definitely consider PID in addition to the usual sources. As a mini plug for a prior issue, PID was actually covered in the December 2016 issue of Emergency Medicine Practice, in detail. Jeff: Getting back to the physical exam: though some question the utility of the pelvic exam as our diagnostics get better, the literature suggests the pelvic definitely still has a big role both in diagnosing and differentiating STDs and other pathology. Don’t skip this step when indicated. Nachi: Now that we have a broad overview, let’s talk about specific STDs, covering diagnosis, testing, and treatment. Jeff: If following along in the article, appendices 1, 2 and 3, list detailed physical exam findings for the STDs were going to discuss, while table 3 lists treatment options. A great resource to use while following along or as a reference during a clinical shift! Nachi: First up, let’s talk chlamydia, the most common bacterial cause of STDs, with 1.7 million reported infections in 2017. Most are asymptomatic, which increases spread, especially in young women. Jeff: Chlamydia trachomatis has a 2-3 day life cycle in which elementary bodies enter endocervical and urethral cells and replicate, eventually causing host cell wall rupture and further spread. Nachi: Though patients with chlamydia are often asymptomatic, cervicitis in women and urethritis in men are the most common presenting symptoms. Vaginal discharge is the most common exam finding followed by cervical ectropion, endocervical mucus, and easily induced bleeding. Other presenting symptoms include urinary frequency, dysuria, PID, or even Fitz-Hugh-Curtis syndrome, which is a PID induced perihepatitis. In men, epididymitis, prostatitis, and proctitis are all possible presenting symptoms also. Jeff: And of note, chlamydia can also cause both conjunctivitis and pharyngitis. Nachi: This article has a ton of helpful images. Check out figures 1 and 2 for some classic findings with chlamydial infections. Jeff: When testing for chlamydia, nucleic acid amplification is the test of choice as it has the highest sensitivity, 92% when tested from a first-catch urine sample vs. 97% from a vaginal sample. While these numbers are similar, and you’re gut may be to forego the pelvic exam, consider the pelvic exam to aid in the diagnosis of PID and to evaluate for cervicovaginal lesions or other concomitant stds. Nachi: Similarly, in men, the test of choice is also a nucleic acid amplification test, with a first catch urine preferred over a urethral swab. Jeff: And lastly, nucleic acid amplification is also the test of choice from rectal and oropharyngeal samples, though you need to check with your lab first as nucleic acid amplification is not technically cleared by the FDA for this indication. Nachi: Treatment for chlamydia is simple, 1g of azithromycin, or doxycycline 100 mg BID x 7 days. Fluoroquinolones are a second line treatment modality. Jeff: In pregnant women, chlamydia can lead to ectopic pregnancy, premature rupture of membranes, and premature delivery. The single 1g azithromycin dose is also safe and effective with amox 500 mg TID x 7 days as a second line. Pregnant women undergoing treatment should have a documented test-of cure 3-4 weeks after treatment. Nachi: Next up, we have gonorrhoeae, the gram-negative diplococci. Gonorrhea is the second most commonly reported STD, affecting 0.8% of women and 0.6% of men, with over 500,000 reported cases in 2017. Jeff: Gonorrhea attaches to epithelial cells, altering the surface structures leading to penetration, proliferation and eventual systemic dissemination. Nachi: Though some may be asymptomatic, women often present with cervicitis, vaginal pruritis, mucopurulent discharge, and a friable cervical mucosa, along with dysuria, frequency, pelvic pain and abnormal vaginal bleeding. Jeff: Men often present with epididymitis, urethritis, along with dysuria and mucopurulent discharge. Proctitis, pharyngitis, and conjunctivitis are all possible complications. Nachi: In it’s disseminated form, gonorrhea can lead to purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: In both men and women the test of choice for gonorrhea again is NAAT, with endocervical samples being preferred to urine samples due to higher sensitivity. In men, urethral and first catch urine samples have a sensitivity and specificity of greater than 97%. Nachi: And as with chlamydial samples, the FDA has not approved gonorrhea NAAT for rectal and oropharyngeal samples, but most labs are able to process these samples. Jeff: Yeah, definitely check before you go swabbing samples that cannot be run. Lastly, in regards to testing, though it won’t likely change your management in the moment, the CDC does recommend a gonococcal culture in cases of confirmed or suspected treatment failure Nachi: It’s also worth noting that although NAAT can be used in children, but culture is additionally preferred in all settings due to legal ramifications of sexual abuse. Jeff: It pains me just to think about how awful that is. Ugh. Moving on to treatment: when treating gonorrhea, the current recommendation is to treat both with cefitriaxone and azithro. 250 mg IM is the preferred dose, up from just 125 mg IM which was preferred dose two decades ago along with 1g of azithro. Nachi: And if ceftriaxone IM cannot be administered easily, 400 mg PO cefixime is the second line treatment of choice. If there is a documented cephalosporin allergy, PO gemifloxacin or gentamycin may be used. And for those with an azithomycin intolerance, a 7 day course of doxycycline may be substituted instead. Jeff: In pregnant women, gonococcal infections are associated with chorioamnionitis, premature rupture of membranes, preterm birth, low birth weight, and spontaneous abortions. Pregnant woman therefore should be treated with both ceftriaxone and azithro in the same manner as their non pregnant counterparts. Nachi: There is also one quick controversy to discuss here. Jeff: oh yeah, go on… Nachi: The CDC currently recommends the IM dose of ceftriaxone, not IV. And this is because of the depot effect. However, it’s unclear if this effect is in fact true, as IM and IV ceftriaxone levels measured in blood 24 hours later are similar. So if the patient has an IV already, should we just give the ceftriaxone IV instead of IM? Jeff: I think it is probably okay, but I’ll wait for a bit more research. For now, I would continue to stick with the CDC recommendation of IM as the correct route. Nachi: And with the continuing rise of STD’s and the public health and economic burden we are describing here, I think the IM route, which is known to be effective, should still be used -- until the CDC changes their recommendations. Next up we have the great imitator/masquerader, syphilis, caused by the spirochete Treponema pallidum. LIke the other STDs we’ve discussed so far, cases of syphilis are also on the rise with over 30k cases in 2017, a 10% increase from 2016. Jeff: Syphilis is spread via direct contact between open lesions and microscopic abrasions in the mucous membranes of vagina, anus, or oropharynx. The organism then disseminates via the lymphatics and blood stream. Nachi: Infection with syphilis comes in three stages. Primary syphilis is characterized by a single, painless lesion, or chancre, which occurs about 3 weeks after inoculation. 6-8 weeks later, secondary syphilis develops. This often presents with a rash, typically on the palms and soles of the feet, or with condyloma lata, or lymphadenopathy. Jeff: Tertiary syphilis doesn’t appear until about 20 years post infection and it includes gummatous lesions and cardiac involvement including aortic disease. Nachi: Patients at any stage may go long periods without any symptoms, which is known as latent syphilis. In addition, at any stage a patient may develop neurosyphilis, which can present with strokes, altered mental status, cranial nerve dysfunction, and tabes dorsalis. Jeff: In early syphilis, dark-field examination is the definitive method of detection, though this is impractical in the ED setting. There are, instead, 2 different algorithms to follow. The CDC traditional algorithm recommends a nontreponemal test like rapid plasma reagin or RPR or the venereal disease research lab test also called VDRL, followed by confirmational treponemal test (fluoresent treponemal antibody absorption or FTA-ABS or T pallidum passive agglutination also called TP-PA). More recently there has been a shift to the reverse sequence, with screening with a treponemal assay followed by a confirmatory nontreponemal assay. Nachi: The reason for the change is that there is an increased availability of rapid treponemal assays. And where available, the reverse sequence offers increased throughput and the ability to detect early primary syphilis better. The CDC, however, still recommends the traditional testing pathway -- that is nontreponemal tests first like RPR or VDRL, followed by treponemal tests like FTA-ABS or TP-PA. The article also notes that emergency clinicians should rely on clinical manifestations in addition to serologic testing, when determining whether to treat for syphilis. Jeff: For neurosyphilis, the CSF-VDRL test is highly specific but poorly sensitive. In cases of a negative CSF-VDRL but still with high clinical suspicion, consider a CSF FTA-ABS test, which has lower sensitivity, but is also highly specific and may catch the diagnosis. Nachi: Treatment for primary, secondary, and early latent syphilis is with 2.4 million units of Penicillin G IM. For ocular and neurosyphilis, treatment is with 18-24 million units of pen G IV every 4 hours or continuously for 10-14 days. In patients who have a penicillin allergy, skin testing and desensitization should be attempted rather than azithromycin due to concerns for resistance. Jeff: For pregnant women, PCN is the only proven therapy. Interestingly, there is some evidence to suggest that a second IM dose may be beneficial in treating primary and secondary syphilis in pregnancy though data are limited. Nachi: We also have to mention the Jarisch-Herxheimer reaction before moving on. This is a syndrome of fevers, chills, headache, myalgias, tachycardia, flushing and hypotension following high dose PCN treatment due to a massive release of endotoxins when the bacteria die. This typically occurs in the first 12 hours but can occur up to 24 hours after treatment. Treatment is supportive. Concern of this reaction should never delay PCN treatment!! Jeff: The next condition to discuss is Bacterial vaginosis, or BV, which, interestingly, is not always an STD. It is therefore critically important to choose your words wisely when speaking with a patient who has BV. Nachi: That is an important point that is worth repeating. BV is not always an STD. So what is BV? BV occurs when there is a decrease or absence of lactobacilli that help maintain the acidic pH of the vagina leading to an overgrowth of Gardnerella, bacteroides, ureaplasma and mycoplasma. BV does not occur in those who have never had intercourse and it may increase the risk of other STDs and HIV. Jeff: 50% of women with BV are asymptomatic, while the others will have a thin, grayish-white, homogeneous vaginal discharge with a fishy smell, along with pruritis. Nachi: To diagnose BV, most use the amsel criteria, which requires 3 of following 4: 1) a thin, milky, homogeneous vaginal discharge, 2) the release of a fishy odor before or after the addition of potassium hydroxide, 3) a vaginal pH > 4.5, and 4) the presence of clue cells in the vaginal fluid. These criteria are 90% sensitive and 77% specific, with clue cells being the most reliable predictor. Jeff: And for those of us without immediately available microscopy, you can make the diagnosis based on characteristic vaginal discharge alone. Treat with metronidazole, 500 mg BID for 7 days, metronidazole gel, or an intravaginal applicator for 5 days, with the intravagainal applicator being better tolerated than the oral equivalent Nachi: BV in pregnancy increases risk of preterm birth, chorioamnionitis, postpartum endometriitis and postcesarean wound infections. Pregnant patients are treated the same as nonpregnant or with 400 mg of clindamycin BID x 7 days. Jeff: Always nice when there is really only one treatment regimen across the board. And that will be a general theme for treatment options in pregnancy with a few exceptions. Nachi: Next up we have Granuloma inguinale, or donovanosis, which is caused by Klebsiella granulomatis. Jeff: Granuloma inguinale is endemic to India, the Caribbean, central australia, and southern africa. It is rarely diagnosed in the US. Nachi: Granuloma inguinale presents with highly vascular, ulcerative lesions on the genitals or perineum. They are typically painless and bleed easily. If disseminated, Granuloma inguinale can lead to intra-abdominal organ and bone lesions and elephantiasis-like swelling of the external genitalia. Jeff: Granuloma inguinale can can be diagnosed by microscopy from the surface debris of purulent ulcers. Nachi: Once you have the diagnosis, the CDC recommends treatment with azithromycin for at least 3 weeks and until all lesions have resolved. Jeff: Next we have lymphogramuloma venereum or LGV. Nachi: LGV is a C. Trachomatis infection of the lymphatics and lymph nodes. This is predominantly a disease of the tropics and subtropical areas of the world. Jeff: On exam, in the primary stage, you would expect a small, painless papule, pustule, nodule or ulcer on the coronal sulcus of the penis or on the posterior forchette, vulva, or cervix of women. The primary stage eventually progresses to the secondary stage, which is characterized by unilateral lymphadenopathy with fluctuant, painful lymph nodes known as buboes. Nachi: Check out figure 11 for a great classic image of the “groove sign” which is involvement of both the inguinal and femoral lymph nodes, and is seen in 15-20% of cases. And actually even more common than the groove sign is a presentation with proctitis. Jeff: Testing for LGV should be based on high clinical suspicion, and NAAT should be performed on a sample from the primary ulcer base or from aspirate from a bubo. Nachi: Treatment for LGV is with doxycycline 100 mg BID x 21 days. Jeff: So, to summarize, for LGV, remember painful lymphadenopathy, especially in those with proctitis. Treat with doxy. Nachi: Next we have Mycoplasma genitalium, which causes nongonococcal urethritis in men and mucopurulent cervicitis and PID in women. Jeff: Unfortunately, there is no diagnostic test for M. genitalium, and it should be considered clinically, especially in the setting of recurrent urethritis. Nachi: Treat with azithro, but not 1g x 1. Instead, M. Genitalium should be treated with a course of azithro, with 500 mg on day 1 followed by 250 mg daily for 4 days. Moxifloxacin is an alternative. Jeff: Simple enough. Moving on to everybody’s favorite, genital herpes. Nachi: umm, I’m not sure sure anybody would call herpes their favorite. Why would you even say that? Jeff: i don’t know, seemed natural at the time… Regardless, primary genital herpes is caused by either HSV1 or HSV2. Though only an estimate, and likely an underestimate at that, it is estimated that at least 1 in 6 people in the US between 14 and 49 have genital herpes. Nachi: That’s much higher than I would have thought. Jeff: Patients usually contract oral herpes from HSV-1 due to nonsexual contact with saliva and genital herpes due to sexual contact with an infected person. Nachi: Keep in mind, however, that HSV1 can and will also cause genital infections if spread via oral sex. Jeff: Localized symptoms include pain, itching, dysuria, and lymphadenopathy and systemic symptoms include fever, headache, and malaise. In women, look for herpetic vesicles on the external genitalia along with tender ulcers in areas of rupture, see figure 12 for a characteristic image. Nachi: Though symptoms tend to be more severe in woman, men may present with vesicles on the glans penis, penile shaft, scrotum, perianal area, and rectum or even with dysuria and penile discharge. Jeff: HSV1 and 2 infections also have the ability to recur, though recurrences tend to become less frequent and severe over time. Nachi: It’s noteworthy that there is also a direct correlation between stress levels and the severity of an HSV outbreak. Jeff: Herpes can be diagnosed by viral culture of an unroofed vesicle or by NAAT. PCR based assays can also differentiate between HSV1 and HSV2 Nachi: While there is no cure, antivirals may help prevent and shorten outbreaks. Ideally you should begin treatment within 72 hours of lesion appearance. Treat with acyclovir, valacyclovir, or famciclovir. In addition, don't forget about adjuncts like analgesia, sitz bathes, and urinary catheter placement for severe dysuria. Jeff: HSV can also be vertically transmitted from mother to child so in pregnancy, treat with acyclovir 400 mg 3x/day for 7 days or valacyclovir Nachi: And because transmission is so easy, babies born to mothers with active lesions should be delivered by cesarean section. Jeff: Let’s move on to human papillomavirus, or HPV. There are over 100 types of HPV with 40 being transmitted through skin to skin contact, typically via vaginal and anal intercourse. Nachi: Most infections are asymptomatic and clear within 2 years. Jeff: Right, but one of the main reasons this is such a big deal is that HPV types 16 and 18 are oncogenic strains and can lead to cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers. Amazingly, HPV is responsible for more than 95% of the cervical cancers in women. Nachi: Hence the importance of the new vaccine series that most young adults and children are now opting for. Vaccination should occur in women through age 26 or men through age 21 if not previously vaccinated. Jeff: Critically important to take advantage of a vaccine that can prevent cancer! Nachi: And though not as important in terms of health consequences, just be aware that HPV 6 and 11 may lead to anogenital warts, known as condyloma acuminata. Jeff: In terms of exam findings, as you just mentioned, most infections are asymptomatic and self-limited. If symptoms do develop, HPV typically causes those cauliflower like or white plaque like growths lesions on the external genitalia, perineum, and perianal skin. Nachi: For testing, there is a limited role in the ED. Diagnosis should be made by visual inspection, followed eventually by a biopsy. Jeff: And just like the biopsy, which is unlikely to be done in the emergency department, most treatment is also not ED based. Treatment options include cryotherapy, immune-based therapy, and surgical excision, which has both the highest success rates and lowest recurrence. Nachi: Next up, we have trichomoniasis. Jeff:Trichomoniasis is a single-celled, flagellated, anaerobic protozoa, that directly damages the epithelium, causing microulcerations in the vagina, urethra, and paraurethral glands. Nachi: With an estimated 3.7 million infected people in the US, this is something you’re also bound to see. Jeff: Risk factors include recent or current incarceration, IV drug use, and co-infection with BV. Nachi: Note the common theme here - co infection. It’s very common for patients to have more than one STD, so make sure not to anchor when you think you’ve nailed the diagnosis. Jeff: On exam the majority of both women and men are asymptomatic. In women, you may find a purulent, frothy vaginal discharge, vaginal odor, vulvovaginal irritation, itching, dyspareunia, and dysuria Nachi: And don’t forget about the classic colpitis macularis, or the strawberry cervix. Though this is frequently taught and stressed, it’s actually only seen in 2-5% of infected women. Jeff: But to be fair, a strawberry cervix and frothy vagianl discharge together have a specificity of 99% for trich, which is really not bad. Nachi: While many EDs sadly aren’t blessed with a wet mount, the wet mount has the advantage of being simple, convenient, and generally low cost. Jeff: While all of that is true regarding the wet mount, it’s no longer first line, again with NAAT being preferred, as it’s highly sensitive, approaching 100%. Nachi: And for those of us who don’t have access to NAAT, there are also antigen-detecting tests which don’t perform quite as well, but they are much more sensitive than the traditional wet mount. Jeff: Treatment for trichomoniasis is with oral metronidazole, 2g in a single oral dose a or 500 mg twice a day for 7 days. Alternatively, the more expensive tinidazole, 2g for 1 dose, is actually superior according to the most recent evidence. Nachi: For pregnant patients, trichomoniasis is unfortunately associated with premature delivery and premature rupture of membranes, with no improvement following treatment. Still, patients should be tested and treated, preferentially with metronidazole, to relieve symptoms and prevent partner spread. Jeff: We have two more special populations to discuss in this month’s issue - those in correctional facilities and sexual partner treatment. If you are lucky enough to be involved in treating those in correctional facilities, keep in mind that rates of gonorrhea, chlamydia, syphilis, and trichomoniasis are higher in persons in both juvenile and adult detention facilities than the general public. Nachi: In general for patients in correctional facilities, maintain a lower threshold for just about everything. This is just an at-risk population. Jeff: Let’s move on to sexual partners, and expedited partner therapy or EPT. Nachi: Once you’ve diagnosed a patient with an STD, you can also provide a prescription or medication to the patient to give to their partner or partners. Jeff: This practice is critically important to stop partners from unknowingly spreading the STD further which is a real problem. Unless prohibited by law, emergency clinicians should routinely offer EPT to patients with chlamydia, gonorrhea, or trichomoniasis. To see your states’ current status, the CDC maintains a list of the status in all 50 states. Nachi: In terms of specific partner therapies, for chlamydia, EPT can be accomplished with a single 1g dose of azithromycin or doxycyclin 100 mg bid for 7 days. Consider concurrent treatment for gonococcal infection also. Jeff: For Gonorrhea, EPT includes a single oral dose of 400 mg of cefixime and a 1g oral dose of azithromycin. Nachi: For EPT for syphilis, unfortunately the partner has to present to the ED for a single IM injection of penicillin G. While this does place a burden on the partner, it opens up an opportunity for additional serologic testing and possibly treatment of his or her partners as well. Jeff: Routine EPT for those with BV is not recommend as the data shows that partner treatment does not affect rates of relapse or recurrence. Nachi: For genital herpes, you should counsel patients and their partners that they should abstain from sexual activities when there are lesions or prodromal symptoms. Make sure to refer partners for evaluation as well. Jeff: Since there isn’t much data on HPV partner notification, for now, encourage patients to be open with their partners so they may seek treatment as well. Nachi: And lastly, for Trichomoniasis, EPT includes 2 g of metronidazole or 500 mg BID for 7 days or that single 2g dose of tinidazole. Jeff: In general, it is always better to have the partner present to a physician for diagnosis and treatment, but EPT is an option when that seems unlikely or impossible. Nachi: Also, when possible be sure to inquire about drug allergies and provide some guidelines on ER presentation for allergic reactions. Jeff: So that wraps up EPT. Let’s discuss disposition. Though most will end up going home, a few may require IV medications, such as those with severe HSV, disseminated gonococcus, and neurosyphilis. Nachi: Admission should also be strongly considered in those who are pregnant or with concern for complications. Those with severe nausea, vomiting, high fever, the inability to tolerate oral antibiotics, and those failing oral antibiotics should also be considered for admission. Jeff: But if your patient doesn’t meet those criteria, as most will not, and they are headed home, stress the importance of follow up. Especially for those with gonorrhea and chlamydia, for whom a test of cure after completion of their medication is recommended. This is even more important for pregnant women. Nachi: Chlamydia, gonorrhea, HIV, and syphilis are among the many infectious diseases that require mandatory reporting. Definitely familiarize yourself with your states’ reporting laws, as most of these patients will be headed home and you’ll want to make sure you don’t miss your chance to prevent further spread. Jeff: Perfect, so that’s it for this month’s issue. Let’s close out with some high yield points and clinical pearls. Nachi: STDs are under recognized by patients and healthcare professionals. They can often present with minimal or no symptoms and are passed unknowingly to partners. Jeff: STD’s can have devastating effects during pregnancy on the fetus. Treat these patients aggressively in the ER. Nachi: The rising rate of STD’s continues to be an economic burden on the U.S. healthcare system. Jeff: Patients can present with multiple STD’s concurrently. Avoid premature diagnostic closure and consider multiple simultaneous processes. Nachi: Urinary tract infections and STD’s can present similarly. Be sure to do a pelvic exam to avoid misdiagnosis. For the exam, always have a chaperone present. Jeff: Acute unilateral epididymitis is most commonly a result of chlamydia in men under the age of 35. Nachi: Chlamydia is the most common bacterial STD. The diagnostic test of choice is nucleic acid amplification testing (NAAT). Treat with azithromycin or doxycycline. Jeff: Gonorrhea is the second most common STD. The diagnostic test of choice here is again NAAT. Treat with ceftriaxone and azithromycin. Nachi: Gonorrhea can lead to disseminated infection such as purulent arthritis, tenosynovitis, dermatitis, polyarthralgias, endocarditis, meningitis, and osteomyelitis. Jeff: Syphilis has a wide variety of presentations over three stages. For concern of early syphilis, send RPR or VDRL for nontreponemal testing as well as an FTA-ABS or TP-PA for treponemal testing. Nachi: Tertiary syphilis can present with gummatous lesions or aortic disease many years after the primary syphilis infection. Jeff: At any stage of syphilis, the central nervous system can become infected, leading to neurosyphilis. Nachi: Bacterial vaginosis presents with a white, frothy, malodorous vaginal discharge. Treat with metronidazole. Jeff: Genital herpes is caused by HSV-1 or HSV-2. Diagnosis can often be made clinically. If sending a sample for testing, be aware that viral shedding is intermittent, so you may have a falsely negative result. Antivirals can help prevent or shorten outbreaks and decrease transmission. Nachi: Lymphogranuloma Venereum presents with small, painless papules, nodules, or ulcers. Groove sign is present in only 15%-20% of cases. Jeff: Consider Fitz-Hugh-Curtis syndrome in your differential for a sexually active patient with right upper quadrant pain. Nachi: Offer expedited partner therapy to all patients with STD’s to prevent further spread Jeff: So that wraps up Episode 27 - STDs in the ED! Incredibly high yield topic with lots of pearls. Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: I’ll repeat that, since saving money is important. APPs, use the promotion code APP4 at checkout to receive 50% off on your subscription. Speaking of PAs - for those of you attending the SEMPA conference in just a few weeks, make sure to check out the EB Medicine Booth, #302 for lots of good stuff. For those of you not attending the conference, just be jealous that your colleagues are hanging out in New Orleans. Nachi: And the address for this month’s credit is ebmedicine.net/E0419, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 3. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr- 03):1-137. (Expert guidelines/systematic review) 5. Torrone E, Papp J, Weinstock H. Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years- -United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838. (Expert guideline/systematic review) 98. Schillinger JA, Gorwitz R, Rietmeijer C, et al. The expedited partner therapy continuum: a conceptual framework to guide programmatic efforts to increase partner treatment. Sex Transm Dis. 2016;43(2 Suppl 1):S63-S75. (Systematic review; 42 articles) 103. Centers for Disease Control and Prevention. 2018 National Notifiable Conditions (Historical). National Notifiable Diseases Surveillance System (NNDSS). Accessed March 10, 2019. (CDC website) 105. Carter MW, Wu H, Cohen S, et al. Linkage and referral to HIV and other medical and social services: a focused literature review for sexually transmitted disease prevention and control programs. Sex Transm Dis. 2016;43(2 Suppl 1):S76-S82. (Systematic review; 33 studies)
The video game website Giant Bomb recently celebrated its tenth birthday so what better time to talk to its creator about the early days of the online games media, the future of games coverage, and getting fired in front of the entire world. iTunes Page: https://itunes.apple.com/us/podcast/noclip/id1385062988 RSS Feed: http://noclippodcast.libsyn.com/rssGoogle Play: https://play.google.com/music/listen?u=0#/ps/If7gz7uvqebg2qqlicxhay22qny Spotify: https://open.spotify.com/show/5XYk92ubrXpvPVk1lin4VB?si=JRAcPnlvQ0-YJWU9XiW9pg Soundcloud: https://soundcloud.com/noclippodcast Watch our docs: https://youtube.com/noclippodcast Sub our new podcast channel: https://www.youtube.com/channel/UCSHBlPhuCd1sDOdNANCwjrA Learn About Noclip: https://www.noclip.videoBecome a Patron and get early access to new episodes: https://www.patreon.com/noclip Follow @noclipvideo on Twitter Hosted by @dannyodwyerFunded by 4,638 Patrons. -------------------------------------------------------------- - [Danny] Hello and welcome to Noclip, the podcast about video games, the people who make them, and the people who play them. On today's episode we talk to a guy who grew up a short drive from the epicenter of the online media revolution. As video game website Giant Bomb recently celebrated its 10th year of operation, we decided to talk to its founder about skipping school, hosting podcasts, and getting fired in front of the entire world. Jeff Gerstmann is a name you either know or don't, depending on whether or not you care about the world of games coverage. Outside of the world of games, Jeff is a husband, son, and a grown-up local kid in Petaluma, a city in Northern California that sits on the outskirts of what many would consider a reasonable commute to San Francisco. There he grew up with his mum and dad who operated a tire shop. A small town kid, with a small town life who loved rap, skateboards, and video games. But inside the world of games Jeff is larger than life. He's part of a dwindling older generation of journalists who were there when the magazines died, and the world of internet reporting exploded. He's lead the charge on finding new ways to talk about games, be it on video, podcast or late light E3 live shows. And crucially, his surname became a rallying cry for media ethics when he fell victim to one of the most lamentable acts of brand self-destruction of the digital age. Much of Jeff's story lives in the gaming zeitgeist. Before I met him, I thought I knew most of it. You see, to me Jeff was a hero. He had figured it all out. Growing up in Ireland, years before Twitch or even YouTube had started, I'd watch him host shows broadcast live from the GameSpot offices in San Francisco. His job was talking about games, and he knew more about games than anyone I'd ever seen trying to do it on television. His job became a north star that I'd spend years following. And when I'd eventually find myself working in the same building those shows were filmed in, sitting at a desk a short walk from his, I slowly began to get a deeper understanding of Jeffrey Michael Gerstmann. Equal parts a quiet, contemplative person and a troublemaker, now responsible for keeping order. I recently sat down with Jeff to talk about the 10 Year Anniversary of his career's second act, the video game website GiantBomb.com. But the story of Giant Bomb and the story of Jeff Gerstmann are intertwined. So to tell you how Giant Bomb was founded we have to go back to a small town in Northern California, to the kid of the folks who ran the tire shop in sunny, quiet, suburban, Petaluma. - [Jeff] The first video game console I owned, it was the Fairchild Channel F, which was, it kinda came out around the same time, same window as the Atari 2600 but it had a few more educational games so I think that tipped my parents in the favor of getting that thing, it had this terrible plunger controller, there was like a decent bowling game but it just immediately failed. I had relatives who had an Atari 2600 and would kinda covet that thing and eventually they gave it to me when the video game industry kinda crashed. But we got into computers not long after that. I got an Atari 400 and that was really the first proper like hey, this is a somewhat successful platform with stuff coming out that mattered. And so I mostly started on a computer. - [Danny] What was the impetus for your parents getting it? Were they interested in technology at all or were you crying for it or what was the story there? - [Jeff] You know, my dad played some video games certainly over the years but I think that was largely because that's what I was interested in. We were going to arcades a lot and on the weekends we would go out, there was an arcade in town called Dodge City and we would go to Dodge City. You know, my mom went once or twice, this was like the height of Pac-Man fever so like I would be there, my dad would be there, we'd be playing games and there would just be this huge line almost out the door of people waiting to play Pac-Man or Ms. Pac-Man. And it was just weird, you know, because it was just another game, like to me it was just like, all right, well yeah, I don't know, Pac-Man's over there and it is what it is and I'm over here playing Galaxian or Vanguard or you know, whatever the heck else, I don't really remember talking to too many people about video games. This was, you know, this woulda been, god, 82 ish, like early to mid 80s really and I was going to elementary school then and just there were like one or two other kids I knew that had computers but most kids didn't and they weren't really into video games per say or if they were they weren't really letting on. So there was one kid I knew that had a TRS-80 and so I'd go over to his place and play Parsec and some other stuff like that. There was a kid near the tire shop that my parents ran that had a VIC-20 and I could go over there and play like Radar Rat Race and some other stuff too. - [Danny] So, I guess, what did you want to be when you grew up when you were like a middle schooler? Obviously games journalism wasn't a target you could exactly aim for so what were you thinking about your future when you were in like middle school, high school? - [Jeff] When I was in high school we saw a posting, so LucasArts was relatively local, they were in Marin County and, you know, this woulda been like 1990, 1991, somewhere around there, and they were looking for testers. And I remember applying for it but like I was 15. Like it was, logistically it would've been impossible for me to even do that job 'cause I couldn't even drive a car yet. And it was 20ish miles away. But also like I remember writing, like they wanted a resume, I wrote an essay and it was like, you should give me this job. It was real dumb, I mean, whatever, in retrospect it was like, that is not a way to get a job. Also, ridiculous to assume that that would've even been possible at 15. But yeah, that was the first time I ever really thought about working in video games, I woulda been like 14 or 15. - [Danny] So how did it actually come to pass then? What was your first gig in the industry and how did you end up getting it? - [Jeff] So, I started going to trade shows, I met a guy a named Glenn Rubenstein who was a year younger than I was and we went to the same school, we went to the same high school. And Glenn was writing video game reviews for the local Petaluma newspaper and also I think he had a column in the San Francisco Examiner which was a newspaper. And so there would be articles about like, this youthful guy writing game reviews, look at this guy, it was like kind of a story or whatever. So we became friends, then he kinda said like, hey, I'm going to CES, do you wanna come with me? And I was like, yeah, I would love to go see video games. - [Danny] How old are you? - [Jeff] This is, I'm 16 at this point, he's 15. - [Danny] Wow, okay. It's in Vegas, right? - It's in Vegas also, yes. He's like, hey do you wanna come to Las Vegas. So I pitched it to my parents and just said like, hey, this thing's going on, I'd really like to go do it and they said yes, for whatever reason they said yes. And so me and Glenn set out to go, he had been to one before, he had been to CES I think the previous CES in Chicago might've been his first and so I went with him to that and just like I bought myself like a blazer and put it on and went to this trade show and went around and played video games and tried to play blackjack wearing a blazer because I looked like maybe I was of age. And that's where we met Ryan McDonald. We needed, honestly, I think we just needed more people to help pay for the hotel room or something like that and Ryan was doing something similar, he was writing about video games for a Healdsburg newspaper, which is about 40 miles north of Petaluma, where I'm now, which, for people who don't know, Petaluma is about 40 miles north of San Francisco, so, you know, Healdsburg's getting pretty far out there. And we met Ryan at the local mall, he seemed like an okay guy and we're like, yeah, you wanna come, let's go to Las Vegas. And so I kind of started just going to trade shows, we all met the guys from Game Informer pretty early on, Andy McNamara and Paul and some of the early other reviewers that were there at the time, Elizabeth Olsen and people like that, and we knew some people that were doing PR for video games at the time and stuff like that so we just kinda started meeting people and getting around. So that led to, Glenn ended up, so Glenn actually got me my first couple of jobs afterwards. We started going to the trade shows, we were doing a local public access show that was not about video games, it wasn't about much of anything really, and basically like barely getting by in high school 'cause we were just doing all this other stuff and not wanting to go to school very much. And so he ended up getting in at a magazine, they were starting up a magazine, they were originally gonna call it Blast, they were gonna call it Blast and it was gonna be like this lifestyle magazine funded by the, I guess the CEO of Creative Labs, so the Sound Blaster people were starting, basically funding a magazine. And so I spent a year commuting to Berkeley working for this magazine right after I got out of high school, so that woulda been like 1994. I was 19 commuting to Berkeley, working for a magazine, having no idea what I was doing, and we were covering Doom and we were covering, what are some fun things you could do with your Creative Labs branded sound card and stuff like that, that place lasted a little under a year before it folded. We made it about three issues, I think there was fourth that was almost done, and then I was out of there and had no idea what to do next. I was 19 and jaded and like burned by how that job went and angry at everything. - [Danny] Yeah, had you dropped out of high school, had you just sorta finished it and then left off or were you thinking about college or were you thinkin', oh shit, do I jump to another journalism gig, what was your head space then? - [Jeff] I finished high school. Between the public access show we were doing and this video game stuff that was still pretty nascent, you know, it wasn't really a job, it was very easy to look at that stuff and go like, man, I don't wanna go to school, like it's a waste of time. And so there was awhile there that like, I'll get my GED which is like so you can kinda test out of high school. And they tell you that it's equivalent to a high school diploma but then in some ways it's kind of not, I don't know, there was a weird. I had missed so much school and also we, so we were doing the public access show and I filmed a teacher, so a teacher at the high school I was going to, our chemistry teacher got fired and I believe the talk was, and I'm not sure, it was sexual harassment from the sounds of things, like to students. And so the first day that they introduced here's your new chemistry teacher I had the video camera that we used to tape the show so I filmed them introducing this new teacher and all this other stuff and like asked them questions like it was a press conference. And they answered, no one said, hey put that thing down. Like I was very clearly pointing a video camera at them. And then like the next day, that day, the day after, something like that, like the principal called me and said, hey, what are you gonna do with that video tape? And I said, well we're gonna put it on television. - [Danny] Oh my gosh. - [Jeff] And he was super not happy about that. - [Danny] I wonder why. - [Jeff] Yeah, and so at that point we realized we had something so we called the papers and said, hey we got this tape and they started investigating it and it became a story, it was something that they, I think they were trying to keep very quiet. Later on that teacher would show up at my doorstep looking for a copy of the tape because he was trying to sue the, I don't know, he was trying to get something out of the school district or something over what happened, this was years later after I was out of high school. So that was very strange. So after that between the amount of school we were missing, I had like a guidance counselor basically recommend that I should go on independent study. Which was basically, at the time it was primarily, it woulda been like pregnant teens and people that like were having trouble in school and that sorta stuff and they were like, oh, we're piloting a new program for kids who don't necessarily fit into the standard curriculum and they pitched it like that but basically it felt like they were just trying to get me and Glenn out of there. - [Danny] Right, journalist at heart it turns out. - [Jeff] I guess, I don't know. And so that led to me getting much higher grades and stuff because I was able to just kinda like crank through stuff really quickly. I graduated early because I just finished the work. I mean, I graduated like two weeks early, not hugely early. But it was great, it felt like I was getting one over on the school district because I was doing a full semester of science while like reading a book in my patents hot tub or, you know, just like stupid crap like that. I was getting like journalism credit for the stuff we were doing going to trade shows and like video production, they were just throwin' credits at me left and right and so yeah, I graduated early, it was great, I was able to take that and go back to the high school that I had stopped going to and go talk to like the one teacher that I liked, Mr. Moore, he was a math teacher, great guy, I think he taught some of the computer stuff also. And I remember telling him like, hey, I just graduated. And he just looked at me and said, god dammit, Gerstmann, you got 'em. He seemed like dismayed that I had managed to get one over on the system somehow but he couldn't help, but yeah, it was a, that felt pretty good. - [Danny] Through his life, Jeff's do-it-his-own way attitude has been both a source of great strength and the catalyst for much drama. He attended a local junior college for a semester, but it didn't stick, preferring to do extra-curricular work like attending trade-shows with his friend Ryan McDonald, hanging out with local bands, and as he put it, learning how to drink. Around this time Glenn, who had gotta him the job at the magazine years earlier, started working for a new website in San Francisco's Richmond district. Just a few blocks from the servers of archive.org on the cloudy avenues of Clement Street, lied an office where a staff of 20 was running the website GameSpot. They had hired Glenn to lead the charge on a new console-focused spin-off of the site that they were going to call VideoGameSpot. - [Jeff] Glenn hired Ryan McDonald not long after that to be like the strategy slash codes editor and then I started freelancing for him because they wanted 100 reviews by launch and they were lookin' to launch like three months, four months from that time. And so I started crankin' out reviews and the way I always heard it was that I was turning reviews around really quickly, really clean copy, and so Vince Broady kinda said like, hey, bring this guy and let's see. And they brought me in as like an editorial assistant which was more or less an intern type role and within two or three months, not even two or three months, within like a month, the launch editor, there was a guy, Joe Hutsko, who would come on, it was one of Vince's friends who had just come on I think to kinda see this console site through to launch and then I think he was gonna go on to do something else somewhere else and I was working late one night and Joe Hutsko walked by and saw me there and he was like, you're still here, what are you doin'? I was like, this work has to get done. And then like the next day I had an offer letter for a full time job at that point. - [Danny] GameSpot would go through several transformations and acquisitions over the coming years. But as the business side of online media was learning how to walk, emerging technologies were creating exciting new ways for people to talk about games. GameSpot led this charge with one of the first video game podcasts, The Hotspot, and a weekly live show, On The Spot. Suddenly these young game reporters were starting to become more than just bylines. For years readers, the folks writing reviews and new articles, were just names at the bottom of a page. But now, for the first time, they were people with voices and faces. People with unique perspectives, opinions and personalities. And Jeff, with his experience doing public access shows in Petaluma, was at the forefront of this new form of media. The idea of streaming video games on the internet now is so blase and normal but back then I think to a lot of people it felt like magical, like a television channel that's broadcasting about games. From your perspective on your guys's end, did it feel weird to be like doing a live show that people were watching while you were just talking about this relatively niche hobby? - [Jeff] It felt like a natural extension of the stuff we had been doing. And it felt like, I don't know, it felt fresh and cool and like the tech was weird and sometimes it didn't work the way you wanted it to but at the same time we were wearing makeup, we had built a studio, we had lights, we had a jib, it was Frank Adams lowering a camera into the shot and all this other stuff and so coming from like these lame public access shows I was doing when I was 16 and stuff, like I had a weird leg up on a lot of other people because I was already relatively comfortable being in front of a camera. - [Danny] GameSpot continued to evolve. It went from indie to being purchased by media house Ziff Davis who then eventually sold it to CNET. By this stage the editor in chief was Greg Kasavin, who you may now recognize as the creative director of Supergiant Games, a studio we're currently running an embedded series on. His two right hand men at the time were Ricardo Torres on previews and Jeff on reviews. But when Greg left to start his career in games production, the role was never properly filled. Instead Ricardo and Jeff sort of ran it together, with increased influence being exerted on them from the powers above. The original founders of GameSpot had come from a editorial background but they were gone and the site was now being managed by people were less seasoned, more traffic orientated, and didn't value the power of editorial independence