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Hosted by jeff good
12 episodes with jeff good
4 episodes with jeff good
4 episodes with jeff good
4 episodes with jeff good
3 episodes with jeff good
5 episodes with jeff good
3 episodes with jeff good
2 episodes with jeff good
Topic: Malcolm and Carol welcome Emmie King (Nandy's Candy) and Jeff Good (Bravo!, Broad Street Bakery, Sal & Mookie's) to the show for a Valentine's Day Coffee Shop. They discuss Valentine's Day dining traditions and trends and taste test candy and king cakes. Martha Allen from Extra Table calls in to talk about March of the Mayors, and Java stops by to join the fun!Guest(s): Emmie King, Jeff Good, Java Chatman Host(s): Malcolm White and Carol Palmer Email: food@mpbonline.org Hosted on Acast. See acast.com/privacy for more information.
Jeff Good is the owner and President of Mangia Bene (and 2 other restaurants) in the Jackson, MS area. Jeff started in the industry as a teen, and also at that time he met his business partner in high school. After college, Jeff went into sales. He left that industry and decided to open a restaurant with his childhood friend, who is a chef. In order to convince investors to invest, he held dinners out of his home. Today, he owns 3 restaurants in the Jackson, MS area. Favorite success quote/mantra: "I ask God to help me do the right thing." In this episode we will discuss: Raising money/talking to banks Work/life balance Market Partnerships Infrastructure Today's sponsor: Meez: Are you a chef, owner, operator, or manage recipes in professional kitchens? meez is built just for you. Organize, share, prep, and scale recipes like never before. Plus, engineer your menu in real-time and get accurate food costs. Sign up for free today and get 2 FREE months of invoice processing as a listener of the Restaurant Unstoppable Podcast. Visit getmeez.com/unstoppable to learn more. Restaurant Technologies the company that helps restaurants, “Control the kitchen chaos.” With RT's total oil management, you get: Dependable fresh bulk cooking oil delivery; Filtration + oil usage monitoring and reporting; Used cooking oil pick-up, and recycling; And say goodbye to messy, dangerous restaurant rendering tanks-yuck. RT's end-to-end cooking oils solution helps you manage your used cooking oil storage, collection, and recycling- conveniently, safely, and cleanly- with no upfront costs. Head to www.RTI-inc.com, and let them know the Restaurant Unstoppable Podcast sent you their way. Owner.com is the leading all-in-one platform for restaurant marketing. Owner.com powers everything from SEO-optimized websites, direct online ordering, automated email and text marketing, built-in loyalty programs, zero commission delivery, and branded mobile apps for your restaurant that integrate right into your POS