as much as they should have. - [Jeff] You know, there was an understanding about like this is kinda how this stuff is supposed to work, it's not always supposed to be an easy relationship if everyone's kind of sticking to their guns and doing their jobs and stuff. I don't know that they always saw the value of that, I think that's something that they corrected quickly, it was just kind of, it was a blip, if you look at GameSpot as a 20 plus year institution there was that brief period of time there where it was like, man, this went a little sideways for a bit and I was just in the right place at the right time, wrong place wrong time, whatever it was. - [Danny] What happened to Jeff next has been told a thousand times with new pieces added as time has provided new context. I myself spent years trying to fill in the blanks on how it all went down. Talking to friends and colleagues of Jeff who were there that day. It was a Wednesday in November, 2007 and the office was busily preparing for the weekly live-show which aired on Thursday afternoon. Jeff had just another another brush-up with management, this time over a review of Kane and Lynch which had made the sales department uncomfortable as they had sold a large advertising campaign to the game's publisher Eidos. If you visited GameSpot that week, the entire homepage was taken over by messaging about the game alongside a six out of ten review from Jeff. Jeff had had some run ins with top brass before and felt like he'd come close to losing his job a few times but this wasn't one of those times. It seemed like it had been dealt with, and he was already working on his next review. Later that morning his supervisor called him into a meeting and then called HR. He was told he was being terminated immediately, and as California is an at-will employment state, Jeff had no recourse. He was told to clean out his desk and bizarrely he was allowed to walk the halls for the rest of the day. Saying goodbye to his friends and colleagues, who were cursing the names of those in charge. Jeff drove home that day, the same 40 mile commute between San Francisco and Petaluma he had done thousands of times before. But this time it would be different, it would be a number of years before he stepped foot in the building again. There was no live show that week, the Kane and Lynch review had been taken down and then reposted and slowly over the coming days rumors began to circulate about Jeff's termination. Popular webcomic Penny Arcade ran a strip outlining the pressure from Eidos. Staff from the website 1UP, who were located just a block north of GameSpot on San Francisco's 2nd Street, held a protest outside the lobby of the building in support of the remaining staff. In an age before social media it would be a full eight days before the staff would actually speak up. And it happened on the next episode of On The Spot. The show ran with a somber opening. Ryan McDonald flanked by Ricardo Torres and a wincing Alex Navarro explained the situation. The camera pans out to reveal a full set with previewer Brad shoemaker, new hire Kevin VanOrd, community manager Jody Robinson and reporter Brendan Sinclar among a dozen of other staff. - [Ryan] Obviously we wanted to start today's On the Spot off a little different than we had in the past. The recent events and what happened last week in regards to our longtime friend and colleague, Jeff Gerstmann, being dismissed. It's been really hard on us and the response obviously's been tremendously immense and it's been on both sides. It's nice to see that everybody speaks up and has been kinda pullin' for us. On the other hand it's been hard obviously seein' GameSpot sucks written 100,000 times on forums and stuff so obviously we wanted to address this and talk to you guys today. Jeff was a personal friend to pretty much everybody so it was really, really hard that it happened the way it did. But yeah, we really wanted to say that we love and miss Jeff and give him, honestly, the proper send off that he deserves so that's what today's show's all about. And obviously you can see this is hard for me personally. - [Danny] For Jeff things were equally as bizarre. Tech Blogs like ValleyWag were running stories about the state of the site which were clearly sourced from somebody inside of GameSpot. The LA Times ran a story about the firing. And Jeff's mother received a phone call from a newspaper in Norway looking for a quote. It was three a.m. when the phone rang. - [Jeff] You know, some of it was just like, some of the people I talked to were very like looking for more dirt, they were expecting me to get on the phone and be like, oh, well here's where the rest of the bodies are buried. But like, you know, I was shocked. I was not happy about the whole thing but at the same time I feel good about the work I did while I was there and there were so many great people there that kinda got caught in some of this crossfire a little bit. I wasn't like, oh well here's the other nasty things that happened, there wasn't any. There wasn't anything else. So some people were coming to me looking for like some bigger story that I just didn't have to give. And that was strange, it seemed like everyone wanted something from me for a little while and it was a very weird time. And so at that point it was like, 'cause you know, like I was not an editor in chief in title but you know, we were running an editorial team. And so there aren't a lot of jobs out there at that level. It wasn't like I could walk into IGN or 1UP or, you know, I don't even know who else was even out there at that point, it wasn't like I could walk into those places and say, yes, make me your editor in chief. Like, they already have people in those roles, it wasn't really a viable thing. So at that point I was like, well I kinda need to maybe start something new. The weekend after everything went down or it might've been, it was like the Friday after or maybe it was like a full week afterwards, a bunch of people that I used to work with came up here to my place and we just hung out, like kinda impromptu, just have a bunch of drinks, play some Rock Band, and that sorta thing, and Dave Snider came by, Ryan Davis invited Dave over. And Dave was working on his stuff, I think Boompa was still up, they had a car website, you know, they were running Comic Vine, they were building Political Base which was another kind of wiki focused site for political donations in the run up to that election there, this was November, 2007. And so they were starting a new company and looking to build, they were building websites. And I was like, oh, that's cool, awesome, and nothing really came of it for a little bit. So I went and did a show on Revision3, so I drove into San Francisco, did that show, and then on the way back from or as I was finishing up that show I got a call from Dave and he said, hey, you should come by the office in Sausalito and just come by. I was like, all right, cool. And so on my way back from there I stopped at the office in Sausalito and looked at Comic Vine, the other stuff they were doing, and we sat in a room and ate sandwiches and I more or less committed to them right there. It was kind of like an, oh, we'll think about it and they were very much like, hey, why don't you just take a month and get your head together, like take an actual break 'cause this is so crazy and then let us know what you wanna do. And so we kinda started building a website not too long after that. - [Danny] Over the coming weeks several of Jeff's friends would leave GameSpot. Some were burned out from games coverage, this latest spell just being the straw that broke the camel's back. But others were leaving to work with Jeff. Fellow Sonoma County local Ryan Davis was the first. The two of them set up a blog, and started to a run a podcast which they hurriedly titled, Arrow Pointing Down. - [Jeff] So, every single person at the company that we were, that I was now a part of were people that had worked at that old company. And so we did not wanna give the appearance of people getting poached out of there and like I don't know if there was an actual non compete with some of the people in the building or anything that would've prevented them from doing this stuff but all of it had to be kind of like quiet and so it couldn't be something as simple as like, hey we want to hire you over here. It had to be like, well, if you were, if you were no longer working and you needed a place to work we do have some opening. You know, it was very much that sort of thing. But I knew pretty immediately looking at it and going, okay, we wanna team of about this size and I knew that Alex would not be available, Alex Navarro, I knew that he was not looking to do this sort of work at that time. He was, you know, I think already thinking about Harmonix, he ended up doing public relations for Harmonix for a brief period of time. Like I pretty much had a whiteboard, I knew in my head that I, at that point it was like okay, this is me, it's Ryan, it's Brad, it's Vinny. Which is not how you're supposed to hire people. You know, some people are like, well what are the positions that we're looking to fill and all this other stuff and, but like knowing like what we looking to build and we needed to be a tight team, who were the people that are gonna be impactful in those roles, like okay, Brad has a lot of experience in previews, he is a person that I know, like he knows a ton of people around the game industry. Like, I've worked reviews and so on the review side of things we didn't talk to companies all that often. Brad had that in his role so he left, he left and he had other things that he was maybe thinking about doing, it wasn't like a, it was not a clandestine like, he left specifically to, it was like, okay, he's out and we're gonna figure this out. And then we needed someone to do do video and we had been working with Vinny for awhile and Vinny was fantastic and it was like, okay, Vinny's really funny, this seems like a good fit for him and so we kinda went about it that way. It felt like night and day a lot of ways, but very similar in others. We were able to sit down for the first time, for me the first time ever, like I never thought I would have the opportunity to build something like this, you know. I was always like very respectful or very envious of like Vince Broady as like the editorial lead of the founder of GameSpot and so I was like, man, he took a chance and built this thing and built it from the ground up and look at it, it's this huge, this monument, it's lasted so long. And I never thought I would have an opportunity like that in my career, it just never seemed like it was in the cards. And so being forced into it was exciting. Because it let me sit down and be like, okay, what do we actually want to do? What do we think is actually the best way to cover games with a small team in this day and age? And when we started in 96 on VideoGameSpot, like the videos had to be very low frame rate and very short because no one could download 'em and, you know, it was like we were doing minute long video clips of gameplay and that was revolutionary at the time. You know, you had to install the Real Video Player and all this, you know, all this other stuff. And here we were on the cusp of like, actually we can kind of, we can kinda livestream, you know, the services to do it easily weren't in place, you still had to host it yourself and that got very expensive and all that and YouTube wasn't really there in the way that they are now, YouTube existed but it was, I don't think you could put up videos that were longer than five or 10 minutes at the time and it just was not a viable place for that at the time. And so we had to kinda sit down and say, well with the technology we have available what can we do? And we wanted to be a podcast, the Hotspot was one of the most fun things I had doing in my entire time at GameSpot and we knew right out of the gate that we wanted to have a podcast be kind of one of the main things. And then from there it was like, okay, well, do we wanna write news? Not really, none of us are really news writers per say. And it was like, well, we need to able to capture video of games and put it on the internet. And we need to be able to talk alongside it or something like that, whether we're cutting it together or doing it on the fly. And so Mike Tatum, who was the head of biz dev for the company just went out to the Apple Store and came back with the biggest ass Mac Pro he could've gotten at the time and set it the room with me and Ryan and we looked at it and we were like, neither of us know how to use any of this shit. And we messed around with it long enough to figure out eventually we could capture some footage. We were like, okay, we figured out, first the game we captured footage of was Hot Shots Golf for the Playstation 3. And we were like, okay, we captured the footage, now what do we with it? And we hadn't answered that question yet 'cause there was no website to put it on or anything like that. So those early silly days of just like putting that stuff together. We didn't really know exactly what we wanted to do, it was just a matter, it was very freeing in way to be able to sit down and be like, okay, here are the things that we liked doing before, let's try to keep doing that. And then the rest is up in the air. For a long time there we weren't even necessarily sold on the idea of just covering video games. It was always meant to be bigger than that. We were gonna cover music, we were gonna cover movies, you know, all this other stuff. But at the end of the day old habits die hard, it was very easy for us to cover video games compared to like, calling music PR people out of the blue and being like, hey, we wanna interview this artist that's coming to town, can you set, you know, it was just, we stuck with what we knew and kinda just mainly covered video games and flavors of Gatorade. Really it was the original mandate for GameSpot was we wanna create a site that we ourselves would use. And I approached it that way and said like, well, what kind of game coverage do I actually care about? And a lot of the preview related stuff at the time was just not, it was a lot of like carved up little parts of a game. Like, we're gonna give you assets on these three new guns and this two new trees and it was like, here's the rims and tires of Grand Theft Auto: San Andreas. Outlets used to compete for the exclusive rights to run stuff like that. It was a very different time so we knew we were never gonna matter to publishers the same way the big sites did and that was fine, we wanted to kinda do our own thing and so that led to it being a little more guerrilla. You talked earlier about long footage of games being something of a novelty or a weird impossibility back then but for us it kinda just became a necessity because of the number of people we had and the lack of time we could devote to actual editing. It was like, just stuff kinda came in long out of the gate. And so we first launched as just a WordPress blog and we went to our first E3 in 08 with just a WordPress blog. We could run videos on it but it was pretty bare bones. It was mostly a placeholder, it was like, here's the name of the site, you can comment on these stories, and we were just kind of writing news and reviews and putting up videos here and there. And it was all pretty straightforward stuff, it was like that and the podcast. And then we rolled out the full site not long after that E3, it was like July of that year I think and then that was like, okay, now here's this full wiki, here's all this other stuff. Better user features, full message boards, all this other stuff. And so we went at it that way for awhile and then the premium membership stuff came later. - [Danny] It wasn't just old staff who were leaving GameSpot for Jeff's new project, users were flocking too. Once the full site was launched tens of thousands of profiles were created, a large portion of which were disenfranchised GameSpot fans who wanted to support Jeff and the staff who had left. I was one of them and I remember that time well. The passion and excitement of those days was one of the most powerful moments I've had as part of an online community. And the folks at Whiskey Media used this passion to help fund the site. Giant Bomb had taken the ad-free subscription model that GameSpot had pioneered, and added much more. For $5 a month you not only supported some of your favorite creators, but got access to bonus videos and features. New users signed up in their droves. - [Jeff] The launch of the site proper exceeded our expectations in a way that like wiki submissions were taking a week or more to approve because so many people were signing up and contributing and all this other stuff, it was just, we were staying up all night working on just the community stuff, moderation stuff. And then the premium membership stuff did well out of the gate. We went back and forth on a few ideas about what are we offering here and all that sort of stuff but yeah, it did really well that first day. Advertising was never really a thing for us, we had one in house ad person eventually for a brief period of time but like, you know, advertising's all about eyeballs and we were never gonna be the biggest website in the world, it was we were about, okay, well we want people who really care about this stuff and so, you know, in advertising you're trying to make a case for just like, oh no, this is a smaller audience but they're smarter and they spend more money and you know, at some point you have to go out and educate brands and say like, here's why you wanna advertise here instead of there or spend your money with us because our people are smarter or this and that and at the end of the day advertisers just want eyeballs so like you can go in and pitch that story all you want, it's just not how the advertising model typically works. So we had a few things where like, you know, we had some sponsored achievements on the site and there was a livestream, I was actually against it, but they did a livestream for, NTSF:SUV:SD, I think was the ordering of that, an Adult Swim show. Actually, I thought it was pretty funny. They did a livestream like live watch along with it. And so we were doing a few things like that that were innovative at the time I guess and so you would have people who understood like, hey, the internet is changing, it's not necessarily about just raw eyeballs. We wanna find people who are more engaged with a thing and you know, this was kinda like the nascent form of like the influencer type stuff about like figuring out who are these people we can get that have sway with their audiences and so on and so forth. But, us being an editorial operation, we could never really go fully into that world. So the stuff that I would be comfortable doing in those spaces kinda, we ended up shooting down a lot of stuff, probably more stuff than we signed because it was like, no, I don't think we can do that. So the advertising stuff was never really gonna be for us and for those reasons, it's just, you know, the advertising market just wasn't really compatible with our size and our scope but also kind of our mentality and where we were at with stuff so we wanted to try and find something different. And again, that was another Dave Snider, Dave was kind of the main first proponent about like, no, people will pay for good stuff on the internet, I know it. And I think I was a little more like, I don't know, man, people like to pirate stuff. But he's like, no, this will, he won me over pretty fast and we went through with it, we went on with it. - [Danny] Giant Bomb has been running for a decade and in that time the site has evolved to keep up with the changing desires of its audience. But there are a few shows that have lasted the test of time. Their weekly podcast The Giant Bombcast has had over 570 episodes and is one of the most popular video game podcasts in the world. And their Quick Looks series predated the creation of Let's Plays, still exists today. I asked Jeff to tell me about some of his favorites are. He notes their live E3 internet show, and eventually making the podcast profitable as some of his proudest achievements. As shows have come and gone, so too have staff. Just like GameSpot created a platform for Jeff to make a name for himself. Giant Bomb has become an incubator of talent all to itself. As the sort of captain of the ship as well, what does it feel like to be responsible for kind of what Giant Bomb has become in terms of its, as an incubator for talent, right. You've had people come through the doors and leave out the other side to go on to wonderful careers as well. Do you take a pride in that, especially considering, you know, how you seem to have a reverence for the people who gave you opportunities in your early career. - [Jeff] It's cool, I don't always think about it. Like, I don't know, like I look at it and go like, did I do anything for anyone, I don't know, I'm just here, I don't know, I just do my thing. And I don't know that I always, I used to take it really personally back in the GameSpot days when anyone would leave. I would always think like, man, why would you, why would you go do something else, we're doing great, we're doing all this other stuff, and now I look at it in retrospect and go like, maybe it was people like me in the senior roles for as long as we were that led to people below us wanting to get out for more opportunities, and go like, man, yeah, okay. But yeah, I used to take it really personally 'cause I just, you know, it was great to just, there were times where, you know, man, this is the best team I've ever worked with, this is great. Oh, three people are leaving over the course of six months, what's goin on? And the people that left in the run up to me leaving, at the time I was really bummed out, in retrospect I was like, oh, yeah okay, I get it. And things change and people change and they want something else out of their careers and they wanna take on new challenges and all that sorta stuff and I think that's great. At the same time, like I miss the people that have moved on. Like, there was a time there that there were, we were starting to have conversations, it's like, no, we need to move Danny O'Dwyer over to Giant Bomb, like we have, this should happen. And then he went out and found fame and fortune on his own without us and I was like, well, shit. Let that one slip away, I guess. - [Danny] There will always be a part of me in my professional sort of hindsight that will, I remember when you mentioned that to me at a certain point, I can't remember, was it when I had already handed in my notice or I think it was probably a little bit before maybe, where like, that is like the ultimate dream come true. But now I have a new dream come true which is that I get to just pop into the office and review European sports games twice a year or whatever. - [Jeff] Right, yeah, I mean, I have a code for FIFA that I don't know what to do with so. Might be callin' you for that one. So, it's stuff like that, like it's great seeing people out there doing their thing, and the thing I've tried to be better at this time around that I was terrible at back in the GameSpot days is try to keep in touch with people on a regular basis. Like it can be so easy just to put your head down and be like, I'm surrounded by these people, these are the people I see everyday, these are the only people I talk to because I don't have time for anything else. Discord has actually been really useful at that, honestly. Like hey, let's keep in touch with friends and try to maintain these friendships and stuff like that. So yeah, it's great being in regular contact with people like Patrick and Austin Walker and stuff like that. - [Danny] Giant Bomb lived under the Whiskey Media banner for four years, but the media startup was struggling to grow at a rate required by the landscape of the bay area investors and so the decision was made to fold the company to sell of its assets to suitable suitors. What happened next seemed impossible to anybody watching from the stands. - [Jeff] The process of us selling the company was strange, for a lot of the reasons you would expect. But you know, I think the thing that happened, every start up that sells or fails or anything always like to say, aw, we were just too early. We had the best ideas, too early. But you know, in some cases if we were a year later or something like that and YouTube had been more viable for longer form videos, like who knows what woulda happened. You know, we made the best choices we could along the way but at the end of the day, you know, they had launched a lot of other sites and wanted it to be this big network and when that kinda, I think that wasn't happening at the rate that they needed it to happen so it became a case of just like, okay, maybe it's time to move on and move onto a different business and do a different thing and so we were at that point lucky enough to be something that was sellable, you know. Like you think about the number of start ups now, especially the number of content companies that launched and just went under. And with Giant Bomb with the premium memberships and that sort of stuff we were in a pretty good position there to where we were doing something that people I think were just starting to get a sense of just like, hey, maybe this direct to consumer like subscription type stuff is something we should care about. And so it was something that people were starting to wake up to and be like hey, maybe we want some kind of back pocket plan in case this advertising thing doesn't always work the way it works now. So Mike Tatum, the head of biz dev for Whiskey, asked me one day, he said, hey, would you be open to maybe selling the company to CBS? And I just laughed. And I was like yes, of course, absolutely, go have those conversations, that's the craziest thing anyone's ever said to me, absolutely, yeah, of course. That's the thing, it was a very different time, a very different company, all that other stuff. Like the stuff that happened to me was this blip on this timeline of this multi decade operation that has had good people at the helm of it for almost all of its time, you know. And most of the people that were there when I was there last time and involved in some of that unpleasantness were long gone. So at this point it was like, hey, do you wanna go talk to John Davison about, you know, maybe comin' over there, and Simon Whitcombe. Yeah, they've been around this space for years, it's totally different people, like yeah, of course. And there were other people that were interested, the company that ended up buying tested was like lightly interested but not in a way that sounded all that exciting to me. And so yeah, I had lunch with John and Simon and in, this would've been, it was around the holidays, I don't remember the exact year anymore, it all runs together, man. But it was the holidays, it was like right after Christmas, we went into Christmas break knowing that it was likely that the company was gonna be sold early the following year. And that the GameSpot team was interested, was kind of like what I went into the holidays knowing. And so I met with them and we just kinda talked it out and, you know, like they had a good head on their shoulders and we were, you know, fairly attractive I guess in the sense that we had our own revenue, it wasn't like we were coming in and like, okay, you gotta bolt us to a sales team, you gotta bolt us to this 'cause otherwise we're gonna be losing money overnight. We were coming in doing pretty well in the grand scheme of things. So yeah, I wasn't in all the negations and meetings and all the back and forth for that sorta stuff but, yeah, it was an exciting weird time because we knew it was happening but we couldn't say it was happening. And rumors started getting out there a little bit, it was a very strange time, you know. It was so hectic. My dad went into the hospital as we were packing up the office to get everything out, and we were entering this quiet period where we wouldn't even have an office and we couldn't even say why, which was so unlike everything we had done with our community and all this other stuff. It was like, here's the thing where we are forced to not talk about this deal or act like anything is weird but we also are not in an office, it's hard to generate content when you're not in the studio. And there was just so much going on around that time, it was really, it was bizarre. I came out of it feeling like we did pretty good. For someone who came into that situation with little more than his good name I feel like I came out of it better. Personally better, better at my job, better at more types of things, better at running a, a little bit more respect for what it takes to run a business but also knowing when to sacrifice the business needs for editorial interest, you know, that sorta stuff. I was able to grasp more pieces of the puzzle, I guess. And so yeah, we came back in and it was fun because I had set up Giancarlo Varanini, I set him up real good where I saw him at an event the week before the deal was getting announced and I think my exact words were, hey I'll see you next week. And we left this Microsoft event or whatever we were at and. - [Danny] Did he know, did he twig it or? - [Jeff] He didn't know at the time but he pieced it together and then he was like, oh my god, you were saying what you were saying, yeah. 'Cause, you know, we still talk to a lot of those people that were over there. - [Danny] So strange, I think I told you, we were in the bizarre situation where the UK, I was at GameSpot UK and the UK sales team had leaked the deal to us, I think maybe six weeks before it was announced. - Wow. - We all knew and we couldn't tell the American office about it. - [Jeff] That's GameSpot UK for you, man. One year they tried to give FIFA an 11. - [Danny]Did they actually? - [Jeff] Actually, yes. They turned in a FIFA review that was trying to give it an 11 out of 10. And we had to be like, no, you absolutely cannot under any circumstances do that. - [Danny] For most of Jeff's life his career and hobby have been impossible tangled. And so for much of his life his identity has been too. For years his Xbox Gamertag was GameSpotting. He only changed it when he set up his new site, to GiantBombing. But since selling to CBS he's tried to create more distance between these two worlds. Jeff isn't the most social person you'll work with. He commutes to and from Petaluma every day, a 40 mile drive during bay area rush hour. Perhaps it's why he doesn't socialize much after work. Or maybe it's a convenient excuse to not have to. At his desk, he sits with headphones on, usually working on something. When he talks to you he speaks openly and honestly. When he doesn't want to talk, he doesn't. He's always struck me as a person who's gears are always turning, thinking about the work. Half enjoying it, half burdened by the weight of it all. He's tried to get better at delegating responsibility but in many ways Giant Bomb is his child and he feels like he needs to be in the room when decisions about it are being made. - [Jeff] For me that's the struggle. Like my personal struggle is like the time management aspect of it and like keeping everything going. Because before I had other things going on in my life you could throw as much waking time as you could at a thing and also we owned the company. It was a sick cycle where in the back of your head you could always say like, well I need to work until three a.m. because this could be the video that puts us over the edge and turns this thing into an even bigger thing. And so it was very easy to justify to yourself incredibly unhealthy work habits that didn't make the site better, that didn't lead to necessarily more content or anything like that, it was just it was very easy to spend every waking moment thinking about it. And now I don't and at first that made me feel guilty, yeah, that's the weird struggle of just like, it's all just kind of a weird head trip. And the worrying goes from like, am I spending enough time with my family, am I spending enough time with my job, this seems like stuff that everyone else figured out a long time ago but I'm coming to it over the last few years and going like, man, this is an interesting new challenge. But it's been great, I wouldn't, if it wasn't for my wife I don't think I would, I'm not even sure if I would still be doing this, honestly. I probably would've completely burned out or something by now without her to kinda have my back and all that sorta stuff. Yeah, she's been great. She's the best thing that ever happened to me, totally. - [Danny] Trying to create a distance between life and work you're passionate about can often be a struggle. But it was impossible for the staff of Giant Bomb to do so in the summer of 2013. This July will mark the 6th year since the tragic passing of their friend and colleague Ryan Davis and in recent months it's been on Jeff's mind a lot more. Last year the site launched a 24 hour livestream that plays videos from throughout the 10 year archive of Giant Bomb and users often vote for videos that Ryan is featured in. So Jeff is confronted with the memory of their friendship a lot more these days. - [Jeff] You know, going back to those videos and stuff, the relationship that Ryan and I had was very complicated and changed a lot over the years because, you know, we were close friends, we were in a band, we were inseparable, I got him hired, we became coworkers, I became his boss. And so the relationship changed along the way too. So yeah, I don't know, when I think about Ryan I think about the days before were working together, primarily. Those are my Ryan memories, usually. The videos, the stuff we did along the way, yeah, we did some really cool shit and I like a lot of it just fine, but me personally, I think about the stuff prior to, when Ryan was answering phones for AT and T internet at three in the morning when people couldn't get into their email, that's the Ryan I think of. The Ryan that was living with three other guys in this tiny ass place and we'd just go hang out and he wasn't 21 yet so I was indispensable. Like that sort of stuff, that's the stuff I think about when I think about Ryan. - [Danny] When I asked Jeff about the future of Giant Bomb he's excited, but cautious. Years of working on the internet has taught him to be careful about over-promising before stuff is built. Perhaps his experiences have also taught him not to plan too far ahead. As the site enters its 11th year its been changing its programming to try and bring in new viewers. Giant Bomb has been successful, it pays its own way at CBS, but it's still a website owned by a large media organization, so often the future is planned quarter by quarter, year by year. Perhaps the most surprising thing in coming to know Jeff, is how excited he still is about games. His Twitter profile reads "I've been writing about "video games my entire life. "It would be insane to stop now." So you wouldn't blame him for being burned out on video games after 30 plus years of talking about them. But if nothing else, the thing that strikes me about Jeff Gerstmann is that these days when you can be so cynical about video games he's still a true believer in the power of the medium, whether it be players of Pac-Man or Fortnite. - [Jeff] I think games are only gonna continue to get more popular. If you look at what we're seeing with something like Fortnite right now. Like, it's having a moment that, that Minecraft had before it. It's huge, it's bigger than a Five Nights at Freddy's, it's crazy. But like I'm just trying to think about like, you know, games that have penetrated the mainstream in a huge way. What we're seeing with Fortnite right now feels almost unprecedented. It's Pac-Man esque. You know, like Minecraft was huge, but not in a, like kids loved Minecraft, kids love Roblox, but Fortnite is cut such a wide swathe across society to where it's like all these popular mainstream sports figures are now doing Fortnite dances in actual sports and it's never been like that before. So in some ways like, gaming has kind of never been cooler or less cool depending on your perspective. Because it's literally everywhere. You know, everyone is carrying around a device in their pocket that is capable of feats that like it would've been insane, no console 10 years ago could've done anything like this. Granted, the controls are still bad. The technology is pushed so far forward and it's so pervasive and in so many different places and in so many different styles. You look at like Pokemon Go and the idea of location based gaming, you know, people getting out there and moving around to catch Pokemon, like all that stuff is amazing and it's crazy. But like where we're going on that front, I think if the technology bears out and data caps don't kill the dream and all this other stuff, we're gonna reach a point where anyone can play top level video games on the device they carry around with them every single day. And in some cases they are, I mean, Fortnite's on phones for whatever that's worth. So I think that this isn't gonna go away, this is gaming's kind of big push into the mainstream kind of once and for all. And I think that games coverage, that's a more complicated thing. If you look at YouTube right now with demonetizing videos and everyone trying to stream and everyone trying to have a side hustle streaming or something like that. Kids growing up like commentating games as they're playing 'em because they just watch people on YouTube and they think that's how you're supposed to play games. That's it, that's where we're going, or that's where we are already. And so I think over the next five years it'll be tumultuous because I think you'll see the bottom drop out of ads in a way that makes the Twitch streaming and YouTube and like the kinda hobbyist turned pro streamer, I think that that's gonna have to even out. I think it's only gonna get harder and I think that will keep a lot of people out eventually, or it'll lead to a growth in just the hobbyist streaming and people will have different expectations. They'll just be like, I'm streaming 'cause I like it, I'm not gonna sit here and think I'm gonna make a bunch of money. The same way I made public access when I was 16, it's like, oh, we're on television. Like I'm not making any money off of it the way real people on TV do but I just wanna do it 'cause it's fun. - [Danny] Thank you so much for listening to this episode of the Noclip Podcast. Sorry it took so long to get this one out, it was quite a long story and it's also kind of an impossible story to tell in its entirety so I had to pick my battles and figure out a narrative that kind of worked. I hope you enjoyed it and I hope it was nice piece to celebrate a website that means a lot to me and I'm sure a lot to you as well. Now for the housekeeping, if you wanna follow us on Twitter we are @Noclipvideo, I am @dannyodwyer, we have r/noclip if you're interested in getting on board and talking on Reddit and of course if you're a Patron keep up to date on all the Patreon posts. Podcasts are available on iTunes, Spotify, Stitcher, Google Play, and loads of other places anywhere podcasts are sold basically. We also have a YouTube channel where you can watch the podcast. That's Youtube.com/Noclippodcast. If you didn't know, we also make documentaries about video games, those are available for free with no advertising at Youtube.com/noclipvideo. Patrons get this show early for 5$ a month, if you're interested in supporting our work please head over to Patreon.com/noclip. And that's the podcast for another episode. We are actually at the Game Developers Conference in San Francisco right now recording bunches of interviews which will be going up on the channel in the next couple of weeks. But we'll be back with another podcast in the not too distant future so make sure you hit that subscribe. We've never actually asked people to rate it, so if you're listening now and you're still listening at the end of this podcast, hey, why not rate us? Thank you so much for listening, we'll see you next time.
The show opens with Jeff talking about turning in the manuscript for new/revised edition of Hat Trick. The guys also talk about Captain Marvel. Will reviews Wanted-Bad Boyfriend by TA Moore and IRL: In Real Life by Lucy Lennox and Molly Maddox. Jeff reviews Diversion by Eden Winters. Jason T. Gaffney and Kevin Held join Jeff & Will to discuss their new movie project, the romantic comedy/paranormal themed Out of Body. They recorded the audiobook of the novelization, which was written by Suzanne Brockmann. We also find out about their history-based podcast, The Bright Side with Kevin and Jason. Complete shownotes for episode 180 are at BigGayFictionPodcast.com. Book Reviews Here’s the text of this week’s book reviews: Diversion by Eden Winters, narrated by Darcy Stark. Reviewed by Jeff Eden Winters Diversion series has been recommended to me for some time now and I finally took the leap. This first book was first published in 2012 but just came out in audio in October 2018 with narration from new to me voice artist Darcy Stark, who does a great job with both the suspense and romance. This enemies-to-lovers, workplace romantic suspense story centers on agents for the Southeastern Narcotics Bureau, Richmond “Lucky” Lucklighter and Bo Schollenberger. Lucky’s nearing the end of his forced stint on the job–forced as it was his way out of jail. Bo is new and eager, but is also at the job because of incidents in his past. They end up working together to bring down a ring of drug diversion and insurance fraud that involves a doctor, a drug manufacturer and a drug destruction company. I fell in love with gruff, no nonsense Lucky right away. He’s extremely good at his job, mostly because he used to be on the other side of the law. He exudes frustration and irritation at what he has to do and why and yet there’s a teddy bear in there too because he cares about getting the job done right. The friction that’s stirred up when Lucky’s saddled with mentoring Bo is sublime. Lucky’s looking to ride a desk during his last few weeks at the bureau, but his boss has other ideas. Bo’s very green in terms of what he has to do here–but he is ex-military so he’s no pushover either. He can take what Lucky dishes out and it pisses the senior agent off… and eventually Bo gives back as good as he gets. The friction gets explosive as Lucky battles with himself about the feelings he develops for Bo. The other thing the friction brings is a ton of humor. Lucky and Bo know how to push each other’s buttons–whether it’s blasting Billy Ray Cyrus, forcing healthy eating habits or being messy. It’s a wonderful odd couple pairing that morphs in a beautiful way as it becomes less about antagonizing and more about a sweet nudging of one another to just maybe move things to another level in their relationships. Both men have complicated backstories that make you feel for even more for them. Lucky ended up at the bureau after going to prison for the part he played in a large scale drug operation. He’d been in love with the guy behind that operation and when it all came crashing down Lucky was sure he wanted no part of loving anyone again. The pain Eden created for Lucky is devastating, which makes him all the more loveable when he’s able to come out of his shell. Bo did illegal things to help an ex and ended up taking illegal substances to the point that it’s very difficult for him to be around the drugs in a Pharmacy, which his job requires. There’s also abuse in his past and Lucky’s careful to keep Bo away from triggers as much as he can. The lengths he goes to keep Bo feeling safe are extremely sweet. Eden takes great care in how backstory is presented. Once the men get past their posturing and disdain for each other, they peel back they reveal themselves in a very natural way–as friends, coworkers and eventually lovers do. The good and bad are offered in equal measure and it’s perfect relationship development. The only thing I wanted in this story that I didn’t get was Bo’s point of view. I would’ve loved to know what was rattling around in his head. Not to take away from Lucky though as he was quite the good narrator and this one point doesn’t take away from my love of the book. The Diversion series is up to book seven as of January 2019–with the third book released in audio in February 2019–so I’ve got some catching up to do. I’m looking very forward to that. IRL: In Real Life by Lucy Lennox & Molly Maddox. Reviewed by Will In Real Life combines the classic alpha billionaire character trope with the time-honored scenario of two characters who are combative in real life, but are secretly corresponding with one another and falling in love. Which is the long-winded way of saying it’s a similar set up as the classic movies Shop Around the Corner, You’ve Got Mail, In the Good Old Summertime, and the musical She Loves Me. The way that the characters write to each other has changed and evolved, but the premise remains the same. There’s also hints of enemies to lovers and opposites attract. This book is ripe with tropey goodness. So what’s it all about you might ask? Nice guy geek Conor is in New York to sell his mother’s bio-med technology to a ruthless CEO. The evening before his big presentation he decides to live a little and begins sexting with who he thinks is the sexy hotel bartender. It’s not. The text exchange he ends up having with a stranger, who he calls Trace, is amazing, and through several flirtatious and super-hot online conversations, they begin a fling. At the meeting the next morning, Wells Grange recognizes Conor thanks to the Dalek tie he is wearing. Conor is the hot and horny guy he sexted with the night before. His first inclination is to use this information as leverage in their business negotiations. But Wells quickly begins to fall for Conor, both the sexy online version and the awkward real-life version. As they work through the contracts for the sale, Wells continues his deception. They spend several days together and get to know one another, Conor unaware that Wells and Trace are the same person. We follow our heroes, almost in real time, as they fall in love while working together, going out to dinner, and taking carriage rides in Central Park. Once the business deal is finalized, Wells and Conor finally give in to their attraction and sleep with each other. Needless to say, it’s amazing and life altering for both of them. But, as is the case in stories like these, Conor finally puts two and two together before Wells can come clean about his sexting alter ego. Conor is humiliated and justifiably furious. He packs his bags and returns to North Carolina, with zero intention of ever speaking to Wells again. And rightly so. I’m going to be super upfront with you guys, there are certain aspects of the billionaire trope that I personally find problematic. I was on board with Wells and Conor for most of the story, but there were moments when I had a hard time dealing with certain aspects of Wells’ alphahole personality. In my view, if the ending of this book was going to be believable, Wells was going to have to move mountains and pull off one of the biggest mea culpas in romance history. It may not have been the biggest, but Lucy Lennox and Molly Maddox crafted a finale that was truly heartfelt and genuinely appropriate for our two heroes. To make amends, Wells makes sure Conor’s sick mom is well taken care of and part of an experimental treatment program (her illness was the reason they needed the money from the business deal). Later, when Conor is unable to attend a Comic convention to unveil an important new development in his gaming business, Wells steps in, and personally gives a rousing presentation on Conor’s behalf. Wells proves he isn’t the billionaire alphahole he seems. Yea for true love and happily-ever-afters! Interview Transcript Jeff: Welcome back to the show, Jason and Kevin. Kevin: Thank you. Jason: Hello. Thank you. Kevin: Nice to be back. How you been? Jeff: Awesome. Jeff: Well, we had you on before, we were talking all about “Analysis Paralysis.” But you guys have a lot more going on besides that movie. You’re actually in pre-production right now on a film called “Out of Body.” Jason: Yeah. Jeff: Tell us what that one’s about. Jason: So “Out of Body” is basically a story where it’s a friends-to-lover rom-com. And basically, Malcolm, who’s Kevin’s character, has his body stolen from him and he kind of ends up as a spirit for a while. And he has to prove that he exists to me, Henry, and then when that finally happens, we do some magic, we fight some demons, we might get the body back, there’s definitely a happily ever after because it’s a rom-com. Kevin: You and your end happily-ever-afters. Jason: Yeah. Jeff: It’s important. Kevin: I know, I know. But I just want to the rom…just one time I want a rom-com to be…it’s mostly romantic and funny but everyone does die. Jason: Or they die hilariously. Kevin: It’s a rom-com drama. Jason: Death by rubber chicken. Jeff: And what was kind of the inspiration behind this movie this time? Jason: I don’t even know how this idea came in my head. But I was sleeping one day and I woke up and I was like, “Oh, that’d be really cool. A movie where someone’s dead but they wanted to be together but then they didn’t get to be together. And then they have to fight to get their body back and come back to life.” And so I wrote a kind of a similar but different kind of script. And we did a table read, and my mom was a part of the table read. And she was like, “I love the story you have here. Can I take it and can I change a lot of it and make it like super romance with the comedy?” And so this particular movie and book and audiobook is definitely heavier on the romance than the comedy, as opposed to “Analysis Paralysis.” But it’s, in my opinion, really, really good because the romance really makes…it’s gripping, it really gets you right in the heartstrings. And she basically saw what I was going for and was able to finesse it and really kind of mold it into what my kind of original vision was and then some. So I’m really psyched about it. It’s got a little bit of everything. Will: Yeah, not too long ago, I talked about the novelization of “Out of Body” here on the show. Jason, your mom, Suzanne Brockmann, of course, wrote that novelization, it was rather amusing. Like, I think in the forward she kind of does like a behind the scenes thing where she kind of tells that story where she says, “Jason, this is great. But do you mind if I take it and make it better?” Kevin: Yeah. Jason: Yeah. And here’s the thing, I am all about that. Like the filmmaking, it’s such a collaborative process and storytelling can be a really collaborative process. And I want to make good movies. And so I was really happy with the script that I had written, but when someone who’s as great of a writer as my mom is comes and says, “I want to have fun with this and let me just see what I can do with it,” I’m like, “Hell yeah. Take it. Have at it.” Yeah. Kevin: And the end result is really a script, a novel, and a script that really looks like if brilliant improviser and plot maker and gay comedy guy let his script be taken over by a bestselling romance novelist, what would happen, it would be this. You know. And so it’s really got great, great aspects of all of those elements. Will: Yeah, I really enjoyed the book and the audiobook as well. And I think it’s a really unique opportunity for people who are interested in “Out of Body,” the movie, to check out the audiobook and sort of, it’s essentially like a preview of what they’re going to be getting when the film comes out to the public. Can you give us a little bit of an idea about what it was like to kind of get into the material early before you even like were thinking about shooting by recording the audiobook? Kevin: I can tell you for my part, like, since I’m not one of the writers on this, which is, you know, traditional for me because I’m not usually the writer on a project that I’m acting in. But it’s completely unprecedented to have a novel that you get to perform about the thing before you even film the script. You know, so we get…like as an actor, it’s a freaking dream because I have…so you know how actors have to create subtext and everything, I just have to go to the book, you know, it’s like, “Don’t worry. I don’t have to make it.” It’s already been written down for me. So if I’m wondering, like, what’s happening for Malcolm now, what’s going on there? What’s the deep, deep part of it? It’s already written out for me now. So I would say, so the book is available. It’s on, it’s called “Out of Body.” It’s on Audible.com. And I would say, don’t deprive yourself of the opportunity to say the book was better. Jason: Yeah. And, you know, it was really cool to do the audiobook in general because it was our first audiobook for both of us as narrators. And when we were talking about doing it, we were talking with my mom about it and I was interested in the idea of recording it in a way where it was more like a radio show where we are our characters’ dialogue voices all the time, even if it’s in the other person’s point of view. Whoever’s point of view reads the descriptive stuff in the chapters. But if Malcolm’s speaking, even though I’m the narrator of that chapter, he still says his line, and he still says the lines of the other characters that he had been assigned and vice versa for me. And that was really kind of fun to do because, you know, how often do you get to do kind of a radio show acting gig? And it was also really fun for me as a director to get to do this with Kevin in advance, because, like, he now really knows the story and I know he knows the story. So I know that when he comes to set, that’s going to be really easy. And I got into the head of the other characters as well reading them, and that’ll help me be able to hold my other actors hands and kind of with them through their parts, and still allow them to bring what they want to bring to the role and have it blossom into how great it can be. Kevin: Yeah, and that’s like all separate and apart from the experience of actually recording the audiobook, which you might think was done him some and then me some on consecutive days or anything, but it was actually live together. So we actually recorded in a space that had two recording booths in it. We could both hear each other so that when I am narrating a section and it’s his line, I can hear him do it. And then I jump back in. So it was live editing, like, to take out any breaths or anything, or mess-ups or anything, so, but we got to…you know, it was amazing because I had him in my head the whole time doing it, too. So that was wonderful. It’s a great experience. Jeff: That’s amazing, especially how it connected to your even now pre-production process that you’re involved in because you’re getting ready to shoot in about a month from when we’re recording. In pre-production, give everybody kind of an idea of what that means. What’s going on as you get ready for your 12 days of shooting? Jason: So basically, what I just did was go through each of the scenes and break them up on a piece of paper so that now I have the page count number, like how many pages each scene is. Kevin: These are them. Jason: Oh, yeah. Little strip paper… Kevin: Each one of these is a scene. Jason: And basically, the page count, when it starts, who is in the scene, all that stuff. Because I need to…you know I don’t have every actor every day. I’m going to have Kevin every day because he’s one of the leads. But there’s other parts in it where they’re only going to film for one day…anywhere from one to three days. And so you have to plan their scenes on the same day. And this time, we’re going to actually be filming in two different locations because our neighbors next door sold their house to flippers and they’re doing construction and it’s been kind of never-ending. So we can’t film when there’s kind of heavy construction going on in this house. So we’re going to do a lot of stuff at my father in law’s house and then will come get the rest of it after they’re done here. And so I’ve been doing that with my dad and breaking it into those days while simultaneously working with my cinematographer Nacia to map out which shots are needed for each scene and what angles are we doing. So I put little maps on the other side of the table here. Basically, me drawing out the room layout and doing little circles with an M for Malcolm and an H or Henry, and the arrows pointing they go here and then they go here… Kevin: Oh my god. And this isn’t even talking about how to deal with SAG paperwork or any of the art direction that he’s doing, or any of the clearances that he’s getting for this or that kind of thing. Jason: We’ve got a, we’re going to have a… Kevin: He’s a bit of a doer. Jason: We got Andrew Christian giving us underwear… Kevin: Oh, yeah, we have Andrew Christian underwear over here. Jason: And I’m working with some other companies too. So Outfit is a gay like sports good wear, they’ve given me a patent to us for the movie. Kevin: He’s been stenciling t-shirts and… Jason: Hand design t-shirts specific to the characters. I’m going to be making him a specific shirt three times because he wears the same outfit the whole movie and so if anything spills on it, it’s got to be good and not spilled upon because he magically can’t get stains. And so it’s intense, there’s a lot going on. Like Pinterest is my best friend. I’ve been learning all about how to make DIY Halloween decorations. Because again, when you’re low budget, you can’t spend, you know, $3,000 on set design. You can spend like $200, and so you have to get a little crafty. You have to start thinking like, “Okay, I’ve got five pages of construction paper and a pair of scissors and some tape, how going to make this look like I spent a lot of money on it?” Kevin: He’s like MacGyver. So that’s his experience with pre-production, mine’s a little bit different because I’m not all the hyphenates. So I’m busy making no changes at all to my daily routine. Jeff: You do have a script to learn. Kevin: Sure, when I get it. Jason: It’s in the mail. Kevin: We’re at your house. Jeff: Oh my goodness. Jason: The creating part, like creating the artwork, it actually makes me feel calm. The paperwork stresses me out. And so Matt, thankfully, jumps on that grenade and deals with SAG-AFTRA and making sure that all the paperwork’s there and all the money is in the right place and all that stuff. So thank you, Matt. Jeff: Now, we should say Matt is your husband, so he’s in the production family. Jason: Yes. Kevin: Yeah. Will: So now that our listeners know how completely awesome and funny this project is going to be, can you give us a little bit of info about the Indiegogo campaign? Jason: We have an Indiegogo campaign, basically we crowd-funded “Out of Body” on Kickstarter first, a successful crowdfunding campaign last year. and Indiegogo came to us and said, “We’d like to do an in-demand campaign for you.” So we have an open-ended campaign on Indiegogo right now, where you can help sponsor the film help and get some fabulous rewards, such as DVDs of “Out of Body” when it finally is all finished, you can get DVDs of “Analysis Paralysis,” our last feature film. Kevin: I’m going to get these down from the thingy here. Jason: So you can show people. Kevin: You can actually, because now we’re in the second feature film that stars the two of us. Like we got other projects that I have to do with like if you’re your fans of “Analysis Paralysis,” or perhaps the audiobook of “Out of Body,” you can get these copies, you can get copies of all that stuff. And so as we are on the way to becoming things of all media. Jason: Yeah, exactly. And yeah, so if you go to indiegogo.com and you go, indiegogo.com/projects/out-of-body-a-feature-length-lgbtq-rom-com-movie/, it’s a very long title. Kevin: Really, why don’t you go to indiegogo.com and search “Out of Body.” Yes. Jeff: Or just come to our show notes, it’ll be much easier. Will: Yes, do that. Kevin: Exactly. Go to “Big Gay Podcast” website and it’s going to be in the show notes. Jason: Another place you can find out information about “Out of Body” in the future and any sort of campaigns we’re having, etc., is if you go to tinyletter.com/mypethippo and join our newsletter, you’ll be able to find out things about “Analysis Paralysis” or “Out of Body,” or our podcast, “The Bright Side with Kevin and Jason,” all sorts of fun stuff. And yeah, so and basically indie film, it’s low budget. So every dollar really does make a difference. Like if we get enough money to buy a better meal for the cast and crew, everybody’s spirits raised, it gets raised up a little higher, you know, or we can afford an extra day of filming, or we can afford…it really does matter. So thank you to everyone who has supported us so far. And thank you to everyone who comes and supports us after this. Kevin: Yes, indeed. Jeff: Now, Kevin had this wonderful term about you guys, you know, essentially taking over media. You mentioned the podcast, “The Bright Side with Kevin and Jason.” It’s a comedy podcast about history. How did this idea spark? Because this just adds to you, I imagine, having to research these historical things. Kevin: Now, Jason does all the research for this, you know, and that’s huge. Like, because basically, he doesn’t have enough to do. But the impetus for the podcast, which is “The Bright Side with Kevin and Jason” is, you know, there’s so much bad news all the time. And my mom taught me how to look on the bright side of stuff, you know. If I got one thing from my mom, it was to…I would always complain about this or that and she would constantly remind me of there’s something good here, you know, and you have to find that. And so that’s really the gem of this, it’s really the heart of that show is that, especially when you look around at the news right now, there’s so much bad stuff that is going on. But you have to also recognize that bad stuff creates the opposite reaction. And so who is making the good out of that? You know, who is looking at that and reacting to it in a way of love, or in a way of furthering acceptance, or you know, who’s looking at the transgender ban, for example, that was finally instituted by the Supreme Court? And who is saying, you know, I want to reach out and tell my trans brothers and sisters that you are people and you are valuable and your service is useful and we love you? You know, so who’s doing that? You know, and so that’s what the podcast really kind of focuses on. We do wallow in some tragedy on the podcast because every week we take a historical episode of some varying degree of tragic-ness and talk about it. But then we also, every episode, find out what good that led to. Jason: And it kind of came about a long time ago after “Analysis Paralysis,” like Kevin mentioned in the last episode, we talked a little bit about how we met on a student film and basically got along really well, really quickly, and then we started hanging out together with our husbands and going on double dates, and so it kind of formed this bond. And after “Analysis Paralysis,” which was so much fun, it was 10 days of basically seeing Kevin and laughing and having a good time, I was like, “I don’t want to wait a year-and-a-half for the next project. I want to do something now with you.” Kevin: The experience of just chatting about a topic on a set or something was so much fun and we thought, “We should bottle this.” And then we thought, “You can.” There’s a method for this that’s called a podcast, and that’s what started. Yeah, you know, so now I get to come over here every damn week. Jason: Yeah, come to the Valley. You’re welcome. Kevin: Yeah, when I moved to Westwood I was hoping that my second bedroom would be a good place to record. But it’s not, it’s not good. Too much noise there. The valley’s a lot of things, but it is quiet. Jason: It is quiet. Unless they’re doing construction next door. Kevin: Right. Jeff: You could just turn that second bedroom into a soundproof area. Kevin: No, actually, currently, we didn’t have any…we moved from a house that had a lot of storage into a house that had another bedroom, but no storage. So that second bedroom has just become basically the id of our house. You know, everything’s like ahhhhh, you know? Jason: It’s like in “Harry Potter,” what’s that closet? Kevin: The room of requirements? Jason: Yes. Kevin: It’s the room of please don’t go in there actually. Will: Now, guys, I’m curious. How do you choose which historical events to feature and how much research goes into each episode? Kevin: That’s 100% question for Jason because though I feel that the podcast is a 50/50 pursuit, because Jason does all of the research for the topics that we do, and I don’t ever know what we’re going to talk about until I get here, but then I do all the web mastering and editing and I put up the shownotes and I do all of that stuff. So I feel like we end up spending around the same amount of time on things. Jason: Yeah. So basically, generally about a day of work I kind of surf the web, I find a topic that…like I kind of search, you know, the rabbit hole as to like what kind of weird historical thing is this? And I’ll like Google really weird stuff so my search history… Kevin: Yeah, they’re coming for you. Jason: …completely messed at this point. But like, you know, I’ll look up like “wild strikes historical funny” to see what I get from it. But honestly, there’s been a ton of them I’ve gotten through recommendations of friends and family and listeners of the podcast, and we really encourage listeners to throw ideas at us because there’s some really obscure events in history that I don’t know about that I would love to know about and I could easily find it if I knew to search for it. And so if anyone out there listening has weird events, definitely tweet me or email me. Kevin: You can find him @jasontgaffney on Twitter, and tell him and I don’t want to know about it. Jeff: That’s right. Kevin has to stay in the dark. Kevin: Right. Jason: So what I look for also, I try to look for topics where there’s a lot of tragedy, but you can still make fun of it. Like, if it’s a natural disaster, I try to find one where people made bad decisions with the natural disaster, not that it’s just, like, everyone got screwed and they tried to do the right thing, but they still got screwed because you can’t really make fun of those people. That’s just sad. Kevin: And mean. And it’s really not. I mean, I know we’re talking about a lot of tragedy, and that’s kind of what we focus on. But it’s not a cruel show. It’s not a Schadenfreude, really, because the ultimate goal is to find out what the hopeful aspect of it, who turned that situation into something good, you know. Jason: And you’d be surprised, like, we generally can find it. I don’t think we found one yet where there’s really nothing, no bright side to it. Kevin: No. Because the arc of history is long and you never know what the end result of a pebble, you know, when a pebble goes into a puddle, you don’t know how farther in they’re going to go, you know, and so, like, we talked about that event but that could lead to something incredible later, you know. Jeff: For you, Kevin, since you come in cold to these, what’s been of the episode so far that you’re like, “What? What did I just hear?” Kevin: Oh, my God. Well, the “Empire” panic, for example, has been insane. Like, I have a feeling when I post the episodes, I have a feeling like I hope…My mom and I listened to the Christmas episode over Christmas. And at the end of it, she said, “That was funny and I learned some stuff.” So that’s what…it was like I was, “Oh, good. There we go.” That’s what I would like people to have from it. Is like, “Oh, I enjoyed that, you know, conversation. That was fun and stuff.” But also, “God, who knew?” Yeah, that’s amazing. Because he’s pretty good at this, every episode there’s gonna be some point where I’m like, “Are you kidding? Human beings did this,” you know? It’s always, “Yes, they did,” good Lord. Jason: It’s also it’s gotten way more fun to do the research than it initially was because I was really nervous the first couple episodes to like, “Oh, my God, is this going to be funny? How can I make this funny?” And I was trying a little like…we actually have a couple of episodes that just never aired because I was trying too hard as opposed to just seeing that, yeah, that was absurd. I don’t need to say anything except what they said. And now that I’ve kind of mastered that to a degree. I mean, I’ll keep getting better as time goes on. But now I can really see like as I’m reading stuff, I’ll be like, “Oh, I know that Kevin’s gonna hear that and go, ‘Stop it.'” And then he’s gonna call it out, call the absurdity of it. I don’t need to do anything except, say, like, you know, “And then she picked up the knife and stabbed her own foot.” And it’s like, “Why?” Kevin: Spoiler alert. Jeff: Did you have a knack for history before this, Jason? Or did this just kind of happen? Jason: So I’ve always loved history. I always love the idea of history. When I was actually a little kid, I used to play with blocks a lot. And it’s probably why I like being a producer and a storyteller. I used to have like this giant castle and a giant village and an army of bad guys and I acted out this soap opera for years with the royal family and all that. And I was fascinated with the Romanovs and stuff so I kind of like did a little spoof on them. And so I kind of created like my own worlds, and history and stuff. And so when I can find sites that tell historical stories like a story, which is what history should be told as because it essentially is our story, it’s really fun. It’s really exciting to read it and be like, “No, oh, my goodness, that person’s totally the villain.” And then you read a couple more paragraphs, and you’re like, “Oh, no, they’re misguided. They have a heart of gold. They didn’t know.” And then five pages later, you’re like, “No, they’re just a dick.” And it’s exciting, it’s riveting, it gets you on the of the edge of your seat constantly with how people just constantly mess up. And then occasionally, you have a hero who’s just like, actually a good person, you’re like, “What’s the catch?” So, yeah, you know, history is really fun, especially when it’s told with a fun storytelling lens because… Kevin: And I think that’s like the thrust of the podcast is also it’s about the topic, sure, but it’s also just about how Jason and I interact with each other. And we just have such a fun friendship. And I don’t mean that it’s fun from the inside. I hope it is, but it’s fun from the inside of it. So I have such a good time with him that whatever we’re talking about is going to be fun for me. Jeff: That’s awesome. So besides “Out of Body” and more podcast episodes, what else is coming up for you both? Kevin: I may never work again. Who knows? Jason: We’ve actually started writing the sequel to “Analysis Paralysis” with the hope of filming it at the end of the year, with the additional hope of trying to film it in Palm Springs. Kevin: First time hearing of that. Really? Jeff: Breaking news. Kevin: I love Palm Springs. Jason: We’re gonna do what we can to make it work. And it would require assistance from the Palm Springs community, sure, help house us and give us locations and stuff. Kevin: It’s gonna be all on the gondola. Only there. Jason: What gondola? Kevin: The gondola up to the mountain thing. Jason: Oh, yeah, that gondola. Kevin: The whole thing is set on the gondola. Jason: I was thinking like the gondola with a little stick… Kevin: Yeah, the canals in Palm Springs. Jason: But another thing that I’m actually working on is my dad and I wrote a couple of novellas that you can get on Amazon. Kevin: What are they called? Jeff: “California Comedy Series.” Jason: The “California Comedy Series.” Yes. And I wrote a version of “Fixing Frank” with the hopes to get that kind of ball rolling. And it’s definitely a film that requires a bigger budget than what we have right now. But I’m starting to get those wheels in motion for you know, movie four, five, six sometime in the near future. And so yeah, that’s kind of what I’m working on. Kevin: We keep cranking them out. If people will keep putting them on screens and things, we’ll keep making them. Jason: The goal is to make people laugh. I feel like that’s why I was put on Earth and I feel like that’s why you were put on Earth. Kevin: Well, yeah. I know am laughing whenever I see you so that’s probably true. Jeff: Do we get new “California Comedy” anytime soon? Jason: I have been talking about that with my dad, we actually have a couple that are in the works, it’s just trying to figure out when we have a good time to sit down and edit it. I think after “Out of Body,” I’ll be able to take a look back at one of them that we wrote a while ago and kind of tweak it because there were a couple of things that just never felt right. And so it’s just figuring out how to fix those kinds of plot holes. And then hopefully that’ll be on the market before the end of 2019. Jeff: Excellent. And Kevin, what about you, anything you want to throw out for people to keep an eye out for? Kevin: Super excited about the podcast, actually. You know, going into production on “Out of Body” is really, really exciting. I don’t have a lot of acting projects coming up after that, that I can think of right now. But that’s kind of the nature of acting projects. Jeff: Sure. Kevin: You know, and so the podcast is where you can find us weekly up until the end…and actually, we make announcements there about projects that do come up for us, you know, in the interim. So, you know, to be a loyal listener to the show would be the best way to find out about what’s new with us. You know. Jason: Oh, and I almost forgot. We’re going to try in some way whether it’s self-published or with some other company helping us, the goal is to turn the “California Comedy Series” into audiobooks as well, similar to “Out of Body.” Jeff: Oh, fantastic. So both of you voicing? Jason: Yeah, for two of them. One of them, the plan is to have my good friend David Singletary come in as the role of Mike since that role is African American. And my friend David Singletary is African American and I’m all about… Kevin: Kevin Held is very much not. Jason: I’m all about own voices reading parts and stuff like that. And he’s great. You’re going to love him. Kevin: He is great. I’m a little jealous, but I’m okay. Jeff: Well, guys, thank you so much for telling us about “Out of Body” and the podcast. We wish you much success with those. Jason: Well, thank you. Kevin: Well, much success with your own podcast, gentlemen. Jason: Thank you, yes.
Jeff Gustafson, known throughout the fishing World as Gussy, grew up on the shores of Lake of the Woods in Kenora, Ontario. At age 14 he guided his first paying client, and now fish's the BASS Master Elite tournament trail with an eye on winning the BASS Master Classic. Jeff is a prolific outdoor writer, professional photographer, and for six years hosted the TV show “Fishing with Gussy”. Jeff is the guest on this episode of Blue Fish Radio. With his customary good nature and humility, reveals the connection between hard work, having a conservation mind-set, and staying focused on your goals.LINK Here to hear the Blue Fish Radio episode with Jeff::For more about Jeff visit his website at:www.gussyoutdoors.com
Shownotes 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 tackling an incredibly important topic - evaluation and management of life threatening headaches in the Emergency Department. Nachi: Fear not, this will not simply be “who needs a head CT episode”; we’ll cover much more than that. Listen closely as this is an important topic, with huge consequences for mismanagement. Jeff: Absolutely. As some quick background - headaches account for 3% of all ED visits in the US, with 90% being benign primary headaches and less than 10% being secondary to other causes like vascular, infectious, or traumatic etiologies. It’s within these later 10% that we are looking for the red flag signs to identify the potentially life-threatening headaches. Nachi: And to do so, Dr. David Zodda and Dr. Amit Gupta, PD and APD at Hackensack University Medical and Trauma Center, and their colleague Dr. Gabrielle Procopio, a PharmD, have done a fantastic job parsing through the literature, which included over 500 abstracts, 89 full text articles, guidelines from ACEP and the American Academy of Neurology, as well as canadian and european neurology guidelines, to summarize the best evidence based recommendations for you all. Jeff: We would be remiss to not also mention Dr. Mert Erogul of Maimonides Medical Center and Dr. Steven Godwin, Chair of Emergency Medicine at the University of Florida College of Medicine. Nachi: Alright, so let’s get started with some definitions and pathophysiology. The international classification of headache disorders 3, or ICHD-3, classifies headaches into primary, secondary, and cranial neuropathies. Jeff: Primary headache disorders include migraine, tension, and cluster headaches. Secondary headaches include those secondary to vascular disorders, traumatic disorders, and disorders in hemostasis. These are the potentially life threatening headaches that can have a mortality has high as 50%. Nachi: And the final category includes cranial neuropathies, such as trigeminal neuralgia. Jeff: And I think we can safely say that that wraps up our discussion in this episode on cranial neuropathies, moving on…. Nachi: Headaches result from traction to or irritation of the meninges and blood vessels, which are the only innervated central nervous system structures. Activation of specific nerve ganglion complexes by neuropeptides like -- substance P and calcitonin gene-related peptide -- are thought to contribute to head pain. Jeff: It is important to note that all headache pain shares common pain pathways, thus response to pain medications does not exclude potential life threatening secondary causes of headache. This led to the ACEP guideline which states just that.. Nachi: I feel like that deserves ding sound as it's a critically important point. To repeat, just because a pain medication relieves a headache, that does not exclude dangerous secondary causes! Jeff: And what are the life threatening headaches? Life-threatening headaches include subarachnoid hemorrhage, cervical Artery Dissection, which includes both vertebral Artery Dissection and carotid artery dissection, cerebral Venous Thrombosis, idiopathic intracranial hypertension, giant cell arteritis, and posterior reversible encephalopathy syndrome, or PRES. Nachi: Slow down for a second and let’s not skip over your favorite section.. Let’s talk pre hospital care for headache patients. Jeff: Good call! Pre-hospital care is fairly straightforward and includes a primary survey, conducting a focused neurologic exam, and assessing for red flag signs, which include focal neurologic deficits, sudden onset headache, new headache in those over 50, neck pain or stiffness, changes in visual Acuity, fever or immunocompromised State, history of malignancy, pregnancy or postpartum status, syncope, and seizure. That’s quite a list. For a visual reference, see Table 3 in the print issue. Nachi: And patients with neurologic deficits or severe sudden-onset headaches, should be transported immediately to the nearest available stroke center. Tylenol should be offered for pain management. Avoid opioids and nsaids. Jeff: Upon arrival to the emergency department, history and physical should include your standard vitals, testing neurologic function, cranial nerve testing, head and neck exam, as well as a fundoscopic exam. As was the case for your pre-hospital colleagues, you should also assess for red flag signs for life-threatening headaches. Check out tables 2, 3, and 4 for more details here. Nachi: With respect to Vital Signs, in the setting of an acute headache, severe hypertension should prompt a search for signs of end-organ damage such as hypertensive encephalopathy, intracranial Hemorrhage, PRES, and preeclampsia in pregnant women. Additionally, fever, and especially fever and neck stiffness, should raise concern for CNS infection. Jeff: For your neurologic examination, make sure to include assessments of motor strength, coordination, reflexes, sensory function, and gait. Don't forget that lesions involving the anterior circulation, such as dysarthria, cognitive impairment, and Horner syndrome may be indicative of a carotid artery dissection, whereas dizziness, vision changes, and limb weakness may be due to a vertebral Artery Dissection. Nachi: And for cranial nerve testing - pay particular attention to cranial nerves 2, 3 and 6. For cranial nerve 2 - look out for an afferent pupillary defect, or a marcus-gunn pupil, which is seen in optic neuritis, giant cell artertitis, and central retinal artery occlusion. For CN3, oculomotor nerve palsies raise concern for a posterior communicating aneurysm and SAH. And lastly, CN6 palsies, which often presents with diplopia on lateral gaze , are often seen with intracranial idiopathic hypertension and cerebral venous thrombosis, in addition to impaired visual acuity, visual field defects, and tunnel vision. Jeff: For the head and neck exam, remember that a partial horner syndrome, with miosis and ptosis without anhidrosis, may be indicative of a cervical artery dissection. Unfortunately, if the patient presents acutely, their only complaint may be pain, as the neurologic sequelae may take days to develop. Nachi: Additionally, with respect to the head and neck exam, evaluate the patient for tenderness and beading along the temporal artery. Jeff: One review noted that temporal artery beading actually had the highest likelihood ratio for GCA, 4.6, whereas temporal artery tenderness only had a LR of 2.6 Nachi: And the last physical exam maneuver you should ideally perform is a fundoscopic exam for papilledema, which is often seen in IIH, malignant hypertension, and CVT. Jeff: Perfect so that rounds out the physical, next we have diagnostic studies. Most importantly, routine lab testing is typically of low utility in aiding in the diagnosis of headache. Nachi: Even ESR and CRP in the setting of possible giant cell arteritis have poor sensitivity and specificity to diagnose it. So even if the ESR and CRP are negative, if the suspicion for GCA is high enough, it should be treated and you should get a biopsy. Jeff: Do consider adding on a venous or arterial carboxyhemoglobin in the right clinical scenario, as CO poisoning represents an important cause of headache you wouldn’t want to miss. This is especially important at this time of year when heating systems are working overtime here in the states. Nachi: And hopefully you have a co-oximeter, so you can even check this non-invasively. Jeff: Interestingly, there may be a unique role for a d-dimer here as well. Several small studies have used the d-dimer to risk stratify patients with possible CVT. In one study a d-dimer level < 500 mcg/L had a 97% sensitivity and a negative predictive value of 99% - not bad! Nachi: Pretty impressive performance characteristics. I think that about wraps up lab work. Let’s talk radiology. Jeff: Though low yield, CT utilization is estimated at 2.5-10% of non-traumatic headaches. A non-con CT should be reserved for those with suspicion for an intracranial hemorrhage, while a contrast CT would be required in those in whom there is concern for an infectious process or space occupying lesion. Nachi: CT angio or MRI should be used in cases of possible cervical artery dissection. MRI also is the neuroimaging of choice for PRES, which is more sensitive for cerebral edema than CT. Jeff: Similarly, MRV is recommended in those with a concerning story for CVT. Nachi: To help guide your emergent neuroimaging utilization, ACEP suggests imaging in those with headache and an abnormal finding on neuro exam, those with new and sudden-onset severe headache, HIV positive patients with new headache, and those over 50 with a new headache. Jeff: With that in mind, let’s dive a bit deeper into the use of CT for SAH, a topic which doesn’t get a ding sound, but is certainly critically important. Recent literature have found that a CT within 6 hours of symptom onset has a sensitivity and specificity and negative predictive value of 100%. In addition, one 2016 study demonstrated a LR of 0.01 in those with a negative HCT within 6 hours. These are really important results because that means SAH is essentially ruled out with a negative study. Nachi: Unfortunately, the 2008 ACEP guideline and 2012 AHA guidelines still recommend a lumbar puncture in those being worked up for SAH. Luckily the ACEP guideline is currently being revised so your decision to forego the LP with a negative HCT in the first 6 hours will likely also be backed by ACEP in the near future. Jeff: That’s a nice transition into our next test - the LP. Since LP carries a risk of herniation, in those with signs of increased ICP, make sure to get appropriate neuroimaging before attempting the puncture. In those without signs of increased ICP, no imaging is necessary. Nachi: While the position in which the LP is performed doesn’t matter as much when ruling out infection or SAH, in those with suspected IIH, make sure to obtain an opening pressure with the patient lying in the lateral decubitus position. An opening pressure of greater than 25 is often seen in IIH. Jeff: And the LP in the setting of IIH is not only diagnostic but also potentially therapeutic, as the removal of 1 ml of CSF can lower the pressure by 1 cm of H20 and potentially relieve the patient’s symptoms. Nachi: Always rewarding to diagnose and treat simultaneously... Jeff: Absolutely. But back to the LP for SAH for a second or two. When evaluating for a subarachnoid hemorrhage, you’ll often note an opening pressure of greater than 20 with persistent RBC in all tubes. Nachi: While there are no RBC cutoffs, one study found no patients with a SAH with less than 100 RBC in the final tube. In contrast, greater than 10,000 RBC increased the odds by a factor of 6. In addition, one 2015 study found that patients without xanthrochromia and less than 2000 RBC were effectively ruled out of having a SAH with a combined sensitivity of 100% Jeff: Lots of 100% sensitivities and specificities being thrown around today, which is definitely not the norm. No complaints here, I’ll take it. Anyway, the last test to discuss is our good friend the ultrasound, specifically the ocular ultrasound. Nachi: Examining the optic nerve sheath 3 mm posterior to the globe, an optic nerve sheath diameter of 5 mm or greater is predictive of an ICP greater than 20. Jeff: Keep in mind that this may expedite the work up, though a normal diameter does not rule out increased ICP, so a head CT may still be indicated. Nachi: Alright, so we’ve talked a lot about testing, both lab and imaging, and we’ve mentioned a bunch of pathologies, but let’s spend a few minutes going over the specifics of each. Jeff: Let’s start with SAH. SAH account for 1% of all headache visits to the ED. Most nontraumatic SAH are caused by aneurysm rupture. A missed diagnosis of SAH can have a case-fatality rate as high as 50% Nachi: Although 75% of SAH patients report an abrupt onset, objective neck stiffness has the highest likelihood ratio of 6.6. Other important features include LOC, neurologic deficit, subjective neck stiffness, photophobia, and onset during exertion or intercourse. Jeff: Additionally, approximately 20% of patients with a SAH have warning signs of a sentinel bleed including headaches, cranial nerve palsies, neck pain, or nausea and vomiting. Nachi: In order to aid you in diagnosing a SAH, you should consider the ottawa SAH Rule which has a 100% sensitivity and a 15% specificity. To use this rule you must be between 15 and 40 with a GCS of 15 and present with a headache with maximal intensity within 1 hour of onset. If you meet those inclusion criteria, and you have no neurologic deficits, no neck pain or stiffness, no witnessed LOC, no onset during exertion, no limitation of neck flexion, and no thunderclap onset, you can essentially rule out a SAH. Jeff: While the ottawa SAH rule has been prospectively validated, know that this study has been challenged for its interobserver variability, but in any case it still provides helpful red flags to consider. If your patient is found to have a SAH, a CT angiogram and neurosurgical consultation should be considered immediately. Nachi: In addition to monitoring ABCs, early care involves the administration of analgesics and anti-emetics. Also consider elevating the head of the bed to 30 deg, which may also improve venous drainage and decrease ICP. Jeff: In terms of BP management, guidelines from the american stroke association recommend targeting a SBP of 160 with a titratable agent like nicardipine or clevidipine. Nachi: In addition, nimodipine, 60 mg q4h, should be given to those with aneurysmal SAH to improve outcomes. Jeff: and any role for anti-epileptics? Nachi: That’s controversial and the authors state it may be considered in the immediate post-hemorrhagic period and should be limited to a 3-7 day course with longer courses required in special populations. Jeff: The next pathology to discuss is cervical artery dissections, which account for 2% of all strokes and nearly 20% of strokes in those 50 and under. cervical artery dissections are most commonly due to trauma, but can occur spontaneously. Nachi: Risk factors include Ehlers-Danlos syndrome, osteogenesis imperfecta, and Marfan syndrome. Jeff: Regardless of the etiology, the management of cervical artery dissections is primarily medical with IV heparin followed by warfarin or a direct oral anticoagulant in those with extracranial dissections, and antiplatelet therapy like aspirin or clopidogrel in those with intracranial dissections. Nachi: Thanks to the CADISP study, we know there is no difference in mortality or neurologic outcome when choosing between antiplatelet therapy and anticoagulation. Jeff: Next we have cerebral venous thrombosis. This typically presents with a gradual onset headache. Though it can happen to anybody, cerebral venous thrombosis typically results from thrombotic disease. Nachi: Important risk factors include oral contraceptive use, pregnancy and postpartum states, Factor V Leiden deficiency, and lupus. Jeff: Treatment for CVT is controversial due to a high risk of hemorrhage and hemorrhagic transformation. According to the best available evidence, anticoagulation is the standard therapy with full dose anticoagulation of low-molecular weight heparin or heparin as a bridge to warfarin. Nachi: Yeah, it’s really a tough spot to be in as one third end up having some form of hemorrhage too…. Jeff: Perhaps yet another good place for shared decision making? Nachi: Honestly, it’s a good thought, but anticoagulation is the guideline recommendation, so I think that is likely the best route in this case. Jeff: Great point. Next we have idiopathic intracranial hypertension. This is typically associated with obese women of childbearing age. It may also be due to hypervitaminosis A from excessive dietary intake and even drugs like the retinoids used in treating dermatologic conditions and cancers. Nachi: idiopathic intracranial hypertension can be diagnosed by the modified dandy criteria which are found in table 8 on page 11. Let’s just run through the criteria. Jeff: The modified Dandy criteria for idiopathic intracranial hypertension include: signs and symptoms of increased ICP, no other neurologic abnormalities or altered level of consciousness, ICP > 20 on LP with normal CSF composition, neuroimaging without another etiology for intracranial hypertension, and lastly no other identified cause of intracranial hypertension. Nachi: And as we mentioned a few minutes ago, an LP can be both diagnostic and therapeutic, though the relief is likely temporary Jeff: For more permanent treatment, weight loss is the key. Acetazolamide, 250 mg to 500 BID is the first line pharmacotherapy. Combined with weight loss, acetazolamide and a low sodium diet has been shown to improve visual field function. Nachi: And if this fails, topiramate, furosemide, and in the worst case surgical options like CSF shunting, venous sinus stenting, and optic sheath fenestration are all options. Jeff: I imagine taking a diuretic for a headache could be a real hindrance on quality of life, though I suppose it’s better than risking vision loss or having a significant neurosurgery. Nachi: Agreed. Next we have giant cell arteritis. GCA is rare, with a prevalence of
Jeff Smith is the owner of Cannon CrossFit, a real estate investor, and leader of the TwoBrain Tinker program.In this episode, Jeff talks about his story, what it means to be a mentor, and what it means to help those in the Tinker Phase.Contact Jeff:Jeff.smith@twobrainbusiness.comTimeline:2:39 – Introduction with Jeff Smith11:30 – Joining Two Brain as a mentor13:09 – Joining the military, the motivation behind the decision15:31 – Jeff’s other business, real estate.17:14 – The importance of being a lifelong learner21:27 – The benefits of splitting up your day with a workout22:39 – How has a real estate investing led to becoming a better mentor26:12 – The importance of learning while mentoring someone else 29:53 – How to contact Jeff“For this reason, they must believe in the cause for which they are fighting. They must believe in the plan they are asked to execute, and most important, they must believe in and trust the leader they are asked to follow.”—Jocko Willink, Extreme Ownership: How U.S. Navy Seals Lead and WinFounder, Farmer, Tinker, ThiefIn the Great Information Age, we all have access to more knowledge than we can absorb, let alone act upon. And action is the only thing that matters. So what knowledge should entrepreneurs have? What action should they take? When?The modern problem for business owners isn’t lack of knowledge: it’s too much knowledge. It’s paralysis by analysis. It’s overwhelm.Entrepreneurs pass through four distinct phases as they first grow their business, and then their leadership. These phases are Founder, Farmer, Tinker and Thief.In the Founder Phase, the entrepreneur leaps off the cliff with his big idea. His goal is simple: to survive.The Founder Phase takes a heavy toll — physically exhausting, financially terrifying, and the largest strain on every personal relationship the Founder has. My job as mentor is to get the Founder out of the Founder Phase as quickly as possible. Many never survive this phase.The Farmer Phase starts when the entrepreneur begins the shift from self-employed to business owner. He’s hired his first employee, even if it’s a low-level role. He’s begun paying himself a little. But he’s probably still the face of the company. He’s probably still baking the donuts at 4am, then answering emails and making sales calls “when he can”. He’s still working in the business instead of working on the business. He’s busy being busy.The Farmer Phase is where 90% of entrepreneurs spend the entirety of their careers. They call themselves “owner-operators”, and most will never even retire from their business, let alone become wealthy.But some do. These are the Tinkers.A Tinker has built a business that runs itself. Now she’s trying to build another; or to duplicate her first success; or to take her first idea to a new market; or to start over with a new idea. If she’s not given new challenges, the Tinker will probably stick her hands in the machine, constantly “tweaking” her original business until it’s broken.My role as mentor to Tinkers is to help them identify the Next Big Project, and then keep them focused on it. I’ve never met a Tinker who didn’t have at least three Big Projects in mind. Free from their original business — and still making passive income from it — the Tinker’s greatest risk is killing the golden goose.The Tinker’s attention must shift from developing their first business to developing themselves as a leader. That means a plan for physical activity, mental acuity, and mental training. It means peer support: “It’s lonely at the top” describes the Tinker to a capital T. It means mentorship from someone who has successfully navigated the “valley of death” created by hiring a management layer for the first time.
Jeff Neumeister, Founder and CEO of Neumeister & Associates, joins us today to talk about cryptocurrency taxes, a confounding area of tax law (what isn’t?) and one that you should master if you are an investor in digital currency. Because what you don’t know could have an adverse impact on your pocketbook. That’s what happened to one U.S. college student in 2017 who invested $5,000 in Ethereum and somehow would up owing the IRS $400,000 in taxes. Yes, you stand to benefit greatly from understanding how the IRS views crypto (Hint: It’s in the same category as your house). And you’ll learn the cardinal rule of crypto taxation: The buck stops with you. This is specially important this year after the 2018 market crash since many investors are selling their cryptocurrency and fleeing the market, without full knowledge of the tsunami of capital gains liabilities that these transactions may be triggering. A forensic accountant by trade, Jeff brings great credibility to the task of walking us through the minefields of crypto taxes. He offers practical tips on everything from what constitutes a taxable event to what makes crypto taxes so challenging and how mined coins are taxed. That’s just a few of the questions Jeff answers in this episode. You’ll come away feeling a lot more confident about understanding your tax burden as you stagger into your tax prep marathon. Topics Covered in this Conversation with Jeff Neumeister What makes crypto taxes so challenging. What constitutes a taxable event? What is the difference between short-term and long-term gains? How are mined coins taxed? What happens if I give some coins as a gift, or someone gives me crypto? Do I have to pay tax on coins that were hacked? What happens if I lose some coins? What are the acceptable ways to report coin gains? What are the biggest obstacles to easily filing crypto taxes? Increasingly, there are charities that accept crypto. Is that something that would be helpful at tax time? How are exchanges doing in terms of making it easy for investors to file taxes? Can crypto losses be balanced against traditional fiat capital losses. What’s the craziest thing you’ve ever seen or heard with it comes to filing or not filing crypto taxes. Let’s step back a bit and look at the process involved - let’s look at two scenarios: Scenario A: Let’s say you are Sally Fey, a beginner investor in 2017 and you got all caught up in the buying and selling during the Bull Market and you didn’t track all the coins you traded across multiple exchanges nor did you jot down the buy/sell price for each transaction. Now your taxes are looming and you have your head in your hands. How do you regroup? Scenario B: Unlike Sally Fey, you are Matt Jones -- a beginner investor in 2019 and it’s a Bear Market and you’ve been told now is the time to buy. You’re starting with a clean slate. You’ve set up your exchange accounts, you are ready to trade. What’s good tax hygiene you should follow from Day One and on to Day 365 to simplify your tax headache for the year? Can you get away with NOT paying crypto taxes? What are the penalties for non-compliance? Any closing thoughts on how to make our crypto tax lives easier? Questions and Comments? chasingunicorns@gem.co Guest Contact Information Jeff Neumeister Website | LinkedIn | Twitter Resource Links: 3 Ways the IRS Is Taxing Cryptocurrencies Taxes and crypto Turning your 2018 Bitcoin and Crypto Losses into Tax Savings What You Don’t Know About Crypto Taxes Can Hurt You Tax Nightmare: Student Invested $5k in Ethereum & Now Owes $400k in Taxes 4 things to know about your cryptocurrency at tax time Year-End Tax Tips And Strategies For Cryptocurrency Investors IRS Guidelines Transcript: Interview with Jeff Neumeister Interview Recorded On: November 12 Topic: Crypto Taxes Chitra: Hello, and welcome to Running with Unicorns, your portal to the world of cryptocurrency. I'm Chitra Ragavan, Chief Strategy Officer at Gem. It's that time of year again, and your crypto taxes are looming. Here's what you can do about it. Our guest today is going to walk us through the ins and outs of crypto tax filing. Jeff Neumeister is CEO and Founder of Neumeister & Associates, an LA-based tax advisory firm with a growing practice in crypto taxes. Jeff, welcome to the program. Jeff: Thank you. Chitra: What makes filing crypto taxes so challenging? Jeff: It'd be probably because there are so many different things that are happening in the crypto world. It's not just mining coins or just trading coins, but there are forks, airdrops. There's just a lot happening. Because it's a new space, it's a lot that the taxing authorities are still trying to wrap their heads around. Chitra: Let's start with the basics. What constitutes a taxable event in cryptocurrency? Jeff: A taxable event is anything that results in a tax obligation or a potential tax obligation. That could be selling something, it could be generating income, it could be incurring a expense. Chitra: Is it different than in regular taxes? What are the differences and similarities? Jeff: It's similar in concept, except with cryptos there's just, again, so much more going on. Normally, if someone is just, say, a W2 earner, they have a paycheck, and that's the sole source of income that is subject to tax. With cryptos, however, if you're mining and trading in the ICO world, there's so many things that are happening that you're constantly subjected to different types of taxes. Chitra: One of the basic things one needs to know is short-term and long-term gains. How does that work? Jeff: Short-term gains just refer to anything, anytime you hold an asset or a piece of property for less than 12 months. Long-term is anything above that. Now, they also come along with different taxable rates. With long-term capital gains, it could be anywhere from 0 to 20%, so much better than what most of us pay with taxes for our income earnings. For short-term gains, it's anywhere from 10 to 37%. Short-term capital gains are essentially the same as ordinary income tax rates. Chitra: Let's look at different types of crypto and how they will be impacted by taxes. Let's start with if you're mining cryptocurrency. How do you account for those? Jeff: Mining's interesting, because it's kind of two things at once. When you mine a coin, or a fraction of a fraction of a coin, you're generating ordinary income, so whatever the value of the mined coin was, or fraction of a coin was, you have to pay ordinary income taxes on that. Then, that also establishes your cost basis in the coin that you now hold. If you do something else with it later on, trade it or sell it, you'll have capital gains on top of that. Chitra: Then, let's look at crypto gifts. If you get a gift of Bitcoin, or Ether, or EOS, how do you handle that when it comes to tax time? Jeff: If you're the receiver of a gift, then you just need to be aware of what the holder's or the donor's cost basis was. If they acquired something for, say, $100 and gave it to you, you need to make sure that you have that down in your records that your cost basis is $100. There's no tax owed on a gift received. However, if you're the gift giver, you might have to do a informational filing, a form 709. What that is is anytime you gift more, at least in 2018, more than $15,000, you have to file a form 709. You don't have to pay gift tax on that, but if you exceed your gift-giving of $5.6 million during the course of your lifetime, then you have to start paying gift taxes. Chitra: If only we could all be so lucky. Jeff: Right. Most of us will never have to worry about that, but make sure that you file a form 709, because there are penalties with not filing. Chitra: Then, can you give crypto to charity? I see that increasingly, there are a lot of, even the Red Cross and other organizations accepting crypto. When that happens, is that a good thing to do, when it comes to tax time? Obviously, it's a good thing to do in any case, but it probably helps with taxes, doesn't it? Jeff: Absolutely. It's just like any charitable contribution, except instead of giving clothes, or fiat, or artwork, or jewelry, you're giving cryptos, yeah. Chitra: It's taxed similarly? Jeff: Yes, mm-hmm (affirmative). Chitra: Then, if you're hacked, what happens? You're losing a bunch of coins because you got hacked. Do you have to pay taxes on that? Jeff: No, but you have to make sure that it's documented. It's the same thing as if someone came into your house and burglarized it, right? It's a casualty loss. That would be an itemized deduction. You have to make sure that you record those things. Chitra: What if you just lose your crypto? Like, they're on some exchange, you don't know where it is, or you've lost the password. Can they figure it out that you have this crypto? How do you account for the missing crypto? Jeff: That's a little bit more challenging. If you no longer have access, say, to your key, and you'll never obtain access, then that could be construed as a casualty loss, as well. If you just say, "I don't know which exchange it's on," hopefully that won't come up if you're audited, yeah. Chitra: And if you are? Jeff: Then, as long as you show a good faith effort in being consistent and transparent with taxing authorities, and they could see that you're not trying to hide anything, then you should be okay. Chitra: Do you hear of people that are trying to hide crypto by claiming losses, that they've lost it? Jeff: Some folks, yeah, yeah. More egregious than that, though, we've had, there was one gentleman that was seeking out a CPA, who made a little over 2.5 million in cryptos, and said, "No, I'm just not going to file. If they want the money, they have to come after me." Chitra: Did they? Jeff: Well, that's what's going to happen over the next couple years, yeah. The IRS has started mounting a task force specialist specifically to investigate cryptocurrency filings. Chitra: Is that going to be an easy task? Will they find people that are scofflaws? Jeff: They will absolutely find people, right? It's going to be interesting in the tax world for the next couple of years, and tax courts, people fighting them. Chitra: You're seeing a lot of new developments in tax filings, in tax law as a result of this? Jeff: Not yet. Really, they're just kind of testing the waters, now. The last, about a year ago, they started issuing subpoenas to exchanges, and they were winning, to get transaction records from them, so they could see what people are trading and how much people are earning, so they could compare that with individual tax returns, to find evidence of those that are evading their taxes. They're just starting to institute those audits now and will be taking these folks to tax court as needed. There's a lot of things that will come out of it, but it hasn't happened yet. Chitra: Because I think, particularly in the early days, there were probably a lot of people who weren't filing taxes. Is there like a statute of limitations, or does it matter if like 10 years ago you weren't filing taxes, and now the IRS is starting to think about this and starting to do these audits? Jeff: There is a statute. It's, generally speaking, three years from the date of which a filing was due, but that's only if it was an innocent mistake. If you're intentionally evading, there's no statute on that. Chitra: How do you report, typically, gains and losses? What's the process? Jeff: The process is usually, you want to have everything calculated, all the transactions. Coin for coin, coin for fiat, and those will be itemized on a form 8949, and summarized on a schedule D, which are attached to the tax returns. Chitra: Having done my crypto taxes this year, it's fairly complicated. It's just, you have to look at every single transaction. Talk a little bit about what that process is like. It's fascinating for me to see the level of detail and how you actually go about finding those records, if somebody hasn't kept those records, and being able to trace the flow of that currency from the exchange to your wallet, or if you're trading, you've got all of these multiple transactions that have taken place, hundreds, maybe thousands of them. Jeff: Yeah, it could get very complicated. That's why a lot of our clients have come to us, to help them untangle these complex array of transactions, ranging from, if they have a few hundred coins that they're trading across multiple years, you can end up having thousands and thousands of cost pulls, because you have to trace every single transaction to its cost basis. Its cost basis depend on whether you used FIFO, LIFO, or HIFO. Chitra: Explain that a little bit. Jeff: Sure, yeah. Those are the manners in which you inventory the cells of different coins. LIFO, last in, first out, that's saying, when you sell a coin, you go to the last time that you had acquired that coin, and you sell it out of that pool. If you're buying and selling coins all day long, go across multiple months, you have many cost pulls, even thousands or tens of thousands of cost pulls. FIFO, first in, first out, is where you sell your oldest coin. What that does is it will result in fewer long-term capital gains, but you're kind of eating up your tax obligation now, versus deferring it to later on. Chitra: Let's say I'm trading, okay? I'm on exchanges, and I'm trading. I'm not really thinking about ... It's not something you think during your trading process, right? It's something you do after the fact. I'm not thinking LIFO and FIFO when I'm like, "Let me find what's my oldest Bitcoin, and let me trade that for Ether." I'm just like, trading. Am I doing the right thing? Is this something you go after the fact, and start to look through it and make those calculations? Jeff: The easiest thing is to maintain good records, so that whoever, whether you're doing it yourself or outsourcing it to a professional like us, then they could go through those records a lot easier, because it does get complicated. As long as you have the information, it could be all untangled. Chitra: What's the largest number of transactions you've done, filing taxes, that you've seen? Thousands, hundreds of thousands? Jeff: Probably in the hundreds of thousands. I think our largest client had a little shy of 200,000 transactions across about 2.5 years. It was a lot. It took a massive amount of manpower, because there isn't a way to fully automate it, yet. We've established a proprietary method to semi-automate portions of it, but not the whole thing. There's still a lot of manual touches that have to be done to it. Chitra: Were you able to do it? Jeff: Yeah, yeah. We were able to untangle all of it. He had a massive tax obligation, but most importantly, it'll keep him compliant with the IRS. He had the cash, right? If you make a million dollars in cryptos, and if you have to pay a few hundred thousand in tax, you know, you're still coming out ahead. Chitra: This is true. What are some of the biggest obstacles today for average investors, when it comes to filing taxes? Jeff: I think having an understanding about how complex the tax aspect is with cryptos, if you're trading, mining, doing anything else. I think just being aware and mindful of that. Chitra: There's also the issue of documentation, right? For example, different exchanges can give you different levels of information about your trades, so at the end of the year, some exchanges will give you a lot of information. Other exchanges give you virtually no information. How do you start to do the detective work to find all of your records? Jeff: That's one of the tricky parts, yeah, because there isn't really any sort of regulation about what all the exchanges have to provide users. There's going to be, and it's moving that direction. For now, it's kind of up to the individual to maintain their own records. If the exchange only provides piecemeal stuff, or in the case of Bittrex that just up and deleted people's information, it's still your obligation to make sure that you're tracking things. Chitra: What happened in that instance where the information was deleted? Jeff: Well, they up and decided just to remove information. Chitra: This was an exchange? Jeff: Yeah, yeah, Bittrex. It's still the user's responsibility to maintain the records. The individuals that were subjected to that, had they downloaded their transactional information, let's say, every week or every month, they would have been okay, right, just in case something does happen to an exchange. That's something we advise our clients to do is don't wait till the end of the year to start pulling your information, even if you're using a CPA like us, right? Pull the information maybe once a month, just in case something happens. Chitra: That's interesting. That's something I've never thought to do. It's kind of surprising that they're allowed to even delete information. Is that going to change, in the future? Jeff: Yeah, there's definitely more pressure in regulation around what the exchanges are doing. Also, keep in mind that a lot of these are foreign exchanges, too, right? The IRS and the federal government only has so much control over what they do. Chitra: Because this is such a global flow of money. Jeff: Exactly. It's a global thing. Right. Chitra: How does the US government, or how is the US government attempting to get a handle on this? Do you feel like the government is kind of playing catch up, now? Jeff: A bit, yeah. I think there was too much downtime from 2014 to now. You know, the last time the IRS issued any formal guidance was in 2014. Chitra: What was that initial guidance? Jeff: It was maybe like a five-page notice, 2014-21, which pretty much just said that it's not legal tender, and to pay your tax on it. There really wasn't much guidance beyond that. Chitra: What happened before then, like 2009 through '14? Was there any guidance? Jeff: Nothing formal. Chitra: What were people doing then? Jeff: I think, at the time, IRS and other government agencies probably just assumed that this is just a fringe thing, it's a temporary thing, it's not going to last, but look at us now. There are industries being built around blockchain and crypto, and they realize that, now, and the amount of money that people have earned in the sector. They see it as, like, it's a huge nest egg waiting to be tapped. Chitra: Build your highways and all of that stuff. Jeff: Right, yeah. Chitra: Now, when you're filing taxes, can your crypto losses or gains, be balanced against your traditional portfolio? Jeff: Yes, yeah. The way it works is short-term gains and losses get netted against other short-term gains and losses, regardless of if they're crypto or not. Then, the same thing with long-term. Chitra: Great. Now, what are the penalties for noncompliance? Jeff: For failing to file a return, it's a flat 5% of whatever your tax obligation is. For not paying the total amount of taxes owed, it's one half of 1% per month. If it's just one month late, half of 1%, it's not a lot, but if a couple of years go by, a few years go by, it can add up really quick, plus interest. Chitra: Can you go to jail? Jeff: Absolutely, unfortunately. If it's deemed that it was tax evasion, like in the example that I gave you of the gentleman that was looking into using our service and decided, no, they can just come after me, a couple million dollars, if they find evidence of tax evasion, then it could be subjected to a felony, which leads up to up to five years in prison and up to a quarter million dollars in penalties. Chitra: Now, there's a lot of money laundering also going on, right? Does that play a role at all in this? Jeff: Not so much with the taxes, but it is something that they're mindful about, out there. I see that more in the banking sector, that being an issue. In fact, one of our clients in the crypto space, their bank account was just abruptly closed with no notice. They said, "You can't bank with us," because they are concerned about potential money laundering. Chitra: What is their fear? Jeff: I think because they don't know where the money is coming from, right? If you have crypto-related money, it's so easy for it to be maneuvered from overseas. I think that's the concern, because there isn't enough regulation out there yet, right? Some people are just distancing themselves. Chitra: It seems like there's a whole bunch of areas in which the federal government and governments around the world are now grappling with, how do you make people accountable for all of this wealth that they're generating, and how do we get a piece of that action? Jeff: Right, that's what it is. They want their cut. As long as you give them their cut, they're not going to bother you. Chitra: Now, let's look at two scenarios. Let's say you're a Sally Fay, you're a woman investor. You're just starting out. You're super excited. It's 2017. The bull market is in full swing, and you've learned how to trade, and you're just buying and selling without any regard for keeping tabs on your cost basis or the proceeds that you're making. Then, come December, you're stuck with having done thousands of transactions, and you have no idea how to go about finding those records, because every trade that you've done is potentially taxable, correct? Jeff: Correct. Chitra: What do you do? Jeff: In those kinds of situations, because it's a lot of cleanup, the best thing to do is consult with an expert like us, so we can get you cleaned up and caught up. Then, going forward, you're on the right path, right? And to be mindful just about all the tax consequences of all that trading activity. Chitra: Do you just sort of systematically start to go back and look at every trade you've made? Jeff: In order to calculate all the gains and losses, historically, yeah. We have to kind of start from inception. If someone started trading in 2014, right, we have to go back to square one. Chitra: That's pretty daunting. Jeff: It is, yeah, yeah. At least once we get you caught up, then you should be okay, right? Chitra: Let's look at scenario B. Let's say that I am a young man, Matt Jones. I'm not in the crypto market yet. It's the bear market, and people are telling me, "Hey, now's the time to come in. Buy low, and you can sell high." I have a clean slate. I've set up my exchanges, but I haven't done any transactions. What are the kinds of things I need to put in place to have tax hygiene, so to speak? Jeff: Some best practices. Chitra: Yes. Jeff: I'd say, first, be mindful that you do any sort of trade coin for coin, that's all going to be a taxable event. Have at it, but just be mindful that there could be a lot of tax compliance to deal with at the end of the year. That affects some people's volume activity. Another thing, to make sure to pull their records on a consistent basis. We usually, we're advising our clients now to download their transactional history from each exchange they use about once a month. Just make it a month-end practice, just in case either they got locked out, the data is deleted, or something is hacked, just in case anything happens, at least you have the records. Then, outside of transactions like that, if you're trading on an exchange, if you're gifting coins, jot down somewhere on a Excel sheet or a Word document who you gave it to, when you gave it to them, and how much you gave, right? Just in case if there's any gift tax compliance to do, we could do that as well. Chitra: Is it advisable to have a notebook and a pen, and when you're making these trades, to actually just jot it down, or put it on an Excel sheet that on this date, I bought X amount of Bitcoin, or I sold X amount of Ether for X amount, and to have that? Is that going to be helpful at the end of the year? Jeff: It could, but like all the transactional data within the exchanges usually is going to have all that information. If someone wants to just separately track it, and if they're not doing a lot of trades during the year, that could be just as efficient and make their process easier at the end. Chitra: Now, tell us some war stories. What are some of the anecdotes that you tell people about folks having challenges in filing taxes, or cases that you've seen, or what the government is doing to come to terms with this new source of income? Jeff: Sure. Probably a couple examples. We have clients that were trading back from, the oldest one is 2013, maybe about a little over $4 million, and of course, they never reported any of it. Thankfully, in contrast to the other individual I was referencing, he said, "You know what, I just want to be compliant, right?" He came to the table. We went through everything, all the records, and got him up to speed. Going forward, if he's audited, or maybe I should say when, because it's a lot, a big amount, we have work papers in place that we could provide in response to an audit. 90% of the time, that'll just make it go away, almost immediately. As long as the IRS can see that you've made a good faith effort, that there's been due diligence in being compliant, and you have work papers and a CPA to back it up, the audit will go away, right? Another example, well, with the IRS, it's not so much a war story, but it's come to my attention that they've selected around 1200 to 1300 cases already from the 2017 filings that they're going to move forward with audits. Now, I don't know which ones those are. That comes from a source I have within the audit community, but we suspect that those are probably the larger ones, mostly, people that have generated hundreds of thousands, if not millions. Chitra: Is the IRS not only trying to get revenue back from these taxable events but also trying to set precedence in some way? Jeff: Yeah. It serves both purposes, yeah. One, it's a huge amount of revenue just sitting there for the government that hasn't been tapped yet. The second is going through this process, and going through these audits, and taking some people to tax court will set precedence, so that it's clear to everyone else that, one, you need to be compliant. Don't play games with them. I wouldn't be surprised if they send at least a few people to jail over this that have evaded their taxes. Also, it allows them to kind of establish authoritative guidance, because they're going to take everything they find. They will undoubtedly issue some pronouncements about, "Here's how you calculate this. Here's why you file things this way," which right now, we don't have. Chitra: What about moving out of the US, like just moving abroad so you don't have to pay your taxes, or even moving to Puerto Rico. You hear a lot about that. Is that going to help you or hurt you, in the long run? Jeff: I think for taxes, temporarily, it would help, right? But, do you really want to expatriate yourself, denounce the US, in order to just save some money temporarily on taxes? I don't know. Chitra: Depends, I would say. Jeff: It depends, yeah, yeah. Chitra: On what the amount is. Are you hearing about people who are actually doing that? Jeff: No one I know has actually done it. Some folks that we know have been debating it, and they asked to do some research on expatriation process. Chitra: It's a fascinating area. When you're doing the forensic work, you've been asked to help, I think, with investigations and things like that. How do you go about collecting the forensic evidence on these cases? Jeff: Really kind of the same way we do crypto calculations for our clients, right? We pull all the underlying third-party documents. In this case, transactional records. We get their narrative about what happened, hear the story, because any forensic case, anything that we do, it's not just the numbers. It's also the context. It's also what happened, the story, if you will. With forensic cases, there's usually a lot of other moveable parts, as well, particularly like divorce cases, where people are sometimes hiding funds. Partnership disputes, where one partner is embezzling money. We see that kind of stuff a lot more often than what people realize. Chitra: What happens in the case of a divorce? Who gets the crypto? How do you actually even split the proceeds, if that's what happens? Jeff: Same thing with kind of like a house, right? If it was community property, assuming it's a community property state like California, then any assets would be split 50/50, unless it was bought with separate property. If you don't want to cash out the portfolio, then usually one partner would buy out the other half from the other partner, just like a house. If you don't want to literally split the house in half, one person wants to keep it, one partner would buy out the house from the other. Chitra: Well, that actually raises an interesting question, because let's say one partner is very crypto-savvy and the other partner is not crypto-savvy. It probably is pretty easy to hide your assets in the form of crypto, because the other person has no way of finding out how much you have and where you have this. Jeff: True. Yeah, there's an opportunity there for someone to try to take advantage. Part of the divorce proceedings process is to come to the table and be transparent with both partners. Usually, like, you're essentially signing off to the court that let the partner know 100% of the assets out there. To try to hide it is essentially perjuring with the court. Chitra: Where do you see all of this going in the next few years, as more and more people get into the space? There is a prediction that you're going to have a billion new crypto investors, over the next five years, entering the market. Where do you see the field of taxation going? Jeff: Yeah, definitely, I see a second adoption, as well, coming in the coming years. I think, by the time that happens, there'll be a little bit more infrastructure in place with the taxation piece. One, with the exchanges. They'll start being a little bit better about what they record for their clients and what they issue out at the end of the year. I think we'll get to a point where exchanges are very, very similar to brokerage accounts, where you just get a 1089 of, "Here's your cost basis, here's your proceeds, here's what you report on your tax," and make it much easier for folks. Chitra: Just as the industry is growing up, the tax piece will grow up, as well. Jeff: Yup. Chitra: Yeah. Great. Is there anything I haven't asked or anything really important, closing thoughts? Jeff: One closing thought, just, I think it's good for everyone to remember that almost everything is a taxable event. If the question is, "Do I have to pay tax on this?" 9 times out 10, it's yes. Chitra: Sadly. Jeff: Yes. Chitra: Thank you so much for joining us. Where can people learn more about you and find out more about the work that you're doing? Jeff: Sure. Our website is neumeistercpa.com, that's N-E-U-M-E-I-S-T-E-R-C-P-A.com. We're a full-service accounting consulting firm, but we specialize in things like cryptos. Chitra: Great. Thanks so much for joining us. Jeff: All right, thank you. Chitra: That's all for now. Join us again next time for another edition of Running with Unicorns. Until then, enjoy your crypto journey, unicorns.
Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine's Emergency Medicine Practice. I'm Jeff Nusbaum, and I'm back with my co-host, Nachi Gupta. This month, we're talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month's episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we're actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let's get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month's issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke's, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It's great to know that there is good literature on this topic. It's incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I'm confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don't forget that if you're listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let's get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience...
Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re talking about a topic… Nachi: … woah wait, slow down for a minute, before we begin this month’s episode – we should take a quick pause to wish all of our listeners a happy new year! Thanks for your regular listenership and feedback. Jeff: And we’re actually hitting the two year mark since we started this podcast. At 25 episodes now, this is sort of our silver anniversary. Nachi: We have covered a ton of topics in emergency medicine so far, and we are looking forward to reviewing a lot more evidence based medicine with you all going forward. Jeff: With that, let’s get into the first episode of 2019 – the topic this month is first trimester pregnancy emergencies: recognition and management. Nachi: This month’s issue was authored by Dr. Ryan Pedigo, you may remember him from the June 2017 episode on dental emergencies, though he is perhaps better known as the director of undergraduate medical education at Harbor-UCLA Medical center. In addition, this issue was peer reviewed by Dr. Jennifer Beck-Esmay, assistant residency director at Mount Sinai St. Luke’s, and Dr. Taku Taira, the associate director of undergraduate medical education and associate clerkship director at LA County and USC department of Emergency Medicine. Jeff: For this review, Dr. Pedigo had to review a large body of literature, including thousands of articles, guidelines from the American college of obstetricians and gynecologists or ACOG, evidence based Practice bulletins, ACOG committee opinions, guidelines from the American college of radiology, the infectious diseases society of America, clinical policies from the American college of emergency physicians, and finally a series of reviews in the Cochrane database. Nachi: There is a wealth of literature on this topic and Dr. Pedigo comments that the relevant literature is overall “very good.” This may be the first article in many months for which there is an overall very good quality of literature. Jeff: It’s great to know that there is good literature on this topic. It’s incredibly important as we are not dealing with a single life here, as we usually do... we are quite literally dealing with potentially two lives as the fetus moves towards viability. With opportunities to improve outcomes for both the fetus and the mother, I’m confident that this episode will be worth your time. Nachi: Oh, and speaking of being worth your time…. Don’t forget that if you’re listening to this episode, you can claim your CME credit. Remember, the indicates an answer to one of the CME questions so make sure to keep the issue handy. Jeff: Let’s get started with some background. First trimester emergencies are not terribly uncommon in pregnancy. One study reported 85% experience nausea and vomiting. Luckily only 3% of these progressed to hyperemesis gravidarum. In addition, somewhere between 7-27% experience vaginal bleeding or miscarriage. Only 2% of these will be afflicted with an ectopic pregnancy. Overall, the maternal death rate is about 17 per 100,000 with huge racial-ethnic disparities. Nachi: And vaginal bleeding in pregnancy occurs in nearly 25% of patients. Weeks 4-8 represent the peak time for this. The heavier the bleeding, the higher the risk of miscarriage. Jeff: Miscarriage rates vary widely based on age, with an overall rate of 7-27%. This rises to nearly 40% risk in those over 40. And nearly half of miscarriages are due to fetal chromosomal abnormalities. Nachi: For patient who have a threatened miscarriage in the first trimester, there is a 2-fold increased risk of subsequent maternal and fetal adverse outcomes. Jeff: So key points here, since I think the wording and information you choose to share with often scared and worried women is important – nearly 25% of women experience bleeding in their first trimester. Not all of these will go on to miscarriages, though the risk does increase with maternal age. And of those that miscarry, nearly 50% were due to fetal chromosomal abnormalities. Nachi: So can we prevent a miscarriage, once the patient is bleeding…? Jeff: Short answer, no, longer answer, we’ll get to treatment in a few minutes. For now, let’s continue outlining the various first trimester emergencies. Next up, ectopic pregnancy… Nachi: An ectopic pregnancy is implantation of a fertilized ovum outside of the endometrial cavity. This occurs in up to 2% of pregnancies. About 98% occur in the fallopian tube. Risk factors for an ectopic pregnancy include salpingitis, history of STDs, history of PID, a prior ectopic, and smoking. Jeff: Interestingly, with respect to smoking, there is a dose-relationship between smoking and ectopic pregnancies. Simple advice here: don’t smoke if you are pregnant or trying to get pregnant. Nachi: Pretty sound advice. In addition, though an IUD is not a risk factor for an ectopic pregnancy, if you do become pregnant while you have in IUD in place, over half of these may end up being ectopic. Jeff: It’s also worth mentioning a more obscure related disease pathology here – the heterotopic pregnancy -- one in which there is an IUP and an ectopic pregnancy simultaneously. Nachi: Nausea and vomiting, though not as scary as miscarriages or an ectopic pregnancy, represent a fairly common pathophysiologic response in the first trimester -- with the vast majority of women experiencing nausea and vomiting. And as we mentioned earlier, only 3% of these progress to hyperemesis gravidarum. Jeff: And while nausea and vomiting clearly sucks, they seem to actually be protective of pregnancy loss, with a hazard ratio of 0.2. Nachi: Although this may be protective of pregnancy loss, nausea and vomiting can really decrease the quality of life in pregnancy -- with one study showing that about 25% of women with severe nausea and vomiting had actually considered pregnancy termination. 75% of those women also stated they would not want to get pregnant again because of these symptoms. Jeff: So certainly a big issue.. Two other common first trimester emergency are asymptomatic bacteriuria and UTIs. In pregnant patients, due to anatomical and physiologic changes in the GU tract – such as hydroureteronephrosis that occurs by the 7th week and urinary stasis due to bladder displacement – asymptomatic bacteriuria is a risk factor for developing pyelonephritis. Nachi: And pregnant women are, of course, still susceptible to the normal ailments of young adult women like acute appendicitis, which is the most common surgical problem in pregnancy. Jeff: Interestingly, based on epidemiologic data, pregnant women are less likely to have appendicitis than age-matched non-pregnant woman. I’d like to think that there is a good pathophysiologic explanation there, but I don’t have a clue as to why that might be. Nachi: Additionally, the RLQ is the the most common location of pain from appendicitis in pregnancies of all gestational ages. Peritonitis is actually slightly more common in pregnant patients, with an odds ratio of 1.3. Jeff: Alright, so I think we can put that intro behind us and move on to the differential. Nachi: When considering the differential for abdominal pain or vaginal bleeding in the first trimester, you have to think broadly. Among gynecologic causes, you should consider miscarriage, septic abortion, ectopic pregnancy, corpus luteum cyst, ovarian torsion, vaginal or cervical lacerations, and PID. For non-gynecologic causes, you should also consider appendicitis, cholecystitis, hepatitis, and pyelonephritis. Jeff: In the middle of that laundry list you mentioned there is one pathology which I think merits special attention - ovarian torsion. Don’t forget that patients undergoing ovarian stimulation as part of assisted reproductive technology are at a particularly increased risk due to the larger size of the ovaries. Nachi: Great point. Up next we have prehospital care... Jeff: Always a great section. First, prehospital providers should attempt to elicit an ob history. Including the number of weeks’ gestation, LMP, whether an IUP has already been confirmed, prior hx of ectopic, and amount of vaginal bleeding. In addition, providers should consider an early destination consult both to select the correct destination and to begin the process of mobilizing resources early in those patients who really need them, such as those with hemodynamic instability. Nachi: As with most pathologies, the more time you give the receiving facility to prepare, the better the care will be, especially the early care, which is critical. Jeff: Now that the patient has arrived in the ED we can begin our H&P. Nachi: When eliciting the patient’s obstetrical history, it’s common to use the G’s and Ps. This can be further annotated using the 4-digit TPAL method, that’s term-preterm-abortus-living. Jeff: With respect to vaginal bleeding, make sure to ask about the number of pads and how this relates to the woman’s normal number of pads. In addition, make sure to ask about vaginal discharge or even about the passage of tissue. Nachi: You will also need to elicit whether or not the patient has a history of a prior ectopic pregnancies as this is a major risk for future ectopics. And ask about previous sexually transmitted infections also. Jeff: And, of course, make sure to elicit a history of assisted reproductive technology, as this increases the risk of a heterotopic pregnancy. Nachi: Let’s move on to the physical. While you are certainly going to perform your standard focused physical exam, just as you would for any non-pregnant woman - what does the evidence say about the pelvic exam? I know this is a HOTLY debated topic among EM Docs. Jeff: Oh it certainly is. Dr. Pedigo takes a safe, but fair approach, noting, “A pelvic exam should always be performed if the emergency clinician suspects that it would change management, such as identifying the source of bleeding, or identifying an STD or PID.” However, it is noteworthy that the only real study he cites on this topic, an RCT of pelvic vs no pelvic in those with a confirmed IUP and first trimester bleeding, found no difference between the two groups. Obviously, the pelvic group reported more discomfort. Nachi: You did leave out one important fact about the study enrollment - they only enrolled about 200 of 700 intended patients. Jeff: Oh true, so a possibly underpowered study, but it’s all we’ve got on the topic. I think I’m still going to do pelvic exams, but it’s something to think about. Nachi: Moving on, all unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic until proven otherwise. Ruptured ectopics can manifest with a number of physical exam findings including abdominal tenderness, with peritoneal signs, or even with bradycardia due to vagal stimulation in the peritoneum. Jeff: Perhaps most importantly, no history or physical alone can rule in or out an ectopic pregnancy, for that you’ll need testing and imaging or operative findings. Nachi: And that’s a perfect segue into our next section - diagnostic studies. Jeff: Up first is the urine pregnancy test. A UPT should be obtained in all women of reproductive age with abdominal pain or vaginal bleeding, and likely other complaints too, though we’re not focusing on them now. Nachi: The UPT is a great test, with nearly 100% sensitivity, even in the setting of very dilute urine. False positives are certainly plausible, with likely culprits being recent pregnancy loss, exogenous HCG, or malignancy. Jeff: And not only is the sensitivity great, but it’s usually positive just 6-8 days after fertilization. Nachi: While the UPT is fairly straight forward, let’s talk about the next few tests in the context of specific disease entities, as I think that may make things a bit simpler -- starting with bHCG in the context of miscarriage and ectopic pregnancy. Jeff: Great starting point since there is certainly a lot of debate about the discriminatory zone. So to get us all on the same page, the discriminatory zone is the b-HCG at which an IUP is expected to be seen on ultrasound. Generally 1500 is used as the cutoff. This corresponds nicely to a 2013 retrospective study demonstrating a bHCG threshold for the fetal pole to be just below 1400. Nachi: However, to actually catch 99% of gestational sacs, yolk sacs, and fetal poles, one would need cutoffs of around 3500, 18000, and 48,000 respectively -- much higher. Jeff: For this reason, if you want to use a discriminatory zone, ACOG recommends a conservatively high 3,500, as a cutoff. Nachi: I think that’s an understated point in this article, the classic teaching of a 1500 discriminatory zone cutoff is likely too low. Jeff: Right, which is why I think many ED physicians practice under the mantra that it’s an ectopic until proven otherwise. Nachi: Certainly a safe approach. Jeff: Along those lines, lack of an IUP with a bHCG above whatever discriminatory zone you are using does not diagnose an ectopic, it merely suggests a non-viable pregnancy of undetermined location. Nachi: And if you don’t identify an IUP, serial bHCGs can be really helpful. As a rule of thumb -- in cases of a viable IUP -- b-HCG typically doubles within 48 hours and at a minimum should rise 53%. Jeff: In perhaps one of the most concerning things I’ve read in awhile, one study showed that ⅓ of patients with an ectopic had a bCHG rise of 53% in 48h and 20% of patients with ectopics had a rate of decline typical to that of a miscarriage. Nachi: Definitely concerning, but this is all the more reason you need to employ our favorite imaging modality… the ultrasound. Jeff: All patients with a positive pregnancy test and vaginal bleeding should receive an ultrasound performed by either an emergency physician or by radiology. Combined with a pelvic exam, this can give you almost all the data necessary to make the diagnosis, even if you don’t find an IUP. Nachi: And yes, there is good data to support ED ultrasound for this indication, both transabdominal and transvaginal, assuming the emergency physician is credentialed to do so. A 2010 Meta-Analysis found a NPV of 99.96% when an er doc identified an IUP on bedside ultrasound. So keep doing your bedside scans with confidence. Jeff: Before we move on to other diagnostic tests, let’s discuss table 2 on page 7 to refresh on key findings of each of the different types of miscarriage. For a threatened abortion, the os would be closed with an IUP seen on ultrasound. For a completed abortion, you would expect a closed OS with no IUP on ultrasound with a previously documented IUP. Patients may or may not note the passage of products of conception. Nachi: A missed abortion presents with a closed os and a nonviable fetus on ultrasound. Findings such as a crown-rump length of 7 mm or greater without cardiac motion is one of several criteria to support this diagnosis. Jeff: An inevitable abortion presents with an open OS and an IUP on ultrasound. Along similar lines, an incomplete abortion presents with an open OS and partially expelled products on ultrasound. Nachi: And lastly, we have the septic abortion, which is sort of in a category of its own. A septic abortion presents with either an open or closed OS with essentially any finding on ultrasound in the setting of an intrauterine infection and a fever. Jeff: I’ve only seen this two times, and both women were incredibly sick upon presentation. Such a sad situation. Nachi: For sure. Before we move on to other tests, one quick note on the topic of heterotopic pregnancies: because the risk in the general population is so incredibly low, the finding of an IUP essentially rules out an ectopic pregnancy assuming the patient hasn’t been using assisted reproductive technology. In those that are using assisted reproductive technology, the risk rises to 1 in 100, so finding an IUP, in this case, doesn’t necessarily rule out a heterotopic pregnancy. Jeff: Let’s move on to diagnostic studies for patients with nausea and vomiting. Typically, no studies are indicated beyond whatever you would order to rule out other serious pathology. Checking electrolytes and repleting them should be considered in those with severe symptoms. Nachi: For those with symptoms suggestive of a UTI, a urinalysis and culture should be sent. Even if the urinalysis is negative, the culture may still have growth. Treat asymptomatic bacteriuria and allow the culture growth to guide changes in antibiotic selection. Jeff: It’s worth noting, however, that a 2016 systematic review found no reliable evidence supporting routine screening for asymptomatic bacteriuria, so send a urinalysis and culture only if there is suspicion for a UTI. Nachi: For those with concern for appendicitis, while ultrasound is a viable imaging modality, MRI is gaining favor. Both are specific tests, however one study found US to visualize the appendix only 7% of the time in pregnant patients. Jeff: Even more convincingly, one 2016 meta analysis found MRI to have a sensitivity and specificity of 94 and 97% respectively suggesting that a noncontrast MRI should be the first line imaging modality for potential appendicitis. Nachi: You kind of snuck it in there, but this is specifically a non-contrast MRI. Whereas a review of over a million pregnancies found no associated fetal risk with routine non-contrast MRI, gadolinium-enhanced MRI has been associated with increased rates of stillbirth, neonatal death, and rheumatologic and inflammatory skin conditions. Jeff: CT is also worth mentioning since MRI and even ultrasound may not be available to all of our listeners. If you do find yourself in such a predicament, or you have an inconclusive US without MRI available, a CT scan may be warranted as the delay in diagnosis and subsequent peritonitis has been found to increase the risk of preterm birth 4-fold. Nachi: Right, and a single dose of ionizing radiation actually does not exceed the threshold dose for fetal harm. Jeff: Let’s talk about the Rh status and prevention of alloimmunization. While there are no well-designed studies demonstrating benefit to administering anti-D immune globulin to Rh negative patients, ACOG guidelines state “ whether to administer anti-D immune globulin to a patient with threatened pregnancy loss and a live embryo or fetus at or before 12 weeks of gestation is controversial, and no evidence-based recommendation can be made.” Nachi: Unfortunately, that’s not particularly helpful for us. But if you are going to treat an unsensitized Rh negative female with vaginal bleeding while pregnant with Rh-immune globulin, they should receive 50 mcg IM of Rh-immune globulin within 72 hours, or the 300 mcg dose if that is all that is available. It’s also reasonable to administer Rh(d)-immune globulin to any pregnant female with significant abdominal trauma. Jeff: Moving on to the treatment for miscarriages - sadly there isn’t much to offer here. For those with threatened abortions, the vast majority will go on to a normal pregnancy. Bedrest had been recommended in the past, but there is little data to support this practice. Nachi: For incomplete miscarriages, if visible, products should be removed and you should consider sending those products to pathology for analysis, especially if the patient has had recurrent miscarriages. Jeff: For those with a missed abortion or incomplete miscarriages, options include expectant management, medical management or surgical management, all in consultation with an obstetrician. It’s noteworthy that a 2012 Cochrane review failed to find clear superiority for one strategy over another. This result was for the most part re-confirmed in a 2017 cochrane review. The latter study did find, however, that surgical management in the stable patient resulted in lower rates of incomplete miscarriage, bleeding, and need for transfusion. Nachi: For expectant management, 50-80% will complete their miscarriage within 7-10 days. Jeff: For those choosing medical management, typically with 800 mcg of intravaginal misoprostol, one study found this to be 91% effective in 7 days. This approach is preferred in low-resource settings. Nachi: And lastly, remember that all of these options are only options for stable patients. Surgical management is mandatory for patients with significant hemorrhage or hemodynamic instability. Jeff: Since the best evidence we have doesn’t suggest a crystal clear answer, you should rely on the patient’s own preferences and a discussion with their obstetrician. For this reason and due to the inherent difficulty of losing a pregnancy, having good communication is paramount. Nachi: Expert consensus recommends 6 key aspects of appropriate communication in such a setting: 1 assess the meaning of the pregnancy loss, give the news in a culturally competent and supportive manner, inform the family that grief is to be expected and give them permission to grieve in their own way, learn to be comfortable sharing the products of conception should the woman wish to see them, 5. provide support for whatever path she chooses, 6. and provide resources for grief counselors and support groups. Jeff: All great advice. The next treatment to discuss is that for pregnancy of an unknown location and ectopic pregnancies. Nachi: All unstable patients or those with suspected or proven ectopic or heterotopic pregnancies should be immediately resuscitated and taken for surgical intervention. Jeff: For those that are stable, with normal vitals, and no ultrasound evidence of a ruptured ectopic, with no IUP on ultrasound, -- that is, those with a pregnancy of unknown location, they should be discharged with follow up in 48 hours for repeat betaHCG and ultrasound. Nachi: And while many patients only need a single additional beta check, some may need repeat 48 hour exams until a diagnosis is established. Jeff: For those that are stable with a confirmed tubal ectopic, you again have a variety of treatment options, none being clearly superior. Nachi: Treatment options here include IM methotrexate, or a salpingostomy or salpingectomy. Jeff: Do note, however, that a bHCG over 5000, cardiac activity on US, and inability to follow up are all relative contraindications to methotrexate treatment. Absolute contraindications to methotrexate include cytopenia, active pulmonary disease, active peptic ulcer disease, hepatic or renal dysfunction, and breastfeeding. Nachi: Such decisions, should, of course, be made in conjunction with the obstetrician. Jeff: Always good to make a plan with the ob. Moving on to the treatment of nausea and vomiting in pregnancy, ACOG recommends pyridoxine, 10-25 mg orally q8-q6 with or without doxylamine 12.5 mg PO BID or TID. This is a level A recommendation as first-line treatment! Nachi: In addition, ACOG also recommends nonpharmacologic options such as acupressure at the P6 point on the wrist with a wrist band. Ginger is another nonpharmacologic intervention that has been shown to be efficacious - 250 mg by mouth 4 times a day. Jeff: So building an algorithm, step one would be to consider ginger and pressure at the P6 point. Step two would be pyridoxine and doxylamine. If all of these measures fail, step three would be IV medication - with 10 mg IV of metoclopramide being the agent of choice. Nachi: By the way, ondansetron carries a very small risk of fetal cardiac abnormalities, so the other options are of course preferred. Jeff: In terms of fluid choice for the actively vomiting first trimester woman, both D5NS and NS are appropriate choices, with slightly decreased nausea in the group receiving D5NS in one randomized trial of pregnant patients admitted for vomiting to an overnight observation unit. Nachi: Up next for treatment we have asymptomatic bacteriuria. As we stated previously, asymptomatic bacteriuria should be treated. This is due to anatomical and physiologic changes which put these women at higher risk than non-pregnant women. Jeff: And this recommendation comes from the 2005 IDSA guidelines. In one trial, treatment of those with asymptomatic bacteriuria with nitrofurantoin reduced the incidence of developing pyelonephritis from 2.4% to 0.6%. Nachi: And this trial specifically examined the utility of nitrofurantoin. Per a 2010 and 2011 Cochrane review, there is not evidence to recommend one antibiotic over another, so let your local antibiograms guide your treatment. Jeff: In general, amoxicillin or cephalexin for a full 7 day course could also be perfectly appropriate. Nachi: A 2017 ACOG Committee Opinion analyzed nitrofurantoin and sulfonamide antibiotics for association with birth defects. Although safe in the second and third trimester, they recommend use in the first trimester -- only when no other suitable alternatives are available. Jeff: For those, who unfortunately do go on to develop pyelo, 1g IV ceftriaxone should be your drug of choice. Interestingly, groups have examined outpatient care with 2 days of daily IM ceftriaxone vs inpatient IV antibiotic therapy and they found that there may be a higher than acceptable risk in the outpatient setting as several required eventual admission and one developed septic shock in their relatively small trial. Nachi: And the last treatment to discuss is for pregnant patient with acute appendicitis. Despite a potential shift in the standard of care for non pregnant patients towards antibiotics-only as the initial treatment, due to the increased risk of serious complications for pregnant women with an acute appy, the best current evidence supports a surgical pathway. Jeff: Perfect, so that wraps up treatment. We have a few special considerations this month, the first of which revolves around ionizing radiation. Ideally, one should limit the amount of ionizing radiation exposure during pregnancy, however avoiding it all together may lead to missed or delayed diagnoses and subsequently worse outcomes. Nachi: It’s worth noting that the American College of Radiology actually lists several radiographs that are such low exposure that checking a urine pregnancy test isn’t even necessary. These include any imaging of the head and neck, extremity CT, and chest x-ray. Jeff: Of course, an abdomen and pelvis CT carries the greatest potential risk. However, if necessary, it’s certainly appropriate as long as there is a documented discussion of the risk and benefits with the patient. Nachi: And regarding iodinated contrast for CT -- it appears to present no known harm to the fetus, but this is based on limited data. ACOG recommends using contrast only if “absolutely required”. Jeff: Right and that’s for iodinated contrasts. Gadolinium should always be avoided. Let me repeat that Gadolinium should always be avoided Nachi: Let’s also briefly touch on a controversial topic -- that of using qualitative urine point of care tests with blood instead of urine. In short, some devices are fda-approved for serum, but not whole blood. Clinicians really just need to know the equipment and characteristics at their own site. It is worth noting that there have been studies on determining whether time can be saved by using point of care blood testing instead of urine for the patient who is unable to provide a prompt sample. Initial study conclusions are promising. But again, you need to know the characteristics of the test at your ER. Jeff: One more controversy in this issue is that of expectant management for ectopic pregnancy. A 2015 randomized trial found similar outcomes for IM methotrexate compared to placebo for tubal ectopics. Inclusion criteria included hemodynamic stability, initial b hcg < 2000, declining b hcg titers 48 hours prior to treatment, and visible tubal pregnancy on trans vaginal ultrasound. Another 2017 multicenter randomized trial found similar results. Nachi: But of course all of these decisions should be made in conjunction with your obstetrician colleagues. Jeff: Let’s move on to disposition. HDS patients who are well-appearing with a pregnancy of undetermined location should be discharged with a 48h beta hcg recheck and ultrasound. All hemodynamically unstable patients, should of course be admitted and likely taken directly to the OR. Nachi: Also, all pregnant patients with acute pyelonephritis require admission. Outpatient tx could be considered in consultation with ob. Jeff: Patient with hyperemesis gravidarum who do not improve despite treatment in the ED should also be admitted. Nachi: Before we close out the episode, let’s go over some key points and clinical pearls... J Overall, roughly 25% of pregnant women will experience vaginal bleeding and 7-27% of pregnant women will experience a miscarriage 2. Becoming pregnant with an IUD significantly raises the risk of ectopic pregnancy. 3. Ovarian stimulation as part of assisted reproductive technology places pregnant women at increased risk of ovarian torsion. 4. Due to anatomical and physiologic changes in the genitourinary tract, asymptomatic bacteriuria places pregnant women at higher risk for pyelonephritis. As such, treat asymptomatic bacteriuria according to local antibiograms. 5. A pelvic exam in the setting of first trimester bleeding is only warranted if you suspect it might change management. 6. Unstable patients with vaginal bleeding and no IUP should be assumed to have an ectopic pregnancy until proven otherwise. 7. If you are to use a discriminatory zone, ACOG recommends a beta-hCG cutoff of 3500. 8. The beta-hCG typically doubles within 48 hours during the first trimester. It should definitely rise by a minimum of 53%. 9. For patients using assisted reproductive technology, the risk of heterotopic pregnancy becomes much higher. Finding an IUP does not necessarily rule out a heterotopic pregnancy. N. Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative. J. The most common surgical problem in pregnancy is appendicitis. N, If MRI is not available and ultrasound was inconclusive, CT may be warranted for assessing appendicitis. The risk of missing or delaying the diagnosis may outweigh the risk of radiation. J. ACOG recommends using iodinated contrast only if absolutely required. N. For stable patients with a pregnancy of unknown location, plan for discharge with follow up in 48 hours for a repeat beta-hCG and ultrasound. J For nausea and vomiting in pregnancy, try nonpharmacologic treatments like acupressure at the P6 point on the wrist or ginger supplementation. First line pharmacologic treatment is pyridoxine. Doxylamine can be added. Ondansetron may increase risk of fetal cardiac abnormalities N So that wraps up episode 24 - First Trimester Pregnancy Emergencies: Recognition and Management. J: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. N: And the address for this month’s credit is ebmedicine.net/E0119, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!
Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’re back with our old routine – no special guests. Nachi: Don’t sound so sad about it! Jeremy was great last month, and he’s definitely paved the way for more special guests in upcoming episodes. Jeff: You’re right. But this month’s episode is special in its own way - we’ll be tackling Electrical Injuries in the emergency department - from low and high voltage injuries to the more extreme and rare lightning related injuries. Nachi: And this is obviously not something we see that often, so listen up for some easy to remember high yield points to help you when you get an electrical injury in the ED. And pay particular attention to the , which, as always, signals the answer to one of our CME questions. Jeff: I hate to digress so early and drop a cliché, “let’s start with a case…” but we, just a month ago, had a lightning strike induced cardiac arrest in Pittsburgh, so this hits really close to home. Thankfully, that gentleman was successfully resuscitated despite no bystander CPR, and if you listen carefully, we hope to arm you with the tools to do so similarly. Nachi: This month’s print issue was authored by Dr. Gentges and Dr. Schieche from the Oklahoma University School of Community Medicine. It was peer reviewed by Dr. O’Keefe and Dr. Silverberg from Florida State University College of Medicine and Kings County Hospital, respectively. Jeff: And unlike past issues covering more common pathologies, like, say, sepsis, this month’s team reviewed much more literature than just the past 10 years. In total, they pulled references from 1966 until 2018. Their search yielded 477 articles, which was narrowed to 88 after initial review. Nachi: Each year, in the US, approximately 10,000 patients present with electrical burns or shocks. Thankfully, fatalities are declining, with just 565 in 2015. On average, between 25 and 50 of the yearly fatalities can be attributed to lightning strikes. Jeff: Interestingly, most of the decrease in fatalities is due to improvements in occupational protections and not due so much to changes in healthcare. Nachi: That is interesting and great to hear for workers. Also, worth noting is the trimodal distribution of patients with electrical injuries: with young children being affected by household currents, adolescent males engaging in high risk behaviors, and adult males with occupational exposures and hazards. Jeff: Electrical injuries and snake bites – leave it to us men to excel at all the wrong things… Anyway, before we get into the medicine, we unfortunately need to cover some basic physics. I know, it might seem painful, but it’s necessary. There are a couple of terms we need to define to help us understand the pathologies we’ll be discussing. Those terms are: current, amperes, voltage, and resistance. Nachi: So, the current is the total amount of electrons moving down a gradient over time, and it’s measured in amperes. Jeff: Voltage, on the other hand, is the potential difference between the top and bottom of a gradient. The current is directly proportional to the voltage. It can be alternating, AC, or direct, DC. Nachi: Resistance is the obstruction of electrical flow and it is inversely proportional to the current. Think of Ohm’s Law here. Voltage = current x resistance. Jeff: Damage to the tissues from electricity is largely due to thermal injury, which depends on the tissue resistance, voltage, amperage, type of circuit, and the duration of contact. Nachi: That brings us to an interesting concept – the let-go threshold. Since electrical injuries are often due to grasping an electric source, this can induce tetanic muscle contractions and therefore the inability to let go, thus increasing the duration of contact and extent of injury. Jeff: Definitely adding insult to injury right there. With respect to the tissue resistance, that amount varies widely depending on the type of tissue. Dry skin has high resistance, far greater than wet or lacerated skin. And the skin’s resistance breaks down as it absorbs more energy. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat have the highest resistance. In between nerve and bone or fat, we have blood and vascular tissue, which have low resistance, and muscle and the viscera which have a slightly higher resistance. Nachi: Understanding the resistances will help you anticipate the types of injuries you are treating, since current will tend to follow the path of least resistance. In high resistance tissues, most of the energy is lost as heat, causing coagulation necrosis. These concepts also explain why you may have deeper injuries beyond what can be visualized on the surface. Jeff: And not only does the resistance play a role, but so too does the amount and type of current. AC, which is often found in standard home and office settings, but can also be found in high voltage transmission lines, usually affects the electrically sensitive tissues like nerve and muscle. DC has a higher let-go threshold and does not cause as much sensation. It also requires more amperage to cause v-fib. DC is often found in batteries, car and computer electrical systems, some high voltage transmission lines, and capacitors. Nachi: Voltage has a twofold effect on tissues. The first mechanism is through electroporation, which is direct damage to cell membranes by high voltage. The second is by overcoming the resistance of body tissues and intervening objects such as clothes or water. You’re probably familiar with this concept when you see high voltages arcing through the air without direct contact with the actual electrical source, leading to diffuse burns. Jeff: As voltage increases, the resistance of dry skin is -- not surprisingly -- reduced, leading to worse injuries. Nachi: And for this reason, the US Department of Energy has set 600 Volts as the cutoff for low vs high voltage electrical exposure. Jeff: It is absolutely critical that we also mention and then re-mention throughout this episode, that those with electrical injuries often have multisystem injuries due to not only the thermal injury, electrical damage to electrically sensitive tissue, but also mechanical trauma. Injuries are not uncommon both from forceful pulling away from the source or a subsequent fall if one occurs. Nachi: That’s a great point which we’ll return to soon, as it plays an important role in destination selection. But before we get there, let’s review the common clinical manifestations of electrical injuries. Jeff: First up is – the cutaneous injuries. Most electrical injuries present with burns to the skin. Low voltage exposures typically cause superficial burns at the entry and exit sites, whereas high voltage exposures cause larger, deeper burns that may require skin grafting, debridement, and even amputation. Nachi: High voltage injuries can also travel through the sub-q tissue leading to extensive burns to deep structures despite what appears to be relatively uninjured skin. In addition, high voltage injuries can also result in superficial burns to large areas secondary to flash injury. Jeff: Electrical injuries can also lead to musculoskeletal injuries via either thermal or mechanical means. Thermal injury can lead to muscle breakdown, rhabdo, myonecrosis, edema, and in worse cases, compartment syndrome. In the bones, it can lead to osteonecrosis and periosteal burns. Nachi: In terms of mechanical injury – electrical injury often leads to forceful muscular contraction and falls. In 2 retrospective studies, 11% of patients with high voltage exposures also had traumatic injuries. Jeff: While not nearly as common, the rarer cardiovascular injuries are certainly up there as the most feared. Pay attention to the entry and exit sites, as the pathway of the shock is predictive of the potential for myocardial injury and arrhythmia. Common arrhythmias include AV block, bundle branch blocks, a fib, QT prolongation and even ventricular arrhythmias, including both v-fib and v-tach, both of which typically occur immediately after the injury. Nachi: There is a school of thought out there that victims of electrical injury can have delayed onset arrhythmias and require prolonged cardiac monitoring – however several well-designed observational studies, including 1000s of patients, have demonstrated no such evidence. Jeff: It’s also worth noting that ST elevation MIs have also been reported, however this is usually due to coronary artery vasospasm rather than acute arterial occlusion. Nachi: Respiratory injuries are somewhat less common. Acute respiratory failure usually occurs secondary to electrical injury-induced cardiac arrest. Thoracic tetany can cause paralysis of respiratory muscles. Late findings of respiratory injury including pulmonary effusions, pneumonitis, pneumonia, and even PE. The electrical resistance of lung tissue is relatively high, which may account for why pulmonary injury is less common. Jeff: Vascular injuries include coagulation necrosis as well as thrombosis. In addition, those with severe burns are at increased risk of DVT, especially in those who are immobilized. In at least one study, the incidence of DVT in hospitalized burn patients was as high as 23%. That’s -- high. Nachi: Neurologic complaints are far more common as nerve tissue is highly conductive. While the most common injury from an electric shock is loss of consciousness, other common neurologic insults include weakness, paresthesias, and difficulty concentrating. Jeff: And if the entry and exit sites traverse the spinal cord – this also puts the patient at risk for spinal cord lesions. Specifically with respect to high voltage injuries – these victims are at risk for posterior cord syndrome. In addition, depression, pain, anxiety, mood swings, and cognitive difficulties have all been commonly described. Nachi: Rounding out our discussion of electrical injuries, visceral injuries are rather rare, with bowel perforation being the most common. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. Jeff: Perfect. I think that more or less rounds out an overview of organ specific electrical injuries. Let’s talk about prehospital care for these patients -- a broad topic in this case. As always, the first, and most important step in prehospital care is protecting oneself from the electrical exposure if the electrical source is still live. Nachi: In cases of high voltage injuries from power lines or transformers or whatever oddity the patient has come across, it may even be necessary to wait for word from the local electrical authority prior to initiating care. Remember, the last thing you want to do is become a victim yourself. Jeff: For those whose electrical injury resulted in cardiac arrest, follow your standard ACLS guidelines. These aren’t your standard arrest patients though, they typically have many fewer comorbidities – so CPR tends to be more successful. Nachi: Intubation should also be considered especially early in those with facial or neck burns, as risk of airway loss is high. Jeff: And as we mentioned previously, concurrent trauma and therefore traumatic injuries is very common, especially with high voltage injuries, so patients with electrical injuries require a complete survey and not just a brief examination of their obvious injuries. Nachi: When determining destination, trauma takes priority over burn, so patients with significant trauma or those who are obtunded or unconscious should be transported to an appropriate trauma center rather than a burn center if those sites are different. Jeff: Let’s move on to evaluation in the emergency department. As always, it’s ABC and IV, O2, monitor first with early airway management in those with head and neck burns being a top priority. After that, complete your primary and secondary surveys per ATLS guidelines. Nachi: During your survey, make sure the patient is entirely undressed and all constricting items, like jewelry is removed. Jeff: Next, make sure that all patients with high voltage injuries have an EKG and continuous cardiac monitoring. Those with low voltage injuries and a normal EKG do not require monitoring. Nachi: Additionally, for those with severe electrical injuries, an IV should be placed and fluid resuscitation should begin. Fluid requirements will likely be higher than those predicted by the parkland formula, and you should aim for a goal of maintaining urine output of 1-1.5 ml/kg/h. Jeff: With your initial stabilization underway, you can begin to gather a more thorough history either from bystanders or EMS if they are still present. Try to ascertain whether the current was AC or DC, and whether it was high or low voltage. Don’t forget to ask about the setting of the injury as this may point to other concurrent traumatic injuries, that may in fact take precedence during your work up. Nachi: Moving on to the physical exam. As mentioned previously, disrobe the patient and complete a primary and secondary survey. Jeff: If the patient has clear entry and exit wounds, the path through the body may become apparent and offer clues about what injuries to expect. Nachi: A single exam will not suffice for electrical injury patients. All patients with serious electrical injuries will require serial exams to evaluate for vascular compromise and compartment syndrome. Jeff: So that wraps up the physical, let’s move onto diagnostic studies. Nachi: First off -- I know we’ve said it, but it’s definitely worth reiterating. All patients presenting with a history of an electric shock require an EKG Jeff: In those with a low voltage injury without syncope and a normal EKG, you don’t routinely need cardiac monitoring. However, in the setting of high voltage injuries, the data is less clear. Based on current literature, the authors recommend overnight monitoring for at least 8 hours for all high voltage injuries. Nachi: While no routine labs work is required for minor injuries, those with more serious injuries require a cbc, cmp, CK, CK-MB, and urinalysis. Jeff: The CK is clearly for rhabdo, but interestingly, a CK-MB greater than 80 ng/mL is actually predictive of limb amputation. Oh and don’t forget that urine pregnancy test when appropriate. Nachi: In terms of imaging, you’ll have to let your history guide your diagnostic studies. Perform a FAST exam to screen for intra-abdominal pathology for anyone with concern for concurrent trauma. Keep a low threshold to XR or CT any potentially injured body region. Jeff: Real quick – in case you missed it – ultrasound sneaks in again. Maybe I should reconsider and do an US fellowship – seems like that’s where the money is at - well maybe not money but still. Let’s move on to treatment. Nachi: In those with minor injuries like small burns and a low voltage exposure – if they have a normal EKG and no other symptoms, these patients require analgesia only. Give return precautions and have them follow up with their PCP or a burn center. Jeff: In those with more severe injuries, as we mentioned before, but we’ll stress again, protect the patient’s airway early especially if you are considering transfer and have any concerns. In one study, delays in intubation was associated with a high risk of a difficult airway. Always make sure you have not only your tool of choice but also all of your backup airway devices ready as all deeper airway injuries may not be apparent externally. Nachi: Fluid resuscitation with isotonic fluids is the standard -- again -- with a goal urine output of 1-1.5 ml/kg/h. Jeff: Address pain with analgesia – likely in the form of opiates – and don’t be surprised if large doses are needed. Nachi: Dress burned areas with an antibiotic dressing and update the patient’s tetanus if needed. While there is ongoing debate about the role of prophylactic antibiotics, best evidence at this point recommends against them. We talked about thermal burns in Epsiode 13 also, so go back and listen there for more... Jeff: There is also a range of practice variation with respect to early surgical exploration of the burned limb with severe injuries. At this time, however, the best current evidence supports a conservative approach. Nachi: Serial exams and watch and wait it is. . We have some interesting special populations to discuss this month. First up, as is often the case, the kids. Jeff: Young children are sadly more likely to present with orofacial burns due to, well, everything ending up in their mouth. And since many of our listeners are likely in boards study mode – why don’t you fill us in on the latest evidence with respect to labial artery bleeding. Nachi: Sure – . There is up to a 24% risk of labial artery bleeding and primary tooth damage with oral electrical injuries. Although there isn’t a clear consensus, current evidence supports early ENT consultation and a strong consideration for admission and observation for delayed bleeding. Jeff: Keep in mind though, that labial artery bleeding is often delayed and has been reported as far as 2 weeks out from the initial insult. Nachi: Moral of the story: don’t put electrical cords in or anywhere near your mouth. Next, we have pregnant patients. Case reports of pregnant patients suffering electrical injuries have described fetal arrhythmias, ischemic brain injury, and fetal demise. For this reason, those that are past the age of fetal viability should have fetal monitoring after experiencing an electric shock. Jeff: If not already done, an ultrasound should be obtained as well and a two week follow up ultrasound will be needed. Nachi: We’re switching gears a bit with this next special population – those injured by an electrical control device or taser. Jeff: Tasers typically deliver an initial 50,000 volt shock, with a variable number of additional shocks following that. Nachi: Most taser injuries are thankfully direct traumatic effects of the darts or indirect trauma from subsequent falls. Jeff: While there are case reports of taser induced v fib, the validity of taser induced arrhythmias remains questionable due to confounders such as underlying disease and previously agitated states like excited delirium Nachi: Basically, [DING SOUND} those with taser injuries should be approached as any standard trauma patient would be, with the addition of an EKG for all of these patients. Jeff: The next special population --- the one I’m sure you’ve all been waiting patiently for -- is lightning strike victims. Lightening carries a voltage in the millions with amperage in the thousands, but with an incredibly short exposure time. Because of this, lightening causes injuries in a number of different ways. Nachi: First, because it’s often raining when lightning strikes, wet skin may cause the energy to stay on the skin in what is known as a flashover effect. Jeff: Similarly and not surprisingly, burns are common after a lightning strike. Lichtenberg figures are superficial skin changes that resemble bare tree branches and are pathognomonic for lightning injury. Thankfully, these usually disappear within a few weeks without intervention. Nachi: Next, the rapid expansion of the air around the strike can lead to a concussive blast and a variety of traumatic injuries including ocular and otologic injury like TM rupture which occurs in up to two thirds of cases. Jeff: An ophthalmologic consult should be obtained in most, if not all of these cases. Nachi: Making matters worse, lightning can also travel through electric wiring and plumbing to cause a shock to a person indoors nearby the strike! Jeff: And like we mentioned earlier, just as was the case with my fellow Pittsburgher or ‘Yinzer. Nachi: Yinzer? Jeff: Forget about it, it’s just what Pittsburghers call themselves for some reason or another - but we’re still talking lightning. Cardiac complications including death, contusion and vasospasm have all been reported secondary to lightning injury. But don’t lose hope – in fact – you should gain hope as these patients have a much higher than typical survival rates. Nachi: From the neurologic standpoint – it’s a bit more complicated. CNS dysfunction may be immediate or delayed and can range from strokes to spinal cord injuries. Cerebral salt wasting syndrome, peripheral nerve lesions, spinal cord fracture, and cerebral hemorrhages have all been described. An MRI may be required to elucidate the true diagnosis. Jeff: Clearly victims of lighting strikes are complex and, for that reason, among many others, the American College of Surgeons recommends that victims of lightning strikes be transferred to a burn center for a comprehensive eval. Nachi: Let’s touch upon any other details regarding disposition. Jeff: Those with low voltage exposures, a normal EKG and minimal injury may be discharged home with PCP follow up and strict return precautions. Nachi: High voltage injuries on the other hand require admission to a burn center and the involvement of a burn surgeon, even if it involves transferring the patient. Jeff: And remember, trauma takes precedence over burn and those with traumatic injuries or the possibility of traumatic injuries should be evaluated at a trauma center. Don’t forget to take the airway early if there is any concern, and consider transporting via air as the services of a critical care transport team may be required. Nachi: That wraps up Episode 22, but let’s go over some key points and clinical pearls. During evaluation, consider multisystem injuries due to not only the thermal injury and electrical damage to electrically sensitive tissue, but also mechanical trauma. Thermal injury can lead to muscle breakdown, rhabdomyolysis, myonecrosis, edema, compartment syndrome, osteonecrosis, and even periosteal burns. Mechanical injury can be a result of forceful muscular contractions, and trauma can manifest as fractures, dislocations, and significant muscular injuries. Electrical injuries due to grasping an electric source can induce tetanic muscle contractions and therefore the inability to let go, increasing the duration of contact and extent of injury. Current tends to follow the path of least resistance, which explains why you might have deeper injuries beyond what can be visualized in the surface. Nerve tissue has the least resistance and can be damaged by even low voltage without cutaneous manifestations. Bone and fat, on the other hand, have the highest resistance to electrical injury. High voltage injuries place patients at risk for spinal injuries, most notably posterior cord syndrome. High voltage injuries have also been associated with cataracts, macular injury, retinal detachment, hearing loss, tinnitus, and vertigo. All patients with electrical injury require an EKG. Low voltage injuries with a normal presenting EKG do not always require cardiac monitoring. High voltage injuries require cardiac monitoring for at least 8 hours. Intubation should be considered early in patients with facial or neck burns, as risk of airway loss is high. Make sure to have airway adjuncts and back up equipment at bedside, as deeper airway injuries may not be obvious upon external exam. For severe injuries, target a urine output rate of 1-1.5 mL/kg/hr. All patients with serious electrical injuries require serial exams to evaluate for vascular compromise and compartment syndrome. Address pain with analgesia. Larger than expected doses may be needed. Dress burned areas with an antibiotic dressing and update the patient’s tetanus if required. For pediatric patients with oral electric injuries from biting on a cord, consult ENT early and consider admission for observation of delayed arterial bleeding. Pregnant patients who are past the age of fetal viability should have fetal monitoring and ultrasound after experiencing an electric shock. Tympanic membrane rupture is a commonly noted blast injury after a lightning strike. Cardiac resuscitation should follow ACLS guidelines and is more likely to be successful than your tyipcal cardiac arrest patient as the patient population is typically younger and without significant comorbidities. When determining destination, trauma centers take priority over burn centers if those sites are different. So that wraps up episode 22 - managing electrical injury in the emergency department. Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. And the address for this month’s credit is ebmedicine.net/E1118, so head over there to get your CME credit. As always, the you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!
Show Notes Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff: Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the August 2018 issue of Emergency Medicine Practice. Nachi: This month’s topic is one that Jeff has significant personal experience with from his college days. We’re reviewing Cannabinoids -- and emerging evidence in their use and abuse. Jeff: Um… that is definitely not true. I was actually a varsity rower in college... Are we still reviewing talking points together before we start recording these episodes? Nachi: Sometimes… Jeff: This month’s issue was authored by Mollie Williams, who is the EM residency program director at the Brooklyn Hospital Center. It was peer-reviewed by Joseph Habboushe, assistant professor at NYU and Nadia Maria Shaukat, director of the emergency and critical care ultrasound at Coney Island Hospital in Brooklyn, New York. Nachi: We’re going to be talking about the pathophysiology of cannabinoids, clinical findings in abuse, best practice management, differences between natural and synthetic cannabinoids, and treatment for cannabinoid hyperemesis syndrome. So buckle up and get ready. Jeff: As you’re listening through this episode, remember that the means that we are about to answer one of the CME questions from the end of the print issue. If you’re not driving while listening, be sure to jot down these answers and get your CME credit when we’re going through this issue.. Nachi: As of June 2018, there are 31 states, the District of Columbia, and 2 US territories that possess state and local-level laws allowing the use of cannabis medicinally or in recreational formulations. Marijuana actually maintains the highest lifetime use of an illicit drug used within the US. Jeff: There are a shocking 22 million past-month users of marijuana in the US, followed by pain relievers at 3.8 million, and cocaine at 1.9 million. Clearly, an important topic worth discussion, especially as synthetic products have become more widely available. Nachi: And worth noting -- Colorado, where medicinal and recreational marijuana use has been decriminalized and later legalized, has shown a nearly 2-fold increase in the prevalence of ED visits, which may be related to marijuana exposure. Jeff: Medicinally, cannabinoids are currently used in the treatment of chronic pain syndromes, complications of multiple sclerosis and paraplegia, weight loss due to appetite suppression in HIV/aids, chemotherapy-induced nausea and vomiting, seizures, and many other neuropsychiatric disorders. In fact, cannabis use has been documented for medical use dating as far back as 600 BC in West and Central Asia. Nachi: All of that being said though, there is an absence of high-quality reviews and evidence to support the use of cannabinoids for any of the indications you just mentioned. And the US DEA maintains cannabis as a Schedule I substance. Jeff: This DEA designation limits the ability to do research and obtain federal funding for such research. General lack of federal regulations on chemical content also leads to product variation, which may be a cause of increased incidences of accidental overdoses. Nachi: To attain the most up to date information for this article, Dr. Williams searched the PubMed and Cochrane Databases from 1950 to 2018. This produced predominantly case reports and retrospective studies. There were just a few randomized prospective studies -- not surprising. Jeff: Let’s get started with the pathophysiology. There are 3 cannabis species to be aware of: Cannabis sativa, cannabis indica, and cannabis ruderalis. Within these species, over 545 active cannabis-derived components have been described. Nachi: There are ten main constituents of cannabis sativa. Of these, 9-tetrahydrocannabinol (delta-9-THC) and cannabidiol (CBD) are found in the greatest quantities. The neuropsychiatric and addictive properties of cannabis are due primarily to the delta-9-THC. Jeff: THC and other cannabis derivatives work through the endocannabinoid system and other neuroregulators. The endogenous cannabinoid system has 4 components: (1) endogenous endocannabinoids, (2) receptors, (3) degradation enzymes, and (4) transport mechanisms. Nachi: There are two endogenous endocannabinoids to know about: anandamide (AEA) and 2-arachidonoyl-glycerol. Jeff: Cannabinoid receptors are broadly dispersed through the central nervous system, and to a lesser degree, also to other organ systems. Nachi: Because CB receptors are concentrated within the central nervous system, they exert the majority of their effects on the neuropsychiatric systems. And -- yes that’s a double ding -- the cannabinoid 1 (or CB1) receptor is most responsible for cannabis-induced neuropsychiatric effects. Jeff: Interestingly, the anti-emetic effects and possible palliative properties of cannabis derivatives are thought to be secondary to the inhibitory effects on serotonin receptors and the excitatory effects on the transient receptor potential vanilloid 1 (or TRPV1). More on TRPV1 later... Nachi: So far we have been talking about cannabinoids from the cannabis plant, but with cannabis being illegal in many states, there has been a growing emergence of synthetic cannabinoids. Synthetics were initially developed in the 1980s largely for research purposes. Jeff: Because the current DEA controlled substances schedule designations are based on original chemical names, synthetics have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designation as well as routine urine drug screening tests. Nachi: You may be familiar with some of the street names for synthetics -- like spice, K2, scooby snacks, black mamba, kush, and kronic. These can often be purchased over the internet or through specialty smoke shops. Jeff: Scooby Snacks, what a fantastic name, mooovingggg on… Synthetic cannabinoids often have greater affinity for the CB1 receptor than naturally occurring cannabinoids -- and synthetics can produce 100 times the effect. As a result, the presenting symptoms with synthetic intoxication can be difficult to differentiate from crystal meth or bath salt abuse. Nachi: Manufacturers sometimes use solvents and other contaminants. Clusters of toxic ingestions and deaths have occurred. Emergency clinicians need to be aware of this and should report suspicious events immediately. Jeff: For more on synthetic intoxications in the ED, be sure to take a look at the recent May 2018 issue of Pediatric Emergency Medicine Practice on Synthetic Drug Intoxication in Children if you haven’t already read it. Also, just a quick FYI - If you’re not a current subscriber to Pediatric Emergency Medicine Practice, we’re giving away a free copy of the issue specifically for our listeners. Just head over to ebmedicine.net/drugs for the PDF of the issue. Nachi: A free issue for our listeners, that’s nice! Let’s move on to a discussion about current indications for cannabinoids. So, there is no clear consensus on these indications, but there is some research of varying quality that supports the treatment of some chronically debilitating diseases with cannabinoids. Jeff: A systematic review and meta-analysis from 2015 found low-quality evidence to support cannabis therapy for appetite suppression in HIV and aids patients; moderate-quality evidence for treatment of chronic pain and spasticity; and also moderate quality evidence for some chronic debilitating diseases. Nachi: While talking about evidence-based medicine here, another review by the National Academies of Science, Engineering, and Medicine on possible associations between cannabis and cancers arising in the lungs, head, and neck, or testicles -- showed no statistically significant associations exist. Jeff: So in case that wasn’t clear - the overall evidence to support cannabis therapy, in general, is weak. Also, be aware that there are various formulations of cannabis that allow for different routes of administration. We’re talking oils, tinctures, teas, extracts, edibles like candies and baked goods, parenteral formulations, eye solutions, intranasal, sublingual, transmucosal, tablets, sprays, skin patches, topical creams, rectal suppositories, and capsules -- just to name, a few. Nachi: A few! That seems pretty complete to me. Basically, any way you can imagine, it seems like a route of administration has been explored. But of importance, these formulations have different absorption times -- as you might expect. The shortest duration to peak plasma levels of delta-9-THC is through the inhalation route, which can produce effects within 3 minutes. On the longer end, rectal cannabis administration can take up to 8 hours to reach peak plasma concentrations. Jeff: Let’s talk about some of the clinical findings and systemic effects associated with cannabis use. First up is the link between cannabis use and stroke or TIA. Cannabis users who smoked at least once weekly had a 3.3 times higher risk of stroke or TIA. Nachi: And there is moderate quality evidence that this link may be dose-dependent. Larger amounts of cannabis use lead to cerebral vasospasm and a reduction in cerebral blood flow. Jeff: In terms of psychiatric effects, several low-to-moderate quality studies have shown statistically significant associations between psychosis and self-reported cannabis use. Some association between high potency cannabis or synthetic cannabinoid use with new-onset psychosis or relapse in previous psychiatric disorders has also been found. Lastly, there is weak data supporting a correlation between cannabis use and depression. Nachi: From a cardiovascular standpoint, cannabis use is associated with increased resting heart rate, hypertension, and decreases in the anginal threshold for patients with chronic stable angina. A 2001 study described an augmented risk of myocardial infarction within the first hour of cannabis use and found an almost 5-fold increase in those who reported smoking cannabis at least weekly when compared to those who smoked monthly or less. Jeff: Dysrhythmias, qt prolongation, av blocks, myocarditis, and sudden death have all been reported with cannabinoids. Nachi: In terms of pulmonary effects, these are not really related to cannabis use directly, but rather the smoke inhalation and combustion materials of synthetic cannabinoids. Effects from chronic use can be seen. Jeff: Renally speaking, acute kidney injury and rhabdomyolysis are associated with synthetic cannabinoids and have been observed in several case reports. The rhabdo is believed to be due, in part, to associated seizures, muscle tremors, and agitation. Nachi: Among metabolic abnormalities, patients can present with hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. Jeff: Orally and dentally, dry mouth is the most common finding in acute cannabis toxicity. Chronic use has also been linked to severe periodontitis. Nachi: And ophthalmologically, there is, of course, the commonly seen conjunctival injection. Cannabis has also been found to decrease intraocular pressure when used topically -- and of note, there have also been rare reports of acute angle closure glaucoma and central retinal vein occlusion. Jeff: While talking about clinical findings and systemic effects of cannabis use, we certainly need to go over cannabinoid hyperemesis syndrome (or CHS), which is -- quite simply put -- associated with frequent visits to the ED in chronic users. It presents with nausea, vomiting, and abdominal pain. Nachi: CHS is commonly misdiagnosed as cyclical vomiting syndrome. After the legalization of marijuana in Colorado, it was reported that nearly twice as many patients had presented for what was thought to be cyclical vomiting syndrome. And ironically, though cannabis has been used as an anti-emetic, chronic use can cause the opposite reaction, leading to CHS, which is typically refractory to traditional anti-emetics. Jeff: And the etiology of CHS is not well understood. Similarly, the exact criteria for CHS are poorly defined. It presents as a recurrent and relapsing disorder that can be divided into 3 phases: prodromal, hyperemetic, and recovery. Nachi: In the prodromal phase, patients complain of early morning nausea without vomiting, and they can have mild abdominal discomfort. This can last from months to years. In the hyperemetic phase, patients complain of severe, unremitting abdominal pain with repeated episodes of vomiting and retching. This is often associated with an inability to tolerate po. Jeff: The hyperemetic phase lasts 24-48 hours and can lead to dehydration, electrolyte abnormalities, and weight loss. Patients may learn to relieve symptoms by compulsively bathing in hot water. Nachi: Resolution of symptoms is seen when the patient stops using cannabis. This is during the recovery phase, which can last from days to months. But this can be short-lived if the patients begin using cannabis again. Jeff: On that note, we should also touch on cannabis withdrawal. Termination of heavy and habitual use can lead to withdrawal syndromes within 48 hours. Symptoms here include irritability, anxiety, restlessness, sleep difficulty, seizures, and aggression. Medications that can be helpful include benzodiazepines, neuroleptic agents, and quetiapine in refractory cases. Nachi: Moving on to the next sections in the article, let’s talk about differential diagnosis and prehospital care. The differential for acute cannabinoid intoxication, as you might suspect, is broad, and it includes some life-threatening processes. We won’t list them here, but be sure to think broadly before deciding on cannabis as the cause of your patient’s symptoms. Jeff: For the prehospital providers -- care here is mainly supportive. Provide airway protection as needed - gather information from the patient’s environment, looking for empty pill bottles or another empty packaging. Nachi: Let’s move on to care once in the ED. All patients who are in distress and suspected of drug ingestion should be disrobed completely and placed on a cardiac monitor. Fully assess for trauma and place an IV in the patient. Search the patient’s clothing for drugs and paraphernalia, which may help in making the diagnosis. Jeff: When getting a complete history from the patient, it may also be worthwhile to talk with any persons accompanying the patient to the ER for more information. In your history, be sure to ask about a pattern of use and possible co-ingestions. Nachi: When considering cannabis hyperemesis syndrome, a detailed history and physical exam are crucial for making the diagnosis. To differentiate between other etiologies of abdominal pain and vomiting, be sure to ask about the use of hot baths for relief, resolution of symptoms after stopping cannabis use, and the predominance of symptoms in the morning hours. Jeff: On physical exam, for cannabis intoxication, there isn’t a particular toxidrome to look for. Monitor vital signs closely, looking out for alterations in blood pressure and heart rate. A complete neurologic and mental status examination will be the key here. Nachi: Decisions for lab testing should be dependent on the patient’s presentation. Possible tests include CBC, BMP, LFT’s, lipase, cpk, ckmb, troponin, urinalysis, urine drug screening, serum tox screens (for alcohol, aspirin, and acetaminophen), and any other drug levels for medications that the patient is taking for medicinal purposes, like phenytoin or lithium levels. Jeff: One study supported point of care urine drug testing in the ED. However, know that acute cannabis intoxication can be difficult in the chronic user, as delta-9-THC will be present in urine for up to 24 days. Testing for synthetically derived cannabinoids is difficult due to changes in synthetic compounds. Nachi: Interestingly, there are a number of medications that are associated with false positive cannabinoid screenings. These include ibuprofen, pantoprazole, efavirenz, and lamotrigine. Jeff: For any patient arriving with suspected cannabis or synthetic abuse, consider checking an EKG. You’re looking for signs of ischemia, arrhythmia, and interval abnormalities. Serum and urine tox tests are not particularly helpful in the acute chest pain patient who is using synthetic marijuana. Nachi: Not surprisingly, there are no specific diagnostic imaging modalities to help diagnose cannabis or synthetic cannabinoid intoxication. But imaging may help with assessing other disease states on a patient’s differential, so stay mindful of that. Jeff: Now that we’ve talked about history, physical exam, and useful testing modalities, let’s talk about treatment for cannabis and synthetic cannabinoid toxicity… therapy is primarily focused on supportive care. Most ED visits only require a short stay. Nachi: That’s right, there are no antidotes to give for treatment here. Be sure to look for and treat dehydration, acute renal failure, and rhabdo though. In severe cases of neuropsychotropic effect, give benzodiazepines, like lorazepam, to help with control. Jeff: For GI effects, first-line treatment is traditional anti-emetics like ondansetron or metoclopramide. Recent literature and case reports have shown significant improvement with butyrophenones like haloperidol as a second-line treatment. Nachi: While talking about treating the gastrointestinal effects of cannabis toxicity, let’s also discuss methods to control cannabinoid hyperemesis syndrome. The mainstays for treatment here are actually supportive therapy and cessation of cannabis use. Jeff: And can you tell us more about why these patients crave hot showers and improve after? Is there a pathophysiology or mechanism to know about there? Nachi: There is a well-studied theory here and it relates to the TRPV1 receptor that we talked about earlier. Temperatures in excess of 109 degrees Fahrenheit, acidic conditions, and compounds found in certain foods and plants (like cannabis) activate this receptor. It’s believed that intermittent and repetitive exposure to agonists of the TRPV1 receptor leads to a persistent state of nausea and vomiting. Desensitization of the receptor happens after repeated stimulation, and repetitive topical capsaicin or hot water is believed to function as an exogenous agonist. Jeff: In any case of repetitive emesis, be sure to consider electrolyte replacement if needed. In many cases, hydration or repletion will need to happen through an IV. Proton pump inhibitors can also help in some cases where GI symptoms are a dominating complaint of the patient. Nachi: Recent literature supporting the use of haloperidol for nausea and vomiting has found that symptoms improve approx 1hr after administration. This can decrease the need for observation or admission. Jeff: Haloperidol works via dopamine 2 receptor antagonism. D2 receptors are found in high concentrations throughout the nervous system and bind with high affinity to haloperidol. The suggested starting dose is 2.5mg IV with a repeat dose of 5mg IV if needed. An RCT is underway in Canada on the use of ondansetron versus haloperidol with an estimated completion of July 2019. Nachi: Capsaicin has similarly shown promise in cannabis hyperemesis syndrome through the TRPV1 receptor as we discussed already. Currently, there are no dosing recommendations or application instructions for capsaicin. There is some evidence supporting relief within 30 to 45 minutes, and capsaicin can be applied topically to any nonmucosal surface like the abdomen, chest, or back. Jeff: So to recap -for cannabis hyperemesis syndrome, treat with anti-emetics, PPI’s, electrolyte repletion, and IV hydration as needed. As a second line treatment, consider haloperidol and topical capsaicin applied to the chest, abdomen, or back. Nachi: Let’s talk about some special populations next -- starting with Pediatrics. According to data from 2012, of the 130 million people reporting illicit drug use within their lifetime, 25% were children between 12 and 17 years of age. Jeff: And according to the national poison data system, states with marijuana use laws have seen a 30% increase in calls related to marijuana use by children. From 2010 to 2011, the number of ED visits by children aged 12 to 17 years old due to synthetic cannabinoid use also has doubled. Nachi: Many children and adults believe that synthetic cannabinoids don’t pose serious health risks, as these are not illegal to purchase. And this class of drugs is particularly attractive to adolescents since it will not readily test positive on urine drug tests. All of this is very concerning for emergency clinicians. Jeff: There have been several recent reports of myocarditis in association with marijuana use. One case resulted in death due to myocyte necrosis after an unknown amount of edible marijuana was consumed by a toddler. Nachi: Horrific! Jeff: And the exact mechanism through which the myocardial necrosis happens isn’t known. Nachi: For all children and adolescents who present to the ED with alteration in mental status, psychosis, or chest pain -- be sure to screen for cannabis or synthetic cannabinoid use. There are case reports in the pediatric literature of STEMIs seen in patients without pre-existing cardiac disease or risk factors. Jeff: Keep in mind that urine drug screens can be falsely positive from certain proton pump inhibitors, so if possible, assess a urine drug screen prior to starting a PPI in these patients. Nachi: Moving on to our next special population… pregnant women. Know that it can be difficult to the differential between hyperemesis gravidarum and cannabis hyperemesis syndrome in pregnant patients. Ask specific questions regarding marijuana use before and during the pregnancy. Jeff: It’s also worth noting that cannabis is known to cause adverse outcomes on babies such as low birth weight and more frequent perinatal ICU placement. Nachi: Let’s move on to the final major section of the article, which is on the legal status of cannabis and cannabinoids. Much of the controversy surrounding cannabis for medicinal use relates to the absence of quality evidence. More research is needed to evaluate potential public health risks posed by variations in quality and potency, potential impact to our healthcare system, and ability to legislate for synthetic cannabinoids. Jeff: Though marijuana and all whole-plant derivatives are schedules I controlled substances, there are a few cannabinoid-based drugs approved by the FDA for medicinal purposes -- with lower schedule designations. Dronabinol is a schedule III drug derived synthetically from delta-9-THC. It’s used in chemotherapy-induced nausea/vomiting, as well as anorexia and weight loss from AIDS/cancer. Nachi: Nabilone, a schedule II synthetic variant of THC, has been approved in the treatment of aids-related anorexia and chemotherapy-induced nausea also. Jeff: Nabiximols, a plant-derived cannabinoid, has been approved in Europe and Canada for multiple sclerosis induced spasticity and cancer-related pain. Nabiximols are not yet approved in the US. Nachi: And lastly, we should mention cannabidiol, which is a schedule I controlled substance approved for treatment of seizures with 2 rare diseases -- Lennox-gastaut syndrome and dravet syndrome. Compared with placebo alone cannabidiol and other medications have shown efficacy in lowering the rate of seizures for these diseases. Jeff: Lots of interesting stuff to look out for there in cannabinoid-related medications. Alright, on to disposition - Nachi: Most patients who present with uncomplicated acute cannabis or synthetic cannabinoid intoxication can be observed until clinically sober. Discharge home should be in the care of a sober family member or friend. Make sure that the patient knows not to operate vehicles or heavy machinery under the influence of drugs. Counsel them on drug abuse also. Jeff: In more rare situations, patients will require admission. Consider this particularly for patients who have end-organ damage, rhabdomyolysis, acute renal failure -- evidence of cardiovascular, cerebrovascular, or ophthalmologic insults -- intractable vomiting, or acute psychosis. Nachi: And for cannabinoid hyperemesis syndrome, patients may require admission for IV hydration and electrolyte correction. Once the patient is tolerating PO and lab derangements have been corrected, they can be discharged. Jeff: Let’s wrap up the episode with key points and clinical pearls… N: Marijuana is the most commonly used illicit substance in the US. States that have legalized marijuana for medical and recreational purposes are showing increased rates of marijuana abuse and dependence. J: When concerned with drug intoxication, search your patient’s clothing for drugs and paraphernalia on arrival. N: The neuropsychiatric and addictive properties of cannabis are due primarily to delta-9-THC. J: Synthetic cannabinoids have gained popularity as manufacturers are able to produce newer compounds and circumvent DEA designations as well as routine urine drug screening tests. N: Manufacturers of synthetic cannabinoids sometimes use solvents and other contaminants, which have caused clusters of toxic ingestions and death. J: The shortest duration to peak plasma levels of delta-9-THC is through the inhalational route. Effects can be seen within 3 minutes. N: Cannabis users who smoke at least once weekly can have a 3.3 times higher risk of stroke or TIA. J: The risk of myocardial infarction is increased within the first hour of use, and there is an almost 5-fold increase for individuals who smoke at least once per week. N: Acute kidney injury and rhabdomyolysis have been noted with synthetic cannabinoid use in several case reports. J: Cannabis intoxication is associated with many metabolic abnormalities like hyperthermia, hypoglycemia, hypokalemia, hyponatremia, and metabolic acidosis. N: Cannabis hyperemesis syndrome, which presents with abdominal pain and vomiting, is associated with frequent visits to the ED in chronic users. J: The mainstay for treatment of cannabis hyperemesis syndrome is supportive therapies and cessation of cannabis use. N: Patients with cannabis hyperemesis syndrome crave hot showers because of activation of the TRPV1 receptor. J: Topical capsaicin may also help in the treatment of cannabis hyperemesis syndrome through activation of the TRPV1 receptors. N: Haloperidol at 2.5mg IV may help in refractory vomiting associated with cannabis hyperemesis syndrome. J: Many children and adults do not believe synthetic cannabinoids pose serious health issues as the they are not illegal to purchase. This is incorrect. N: Most patients with acute uncomplicated cannabis intoxication can be observed and discharged. Admit if there are any signs of end organ damage, intractable vomiting, or acute psychosis. Jeff: So that wraps up the August 2018 episode of Emplify. Nachi: For those of you looking for CME - the address for this months credit is ebmedicine.net/E0818, so head over there right away to get the credit you deserve. Remember that the you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. See you next time! Most Important References 5. * Kim HS, Monte AA. Colorado cannabis legalization and its effect on emergency care. Ann Emerg Med. 2016;68(1):71-75. (Literature review; 21 studies)7. * Baron EP. Comprehensive review of medicinal marijuana, cannabinoids, and therapeutic implications in medicine and headache: What a long strange trip it’s been …. Headache. 2015;55(6):885-916. (Review)9. * Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456-2473. (Retrospective chart review; 4 cases)64. * Tournebize J, Gibaja V, Kahn JP. Acute effects of synthetic cannabinoids: update 2015. Subst Abus. 2016:1-23. (Systematic review; 46 articles, 114 patients)83. * Wallace EA, Andrews SE, Garmany CL, et al. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. South Med J. 2011;104(9):659-664. (Review)
Job Insights Extra: Adjustment to Blindness - Meet Rob Hobson: College Prep and Success All in One. Transcript Provided Job Insights Extra brings you Rob Hobson, Cordinator for Professional Development and College prep at Blindness Learning In New Dimensions, Inc. Best known as Blind, Inc. located in Minneapolis, Minnesota. Rob tells his story how he overcame the challenges that nearly defeated him when entering his Masters program. He made a decision to improve his Blindness skills and this led him on the journey he continues today. From nearly bailing out to exceeding his own expectations by finishing his Masters degree ahead of time and landing a job in the career he wanted. Rob talks about his job details when he started as an Orientation and Mobility instructor to his duties today as Cordinator of Professional Development and the College Prep program. Join Rob Hobson and Jeff Thompson on this brief look into Rob’s Adjustment to Blindness and how he is helping others adjust to their Blindness today. You can find out more about Blind,Inc and Adjustment to Blindness on the web at www.BlindInc.org You can also contact Rob and Blind, Inc. via email You can find out more about State Services for the Blind on the web at www.MN.Gov/Deed/SSB And to find Services in your state check out the American Foundation for the Blind web site and enter your State’s name in the, “Find Local Services” section. Thank you for listening! You can follow Job Insights on Twitter @JobInsightsVIP Send the Job Insights Team and email and give us some feedback and suggest some topics you would like to see us cover. Job Insights is part of the Blind Abilities Network. You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Get the Free blind Abilities App on the Google Play Store. Job Insights Extra: Adjustment to Blindness - Meet Rob Hobson: College Prep and Success All in One. Transcript Provided [Music] Rob: When I started that semester, I soon realized that the skills I used in college from my undergrad weren't gonna work in grad school. Jeff: That's the voice of Rob Hobson, Coordinator of Professional Development and College Prep at Blindness Learning in New Dimensions. Rob: Set up an interview and came up here in early December of 2008 and I was offered a position and I accepted. Jeff: Rob talks about the challenges that he faced when transitioning from college to his master's degree program, and how adjustment to blindness training gave him the skills and confidence to succeed. Rob: We use structure discovery which utilizes the environment as a teaching tool and if you only just know one specific route, that can be really debilitating because that's all you know. Jeff: And you can find the Job Insights podcast on blindabilities.com, part of the Blind Abilities Network with host Serina Gilbert and myself Jeff Thompson, and you can contact us by email at JobInsights@blindabilities.com, and join us on the job insight support group on Facebook, on Twitter at Job Insights VIP. Rob: Get that adjustment to blindness training because it is vital for you to be able to compete out there with your sighted peers. Keep an open mind because there is a lot of life after blindness. [Music] Jeff: I went down to South Minneapolis to the historic Pillsbury mansion, the home of Blind Incorporated and that's where we met up with Rob Hobson, we hope you enjoy! [Music] Welcome to Blind Abilities I'm Jeff Thompson and today we're down at Blind Incorporated in Minneapolis we're talking to Rob Hobson and he's the Coordinator for Professional Development and College Prep. How are you doing Rob? Rob: I'm doing well on yourself Jeff? Jeff: Doing good thanks, Rob thanks for taking the time to coming on the Blind Abilities and sharing a little bit about your journey through blindness and your job that you have. Rob: Oh thank you I'm happy to be here. Jeff: Well Rob, can you tell a little bit about what your job is like here? Rob: Well working here at Blind Incorporated, it's a lot of fun, we have a great team and we work together as a team to provide adjustment to blindness training to college-age students, to adults, to seniors, and we have transition programming, and we even have a buddy program which covers 9 to 13 year olds. Jeff: You cover the whole gauntlet? Rob: Yeah we do, it's, it's great, it's, it's a lot of fun. [Bass guitar sound effect] Jeff: Now you did not start out as a Program Coordinator? Rob: Well when I started at Blind Incorporated, I started in 2009, but I should go further back, actually, it's actually a little journey. In 2006 I started grad school at Southern Illinois University in Carbondale to get a master's degree in public administration, on paper that sounds great, when I started that semester I soon realized that the skills I used in college from my undergrad weren't gonna work in grad school. The bar was a lot higher, note takers were hard to get, because I utilized their services through disability services through the campus and I realized that my skills weren't up to par because I just couldn't keep up. Every time I thought I did great, I was still further behind. What really hit it for me was when I took this budgeting class and I thought I got all the points possible, and in that class it was zero to five, five was like the max of points you can get, so I thought hey, I might have gotten a four or five, and I got my grade and it was a 1.5, and the words that really changed my view was, well I felt bad, so I just gave you a 1.5. And that really hurt, it really set, threw me back a loop, you know, it's like wow, I've never had that happen to me before. I called some friends who are in the NFB and I talked to them about, you know, maybe it's time for me to get some adjustment to blindness training. I knew it would be a process because getting Illinois, because that's where I lived at the time, to pay for it was a process. I've heard horror stories that sometimes it could take two years but I was pretty confident that it wouldn't take that long. So in August of 2006 I met with a counselor, I convinced her to start the process and I had an O&M evaluation. I wrote a letter stating why I needed this training and what it was going to do for me, so I had an O&M evaluation, through the letter I was able to convince them to provide me the opportunity to go to the Louisiana Center for the blind in Ruston Louisiana. I started my program at the end of March of 2007, and that's when I started my journey in blindness training. Now to be fair, my goal was to get through the program, go back to Southern Illinois University in Carbondale, and complete my Master's in Public Administration Degree. Well while I was in the program, it was suggested to me that I should consider the Louisiana Tech O&M program and I considered it for about 1/2 a second and I thought no that's not me. As they say it, it put the seed there and throughout the summer of 2007 I realized that hey, you know I might actually like this. I started the process in the fall to go into Louisiana Tech, in the end of November I started my first classes as a Louisiana Tech student in grad school. Jeff: Now Rob, could it be that winter was coming and.... Rob: I'm not gonna lie, that was true, I thought that was a good benefit but really I was excited to start this program because I knew that, you know at the end of this program I would be able to get a job, and believe it or not, throughout that year it took me a year, end of November of 2007, and by November 19th of 2008 I walked away with a college degree, a graduate degree, from Louisiana Tech. It was a rough year, they say that a master's degree generally is a year and a half to two years, I did it in a year, it was probably the hardest year of my whole life at that time. Jeff: Congratulations! Rob: Thank you. I soon talked to Sean Mayo who was the Executive Director of Blind Incorporated, set up an interview and came up here in early December of 2008 and I was offered the position and I accepted. In January of 2009 I started as a Blind Incorporated employee, and to be fair, I only planned to be here year after about a month of working here because it was so cold, but I soon liked it, teaching cane travel was a lot of fun, it took me a while to get into my zone, you know because when you come to a new city you have to learn how to navigate the streets and learn the grid, the outline, you know all of the names of the roads, and I knew I had the skills to teach, it was a matter of learning the environment so I could teach and understand how to relate that information to my students. Jeff: So did you do a lot of exploring in your off time and just try and navigate the city and learn it? Rob: I did, I spent a lot of time learning south Minneapolis, I spent some time with Zach Ellingson who was the full-time cane travel instructor at the time, and we talked a lot, he really helped me gain the information necessary to teach. I spent some time observing him just to see how he taught because you know, when you're still a new teacher, you still like to get other teaching styles and I knew Zach was really successful at what he was doing and it was a good resource to work with. I spent a lot of time on weekends going out to other places in the city but at the time I really focused on south Minneapolis because I knew majority of my instruction was gonna be during that time. I later throughout the years, I gained knowledge in Northeast Minneapolis, Southeast Minneapolis, St. Paul, I know some of St. Paul, I don't know a lot of it but I know enough to to be able to teach it. Jeff: Now learning the areas that you did, it's pretty much transferable skills the way you teach here right? Rob: It is, the skills are transferable but you know it's like anything else, when you want to teach someone you have to still know what you're teaching, does that make sense? Because we also teach how to navigate the area via some of the names, so I needed to know those names so I can you know pass that information along, learn bus routes, I learned a lot of the bus routes, but yes, the skills I learned in Ruston Louisiana were transferable once I figured out the grid system and for an example, Hennepin Avenue is your divider between north and south Minneapolis, and the river, the Mississippi River divides southeast Minneapolis and northeast Minneapolis from north and south Minneapolis, and anything more than that you get a little complicated because it depends on where you are further south in the city, you actually have the river divider between St. Paul and Minneapolis. [Bass Guitar Sound Effect] Jeff: There's always been a debate about people sometimes teaching route travel compared to teaching skills that will allow you to explore other areas and use the same set of skills. Rob: That is true, in our format we use structure discovery which utilizes the environment as a teaching tool. We do start off with students in the beginning giving them simple route assignments so that they learn to gain that confidence and gain those problem-solving skills so that they're able to change those routes, make a diversion if need be, I mean because, well if you've walked in Minneapolis in the summer, you know that, maybe every, about every few blocks there's construction, or they tear up a sidewalk to put in a new one, or whatnot, you have to be able to problem solve in that and if you only just know one specific route, that can be really debilitating because that's all you know, and how are you gonna be able to get through that situation. Jeff: Yep I graduated from Blind Incorporated and I remember the whole thing, the only thing Zack always got upset was, I grew up here so, when he was trying to fool me or something, I'd hear a church bell. Rob: Oh, and that gave it away didn't it? Jeff: I could identify the church, so he would be more creative next time you know, just knowing that I had a few cues that other people didn't have so it was always interesting. Now in your new position, what do you do for Blind Incorporated? Rob: Currently I set up all of our activities, I coordinate from beginning to end. For an example last year we went camping for the first time in I don't know how many years, at least since I've been here we've never gone camping up to that point, and we actually went camping, we stayed in tents and that was a long process to put that together because there's a lot of details involved. It's not like we all just got in a van and drove up to Duluth area and pick the camping site and just went camping. There's a lot of details involved when you take 30 people, 30 of your closest friends and students up to, up to go camping. So there's logistics because you have to work on you know the amount of food, how many tents, how many people per tents, just a lot of logistics. I coordinate all of the logistics to make sure everything falls in line, all of our activities from camping to just going rock climbing at vertical endeavors. Starting last year we started putting together professional development for the staff and students, some of the highlights, we had Kevin O'Connor come in, who is a renowned professional speaker who came in and talked to our staff and students on basically just professional development, working with each other, and what does it mean to be professional, and covered all of those components. We also had somebody come in and do a multicultural training, we had somebody come in and talk about cognitive disabilities, we've done some first aid CPR, so we've done a lot of different programming, but we've done it before but not to this caliber, so we really have a professional development piece about every three months or so for the staff and we started incorporating the students in that as well because it's important I think for our students to be able to have that information, they can put it on their resume, and I think it makes them even more employable. [Music] Jeff: You also had a program called Blind and Socially Savvy, can you tell us a little bit about what that is? Rob: So Blind and Socially Savvy really covers the soft skills, starting in conversation with somebody, proper way to introduce somebody, etiquette, so they have an etiquette meal where they actually sit down, a full meal and they learn how to conduct themselves in a professional environment because I'm sure you know Jeff that there are always interviews, sometimes those interviews are sitting down with a meal with your future employer, so it's a great opportunity to be able to conduct yourself professionally, it makes it even more likely for you to get that job. Also it's good to be professional and to have that proper etiquette because you're going to be amongst peers, whether they're your fellow co-workers, or friends, family, maybe you volunteer in an organization, it's great to have that etiquette because it puts you even higher up on the bar of success. Jeff: I attended something very similar to that and I remember they said, your bread is not a mop and turn your phone off, and pay all your attention to the person, it's not about the food mostly, it's about the interview so to say, or the person that you're attending with. Rob: That is correct. Jeff: And then they went through, start from the, just like on the Titanic, start with the outside silver and wake work your way in, so there's a lot of information there that people are kind of expected to know, but if you haven't had the opportunity to learn it, Blind and Socially Savvy that you guys provide here, is awesome! Rob: Yeah and we didn't do it ourselves, we did it along with State Services for the Blind, we worked well with them and Sheila Koenig who's the coordinator for transition for SSB, she worked really well with Dan Wenzel the executive director here, and Michelle Get, who coordinates our transition programs. Jeff: And you do have a lot of programs here and opportunities that you mentioned early and it's really neat to see all the stuff that's happening from the summer to prep to like I said you cover the whole gauntlet here. Rob: Yep we also are starting a new program, it's our College Programming or I like to call it College Prep and what it is is students come in maybe they don't want to do a full six to nine month program but they want to come in and get some of those non-visual adjustment to blindness skills. So they'll come in for a summer, get that training, and if they're new to going to college we actually have a college class component that would start in the fall where they could take a class and still continue to get some adjustment to blindness skills, we would work with them on navigating a campus, and specifically that campus, and we would also work with them on study skills, note-taking skills, all of the the skills necessary to be successful in college. I know when I first started college I was absolutely terrified and I think even now with, with the technology being the way it is, back then you know if you had a computer you were lucky, but nowadays there's phones, there's Braille displays, there's lots of different technology out there that we would be able to work with students on so that they are fully competent and capable to be successful in college so that they can be employable in the future. Jeff: And being able to use that equipment on day one! Rob: Exactly, I mean that's, I think that's a really good point Jeff, you don't want to start, get your technology September first when you start at the class in late August and then have to learn how to use it while taking classes at the same time. We like to work with students early so that they have those skills when they start the college class, that they are able to know how to use their technology, take the best notes possible so that they can be self-sufficient. [Music] Jeff: Rob Hobson thank you very much for what Blind Incorporated does here in Minneapolis and across the nation because other students come from other states and you guys give them an opportunity to succeed, give them skills and the confidence to do so. What advice would you give to someone who has recently become blind visually impaired or has trouble reading the printed word, and what advice would you give them as they start that journey? Rob: I would say keep an open mind, blindness is probably the one of the most terrifying disabilities out there, and really it's because of the unknown, it's a sighted world out there, people perceive through what they see, but keep an open mind because there is a lot of life after blindness. I lost my vision I, I wasn't fully sighted but when I did have some vision I lost it pretty quickly due to a retinal detachment and, and that's a long journey itself, but I know what it's like, it's tough, but what I can tell you is working with State Services for the Blind, figure out your options, whether it's Blind Incorporated, VLR, or Duluth Lighthouse, get that adjustment to blindness training because it is vital for you to be able to compete out there with your sighted peers and really that adjustment to blindness training is what's going to put you on that same platform for success. Learn those skills, know how to cook, clean, learn to read Braille, technology, cane travel, because you got to be able to get there on your own. You can always use Uber and Lyft but I can tell you that stuff's expensive, I know I look at my bank account every month, not that I use it every day but I use it just for quick things, it's expensive, so you're not going to be able to do that all the time, so you've got to pick up those, you know learn those non-visual skills that you can travel independently. Remember that blindness is not a tragedy. I like to say blindness is what you make of it, you can look at it as a tragedy, or you can look at it as, you know what, this is a new challenge, and I'm here to overcome it. Jeff: So Rob, if someone want to get a hold of you or Blind Incorporated, do you have any contact information? Rob: Sure do, you can call our main number 612-872-0100, and ask for Jennifer Wenzels, she handles our intake. You can also ask for me, I'm happy to talk to you if you have any questions, my extension is 220, and Jennifer's extension is 251. We also if you like email, you can send an email to info@blindinc.org. Jeff: info@blindinc.org, well Rob thank you once again for taking the time, sharing your story, sharing your experience with the listeners and, really appreciate it. Rob: Oh you're welcome Jeff, it was a pleasure. [Music] Jeff: Yes it was a real pleasure talking to Rob Hobson, and if you want a contact Blind Incorporated, send them an email at info@blindinc.org, on the web at blindinc.org, and to find out more about State Services for the Blind check us out on the web at www.mn.gov/deed/ssb, and to find services in your state check out American Foundation for the Blind's website at AFB.org. And Thank You Chee Chau for the beautiful music and you can follow Chee Chau on Twitter at lcheechau. Once again, thank you for listening, we hope you enjoyed, and until next time bye-bye [Music] [Multiple voices] When we share what we see through each other's eyes, We can then begin to bridge the Gap between the limited expectations and the realities of Blind Abilities. Jeff: For more podcast with the blindness perspective, check us out on the web at www.blindabilities.com, on twitter at BlindAbilities, download our app from the app store, Blind Abilities, that's two words, or send us an email at info@blindabilities.com, thanks for listening.
Job Insights #4: Apps With Productivity in Mind for Education and in the Workplace. Transcript Provided Welcome to the 4th episode of Job Insights with Serina Gilbert and Jef Thompson. We focus on Employment, Careers, enhancing opportunities and bringing you the latest innovations from across the Vocational Rehabilitation field to ensure your choices lead you down the career pathway that you want and succeed in gainful employment. From getting started with services, to assessments, Individual Plan for Employment (IPE) to gaining the skills to succeed and tools for success, Job Insights will be giving you tips and tricks to help your journey to employment and break down the barriers along the way. On this 4th episode of Job Insights Hope Paulos joins Serina Gilbert and Jeff Thompson in the studio and they talk about productivity apps and software. From the classroom to the workplace, these apps are geared towards making your daily challenges a bit more manageable, efficient and productive. Hours Tracker, Black Board, Drafts, Files, SeeingAI, Dictionary Thesaurus Pro, KNFBReader and Bookshare’s Read To Go app are all mentioned with some great discussion about how we use these apps. A great little Scan Stand named Foppidoo makes the scene and a conversation on Lift and Uber gets quite a chat as well. You can check out the Meet Me Accessibly book from Jonathan Mosen and learn about Zoom on the PC. Join the Job Insights crew and download some apps and give them a whirl. Hey, productivity rocks! We hope you enjoy this Job Insights episode and you can send your feedback and suggestions to the Job Insights team by email at JobInsights@BlindAbilities.com Follow the Job Insights team on twitter @JobInsightsVIP Job Insights is part of the Blind Abilities network. A big Thank You goes out to CheeChau for his beautiful music! Thank you for listening! You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Job Insights #4: Apps With Productivity in Mind for Education and in the Workplace. Transcript Provided [Music] Female voice: I feel like I'm getting a lot better education so yeah, I think, I think the online learning is an equalizer. Jeff: Job Insights, a podcast to help you carve out your career pathway and enhance the opportunities for gainful employment. Female Voice: But sometimes I require KNFB Reader when I have more than one page that I want to kind of read continuously. Jeff: Learn about resources for training education and employment opportunities. Female Voice: Blackboard, that is a learning management system and a lot of universities are using them as well for classes. So this particular app is available on Android, iOS, and PC, and Mac of course. Jeff: We will hear from people seeking careers, employment, from professionals in the educational field, teachers, and innovators in this ever-changing world of technology to help you navigate the employment world and give you Job Insights and enhance the opportunities to choose the career you want. Male Voice: Fopydo people sounds good and I actually at that time asked my son, and I, it was actually a play on the on Scooby-doo. Jeff: And you can find the Job Insights podcast on BlindAbilities.com, part of the Blind Abilities Network with hosts Serina Gilbert and myself Jeff Thompson, and you can contact us by email at JobInsights@BlindAbilities.com, leave us some feedback, or suggest some topics that we cover. On Twitter at Job Insights VIP, and check out the Job Insights support group on Facebook where you can learn, share, advise, and interact with the Job Insights community. [Music] Female Voice: Lift also released an update to their service dog policy saying that an allergy or fear of animals is not a valid reason to not pick up an individual with the service animal. Jeff: But hey it's a good learning tool, because it's just repetitious and pretty soon it just starts coming to you, mm-hmm, so I dug right in, when I saw they had flashcards I went Wow! [Music] Jeff: And now please welcome Serina Gilbert and Jeff Thompson with Job Insights. [Music] Jeff: Welcome to Job Insights and this week we're talking about apps, apps that you'll use in school, at the workplace, and these are productivity type of apps, and with me today of course is Serina Gilbert how are you doing? Serina: I'm good Jeff, how are you? Jeff: I'm just doing great and we got a guest today all the way from Maine. Hope Paulos, how are you Hope? Hope: I'm doing great, how are you? Jeff: I'm doing good, we're all doing good, so that's good. Today we're gonna talk about apps, you know some of these apps are mostly productivity type of things, stuff that you'll use to, you know get things done and that's, that's what we're, we're all about here on Job Insights. So Serina, last podcast you said you were holding out on us from what you're gonna tell us, is the cliffhanger over or are you gonna tell us? Serina: Oh we've got a little bit of a wait cuz we have to talk to Hope first, we have a guest. Jeff: How about you Hope, what do you got? Hope: I certainly don't have a cliffhanger. [Laughter] Serina: We set her up there Jeff! Jeff: yeah. Hope: Yeah you did! [Laughter] Jeff: So Hope, how's it going out and Maine? Hope: It's going well, the weather is nice finally, when I talked to you and Pete last time, it was March, and it was in the 20's, 20 degrees. Now we are in about the 60's, 70's, so I am absolutely loving it, birds are chirping, the guide dog is going for walks, he's enjoying it, Jeff: Is he bringing you with? Hope: Oh yeah of course! [Laughter] Jeff: That's great! Serina: But Jeff needs to know if you planted any Apple trees? Hope: No. Serina: Only PC trees? Hope: Only PC trees. [Laughter] Jeff: Oh that's the running joke isn't it? So when it comes to productivity type of apps, Hope what did you bring to the show today? Hope: Sure, so I have a couple of them. I don't use this particular one very much right now because I do work for Apple, and Apple has me on a strict schedule so I don't need this particular one, but for people who are freelancing, the name of the app is called Hours Tracker, it's a free app and basically it allows you to track your hours of course, hence the name, but it also allows you to track your earnings, and it will deduct the taxes as well. So it will tell you how much is deducting for taxes. So it's great for individuals who are freelancing. The second app that I have brought to the show is Blackboard. That is a Learning Management System and a lot of universities are using them as well for classes, so this particular app is available on Android, iOS, and PC, and Mac of course. This will allow you to do your classes online literally anywhere and actually a couple of the blindness organizations were working in tandem to get this particular app accessible. It's extremely accessible, there was only one thing that I commented on a couple weeks ago and I sent feedback in to the iOS developers and they fixed it. They're very very good about fixing issues that people might have. The other app that I brought, that I brought to the show is Learning Ally. This is an app that will allow you to download books and it's also good for individuals who are dyslexic and who have low vision because I believe it will allow you to magnify the print in the actual book so you can read along with the narrator which is quite helpful. That's more University as well, University-type app, Productivity app and of course the last app would be the Bookshare app. The Read2Go, this allows you if you have a membership to Bookshare, which I believe most students can get for free, it allows you to read the books on your phone be it Android or iOS. Jeff: Now on the Hours Tracker, is that what it's called? Hour Tracker? Hope: Hours Tracker yeah. Jeff: Hours Tracker. So when you're doing the setup, your presets, do you put in your wage, and then it just calculates it and are you able to output that anywhere, or is it just something you read? Hope: Absolutely, so this particular program allows you to put in the wage, and it allows you to put in whether or not taxes are withheld, so technically even if you were, you know not freelancing, if you working a job as an employee, a W2, you could use it as well. Basically it allows you to put in your breaks and your lunches and things like that, and it lets you know when to go on the break, and when to go to lunch, and when to clock out, and when to clock in. [Music] App Voice: Sample Job, 0.05H today, 0H button, clock out now or long-press for extras menu, button, next clock out now, button, cause now, button, break now button, break now, sample job 0 H on break 8:10 a.m., 0.02H button, end break or long press for extras menu button, end break. Hope: It also will let you know, like you can, you can set a reminder to have it automatically clock in when you get to work, and yes you can send it, I think it's a CSV file, or CV file, something like that, a database file, and it will put it in an Excel spreadsheet I think as well, so that you can show it to your employer. Jeff: That's kind of neat. Serina: That's pretty cool I like that. Hope: Yeah it's a it's a pretty neat app for sure. Jeff: Intuit the makers of QuickBooks and various tax applications has a program and it might be part of their bundle and I believe you can buy it separately, I believe it's called Self-Employed, but that sells on a monthly subscription for 7 to 8 dollars a month. Hope: Yeah this is free and I think, I'm trying to think if I paid for anything, I think I did just because I was freelancing at the time and I wanted them more, more, so it has a lite version and it has a full-featured version, but even the full-featured version wasn't some really really, you know cheap price. Jeff: A one-time fee? Hope: A one-time fee yeah. Jeff: That makes perfectly good sense, economically I can track that pretty good. [Laughter] [Music] Jeff: You can download Hours Tracker free from the App Store or the Google Play Store. Hourlys Tracker is free for up to 21 days of time entries and if you upgrade to the pro or professional, you get rid of all the ads, unlimited amount of entries that you can make, the only difference between the professional and the personal is you can have unlimited amount of jobs in the professional, and you can upgrade to the professional or the personal in the in-app option. The professional will run you $9.99 and the personal will run you $5.99. Once again, a one-time payment, I was really intrigued when I heard about Hours Tracker, I downloaded to my iPhone, and started using it right away, I named a job, I started the time, and when I was completed I stopped the time. I also had the option to input the time that I wanted it to start or input the time that I wanted to stop, otherwise you could do it in real time and that works out really nice. There's also an option that you can take notes and keep them with that job. I found that the accessibility on Hours Tracker on my iPhone was second to none, all the buttons were labeled and the intuitiveness was what I expected for when I have started logging the job, putting in the hours, getting out of the job, putting notes in, was just exactly how I expected it would work and it did work that way. Another small part of the accessibility, it lets you cancel a pop-up or dismiss the pop-up that comes up, and I really like that because if you've ever had a pop-up pop-up and not be able to get rid of it, that's not good. So after kicking around Hours Tracker on my iPhone for one job, I personally recommend this for anybody who is self-employed or someone who works on projects and just wants to have better records of the time they spend on their projects and jobs. [Music] Jeff: So on the Blackboard, I remember I have not experienced Blackboard yet, but I remember going to college and I was at the mercy of every professor that was experimenting by putting stuff on the web and accessing it through a link they give you, and if it was accessible you got lucky, so Blackboard is a collective effort to make it accessible for everyone. Hope: Absolutely, so it all depends on the type of class you're taking obviously right, if people don't know I'm going back to school to become a teacher of the blind and visually impaired and so all of the courses need to be accessible to me. So the professor's will tag their images so that I can know what's going on, their quizzes are all accessible, obviously the discussion boards are all accessible, and I use a combination of the two apps, so I use the combination of Blackboard and I use Learning ally to be able to do my classwork, and literally like I said, I can do it anywhere. With the phone if I have a Braille display and/or a Bluetooth keyboard I can do my homework on the beach or in the park you know, so literally anywhere and that's huge compared to when I was going back to school to get my undergrad degree, like you know 2009, that's when I graduated so it's, it's huge it's a huge step up. Serina: Yeah I remember using Blackboard when I was doing my master's degree which would have been gosh, probably around the same time as you are doing your undergrad, so I finished in 2010 and so, I don't know, 2007, 2008, somewhere around there's when I started it and they used Blackboard for everything. My program was pretty much 100% online, we didn't have the app back then, we just had the website, but even back then the website was pretty accessible. I rarely had any difficulties with it and I was going for the rehabilitation counseling so the professors were a little bit more cognizant of accessible media and documents and things like that. I loved using blackboard because it is easy to log on to, you know if I was on a break at work or whatever, or at home trying to get a discussion posted or something like that. Hope: Yeah it is really easy to use extremely easy to use. Jeff: Is that why you opted to do your classes online, not that you're on an island out off the shore of Maine, but..... [Laughter] Hope: Yeah I think, I think it's easier because I've done classes on site to, not having to do as my masters, but having to do with my undergrads degree. I find the digital world to be a lot more accessible, I just remember going to classes on site and didn't have a lot of input from the professor. The professor was teaching to a lecture hall full of I don't know, a hundred students, I just felt like I was kind of left out and wasn't getting all the notes that I needed to get, whereas here taking the classes online and using, again the combination of Blackboard and Learning Ally, I'm able to take the notes that I need, I'm able to contact my professors if I need to. I have peer to peer interaction as well. I feel like I'm getting a lot better education, so yeah I think, I think the online learning is an equalizer. Jeff: Mm-hmm. Hope: Of sorts. Jeff: Yeah that's great because you know everyone has to do what works for them and if you found a good way of doing it that's great, having those two apps makes it all accessible. Hope: For the most part yeah everything is accessible, even from registering for classes, I go to Missouri State University, so using Missouri State's website is accessible. It's just huge, it's what we're able to do as people who are blind and visually impaired with a digital world, it's absolutely huge. Jeff: So is that something you looked for when you were looking for an online course that they did use Blackboard? Hope: Not really, I didn't know what they used, I contacted them, I did ask them in the beginning when I was registering for the program what they used and I could have used Moodle, Moodle was another application, another learning management system that I'm familiar with and either one I would have been fine with. I looked online and and saw the collaboration between the two blindness organizations regarding Blackboard and I'm like okay this is going to be fine, this is gonna be great, I know it's gonna be accessible, I contacted my professors beforehand and gave them my accommodations and all that and said I need extra time and because it's a digital world they can input my time-and-a-half for quizzes and allow me to have that time and you know they can input that in Blackboard and all is good. I can't speak enough good things about accessibility and digital stuff. Jeff: So let's see, there's Learning Ally, we will put that in the show notes, we'll put Blackboard in the show, we'll put all these in the show notes so people can click on them and go right to the App Store or the Google Play Store and we'll have the links there, so back to the cliffhanger. [Laughter] Jeff: Hi Serina. Serina: And I thought of one like while we were sitting here, so even you'll be surprised Jeff. Jeff: Ooo. [Laughter] Serina: My absolute number one favorite app and I see it all over all of the groups like iPhone and iPad apps, and the assistive technology group, all of them, a seeing AI, I don't think it's any surprise there. That app allows me to be a lot less dependent on a human reader to just go through what's in my mailbox that I get at work. Now I can just kind of okay, yeah I need someone to finish reading that to me, or oh, this is just something that needs to go in the file, it's cut down on how much time I have to spend with somebody sitting at my desk with me going through stuff, and it's free, which is amazing to me because I remember reading gosh, I think it was like two years ago when Microsoft had their hackathon and they had released a video about seeing AI and they were showing a demo of it and I was like, well that's cool but it'll never come out and if it does it'll be super expensive. And then all of a sudden there's a link, and it's free, and it works, like amazingly and it, I can't thank Microsoft enough for that, that actually was a big surprise for me. Jeff: Yeah, you just open it up and boom, short text is reading. Serina: Yeah, from across the room right Jeff! [Laughter] Jeff: Yeah, that happened to me and, I shouldn't say it but I was that Orcam demonstration when they were having the little issues, and I was reading the wall that had their sign on it, so I was like wow, this is already talking, just out of the box, just turn it on and there it is. Male Voice: I use seeing AI all of the time to determine what's in my medicine cabinet, for documents you know I use seeing AI for short text. [Music] Female Voice: I use the document reader all the time, not gonna say it's as good as KNFB Reader because it's not. I did a test between reading my mail with it and with KNFB Reader and I found KNFB Reader to be far more stable, but I still like the app, I use it a lot, I'm glad that it's one of the tools in our toolbox. Female voice: For reading and stuff I used to go to KNFB Reader all the time but it just seems like Prizmo go and seeing AI is so much easier that I tend to go to them more. Male Voice: Seeing AI is my main go-to app and I use that, the short text channel mostly if I can't identify an item with that I will switch to the product channel if it has a barcode. A lot of the apps like [Inaudible] and Aipoly Vision and [inaudible], I've deleted most of those off of there because I can accomplish the same thing with seeing AI [Music] Male Voice: Jeffrey I see apps like Aipoly Vision, [Inaudible], Identifee, of course the KNFB Reader, I think seeing AI is becoming the main tool in the toolbox. Jeff: And you know, all the other channels that they have on their to four options but that's the one I use all the time because, you open it up it works. Serina: Yeah there's a handwriting one too that I've tried only a couple of times, but it surprisingly did recognize the handwriting enough for me to figure out at least what the note was generally about cuz sometimes my clients will stop in and I can't see them, and they'll leave a handwritten note at the front desk and obviously it's probably dependent on the individuals handwriting but I was at least able to get the name of the client and know, okay I'll just call them and see what they needed. Jeff: Hmm, well that's good. Serina: That one's in BETA I think. Jeff: Yeah you always wonder when they have a little feature that's in there and they tag the word BETA after it's like, you better use it now because it may not be there! Serina: Or it's like the disclaimer don't trust this feature. It might not work right! Jeff: Mm-hm try it on a doctor's prescription. [Laughter] Serina: Oh gosh. Jeff: That's the to test. Serina: This is totally not productive but when seeing AI first came out, we were playing with it in my office to see how old it thought everyone was. [Laughter] So all of my co-workers were like changing their hairstyles or putting on glasses or taking off glasses to try to trick it to make it think that they were younger. Jeff: That's a great use of state-funded money. [Laughter] Serina: Hey! Jeff: I know everyone's been doing that, it's kind of a novelty thing and that's like artificial intelligence to me when they're built into apps to me, it's like you know when you go to the carnival, you know, they'll guess your age and you win the whistle or something but you know, I'm not into the novelty stuff but that really does work. Serina: Hope, do you use seeing AI for any of your school work, or since it's mostly digital do you not have to use it a lot? Hope: Yeah I use it sometimes, I use it for work actually to find out whether or not my Mac, my work Mac is gonna turn on correctly. We have so many policies in place at Apple that sometimes voice-over doesn't turn on correctly and so I use either seeing AI or I also use AIRA for that, but most of the time I just grab my phone and you seeing AI. Speaking of the, or how old people were, I actually did that last weekend I think it was on my grandmother's 93rd birthday. I went up to her and took a picture of her and had seeing AI tell her how old she was, now again she's 93 right, so it said a 65 year old woman is smiling, or looks happy or something like that and she's like, wait, did it say 65? [Laughter] Hope: Shes like, I like that! So it made her day. Serina: Yeah. Jeff: I actually think for women they do have a built in algorithm that knocks off a couple years just to you know, keep the customers happy. Serina: No it added 10 years to mine, no matter what it says 10 years. Hope: Oh really. That's funny! [Laughter] Jeff: The algorithm breaker! Serina: Gosh. [Laughter] The other one that I use is obviously very similar to seeing AI but sometimes I require KNFB Reader when I have more than one page that I want to kind of read continuously. To my knowledge I don't know that you can scan multiple pages in seeing AI and if you can, somebody let me know, cuz I actually like it a little bit better. But sometimes when I'm working from home and I don't have access to my flatbed scanner but I need to read some printed like medical documents or things like that, I'll take out KNFB Reader and just scan a whole bunch of pages all at once and then read it, through it continuously, so that's very helpful, and then also you can save on KNFB Reader in their file system, and I think I saw on the latest update that now they can sync with Google Drive and Dropbox now to, so that's kind of a really cool feature that they've integrated in there now. Jeff: Yeah I like the KNFB Reader when I have like, I might have 10 pages of something to read and I don't want to take a picture of each of them so I put it on double sheet and then batch mode and when I turn the page it'll sense that, so you know you got the page turning then ch-ch-ch. KNFB Reader Voice: Manual picture button, automatic picture, picture from ste..., alert, please place your device on an empty document stand and align the camera with the aperture, okay, button, flash off, button, multi-page mode off, button, multi-page mode on. [Camera Sound Effect] Serina: Do you have a stand that you use with it? Jeff: Yeah I do, its the Fopydo and it was designed by Thomas Wardega, and here he is. Thomas: Fopydo sounds good, and I actually at that time asked my son, and it was actually a play on the on Scooby Doo. So basically this was designed from the ground up for people who are blind and visually impaired and along that process I learned to work with people who are blind so I went through a couple of revisions of the stand before I even started selling it just to make sure that people are happy with using it and that it fulfills whatever is needed from a scanning stand for people who are blind and visually impaired. [Camera Sound Effect] Jeff: It comes with a set of instructions that you can scan, you can put it together, once you got it together it just folds right up and you can put it in a suitcase, it takes up very little real estate. Serina: Oh I need one, and does it work with any phone or? Jeff: Well back when I talked with him he said it would handle, if you balanced it right, and iPad Mini, so I, I guess your your beast of a phone, your iPhone X may work. [Laughter] Serina: Yeah and put the link in the show notes cuz I've been, I thought, I had somebody looking for one before and they were like $50, I'm like mm-hmm, I'll just hold it up, you know. [Laughter] Jeff: Having the batch mode on the KNFB Reader really makes it viable product for someone that's in school that may have to be scanning a lot of pages. Serina: I definitely need one of those. Jeff: Yeah we'll put the link in the show notes and I believe he sells it on Amazon and if you have Amazon Prime, there you go, ten, twelve bucks. Serina: Primes getting expensive though it's like $120.00 starting this year. Hope: I think there's a discount for students. Serina: It's half off for students cuz I had that for a couple of years, and then they got smart and realized that I'm not a student anymore because my school let me keep my student email address for years, and I don't even think I have it anymore now. Now they make you verify by sending in like a schedule. Hope: Oh really? Serina: Yeah. Hope: Similar to Apple music, they do the same thing. Serina: Yeah, and I think Spotify does the same thing too. Hope: Yep. Serina: They got smart. Jeff: So we'll have to put the link in there for Amazon Prime half off for students, that's good news. Serina: Yeah that's it, and half off of Apple music and Spotify, not that those are, those could be productivity apps because if you need music to stay focused. Hope: Technically yeah, exactly, that works! Jeff: Or books. Hope: Yeah. Jeff: Amazon still sells books. Serina: Who orders books anymore? Jeff: Does anybody use Audible for books? Serina: I do not, I totally looked at it, but every time I looked at it I just can't, like I think it's thirteen ninety-nine a month for so many credits and one, the amount of credits you get for that amount is equal to downloading one book, and I haven't found that it's better than just using BARD, because they usually have especially if it's a best-seller what I want anyway. Jeff: Mm-hmm and the BARD app is totally accessible too. Serina: Yeah it's, it's a little old school sometimes, it has its glitches but it gets the job done. Hope: It can be yeah, exactly. Jeff: But it's, it's something that if you do send in a report and stuff like that they'll fix it? We can hope for the best right Hope? Hope: Yeah exactly, yeah sure, I'll write them, I'll give them a good report! Jeff: There you go. Hope: Sure. [Laughter] Serina: Well and it's hard because I know, I think that's run by the Library of Congress so that probably takes like an act of Congress just to get a glitch fixed you know. Jeff: Oh good one! Serina: I didn't mean it to be all cheesy but it's kind of funny. Jeff: Yeah it is, it is, it's nice when things work and you know, you were talking about seeing AI when you open it up short text just starts. I got an app called Drafts, just like the seeing AI, when you open it up it just works the short text is working, do you open it up and the cursors waiting up in the upper left-hand corner and you can start typing, you don't have to open up a new file. The neat thing is if you're in a meeting and you're taking notes and you can set it for certain increments of minutes that pass by and then next time like you open your phone, say it closed, it'll start a new file automatically. Serina: Well that's cool. Jeff: So you're not adding to your recipe you wrote two days ago that's still sitting there, do you want to save it, you don't know if you should save it, it automatically, so if you set it up for 10 minutes, if 10 minutes goes by, it saves it, and opens up a new one, just ready to go, so it's like a new sheet of scratch pad for you, can actually do some markups on it, yeah share it anywhere you want, it's really cool. I do the cut and paste and then just pop it into an email, bang! Serina: I like that, is that a free up too? Jeff: Yeah Drafts is free, I think it's called Drafts 5, there is a professional upgrade, a pro version and that is $20 a year or two dollars a month, but you can do a lot with just the Drafts app. I just love that because when you just want to take down a note, I don't like going into, I use pages because it syncs up with my apple orchard but when I'm at someplace where the meetings starting and I open up pages, you know it has to load up, it goes to the recent, and it seems like, you know all the gears have to spin around five times before anything happens, but this one opens up just bang, it's ready to go. Serina: I especially have that problem using the native Notes app on the iOS devices. Ever since they made it where you've got some notes on your iPhone, some on iCloud, some on Google Drive, or Dropbox or wherever, it's so hard for me to figure out where my notes are anymore that I just don't use that app anymore. Jeff: And that's my second app that I was going to talk about, it's the files app in iOS platform on the iPhone. Files, if you don't know where it went because it says, oh it's stored on the iCloud, or on the desktop in the iCloud, or on the iCloud Drive or wherever, and you start hunting around, but if you go to files and go to most recent, it'll check all those files, all those different drives, all the different places on your phone and everything, but if you go to recent and then if you click up on top you can go back and actually go specifically only to one area where you think it is, but if you put it on all, its checking all those drives that you have synced up with it and you can usually find it, so when I get lost for a second I just open up files and go to the most recent and there it is. Serina: That's a good tip, I didn't know that. I never really knew the point of the files app. Jeff: Yeah check it out, open it up and just see, and you'll see what you've been doing lately. Seirna: So I have one more that you do not know that is my favorite apps to use, any guesses? Jeff: Hope, what do you think it is? Hope: Hmmm, Uber, no it's not productivity, nevermind. [Laughter] Serina: Well technically it is, I do use Uber and Lyft a lot for work actually because I have to go as part of my job, I have to be at high schools and things like that and I am almost an exclusive Lyft user personally. Jeff: And why Lyft over Uber? Serina: I just have found just with my personal experience in the city that I live in that I've had better luck with Lyft drivers as far as friendliness and I have a service animal so, I've never been rejected on Uber, I'm actually, the only place I was was actually on Lyft. I found that the cars have been cleaner and the drivers just seem friendlier and with Uber I specifically am NOT a fan of the, if we wait more than two minutes, we're gonna charge you policy. Hope: Oh that's not good. Serina: Yeah that's a newer policy, maybe in the last six months and that policy just really bothers me especially when you're visually impaired. Drivers will say they're there and you're like where? You know, and if they're automatically gonna charge you, I think it's, I don't, I guess it's maybe like five dollars, if the driver has to wait I believe it's more than two minutes, like that's stressful, it's already nerve-racking like being like, hey I've got a service animal, are they gonna drive right past me, are they gonna pick me up, and then to know they're also gonna charge me an extra five bucks if I can't find them. And then they also tend to do the walk here and meet your driver thing. Jeff: Oh yeah. Serina: And I've never had that happen with Lyft no matter, I've been in downtown Denver and that's not happened before, but Uber will send you up a random parking lot or something to meet your driver. Hope: Oh wow! No thank you. Serina: Yeah so that's more why I'm Lyft exclusive, and then on the driver side I'm not quite sure how it breaks down, I don't remember how much the drivers get but I know with Uber it's not like a set percentage that the drivers get as far as, like I think it with Lyft the drivers get 75% of the fares With Uber, nobody really knows what percentage of the fare they get because they can, I've had drivers say like, yeah I've done rides Denver to you know, the DIA Airport and sometimes I get 60, sometimes I get a hundred, like there's no, I guess transparency with it. Jeff: Mmm-hm. Serina: And I can only speak to you know what I'm told, but I just personally feel better about using Lyft and for those who don't know, Lyft also released an update to their service dog policy saying that an allergy or a fear of animals is not a valid reason to not pick up an individual with a service animal and I feel like that's a very strong policy, and that's telling you where they stand on that very clearly, and I'm not, I'm not sure if Uber has come out as strong as they did. But that's all for a whole another podcast, you have to use all that when we talk about transportation. [Laughter] Jeff: No that's, that's good information because in my neck of the woods my wife uses Lyft, I use Uber and yet, I've been noticing that at certain peak times the price goes way up and other times it's low, and the waiting time changes, but you know, if it were two minutes, it's sometimes it's as low as thirty seven cents, but other times it's higher, you know, so things, I think it's the area you're in that really has, it makes a difference between which one you use, it is productivity because you got to get places and it's nice to know you can get there. Serina: And on time and on your own time. Jeff: Good. Serina: But that was a really good guess that brought on a whole another discussion, I liked it. [Laughter] Serina: But honestly we're on the app right now. Jeff: Ahh, zoom zoom. [Laughter] Serina: But part of my job is to train other people and to hold conference calls and things like that, and to my knowledge as far as like a true training platform where you can record and share your screen and things like that, I found that Zoom is the most accessible system out there that's also used by like companies all over the place. I know Skype is out there, but I don't know if Skype lets you like record the calls and things like that, I don't, like independently, not by pushing it through a different software but just right in the program recording it and having that access to be able to share your screen and still use your PowerPoint effectively and things like that. Jeff: Mm-hmm, and we're doing a neat thing for the first time here and we didn't know if we could do it but Hope sat beside us waiting patiently for us, but we figured it out and we're recording on two ends right now. Serina: Unless I pushed the wrong button again which is very possible. [Laughter] Jeff: Another cliffhanger, stay tuned next week when we find out! Serina: That will be our opener next week. Guess what I actually did it right! Jeff: You know, I'm starting to like Zoom because it's like I can't even tell you, you guys are here, because typically when we're using Skype in my headphones, I have this hiss when other people aren't talking so there's continuous hisses going on and then in the editing phase. So Zoom's really good and I really like the feature where you can send an email and people can just click on the link and they connect right up. Serina: Yep, it makes it really really easy. Hope: So a question I have, you mentioned sharing your screen, how accessible is that with voiceover? I heard through the grapevine that the voice-over will read actually what's on the screen. I don't know if it's true or not? Serina: So I haven't had a chance to test that because at work we don't use any Max, and then when I'm on a Zoom call and I am a participant I'm not usually on my iPhone. Hope: Right. Serina: So if you are leading the meeting and you're sharing your screen, it's actually pushing through a video of your screen, so it's almost like, I just imagine like a webcam watching your screen or whatever. Hope: Right, so I would assume it's not accessible then. Serine: Correct, but and I don't remember the keystroke, maybe Jeff knows, but I know in the latest major update to the OS on the Macs and iOS, you can have it essentially perform an OCR on the screen like live, with the software on the Mac, but I haven't had a chance to truly test that out just because I'm not usually on Apple devices when I'm participating. The way that I work around that, because I do have to present to individuals that use screen readers as well sometimes, is I usually will send my PowerPoint out ahead of time so that they can follow along while they're listening to the meeting, but then they also have access to the chat panel and everything else, it's just the visual of the video that they're not quite having access to but I, I just send it out ahead of time. Jeff: Yeah I haven't dug too deep into this, but Serina told me about Jonathan Mosen's book, and he did a full fledge book on using Zoom for calls and meetings and stuff like that, and yeah, I believe you can get that on Mosen's consulting on the website, and we'll put a link to that in the show notes. Serina: Yeah the book is called "Meet Me Accessibly" and it's very current based on, because I listen to maybe four or five chapters so far, and it sounds like he recorded it maybe in June of 17 and he does a really good job of letting you hear the screen reader and how it interacts with everything and going through all the different settings and explaining what exactly it is that they all do. Jeff: Yes he does he has quite a few books on Mosen's consulting so when you get there, just look around and he has tutorials on a lot of different topics, he's into the Mac, he's into, no not the Mac as much anymore, but he's into the PC, Microsoft. Serina: All these plugs Jeff, you're going to need to get some royalties! [Laughter] Jeff: Hopefully I get their name right and their website right. Another app that I have that I use and some people laugh at this, I use Dictionary Thesaurus Plus, and if you get the dictionary you can upgrade and you get, its a combination of Dictionary and Thesaurus Plus and I get the word of the day, and I'm just waiting to get that specific word to send Serina because she laughed at me when I talked about this app before. But it's just kind of neat because in there, they have flashcards and I'm on the bottom, they're not labeled but I figured out what two of them are, flashcards, so I took insight today just when I was skipping around there and I made a flashcard so on one side it says insight, on the other side it says the definition, so someone could actually go through there if they have a 10 word list that need to know or learn, like they're in school and they could actually input the word, get the dictionary, and there's also a button that says go to page, so if you want more definition you can just click on it, brings it right to the dictionary page and it's just kind of a neat resource if you're into that you know. If you want to know what words mean. Serina: Well that could you, I mean you just brought up a good point though, that could be a really good study aid for somebody if you're in a class where there's a lot of maybe theories, or specific definitions you need to know, you could load all those in there and while you're on the bus or whatever kind of be going through those, probably a more fun way than just reading the book. Jeff: Yeah and that's why I did it, like when I took Spanish, I made, I made note cards. I took these note cards and I brailled on one side, and then on the other side I had some other Braille, the translation in English to what it was, so I could just go through, and people were like joking with me like, Oh flashcards, it's like it's something for the kids or something, but hey, it's a good learning tool because it's just repetitious and pretty soon it just starts coming to you. Serina: Mmm-hmm. Jeff: So I dug right in when I saw they had flashcards, I went wow! So I really like that and it's, uh I think there's a fee for the upgrade, might be a few dollars but you can get download at all for free and test it and then in the in-app you can upgrade. Serina: Nice! Jeff: Well I think we got a handful of apps here that you know through experience we, we've been trying, we've been using and stuff. Some of these apps if you find them useful click on the show notes, download them, check them out, and if you have any feedback or suggestions on the apps that you want us to do on our next show, give us a jingle, drop us an email at JobInsights@blindabilities.com, on Twitter at Job Insights VIP, and uh, let us know what you think. Serina: What are we talking about next tiem John....John? Wow! Sorry! [Laughter] Jeff: Well Sarah! [Laughter] Jeff: What will our next one be on? Serina: I don't know, we have so many topics, normally I'm like, let's take this, let's let Hope pick the next topic, no pressure! Hope: No pressure yeah right mm-hmm! Let's do transportation since we kind of talked a little bit about it in this one, that would make sense. Serina: Getting to work. Hope: Yeah, absolutely. Serina: Perfect. Jeff: Getting to work, school, college. Hope: Yeah. Jeff: There you go Sarah! Serina: Stop it! [Laughter] Jeff: And if you want to contact Hope, she's on Twitter. Serina: If you want people to have it? Hope: Yeah my Twitter is Fidelco, capital F as in Foxtrot, I, D as in Delta, E, L, C, O, 4, the number four, ever. My email address is hopepaulos@gmail.com, so hopepaulos@gmail.com. Jeff: Well Hope thank you very much for coming on to Job Insights, it's really neat to have you and we're gonna have you back as soon as possible here for our next round table. Hope: Thank you so much Jeff and Serina, it was wonderful being here. I appreciate it! Serina: Yep, you have a great day! Hope: Thank you! Jeff: Do you know it's nearly midnight and you said have a great day? Serina: Well this will come out during the day. [Laughter] [Music] Jeff: It was a real pleasure having Hope Paulos join us on the show today, all the way from Maine, and next week when we're talking about transportation all the way from New York we'll have Joe De Niro, so stay tuned to the next episode of Job Insights. And a big shout-out to Chee Chau for his beautiful music and you can follow him on Twitter at lcheechau, as always thank you for listening, we hope you enjoyed, and until next time bye-bye [Multiple voices] When we share what we see through each other's eyes, We can then begin to bridge the Gap between the limited expectations and the realities of Blind Abilities. Jeff: For more podcast with the blindness perspective, check us out on the web at www.blindabilities.com, on twitter at BlindAbilities, download our app from the app store, Blind Abilities, that's two words, or send us an email at info@blindabilities.com, thanks for listening.
Job Insights Extra #3: College Advice from Michael Hingson, Best Selling Author, Advocate and Inspirational Speaker. Transcript Provided Welcome to Job Insights Extra, part of the Job Insights Podcast with Serina Gilbert and Jeff Thompson, a podcast focused on the world of employment, career pathways and gainful and meaningful employment. The Job Insights Extra podcasts are success stories, interviews and demos that enhance the experience of reaching that career you want. On Job Insights Extra #3: we bring you College advice from Michael Hingson, Best Selling Author, Advocate and Inspirational Speaker. Michael Hingson joins us in the studio and shares his advice to students transitioning from high school to college and the workplace. He refers to some of his college experiences and how he transferred those skills into his workplace. Michael tells us how those very skills attributed to his successful navigation down the 72 flights of stairs to safety with his guide dog Roselyn. Michael led many others to safety that 11th day of September back in 2001 and shares part of that story with us here on Job Insights Extra. We previously interviewed Michael about his book, “Thunder Dog” and you can listen to that podcast on Blind Abilities.bringing-the-thunder-to-aira/ You can learn more about Michael Hingson on his web site www.MichaelHingson.com And follow Michael on Twitter @MHingson Here is a short bio taken from his web site: On September 11, 2001, a blind man escaped the World Trade Center by walking down 78 flights of stairs with his guide dog. Days later, America fell in love with Mike and Roselle and the special bond that helped them both survive one of the country’s darkest days. Immediately after the 9-11 tragedy, Michael was featured on the Larry King show five times. To quote Larry King… “This media exposure changed the course of Michael’s life and launched him into a speaking career that has spanned over a decade. He now travels the world as a keynote and inspirational speaker that can motivate audiences to action.” Thank you for listening. Follow Job Insights on Twitter @JobInsightsVIP Do you have any suggestions or feedback? Send the Job Insights Team an email Job Insights is part of the Blind Abilities Network. You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Get the Free Blind Abilities App on the Google Play Store. Full Transcript Job Insights Extra #3: College Advice from Michael Hingson, Best Selling Author, Advocate and Inspirational Speaker. Transcript Provided [Music] Jeff: Job Insights is a podcast that is helping you find careers and gainful employment through innovations and opportunities. You can find the Job Insights podcast on BlindAbilities.com, part of the Blind Abilities Network, and as part of the Job Insights podcast we will be bringing you the Job Insights Extras, consisting of interviews, demonstrations, and news surrounding employment, careers, and jobs, with hosts Serina Gilbert and myself, Jeff Thompson. sAnd you can contact us by email at jobinsights@BlindAbilities.com, leave us some feedback or suggest some topics that we cover, on Twitter at Job Insights VIP. [Sound Effect] Micheal: Everyone just turned in ran as we heard this Rumble that became this deafening roar in like about a half a second which was tower two collapsing about a hundred yards away from our position. The airplane hit 18 floors above us on the other side of the building, we had no clue what had happened. [Sound Effect] Jeff: Those are the words of Michael Hingson, he's the author of Thunder Dog, a book about 9/11 where on September 11th 2001, a terroristic attack took down the World Trade Center towers. Michael happened to be in one of the towers and led a group of people along with his guide dog Roselle to safety. We did an entire podcast on this topic and we put a link in the show notes where you can find it on Blind Abilities. Once again we caught up with Michael Hingson and asked him the question about transition age students, what advice he would have for someone transitioning from high school to college to the workplace? Michael was so kind to share with us some advice and some of his experiences from his college days as well, so we hope you enjoyed this Job Insights Extra. Micheal: We have some unique advantages now and we have some real serious problems now compared to when I went to college. [Sound Effect] For high school kids going on, learn all that you can, learn to know yourself, learn skills. [Sound Effect] Jeff: And now, here's Michael Hingson. Micheal: I think that college is an adventure. I think that becoming more independent as most people will if you go to college and leave home to go to college live on campus or an apartment, but typically on campus, maybe not too far away from home, may be a long way from home, but that's an adventure and, and accept it and embrace it as an adventure first and foremost. Live every life moment to the best that you can, live to the fullest because you won't have that opportunity again. Everything that you do will be a memory but it will also be a learning experience for you. I know that when I went to college, went to the University of California-Irvine which was a hundred miles away from where I grew up. I lived on campus for three years and I remember a lot of what I did on campus because I just considered it a great adventure. We have some unique advantages now and we have some real serious problems now compared to when I went to college, the advantages are there's a lot of Technology, there are a lot more books available, and again if people aren't proficient in Braille, they ought to get proficient in Braille, but we have some disadvantages. Most colleges have an office for disabled students and they have these people who are hired to basically do everything for us, they hire our readers, we don't get to do that like we used to, which means that we lose the opportunity to develop a skill that will help us in the workforce. The skill is finding readers, finding readers that work for us not that work on the terms of the office for disabled students, and likewise, if we don't do well with them, we can fire them, we don't have that option nearly as much as we used to. So students need to use college to learn that independence and to learn those skills that will help them in whatever else they do in life. Braille is important because without the ability to truly read and write, people will not function well in college, much less when they leave College, they will not have the skills that they need to be able to compose good articulate relevant sentences and they won't spell as well and they just plain won't have had the opportunity that they really should get. So I think it's important that students in high school take advantage of all the things that are offered and learn to be self-reliant, and it doesn't mean you don't learn to ask for help, but learn to be self-reliant. I spent time at the World Trade Center learning where everything was, I walked around with a cane, I worked after a while to get, just to get lost, because by getting lost I obviously found someplace I didn't know before and it got to the point where I couldn't get lost in the World Trade Center, and as I loved to tell people, you could drug me and knock me out, and I wake up, and you've put me somewhere and I'll know where I am within just three seconds because I knew that complex that well. I did that in part because I kept thinking, what am I gonna do first emergency and how am I going to get out? It was the mid-atlantic region Sales Manager for my company that is as the leader of that office I had to be responsible for the people in the office, which means I had to know what to do in order to get them to do what needed to be done on what they had to do. I could not have done that if I didn't take the time to learn to be self-reliant and to learn to do whatever I need to do in any circumstance that I could. So for me every day I went in the World Trade Center I almost subconsciously thought, what am I gonna do if there's an emergency today? Well one day I guess I made it happen, and suddenly an emergency did occur, but I knew what to do, and that's why I didn't really panic. People have said to me, well you were so calm, I was because I knew what to do, and I also know myself well enough that, if something different had happened and suddenly it was a real crisis situation, well it was when Tower 2 was collapsing, I could deal with it or or I couldn't. You know, yeah we were going to survive or we weren't, but I knew that I could deal with whatever situation there was to the best of my ability and stay focused. So high school kids need to learn that, they need to spend that time, especially blind kids, I don't mean totally blind but I mean blind with eyesight, but kids just who don't see well enough to function as a fully sighted person, and I think that's the definition of blindness. You're blind when your eyesight is diminished to the point where you can't see well enough to function as a sighted person and you have to use alternative techniques. That includes Braille, and I keep emphasizing that because I think it's so important for people. So for high school kids going on, learn all that you can, learn to know yourself, learn skills and use them in college. When you go to college, don't learn how to just get from your dorm to the library, learn how to get around the campus, learn how to go from any point A to any point B. What I did after a while having learned that other kids did it on campus, was I learned where all the shortcuts were, that is through the steam tunnels that went underground and that you weren't supposed to use, but hey we all did because it cut the time to get from one side of the campus to the other by half, so we did it, and I learned how to do that as well as anyone else because I wanted to have those same opportunities. I didn't know just how to get from my dorm to computer science or physical sciences or whatever, I learned where every building was so that I could go wherever depending on what kind of class I, I had. I learned to make friends with faculty. I was, I never said Dan, but I knew Chancellor Dan Aldrich, and I would, I spent time in his office a couple times because he wanted to get to know me and I wanted to certainly get to know him to, to just understand him and and hopefully educate him a little bit more about me being blind. My academic adviser was the Dean of physical sciences, Fred Reines who was the discoverer of the subatomic particle of the neutrino, won a Nobel Prize for it, and he was the one who encouraged me to do that, he encouraged me to get to know the administrative staff, he said there will be time that they can assist you and and they may ask you things, but they'll never do it if you guys don't know each other, and I think that was an important lesson too. So again there's a lot, there's a lot to do when you get to be a blind college student, but it's worth doing all of that to make the experience better and to make sure that you have all the power and all the skills behind you that you need. Jeff: Michael do you have any favorite quotes that you would like to share with our listeners? Micheal: Well I think in Thunderdog especially, one of my favorite quotes and the one I use most often is, "don't let your sight get in the way of your vision", and I try to use that with sighted people a lot who talk about blindness and all that and they say, well you know, but, how can you do that? Well I'm doing it, don't lay your sight get in the way your vision right? When people tell me, well you don't have any vision, and I say, no I don't see, but I have lots of vision. Now I'm certainly creating a play on words, but still it's true. We often don't see beyond our eyeballs, and bottom line is that we have as much vision as the next group of people if given the opportunity to use it and again eyesight isn't what should hold us back so that's one of my favorite quotes. Another one and again I use it in Thunderdog is, because it's true with Roselle, and was true of others on September 11, 2001, "Sometimes being a hero is just doing your job", and you know, I was just doing my job, people say you're a hero, and if they do they do, but I was just doing what I needed to do and I was helping people get out and I got out and that's what we should do. But if it helps people to think that it, but, and if it will help them think more possibly about what, possibly about what we can all do then it's a worthwhile thing. [Sound Effect] Jeff: We've been speaking to Michael Hingson, number one book seller, author of "Thunderdog", inspirational speaker, advocate, and you can follow Michael on his website at Michaelhingson.com, and on Twitter at M Hingson, that's M H I N G S O N on Twitter. We hope you enjoyed this episode of Job Insights Extra and you can find all the Job Insights podcasts and the Job Insights Extras on Blind Abilities. You can find us on the web at www.blindabilities.com, on Twitter at Blind Abilities, and follow Job Insights on Twitter at Job Insights VIP. Download the free Blind Abilities app from the app store or the Google Play Store. Enable the Alexa skill just by saying enable Blind Abilities. [Music] Jeff: Once again, thanks for listening, we hope you enjoyed, and until next time, bye bye! And thank you Chee Chau for the beautiful music. Follow Chee Chau on Twitter at LCheeChau. [Multiple voices] When we share what we see through each other's eyes, We can then begin to bridge the Gap between the limited expectations and the realities of Blind Abilities. Jeff: For more podcast with the blindness perspective, check us out on the web at www.blindabilities.com, on twitter at BlindAbilities, download our app from the app store, Blind Abilities, that's two words, or send us an email at info@blindabilities.com, thanks for listening.
Job Insights #3: Mastering the Elephant in the Room - Disclosing a Disability in the Job Interview Process. Transcription Provided Full Transcription Below Welcome to Episode 3 of Job Insights with Serina Gilbert and Jef Thompson. We focus on Employment, Careers, enhancing opportunities and bringing you the latest innovations from across the Vocational Rehabilitation field to ensure your choices lead you down the career pathway that you want and succeed in gainful employment. From getting started with services, to assessments, Individual Plan for Employment (IPE) to gaining the skills to succeed and tools for success, Job Insights will be giving you tips and tricks to help your journey to employment and break down the barriers along the way. In this episode we take on the White Elephant in the Room, that is, the job interview room. With guest voices answering the question, “Do you disclose your disability during the job interview process, and if so, when do you disclose?” Hosts Serina Gilbert and Jeff Thompson take a good look at this Million Dollar question from all points of view and leave you with information that will better prepare you for your job interview process. There may not be one set way and being prepared for the job interview gives you an advantage that may help you land the career you want. Check out episode 3 of Job Insights and send us your feedback and topic suggestions by email. mailto:jobinsights@blindabilities.com Follow the Job Insights team on twitter @JobInsightsVIP http://www.twitter.com/jobinsightsvip Job Insights is part of the Blind Abilities network. Thank you for listening. You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Get the Free Blind Abilities App on the Google Play Store. Full Transcription [Music] Female voice: And most of the people that worked there did not know that I had any sort of vision impairment or anything like that, and at that time I was not comfortable walking around with my cane. Jeff: Job Insights, a podcast to help you carve out your career pathway and enhance the opportunities for gainful employment. Female voice: Because an interview is not just the employer figuring out if they want to hire you, it's you figuring out if you want to work for the employer as well. Jeff: To help you navigate the employment world and give you Job Insights and enhance the opportunities to choose the career you want. Selling yourself, you want to be the best box of cereal on the shelf because when people come down they're looking at all the colors all the things, what makes them pick a certain box? Is it the toy inside, is it the fancy colors? So you had to start selling yourself and be the one they pick. Female voice: If you have more of a obvious disability, you want to make sure that you kind of address that in a way that makes it so that they're not thinking about that, they're thinking about your skills, that's what their inner monologue isn't about you, it's about what they think that you can't do in their bias. Jeff: And you can find the Job Insights podcast on Blindabilities.com, part of the Blind Abilities network, with host Serina Gilbert and myself, Jeff Thompson. And you can contact us by email at Job Insights@BlindAbilities.com, leave us some feedback or suggest some topics that we cover. On Twitter at Job Insights VIP and check out the Job Insight support group on Facebook where you can learn, share, advise, and interact with the Job Insights community. [Music] Female voice: I didn't catch them off guard by showing up with a cane, and I found that that approach worked really well for me. [Music] Jeff: Learn about resources for training, education, and employment opportunities. Female voice: I think sighted people just like since video calls exist, they, that's what they use, so it's definitely becoming, it's going to be a type of interview than most people will have I think. Jeff: And now please welcome Serina Gilbert and Jeff Thompson with Job Insights. Hey Serina! Serina: Hey Jeff! Jeff: To disclose or not to disclose, that is the question I ask of thee. Serina: Have you been reading Shakespeare? Jeff: No, but I have been reading the Job Insights support group page. There's been a topic going on there about disclosure. Serina: Yeah it seems like a lot of people have some different opinions on, do I talk about my disability in the job interview, do I not? [Sound Effect] Female voice: I have a very disability in that I use a cane, and I can't make eye contact and so I find that usually, and this is the same thing that I did after the phone interview but before the in-person interview, I disclosed. [Sound Effect] Female voice: Do I talk about it when I'm doing my cover letter or my resume or not? [Sound Effect] Male voice: If you're applying for a position and it involves using some kind of accommodation, then it's probably wise to disclose it. [Sound Effect] Serina: And I really wanted to see if we could talk about that a little bit today get some different opinions. [Sound Effect] Female voice: If I need to than I do, if I don't need to I don't. [Sound Effect] Serina: Just get it all out there, I know this will be a pretty divisive topic, everyone has some pretty strong opinions on disability disclosure. We're here to offer you some tips on what might help you in the job interview process, when might be a good time to disclose and work to your advantage in a job interview, and maybe when might not be a great time to bring that up in a job interview. Jeff: And when to know the difference, that's um, I think the most important thing. Serina: Exactly. Jeff: Some of the topics that came up really shocked me like, I do my own accommodations a gentleman said, and that just made me cock my head and I had to think about that for a little bit, and yeah I get that, or someone says how dare you can you show up and shock them by showing up with a cane, you didn't tell them, and I'm thinking, like in some situations the resume does not have a spot for that, they may be able to dissect it out of the some of the positions you've held, or some of the companies who worked for, but I think mostly it's one of those situations that you're prepared for either way. Serina: Well and it's interesting that you brought up the I provide my own accommodations piece of the equation. I respect anyone who wants to step up and say here's what I need, I already have it, that's great, but in a lot of systems you can't install your own programs onto computers without having some significant permission. For example I work for a government agency, there's no way they're gonna give me an administrative password and all kinds of leeway to install any programs that I want because who knows what they could do to their network. Of course I know that JAWS is safe and I know that they know that JAWS is safe, but they still have to have some sort of system for managing the programs that are on their server and other network because what if you install a pirated piece of software then what, not saying that you would, most employers unless it's a real small company, it is their legal responsibility to provide you with that reasonable accommodation so why not take them up on it as opposed to using your hard-earned money to purchase those licenses and keep that up on somebody else's computer. Jeff: So having JAWS, having accommodations, and talking to them about accommodations that to, to read the screen, you can even have a person come in to do evaluation of what kind of software they're using, what kind of databases they're using, the see if you can gain access, and further down the line some scripts could even be made to help these specialized programs that they utilize just so you can overcome that hurdle, and it might be just a button that you have to get past. Serina: Exactly. Jeff: So there's some great services that are out there when you're trying to get a job, especially when you're into the job field, it seems like State Services has a whole arsenal of people that are help at that point, or if you're trying to retain a job too. Serina: That's a really good point, yes if you maybe already have a job, gosh I didn't even think about that Jeff, if you, if you already are working, I've seen that and quite a few of the support groups on Facebook, I'm working, I'm losing my vision, I don't think I can work anymore, and just remember that if you are having vision difficulties at work, you are still able to go apply for services at vocational rehabilitation and see what kinds of things they might be able to put place so that you can keep your job. I'd hate to see somebody that has 20 or 25 years in a career and you're just that close to retirement and feeling like you have to give up because your vision is changing with all the technology that's out there now, not saying it's gonna be easy, there's gonna be some learning curves for sure, but the sooner you start getting those services, the sooner you can get back to working in the job like you used to. Jeff: Yeah and that job retention it's a lot, I'm not gonna say it's a lot easier, but what it does is, you're gonna go into some specifics you know, you're just gonna do this to bridge this, to bridge that, to shore up what you're not able to do because it's obvious right away, rather than if you leave the job you go back home then you get to start from scratch like, I want to learn how to cook, I wanna, you know so it's interesting at different points when people are losing their vision, but when we're talking about disclosure, is that's a unique point too. I suppose because I've been blind for so long that to me I can live within my skin, and I think the difference is people who are trying to, especially high partials, or partials, they're either around blind people, there the sighted person around sighted people or they're the blind guy, or the blind person. Serina: Mm-hmm. Jeff: But at a job interview, there's a quandary there, do they use their cane or not use their cane and bump into things or do they bring their cane? Serina: You just brought up a really interesting point because I just thought back to when I was 19 and I started getting cane training from vocational rehabilitation, and at that time I was a cashier at a retail store, and most of the people that worked there did not know that I had any sort of vision impairment or anything like that, and at that time, I was not comfortable walking around with my cane. I'd rather bump into somebody then be seen as the blind girl. So at the age of 19 I would have absolutely said, no way I am not disclosing my disability, I can do it just as well as anyone else. I will just work twice as hard, and struggle at times, but now gosh, 20 years later ish, I think totally differently I, I could never personally see an instance where I would not want to disclose that because I don't want it to be the elephant in the room, when I'm being interviewed. Jeff: Mm-hmm. [Sound Effect] Rob Hobson: It's really up to the individual, some people like to not say a thing, show up to the interview, surprise I'm blind, you know, granted they don't say that. I think to the interviewer that, that's a surprise, but if you want to go that route, that's totally fine it's entirely up to you. But I want you to think about something when you go in for that interview, blindness is that, the white elephant in the room, if you don't address it, you're left to whatever conceptions they have a blindness, positive or negative, but if you address it as in a positive way, you bring up the fact that you are blind, and that you utilize accessible technology via you know whether it's JAWS or NVDA, or a system access, whatever it is you use, explain to that employer why you're the best candidate for the job. The long answer is, it's up to the individual, but if you don't address the fact that you're blind, I think it puts you at a disadvantage. Jeff: And that was Rob Hobson, he's the director of programs at Blind Incorporated in Minnesota. [Sound Effect] Jeff: And that's what it is, it's that the elephant in the room, and if you don't squash that, they're gonna paint their own picture as big as a an elephant any way they want to. Serina: Well and the reality is is that every employer knows that they can't come out and say, what's your disability, they can ask, do you require any reasonable accommodations to perform the essential duties of this job, which is a roundabout way of still figuring it out obviously. But if you're coming to an interview and you're using a service animal, or you have a cane, it's right out there and then they're just wondering, well how on earth is she going to be able to do this, or how is he going to be able to spellcheck documents for me, or access the computer? Because the technology that we use is not mainstream, most people don't even understand what a screen reader is unless they know somebody who has a visual impairment. Jeff: Mm-hmm, yeah and that's the point where you have the opportunity to educate them and sell yourself with the skills that you do have. Serina: Exactly, one of the other panelists did bring up a really good point. If it's a phone interview, that's totally different, they don't see you, they have no clue what you look like, what your abilities and capabilities are, and then what you're selling to them. I don't think I would mention it in that interview type of setting, what about you Jeff? Jeff: No I really don't think so, I think the phone call is a situation where they're just starting to get a good feel of how you, you know your social skills, they want to find out if you're a good fit for the team, for the company. Serina: Correct, because we talked about this a little bit on our very first podcast, if you got the interview then they have already determined that you're qualified for the position, they're just trying to see if you're a good fit for the office but, whether that be the culture, or some more specific questions that they weren't able to flush out in the application process, by not discussing your disability when you have a visible disability, you're almost causing the employers to only focus on the fact that you just walked in with a service dog, or with your cane, and is human as people want to be, and is empathetic and understanding as they claim to be, that's still going to be in the forefront of their mind especially if they're not familiar with your disability. Jeff: That's where Daysha the employment specialist brought up a very good point about where you're just talking about and she called it the internal monologue that the hiring person will be creating. [Sound Effect] Daysha: When you do talk to somebody, especially if it's an interview, you're gonna get that tell me about yourself, you could even get that when you just meet an employer at a job fair or an internship fair, tell me about yourself. You want to make sure especially if you have more of a obvious disability, you want to make sure that you kind of address that in a way that makes it so that they're not thinking about that, they're thinking about your skills. A lot of people make the mistake of never seeing anything and then an employer, the whole time that they're talking is thinking, well because they don't have any experience with vision loss, so they're thinking to themselves, I don't know that I could do that if I couldn't see right, I'm not sure that they're gonna be able to do that, that's what, their inner monologue isn't about you, it's about what they think that you can't do and their bias. Tell how you do things, go into it with confidence, know what your skills are ahead of time, know what you have to offer an employer, and just go into it that way. [Sound effect] Serina: Exactly they start putting those doubts in their mind. I don't know if they'll be able to do this, what about safety concerns? That's a really big one, is my workers compensation insurance going to go up because I have this individual in my office who's presumably, whether correct or incorrect, going to be causing more workplace incidents or accidents. Which we all know if you've gotten your orientation and mobility training in your personal adjustment training, your always more safe than the people who are sighted in the office, because you're not walking around on your cell phone or distracted. [Laughter] Jeff: We'll have to put in ramps and handrails, we'll have to label everything and yeah, but you can control that, and I think at that point, you know you're coming in with a cane and you know they don't know it yet, so that's your opportunity right there, that's your opportunity to call out the white elephant in the room in your favor. You can address it and you can tell them exactly like we said, selling yourself, you want to be the best box of cereal on the shelf, because when people come down, they're looking at all the colors, all the things, what makes them pick a certain box? Is it the toy inside, is it the fancy colors? So you have to start selling yourself and be the one they pick. Serina: It's interesting that you mentioned when you come to the interview, let's say with your cane or your service animal, I have seen situations where individuals do have a visual impairment that warrants the use of a cane and they opt to not bring that to the job interview, and I have seen that cause some problems, because when you don't have your cane or your service animal that could create some super awkward situations when you're trying to interview with the employer. As an example, the employer comes out to the lobby to get you, and maybe your vision is not adjusted or whatever the case may be to that particular office environment, and you're walking not so steady, or unsure about yourself, just think of the assumptions that they're putting in their mind now with the individual that's interviewing for the job, but not walking appropriately in their office, or not making eye contact, or not quite getting the handshake. Jeff: Mm-hmm, yeah and that's very important because myself, I have no central vision, and I can pick up some peripheral stuff, but in an interview you're probably trying to make the best eye contact you can, and I was just in an interview, this was a podcast interview and I told the person right off the get-go, don't think I'm looking over your shoulder or something behind you because that's how I sometimes pick things up by looking away from what I'm really looking at, so I actually made them feel more comfortable than them trying to talk during the interview wondering, what's behind me he keeps looking at, or something like that. Serina: Exactly, yeah. Jeff: In reality I, whatever I'm looking at I can't see anyways, so you can control the situation. They're going to start working this white elephant up in the room, they're gonna start, and not even hearing what you're talking about, all the stuff you're talking about, so you have to get control of the conversation a little bit and that's where you can start saying that, how you overcome doing job details that they want like word document that you use because you use JAWS, or how you can use other type of apparatuses or tools for success that get you to the point where you can compete against anybody that they hire. [Sound Effect] Miranda: I say no because I feel like with as much misunderstanding as there is in the world with with blindness, it's easy for a employer or potential employer to look at your resume and see that you're blind and see all these other resumes that he's got to go through that are just as educated, just as qualified as you are, and to simply just let that one go, like alright, I'm not gonna deal with that. I mean because you're you're talking about them having to deal with ADA and all this, all that other kind of stuff, walk in there confident and stuff, don't disclose before you go in, and just be like, hey this is what I can offer your company. If you made it in there, if they invited you in then that means you're qualified and you should have a shot at it just as everybody else. Jeff: You're listening to the voice of Miranda Brandenburg, she's a certified personal trainer and nutritional specialist. Miranda: The vast majority of people out there have never dealt with a blind person or encountered someone, especially one that is out there making waves, that's out there leading the charge, that's out there willing to work and get in there and travel and do this and do that and get out on the mat and fight and compete with sighted peers on every single level that they can. [Sound Effect] Serina: And it doesn't have to be the first thing you talk about you know, it can be something that, because I've never been an interview that didn't say at the end, do you have any other information like to offer me, or do you have any questions for me, I don't, what about you Jeff? I've never not been asked that? Jeff: Every time and have that question, because they want to know something, so I suggest before you going into an interview, go online, read their mission statement, see what company they are, see what they're all about, what, what's their key words, and that's something that you might want to integrate into your dialogue with them, and then when they come with that question, ask that question, like do you have any questions about my ability to do this job? Serina: And the way that I've approached it, I've only had to do it once, because one was I was applying for a County job at a local Workforce Center, and the second interview was using a white cane, was at the division of vocational rehabilitation. So it could not be more of a comfortable environment. I didn't even have to address it there, but the first one I did come in, I had my white cane, towards the end they said, do you have any more information you'd like to share with me? And I said well, you know, you obviously know I have a visual impairment, I just wanted to give you some information on the technology that I use in order to get things done, and I had gone as far as to print out some real short tip sheets on, at that time I was using a portable CCTV, and JAWS, so that they knew I had already thought about the types of things that I might need on the job and was already skilled in that, so that they didn't have to worry about, okay, obviously I'm gonna have to train her on our procedures, but is she also going to have to get training on her technology needs. Jeff: Mm-hmm, and that's a good point to come in there and let them know how you're gonna access the material that they have. Serina: Mm-hmm, now I have seen some questions in our support group about, do I disclose in the application process? A lot of applications are automated and they, some of them do ask if you have a disability. So I wanted to talk a little bit about that because, yes they might be asking if you have a disability, but if, unless they're breaking the law, that information is not to be passed on to the hiring manager or the individual that's reviewing your application. Typically when they're asking if you have a disability or require reasonable accommodation, that information is used for one of two things. The first would be that there is a program called Work Opportunity Tax Credit which allows employers to have taxes reimbursed to them to offset hiring expenses and things like that for hiring individuals in a variety of situations including those that have a disability, as well as those that are on public assistance, or they're using it because they know that they have some sort of testing that all the applicants have to do, and they really truly are trying to reasonably accommodate anybody that might need those accommodations. So I wouldn't hesitate to answer that personally because that could put you in an awkward situation down the road should you have to take, for example if you're applying at a call center, should you have to take one of their tests and all of a sudden you're asking for an accommodation when on the application you said that you don't need accommodations or don't have a disability. Jeff: And the same thing in Minnesota our Governor passed two years ago, he passed the proclamation that 7% of all employees in the state jobs, they'll hire people with disabilities to fill that 7% goal that they want to have, and so in some applications, some situations, there is a checkbox for that, and that way companies that do want to hire people can have that choice too. Serina: And that brings up another good point, the federal government also has a mandate that they have to hire a certain percentage of individuals with disabilities, and in fact, if anyone has been through that federal hiring process, it's a nightmare to say the least. If you do not check that you have a disability, then you're not going to be considered in any of the priority categories which means that your application might never even get looked at for open position. Jeff: Yeah it's a tough area and a lot of us, like I said on the last podcast, a lot of us aren't fully up on everything that there is to know about blindness when you probably, if you weren't born blind, or you just became blind, there's a lot to learn and there's lots of people that are offering suggestions and no one's really wrong, but I think the best fit is the best fit that you feel most comfortable with because if you're uncomfortable they'll know you're uncomfortable with it so, that's why in Minnesota here at the state agency, they do tutoring on job interviews, mock interviews, where you do get the situation that you know, mister mister boss might ask questions or make you feel awkward in a sense just so you can understand that every interview that you go to, you're gonna get a different person that has different preconceived ideas and it's gonna be in a different situation each time. So if you have an opportunity to try a mock interview, that'd be really great experience. Serina: Well and frankly I remember reading an article, I think it was last year, people are actually scared of blindness, they would rather have cancer than be diagnosed with being blind or visually impaired. So imagine that fear then being put into the situation of, oh my gosh how could I possibly hire somebody that has this visual impairment? If you don't address how you do things in the workplace. Jeff: Mm-hmm that's a great point, another great point is to remember they want to hire someone who can get the job done. Bottom line, get the job done. Susan Robinson, an entrepreneur out in New York and a TEDx speaker, and visually impaired by the way, she told me that she has never terminated a person because they were sighted. Serina: Hmm, that's an interesting way to put that. Jeff: Mm-hmm, she has a job that she needs to get done, she wants to hire the person that could come in and do that job, that's it. Serina: Wow, look at you getting all philosophical over there! [Laughter] [Sound Effect] Female voice: To me it was no different than anyone else doing the same thing with the exception of letting people know during an interview process what I might need from them. So again it was the same sort of self-advocacy to use your wonderful term as I did in college, so in an interview process, the first interviews is sort of getting to know each other, do I think I like working for this person? Because an interview is not just the employer figuring out if they want to hire you, it's you figuring out if you want to work for the employer as well. Once we got to maybe a level 2 or level 3 conversation in the interview process, at that point when it seemed to be a little bit more concrete that the position possibly could be mine, I would disclose and I would say, I just want to let you know I have a visual impairment, it may not be obvious to you, but what that means is I'm gonna bring everything that we've already talked about, my, all of the skills and characteristics that we've discussed, but I am going to need a large monitor for my computer so that I can see things you know enlarged a little bit, and generally people were very receptive to that because again I'm letting them know which is what every potential employer wants to know, can you do the job, are you willing to do the job, and are you going to be a good fit? [Sound Effect] Jeff: Serina, when we had our conversation with Cindy Bennett, a researcher out in Washington and a former intern at Microsoft, she mentioned something that we hadn't even considered, and that was, an interview via videoconference. [Sound Effect] Cindy: I think if I had a video interview I would probably disclose, but I would frame it something like, I'm actually blind so, I might be like, hey does the camera look okay, okay cool, like just like that, just really quick. I do practice if I do a video interview, I always like first of all clean my apartment and look nice. [Laughter] Second of all, I set up my computer on a table in front of my couch and call someone I know, like I video call someone I know and they tell me okay this is good. I found that just like a quick little thing at the beginning of the video interview, I'm like, oh by the way I'm blind, I just wanna make sure that you can see me okay in the camera. If it's an old-fashioned audio phone interview, then usually the person emails me and says we'd like to invite you for an in-person interview and I say thank you and confirm the dates and say, oh just for your information, I'm blind, here's what I need. Jeff: Were you excited when we asked for a podcast that you didn't have to clean your house? [Laughter] Cindy: Yeah [Laughter mixed with inaudible talking] I don't want to do a video call ........ I think they are important things to think about, like I honestly with a lot of my colleagues now that I'm comfortable with them, I'm just like, can we just do audio because then I can just set my phone down beside me and we can go on with our business, but I think sighted people just like, since video calls exist, they, that's what they use. So it's definitely becoming, it's going to be a type of interview that most people will have I think. Serina: I honestly didn't even think about how the video interview, how that would be impacted by the visual impairment, so I'm glad you brought that up because I haven't had an interview for a job since 2010 and it was definitely not when people were doing video interviews or anything like that, so that's definitely something to think about. [Sound Effect] Jeff: It's really great that so many people came on board and shared their experiences, the way they handle disclosing a disability during an interview and the people leaving comments on Job Insights support group page on Facebook. And to sum it up, here's Rachel Hastings, she just got done running the marathon, the Boston Marathon and she's a music therapist. [Sound Effect] Rachel: I've done it both ways, so I've done it one time I didn't tell them that I was blind until I got there and I think it kind of caught him off guard. I mean part of me is like deal with it, but the other part of me is like, well you know, there's no harm in telling them over the phone. After they invite you to an interview, and so because I kind of felt like I made it awkward, so the next time I was first offered a phone interview and I told them over the phone, I'm like, by the way I want to let you guys know that I'm legally blind, but I'm very independent and that, that was after they invited me for an in-person interview. So it's like there was no way they could turn me down but yet I didn't catch them off-guard by showing up with a cane in person, and I found that that approach worked really well for me. [Sound Effect] Jeff: So Serina, next week we're gonna be talking about some apps. Apps for the workplace, apps for productivity, apps for a school. Serina: Yep, I know that I have my favorites. Jeff: Hmm, you gonna save them, you're gonna make us wonder till next week aren't you? Serina: You guys will have to wonder till next week. Jeff: The cliffhanger strikes again. [Laughter] Serina: So I'd like to thank everyone for listening to our show today. As always if you have any questions or topics that you'd like us to follow, you can give us a message on Twitter, that's at Job Insights VIP, or on our Facebook page which is Job Insights, and we also have a brand new job insight support group on Facebook, just search Job Insights support group, see you next time. [Music] Jeff: Thank You Chee Chau for your beautiful music, that's lcheechau on Twitter. We really hope you enjoyed this podcast, thanks for listening, and until next time bye-bye! [Music] [Multiple Voices] When we share what we see through each other's eyes, we can then begin to bridge the gap between the limited expectations and reality of blind abilities. Jeff: For more podcasts with the blindness perspective check us out on the web at www.blindabilities.com, on Twitter at Blind Abilities, download our app from the app store, Blind Abilities, that is two words, or send us an email at info@blindabilities.com. Thanks for listening.
Job Insights Extra #2: Advice from Team Sea to See on Transitioning and Rebranding Disability Through Achievement Welcome to Job Insights Extra, part of the Job Insights Podcast with Serina Gilbert and Jeff Thompson, a podcast focused on the world of employment, career pathways and gainful and meaningful employment. The Job Insights Extra podcasts are success stories, interviews and demos that enhance the experience of reaching that career you want. In Job Insights Extra episode #2 we share the insights from Team Sea To See, a team entered in to the Race Across America (RAM). The team of 4 will tandem bike race across America dipping there wheels in the Pacific Ocean and racing non-stop to the Atlantic Ocean. While they were in the Blind Abilities studio promoting the race, they hung out to talk about a topic they feel is very important. We asked them what advice they would give to a student transitioning from high school to college and the workplace? Jack Chen, dan Berlin and Tina Ament each took turns talking about their personal experiences and gave us some very good insights and we are glad to share the conversation with you all on episode #2 of Job Insights Extra. Full Transcript Below You can check out the Race Across America podcast with Team Sea to See on Blind Abilities.plain-sight-meet-team-sea-to-see/ And check out Team Sea to See on their Facebook page. You can learn more about Rebranding Disability Through Achievement on the web at Lime Connect Thank you for listening! Follow Job Insights on Twitter @JobInsightsVIP Do you have any suggestions or feedback? Send the Job Insights Team an email Job Insights is part of the Blind Abilities Network. You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Get the Free Blind Abilities App on the Google Play Store. Transcription: Job Insights Extra #2: Advice from Team Sea to See on Transitioning and Rebranding Disability Through Achievement [Music] Jeff: Welcome to a Job Insights Extra and today I want to share with you some job insights that came from Jack Chen, Dan Berlin, and Tina Ament. They're three quarters of the team of Team Sea to Sea, and they're entering the race across America this summer and some of the feats these three have been in is quite astonishing. From climbing Kilimanjaro, to racing in ultra marathons, world champion Hill climber, Google lawyer, a US attorney, co-founder of a major food company, the list goes on and on. And be sure to check out the podcast with the Sea to Sea race across America. I'll put the link in the show notes and you'll learn so much more about each of these individuals and the feats that they've accomplished. While I had them in the studio I asked them some questions about transition age students and employment and I really appreciated them taking the time to answer these questions and being willing to share their experiences and advice with us, so please welcome Jack Chen, Dan Berlin, and Tina Ament on transitioning students and employment. We hope you enjoy and thanks for listening to this episode of Job Insights Extra. Job Insights is a podcast that is helping you find careers and gainful employment through innovations and opportunities and you can find the job insights podcast on blindabilities.com, part of the Blind Abilities network, and as part of the Job Insights podcast we will be bringing you the Job Insights Extras consisting of interviews, demonstrations, and news surrounding employment, careers, and jobs. With host's Serina Gilbert, and myself, Jeff Thompson. And you can contact us by email at jobinsights@blindabilities.com, leave us some feedback, or suggest some topics that we cover, you can also follow us on twitter at Job Insights VIP. So while we're here I want to take this opportunity to ask you a couple questions about transition and employment and some words of advice. Dan there's a topic that you brought up and it's about people not knowing what they can't do, something of that nature, can you explain what you meant when you said that? Dan: Yeah it's so, it's so true in human, you know our existence, and so often I mean, none of us know what we can't do, we all know what we think we can't do, but until you put it out there and actually try it, actually go for it, we really don't know what their limits are. And so often what we're pushing up against as blind individuals just happen to have it highlighted more than others, but this is universal, we're pushing up against our perceived limitations. That's something that all of us can challenge, that's why this message can be universal, you know beyond blindness, beyond disability. We catch a lot of attention because we're a cyclist who was blind, or a runner who is blind has done X Y Z, and I hear the comments all the time from folks that say yeah, I can't believe you run a marathon, I can't believe you did an Ironman, I could never do that, and that label right there, it's like, you know no, you probably could do it, you just, it would need a lot of work and and you know we tend to limit ourselves quite a bit right there. And it's so freeing to have those limitations removed, just that idea that you know we really can do whatever we want to do, it's just where we're going to focus and whatever we're going to put into it, so attitude, effort, and discipline is really what it all comes down to. Jeff: Dan, you mentioned at around age 30 you went through some vision loss and that you said you weren't even much of an athlete, now I don't know what not much of an athlete at the level that you're at right now means, but could you explain that? Dan: Yeah definitely, you know I started losing my sight when I was 7, and it was a slow progression all the way up through my 20's and by 30 I was pretty much legally blind you know early thirties. I was an amateur athlete, I was the type who would run two to three times a week 2 to 3 miles a time, I jogged for 20 minutes on the treadmill, I go to the gym once or twice a week and lift weights up until I was about 39 years old and then I had moved from New York City to Colorado, given up a lot the public transportation, was feeling pretty down, I mean I was, I was really low for a while, my whole family had moved out here with me, for me to start my own company out here. I realized at some point that I needed to take on something to kind of turn my mental state around and that's when I just started, I started running, I started just running around my neighborhood you know three miles at a time. Soon realized I needed to find a goal and so signed up for a half marathon and took it from there, so I've been running now, I did my first half marathon, well it'll be seven years ago, let's see I'll be eight years ago in September, so I've really started what I would consider converting myself into an average middle-aged dad about eight years ago into what I would define myself more as an athlete now, and it was completely done just by saying, I was going to do it. I joke with everybody, I definitely don't have the genetic gifts for running or pretty much any endurance sport, but I have the willpower to do it, and you know will trumps skills almost any day. Jeff: Mm-hmm, now you also climbed Kilimanjaro, I mean is it just because it was there, or did you go down to your local gym and just start wall climbing and want another challenge, how did that come about? Dan: Well you know it's because it's there. [Laughter] Jeff: Well there you go. Dan: Just kidding it's, yeah that's it, no it was just a challenge, you know was something that you know I love mountains I moved to Colorado like I said about ten years ago now and after being out here, I love being in the altitude, I love being in the mountains. You know for me what a lot of this comes down to is this idea of setting a goal and going out there and focusing on it and seeing if we can achieve it. Part of the excitement is you know is one of my good friends has a quote that he often says "if something excites and intimidates you it's worth doing" Jeff: Mm-hmm, that's a good one. Dan: And that's what RAM is to me, that's what I think RAM is to all of us on the team. None of us are sure we can do it, but we're all excited by it. Jack: And I think it's a really important point Jeff to drive home is, a lot of people count themselves out before they even get started right, I mean they ask the question can I, but they don't say I can, and so I think that for all of us, I think I would say, where our blindness started, our lives really began, and what I mean by that is, it's easy for folks and this is not just cyclists of course, but for anybody to have something significant happen to them, and in their lives, or to be treated in a particular way, our fifth grade teacher told me very specifically that, you know you don't have to work so hard, government's gonna take care of you, don't stress out, don't, don't work so hard in school, because that was a kid who I really wanted to do well when I was younger, and I struggled, and so the mentality sometimes sets in that, well I do have certain limitations and I should really count the costs, and, and for me I've come to the point now where I say, well rather than thinking first about whether I can do something I say, how can I do it, you know, so it's not can I, but how can I? And that extra word adds an incredible amount of power and success in one's life, and that's kind of one of the things that we want to communicate. Jeff: Well put, very well put Jack. Tina, being that you lost your eyesight early on, how did you overcome the obstacles that you faced? Tina: Well to some extent, with a lot of help, a lot of support from family. I grew up in the days when my parents fought to get my sister and me into public school and we sort of fought for every you know, between them and, and, and us individually, we fought for every little thing, and on the be careful what you wish for side, you know there were, there was a lot of bullying, you know back then teachers didn't care if kids picked on us, there was no stigma attached to bullying or any of that, so a lot of it was between that and being military kids who had to move all the time, you just had to learn how to jump in and swim, like essentially. I think having sports and activities was a way to belong and I can remember when I was a, in fourth grade and I had a little bit more vision than I do now being forced into gym class, and the day that we were doing soccer drills and I actually saved a goal and the class cheered for me was you know one of the greatest days of my life. I mean who remembers a silly a PE class in fourth grade, but I do because it was sports was a way do you belong with my sighted peers and I think it's so important for anybody with a disability or, to have the chance to fit in because it's, it's such a big part of growing up in the states and you know, sports, music all these kind of activities that kids do, my parents and my sister and I both, we had to push ourselves to get off the sidelines and be able to do something to belong. So I think you know, doing sports through, for me I'm a very competitive person, so like Jack, I always wanted to do well in school and was sort of you know very self motivated to do well, but it was hard and you did have to deal with low expectations, because a lot of teachers and and people didn't expect much of you, and you know you had to find it within yourself to decide, hey I'm gonna go for what I think is important because, you know nobody's going to tell me. Jeff: Tina what advice would you have for someone who is transitioning from high school to college to the workplace, and has their job sights on employment? Tina: Be your own best advocate. I think that the hard thing about leaving high school is, and then about leaving the education environment going into the work environment, is that the older you get the less built-in support systems you're gonna have, so my advice would be to learn early on how to advocate for yourself and how to dispel people's assumptions about you. When I started at my law firm out of law school there had been another blind attorney who worked there before me and he had left to go and teach and I started maybe six months after he did, and I got put in the same office as he had been, and I remember one of the partners coming in and saying, don't let this firm decide that you are Max, you're not Max, you're you, and not that Max wasn't a great guy and had a lot of you know great talents, and, and nothing against him, but you have to overcome people's assumptions that either, they know what's best for you, or whatever some other blind person did is what you do. So I would say learn how to self-advocate and learn how to recognize people's assumptions for what they are because sometimes you won't necessarily see them unless you're on the lookout for it. Jeff: That's a great point, how about you Jack? Jack: One of the things that's absolutely key is to find people who have done this thing, whatever it is that you're doing before you, if that's possible. And one of the great things that I've also been involved with is creating a network of people who have incredible talents who have disabilities. It's called Lime Connect and its motto is to "rebrand disability through achievement" and one of the the great things about this organization is there are ten thousand, ten thousand plus other people out there who have disabilities who are doing what you're doing, and who can act as a resource, and you know when you go to your first job interview and they ask you a question that you don't know how to answer, like for example they come to you and say, hey, well how are you going to draw this drawing? Well you go back to your network and you say, hey guys, anyone else face this issue, how did you deal with it? And just being empowered by having this as a resource is incredible, incredibly valuable I think. I know I didn't have that when I was growing up but, sounds like Tina didn't have that when she was growing up, but now there are resources available just, you know, quote unquote click of a mouse. You can find people who are similarly situated with you or people who've gone before you so, finding those individuals who know what you're going through and can help give you some advice and some support along the way, that our resources are out there, so go find it. Jeff: Dan, I know these are two tough people to follow, but you want to give it a shot? Dan: Tell me about it. [Laughter] Yeah sure I mean, I have a little bit different perspective too because I lost my vision a little later in life so I was into my career and working hard at it. I hid it for years you know kind of that fake it to you make it mentality, and then I had an epiphany at one point, I had this whole change in attitude that was so great for me, and the advice I would give to someone is to be yourself you know just be comfortable in your own skin, you know at the end of the day, you are who you are and nobody can change that. The second thing is, with that in mind, don't be afraid to ask for help. You know if you need some help, if you need to tap into your resources, if you need to ask somebody, hey can you tell me where this is, don't be afraid to ask. The third thing is, use the limitation as your advantage, you know, one of the things that whether we like it or not, and it's just what Tina was alluding to here is, the standards are set lower for people with disabilities. So not that, we have we do not have to live up to these standards, but that's our benchmark now. So it gives us the opportunity to achieve above and beyond these standards, so look at this as an opportunity. Opportunity that the shackles are off, my expectations are low on what I'm going to do, so I'm just going to blow it out of the water. Because my my downsides of being wrong is quite minimal, so take advantage of that, you know just go for it! Tina: I would sort of add to that I, I think the one thing that sometimes you know I let for me or discourage me as, you know as I said before people are always making assumptions about you and the first thing they're going to make an assumption based on, is that you're blind or differently-abled, and so much of the time I mean, you don't know how many times I get on to public transit and somebody says, do you know what stop you're going to? As though I would get my fare card, dress up and work clothes, and get on the train having no idea what stop I wanted to go to, [Laughter] So it's it's sort of like half the world assumes that you're feeble-minded, and then a quarter of the world assumes that you're some sort of superhuman like you must have Steve Austin bionic man hearing and of you know computer chip implant for a memory because you actually get up and function in the world, so a lot of the time I just have to remind myself not to let either of those assumptions you know, or people say like, oh well you're just so much more doggin and determined because you do your sports, it's like well no, I'm not a Superman, I'm not a bionic woman, I don't have a Harry Potter time turner so I can do twice as much training as anybody, I'm just a person who doesn't see, and so when you strip away a lot of the assumptions, you have to remind yourself, like I'm not as great as some of them think and I am not as feeble-minded as some of them think I am. But you have to I think really look to your own self to try to decide where your self-worth comes from because assumptions that a lot of people make about you are so bogus and so out of hand that if you listen to them you'll drive yourself crazy. Dan: To put that into you know perspective too, in our modern capitalistic business world here too, I would love nothing better than all my competition to underestimate what we as a company are capable of doing, and then you get out there and you just outperform it. It's one of the classic mistakes that people make you know in life and in business, and it's one of those things where we again can turn the disability, we could turn the perceptions others have of us into a positive. Jeff: That's great, turn it into a positive! [Music] Such a great opportunity to talk to Jack, Dan, and Tina, team Sea to Sea in the Race Across America this summer. That's Ram, Race Across America, we'll be covering it, stay tuned, and such a great thing that they shared such great advice, such transferable advice, it's not just for school, not for employment, but life itself that they shared with us today. Thanks for listening to this episode of Job Insights Extra and be sure to check Job Insights on the Blind Abilities Network. We hope you enjoyed, and until next time, bye bye. [Music] [Multiple voices] When we share what we see through each other's eyes, we can then begin to bridge the gap between the limited expectations and the realities of blind abilities. Jeff: For more podcasts with the blindness perspective check us out on the web at www.blindabilities.com, on Twitter at Blind Abilities, download our app from the app store, Blind Abilities, that is two words, or send us an email at info@blindabilities.com. Thanks for listening!
Job Insights Episode 2 - Vocational Rehab 101: Demystifying the Myths and Planning For Employment Welcome to the second episode of Job Insights with Serina Gilbert and Jef Thompson. We focus on Employment, Careers, enhancing opportunities and bringing you the latest innovations from across the Vocational Rehabilitation field to ensure your choices lead you down the career pathway that you want and succeed in gainful employment. From getting started with services, to assessments, Individual Plan for Employment (IPE) to gaining the skills to succeed and tools for success, Job Insights will be giving you tips and tricks to help your journey to employment and break down the barriers along the way. In Episode 2 of Job Insights Serina and Jeff break down Vocational Rehab services from eligibility, intake, personal adjustment training, training centers, and your responsibilities as well. Navigating the services may seem daunting at first but with a little bit of information and explanation you will soon fine your pathway to gainful and meaningful employment does not have to be a solo journey. Your Voc-Rehab team wants you to succeed and is their for you all the way. Full Transcript Below We hope you enjoy this Job Insights episode and you can send your feedback and suggestions to the Job Insights team by email at JobInsights@BlindAbilities.com Follow the Job Insights team on twitter @JobInsightsVIP Job Insights is part of the Blind Abilities network. A big Thank You goes out to CheeChau for his beautiful music! Thank you for listening. You can follow us on Twitter @BlindAbilities On the web at www.BlindAbilities.com Send us an email Get the Free Blind Abilities App on the App Store. Transcription: Job Insights Episode 2 - Vocational Rehab 101: Demystifying the Myths and Planning For Employment Serina: I know sometimes that a lot of individuals can be a little bit overwhelmed by applying for services with vocational rehabilitation and we'd like to hopefully demystify some of the myths and help you learn a little bit more about the process. Jeff: Job Insights, a podcast to help you carve out your career pathway and enhance the opportunities for gainful employment. Serina: Helping you with independent living skills, helping you get around town, helping you with cooking, money management, all those things that you need in order to be successful on a job. Jeff: Learn about resources for training, education, and employment opportunities, to see what best suits you to see if you're prepared to move on to the next step. Serina: Correct. Jeff: Thus it's an assessment. Serina: Correct, it helps the counselor out and it helps you out too. Jeff: We will hear from people seeking careers, employment from professionals in the educational field, teachers and innovators in this ever-changing world of technology to help you navigate the employment world and give you Job Insights, and enhance the opportunities to choose the career you want. Serina: We would hate to see you move forward with an employment goal that you thought you would absolutely love, only to find out maybe three months into the job that you obtain, that you really don't like it so much, so it helps us save a little bit of time and prepare you for realistic expectations on the job. Jeff: You can find the Job Insights podcast on BlindAbilities.com, part of the Blind Abilities Network, with host, Serina Gilbert and myself, Jeff Thompson. And you can contact us by email at jobinsights@blindabilities.com, leave us some feedback, or suggest some topics that we cover, you can also follow us on Twitter at Job Insights VIP, and check out the job inside support group on Facebook where you can learn, share, advise, and interact with the Job Insights community. [Music] Serina: Sometimes it might be getting more evaluations done with an orientation and mobility specialist, or a vision rehabilitation therapist to see what kind of personal adjustment training you might need. Jeff: And now please welcome Serina Gilbert and Jeff Thompson with Job Insights. Serina: Hi Jeff how are you? Jeff: I'm doing good how are you Serina? Serina: I'm doing great, how was your week? Jeff: It was good, it was good, the sun has come, spring is finally here. Serina: I don't know, I think you might get some more snow. It's not May yet. Jeff: We're just so glad to have it, I already got the patio furniture out, so I'm excited, I'm excited. Serina: You gonna be barbecuing for me? Jeff: We did that yesterday. Serina: Nice! Jeff: And I didn't even let you know did I? Serina: No you didn't even invite me, even though I'm, I don't even know how many miles away from you. [Laughter] Jeff: I'll waft the barbecue smell west. Serina: Send it over with an Amazon drone you know. Jeff: There we go. I wonder what that sound will be? Serina: They'll probably have like a special Amazon Prime sound for us all. Jeff: Oh yeah so it's recognizable. Serina: Everyone's jealous because we got something from Amazon. Jeff: The dogs will whine just a little bit, it is exciting though when a package comes. Serina: So I heard that we got a ton of positive feedback on our very first introductory episode to Job Insights? Jeff: Yes we did, it did not come by drone, but we got so much positive feedback, it's really exciting. Serina: I think that's great. I know today we were talking about vocational rehabilitation 101, and we'll chat a little bit about the process, what to expect. I know sometimes that a lot of individuals can be a little bit overwhelmed by applying for services with vocational rehabilitation and we'd like to hopefully demystify some of the myths and help you learn a little bit more about the process. And I know, as I talked about on the previous podcast, I was also a client of vocational rehabilitation and I believe you were as well right Jeff? Jeff: Yes I did, but unlike yourself Serina, my ophthalmologist did not send me there, so getting started with State Services was interesting. Serina: At least you got connected, that's that's the biggest part. Jeff: Mm-hmm. Serina why don't we start out by telling the listeners a little bit about what it takes to qualify for services, and if it's a federal or state standard that they go by. Serina: So it's a federal mandate, the eligibility requirements for vocational rehabilitation systems, in general, you have to have a documentable disability that poses some sort of barrier towards you entering into employment, keeping employment, or advancing in the current position that you have. You also have to be able to basically benefit from the services and that's a presumption that most agencies make. Jeff: A presumption? Serina: A presumption of eligibility. Jeff: Hmm? Serina: Another eligibility criteria that helps is, I believe if you receive SSI or SSDI then you are automatically eligible for vocational rehabilitation services. Jeff: So that's usually a process when you go there for services then you probably have to get it to go to a doctor so it's documented. Serina: Well, you can go to a doctor, but if you do not have documentation of your disability, vocational rehabilitation can actually either send out for the records, or send you for evaluations in order to obtain that documentation. Jeff: And that's just one of the steps of the intake process. Serina: So that first step is your intake appointment, which your counselor will go over a ton of different paperwork with you, you'll sign some releases of information for them to be able to talk to necessary individuals that might be working with you on the case, or to obtain medical records, or again refer you for those necessary evaluations, and from that time frame of the first date that you officially apply for services your counselor has up to 60 days to determine you are eligible for services. It can take that long depending on the counselors caseload, but sometimes it's faster, it just depends on the documentation that you already have, and what that counselors caseload looks like. Jeff: Is that the same for when agency is on order of a selection? Serina: Correct, they still have the same 60 days eligibility determination requirements, even if they do have a waitlist or order of selection. Jeff: So if they determine on the intake that you're in, then what's the next step? Serina: The next step is what's called the comprehensive assessment. What happens in this stage is you and your counselor are working together to identify a reasonable and suitable employment goal and also identify the necessary services that might be provided to you in order to help you achieve that employment goal. Sometimes this process could include you trying out work, doing what's called a situational assessment, and that would involve you going to a worksite and trying out the job to see if you like it, see that the duties are something that work well with your personality, in your disability, and also to help you with networking. Sometimes it might be getting more evaluations done with an orientation and mobility specialist, or a vision rehabilitation therapist to see what kind of personal adjustment training you might need. Jeff: Serina, personal adjustment training, can you break that down for our listeners? Serina: Definitely, personal adjustment training might include helping you with independent living skills, helping you get around town, helping you with cooking, money management, all those things that you need in order to be successful on a job. Jeff: And typically you could be sent to a blindness training center or a vendor of the agency? Serina: It depends on this state, some agencies do use the blindness centers, some do have in-house service providers that work specifically for DVR, or third-party vendors like you mentioned, and then I'm not sure about other states, but here in Colorado we do actually have a center based program that the vocational rehabilitation program staffs as well. Jeff: And in Minnesota were fortunate to have three adjustment to blindness training centers, Vision Loss Resource in Minneapolis, Blind Incorporated in Minneapolis, and in Duluth we have the Lighthouse for the Blind, plus State Services for the Blind, and various vendors that will provide specialized services as well. You mentioned doing a situational type of thing where you go to an employer and they do an evaluation, would that be set up with your employment specialist to see if this is an interest of theirs or to see if they like it? Serina: It can be set up through an employment specialist if the state that you work in is structured in that manner, sometimes it's your vocational rehabilitation counselor that's setting it up, and sometimes it can even be a third party vendor that you're working with that is providing that assessment service for us. Jeff: And this is all in an attempt to see what best suits you to see if you're prepared to move on to the next step. Serina: Correct. Jeff: Thus it's an assessment. Serina: Correct, it helps the counselor out and it helps you out too because we would hate to see you move forward with an employment goal that you thought you would absolutely love, only to find out maybe three months into the job that you obtained that you really don't like it so much, so it helps us save a little bit of time and prepare you for realistic expectations on the job. Jeff: So if you do need some soft skills, if you do need some technology skills, and it's determined that you should go to a blindness training center of some sorts, that might set you back six to nine months or whatever it takes right? Serina: That's correct, the blindness training centers are not super short programs, I think the shortest program that they have is the summer youth program for those that are still in either high school or college perhaps, and I believe that's even eight weeks. Jeff: And that's basically like a step program to bridge you into college preparedness? Serina: Correct. Jeff: And if you're planning on going just straight into the workforce then a training center might give you the skills that are needed to help gain employment. Serina: Correct, they work on every skill that you can possibly think of from independent transportation, orientation and mobility, independent living, I do believe they do some self-advocacy training, as well as working on basic social skills because you are living on campus with lots of other people and there's gonna be times when you disagree and you're gonna have to use those conflict resolution skills which will help you for sure once you start working. Jeff: I know we talked about transition aged students quite a bit, but there's also other people adults that have vision loss and they want to get their employment back and so these training centers do adult programs as well. Serina: And it can be quite helpful because I know last time we talked a little bit about an individual maybe who's coming in that has lost sight a little bit later in life but still really wants to work, that's a hard transition coming from having a driver's license and being able to independently transport yourself and work on a computer, to all of a sudden not having those skills anymore and abilities, and those centers and also other field based programs through vocational rehabilitation can certainly help with that transition, and also help you connect with different support groups and things like that so that you can start networking with individuals who've maybe been there as well. Jeff: However, before you move on to this step you must set up an individual plan or employment. Serina: That is correct, and all of the individualized plans for employment can only have services on it that the counselor and you agree are necessary and appropriate, and then they are always purchased at the least possible cost. So there might be times when there's certain products that you really really would like, but the counselor has to follow certain policies and purchase things at the lowest possible cost that is still appropriate for what you need the items for. Jeff: But typically the items will get you to your destination? Serina: Exactly, like as an example, there's lots of different types of computers now, we have our personal computers that maybe would run a screen reader or screen magnification software, and we have our Mac books that also have that same type of software built into it. Typically vocational rehabilitation is going to look at purchasing personal computers more so because we're looking down the road at employment and most employers still use personal computers, so it makes the most sense to get you used to using that type of a technology if you're going to be working in an office environment down the road. Jeff: And when you're saying personal computers, you're talking about Microsoft based platform. Serina: Correct, like a Windows computer. Jeff: Mm-hmm, Serina, can you tell us how flexible and IPE, individual plan for employment is? Serina: Yes, it's a plan, yes it's written on paper, but that doesn't mean that it can't be changed. So it's really important to communicate with your counselor if you feel that something's not going the way that you want it to go, or that you want to try something different, because that plan can definitely be amended, it's actually quite rare that we have the exact same plan from start to finish. Jeff: Okay someone goes through the process and they get their training, making progress, and you're checking the list and moving forward and now they're going to college and they are succeeding, according to the plan, and it comes time to where they start thinking about the job and job resumes, and job interviews, and all that, is there any services for that type of area? Serina: Definitely, it can be considered part of vocational counseling and guidance, which is on every single plan for employment across the country, I don't think there's any plans that don't have that, but it's also part of what we call job seeking skills training, which would be, you either working with your counselor, or perhaps a third party vendor to develop that resume, develop a general cover letter, and also start doing mock interviews, and begin talking about how do you want to handle the interview, how do you want to disclose your disability, if you want to do that at all, and how do you advocate for yourself during that interview. For example if you need an accommodation for testing and things like that as part of the interviewing process. Jeff: Now when it comes to disclosure, there's so many debates about it, and there I don't think there is any one answer, one fits all for this topic. Serina: Correct and I know we're probably gonna talk about that, maybe that'll be our next episode, because that's a hot topic of how do I disclose my disability, and what when and where, am I going to get discriminated against, things like that, I know people are very fearful of that, that definitely will warrant a full episode. Jeff: And that's a big one, so is writing your resume, because a resume is a work in progress, because if you're looking at one job, looking at a next job, it has to form to the job, the keywords and everything, so it's a good skill to have and a good thing to have a template to be able to adjust it for the job you're seeking. Serina: Exactly, we call it tailoring your resume because if you're not putting in specific keywords, a human's not even going to see your resume because there's so many electronic ways that they use, optical character recognition, and scanning the resume that you've submitted either online or even email, where they just scan to see specific keywords and skills and if it doesn't meet that, then it automatically gets denied. Jeff: Optical character recognition, it was such a gift and now it's working against us. Serina: Yep, sound familiar though right? Jeff: Mm-hmm, Serina with all your experiences, what tips would you have for someone who's receiving services and working with the counselor? Serina: So during the vocational rehabilitation process it's really important that you stay in close contact with your vocational rehabilitation counselor. There will be a lot of times when they're going to be asking for tons of paperwork that you might find cumbersome or even redundant. I promise you they wouldn't be asking you for it if they didn't need it because we get a lot of paperwork, if we didn't need it, we wouldn't be asking for it for you. So especially if you're on/in a plan for employment that includes training, every semester we're going to be looking at what grades did you get, what classes are you registering for next semester, do you need any books, did you apply for your federal financial aid? All of those things are things that are required before we can say yes we will pay for your tuition this semester at the school. If your counselor sends you an email asking for something, the quicker you reply the quicker things can move, and just know that sometimes things can't move overnight, if you call us and for specific piece of technology, we might not be able to get that for you immediately, especially if it's not included on your plan for employment, there might be some paperwork things that have to be done and ordering processes and things like that. So we ask that you're a little bit patient with us, but also the more you communicate with us, the better service provisions you will have. Jeff:And staying ahead of the game is the whole thing. Serina: Exactly. Jeff: Yeah, being on the State Rehab Council I get a lot of documents about this it's agencies and I see that one of the highest percentage of closures is because of lack of communications by the client back to the agency. Serina: That's probably actually pretty accurate because especially with my caseload I work with a lot of young adults, so they're still learning how to keep in touch so I do give them quite a few chances but it never fails that as soon as I close a case because I haven't heard from them despite multiple attempts on my end, about two weeks later is when they call me back and say, well I didn't know that you were gonna close my case. And obviously yes you can go back through the process and we can open it again but it's much more efficient even if you just send me a text message saying, everything's all right, I'm still out here, and that'll keep things going for you, but we have to remain efficient and show that the people that were working with are making progress in order to meet our goals and outcomes. Jeff: Serina, this is a lot of great information for someone who is going through vision loss, what advice would you have for someone who is seeking services from their division of vocational rehab or their State Services for the Blind? Serina: If you are a transitioning student and you're at least 15 years old and you are definitely starting to think about employment and what's next and actually some states that's as little as 14, but most states is about 15 or 16, but if you're starting to think about employment, I would say do not hesitate to contact your local vocational rehabilitation, talk to them about services, even if you call and you meet with them and it's not quite the right time, you are at least ahead of the game and knowing what to expect when you do decide that it's the right time for you. If you're an individual that's lost sight a little bit later in life or maybe have never heard of vocational rehabilitation and you're struggling with some vision difficulties, pick up the phone and give them a call, especially if you're looking into employment. All of our services at vocational rehabilitation are for sure geared towards employment now, so any services that we provide do you have to be tied to an employment goal with an eventual goal of being employed in the long-term. Jeff: You know Serina when I first lost my eyesight, I was skeptical you know, I was like worried about what's gonna happen and I didn't know, I didn't know where the blind were, I didn't know anything and I kind of felt like State Services, the agency was kind of a safety net, so I was gonna go out there and forge my own path and if I failed I would head towards the agency and get services, but now today, the more I know about it, it seems like it's a vehicle towards a future, and I've said this many times, but it is, it's it's, it's a resource, it's a place to go to learn about the pathways that you can take towards employment. Serina: And I'm curious what was your experience on the client side? I know you're on the state rehab Council and things like that, but do you remember being your very first experience when you first applied for services? Jeff: You know this is a great question for me because my experience was quite unique I think because when I first lost my eyesight I sold my pickup truck and I bought a brand new computer, I bought jaws and I started doing things the way I thought was best, I did things my own way. I did not understand that State Services for the Blind with an IPE, an individual plan for employment would have set up something of the nature to provide me the tools for me to succeed according to the plan and my goals, and once I understood that there were services as such, I then meticulously figured out what I would have to do for myself, and what they could do for me, and together we could reach the goals that we both set up. So I think part of the demystification of this is, they won't buy you everything, it's not a toy store, but they will assist you in succeeding, and those services do range from, you know, picking the right college that best suits your field, the technology that you'll need to succeed in college or in the workplace, there's so many services that are available there, you just have to make that call, like you said Serina, make that call and find out what they can do for you, and what you have to do as well. Serina: Well and that, someway just popped a thought into my head, I know that some individuals, most you know, most likely receive SSI or SSDI, some sort of Social Security benefits and it can be a little nerve-racking wondering, what if I start work and then it doesn't work out, how are my benefits impacted, there's lots of different rules related to social security and work. So I'm thinking that might be a really good idea for another future topic as well. Jeff: Absolutely, and when a person is going through vision loss it doesn't mean that they're totally educated on all the intricacies that are involved from your State Services, from your DVR, from the government, from Social Security, all these things have to be learned and dealt with and that's why talking with your counselor to learn, to educate yourself, so you can better be prepared for the opportunities that are ahead of you, and I think calling your State Services is one of the best things that a person can do, and that's why they call it a informed choice. Serina: Exactly, so many topics Jeff, we're never gonna end. [Laughter] Jeff: Hmm, that's job security huh? Serina: For sure, how insightful. [Laughter] Jeff: Speaking of something that never ends, I thought winter was the same way around here, but we got grass out back now and the trees are starting to bud, I could feel that a little apple trees with the little buds on them. Serina: That's awesome, you'll start sneezing pretty soon here. Jeff: Mm-hmm, I'm just glad I planted apple trees because I don't think they make PC trees. Serina: Ba dump bum[Imitating comedic snare drum] [trumoet sound effect] Well that concludes today's podcast, but next week we will be tackling that tough topic of disability disclosure, and the job interview. If you have questions you can email us at: Jeff: JobInsights@BlindAbilities.com. Serina: Or follow us on twitter: Jeff: at Job Insights VIP. Thank you CheeChau for your beautiful music, that's @LCheeChau on Twitter. [Music] We really hope you enjoyed this podcast, thanks for listening, and until next time bye-bye. [Music] [Multiple voices] When we share what we see through each other's eyes, we can then begin to bridge the gap between the limited expectations and realities of blind abilities. Jeff: For more podcasts with the blindness perspective check us out on the web at www.blindabilities.com, on Twitter at Blind Abilities, download our app from the app store, Blind Abilities, that is two words, or send us an email at info@blindabilities.com. Thanks for listening!
Jeff Henderson is the lead pastor Gwinett church. Prior to Gwinett Church, Jeff served as the lead pastor of Bucket Church, North Point’s first multi-site location. He spent 21 years in marketing, mostly at Chick Fil A. He and his wife Wendy have 2 children, and they live in the Atlanta area. Jeff Henderson Interview Ted: If someone listening is a busy leader who has a lot going on, why does that bring so much challenge to a marriage? Jeff: For us it has been a lot about scheduling, as simple as it sounds. There have been many times that I forget to tell Wendy about a trip I’m going on. We have had to learn to get ahead of this – We have each other’s calendar, so Wendy can look on mine anytime. Managing the busyness together - that’s the key. I would suggest reading Choose to Cheat by Andy Stanley – Andy unpacks the principles he used to approach work in a smart way, without sacrificing his family, Ted: But what about the people whose boss doesn’t appreciate when they put their family first? Jeff: Lead up as well as you possibly can – have those conversations with your boss and then ask them to trust the results. When you produce the results, often leaders will acknowledge that. If you have a boss who is unwilling to talk about it, it may be time to ask the Lord if He still wants you there Know that there are seasons of crazy, but it shouldn’t last forever. During the seasons of busy, make the decisions about how you’re going to spend your time mutually with your spouse. Ted: I know this is a marriage podcast, but tell us a little about what you’re doing at championtribes.com. I know that means a lot to Wendy and is important for marriages too. Jeff: Campion Tribes is a group experience that gives dads tools to raise their sons. Many sons are living FOR their father’s affirmation, instead of living FROM their father’s affirmation. We’re giving dads a plan to help them navigate their son’s 11-14 year old window. We also have a version coming soon for mothers with daughters. And when you’re parenting your kids well, that has a huge positive impact on your marriage as well! Thanks for joining us for the Married People Podcast! We hope today’s episode helped you realize that marriage is a little easier than you may think. We hope you’ll subscribe to the podcast on iTunes and leave a review – they help us make the podcast better. If you want more resources, check out Your Best Us and our blog at MarriedPeople.org. You can find more about what Jeff is doing with Champion Tribes at championtribes.com. Finally – we hope you’ll join us for next week’s episode!
Join Dawn & the guys behind the scenes of the blog & show - who are working like dawgs to make it all happen... Alex Jon Aaron Andy and Jeff For their spin on current events and what's hot online and what's happening out there in the world of business, entertainment, technology (and everything in between).? Stay tuned for the Back Talk for the Week Blog Post on www.thedashradio.com for links to the topics covered on todays show.? Click Follow on the top left corner of your screen to get plugged in to the show reminders & specialsSubscribe to our newsletter and blog @ www.thedashradio.comText "dash" to 37404 for our mobile experience
Join Dawn & the guys behind the scenes of the blog & show - who are working like dawgs to make it all happen... Alex Jon Aaron Andy and Jeff For their spin on current events and what's hot online and what's happening out there in the world of business, entertainment, technology (and everything in between).? Stay tuned for the Back Talk for the Week Blog Post on www.thedashradio.com for links to the topics covered on todays show.? Click Follow on the top left corner of your screen to get plugged in to the show reminders & specialsSubscribe to our newsletter and blog @ www.thedashradio.comText "dash" to 37404 for our mobile experience
Join Dawn & the guys behind the scenes of the blog & show - who are working like dawgs to make it all happen... Alex Jon Aaron Andy and Jeff For their spin on current events and what's hot online and what's happening out there in the world of business, entertainment, technology (and everything in between).? Stay tuned for the Back Talk for the Week Blog Post on www.thedashradio.com for links to the topics covered on todays show.? Click Follow on the top left corner of your screen to get plugged in to the show reminders & specialsSubscribe to our newsletter and blog @ www.thedashradio.comText "dash" to 37404 for our mobile experience
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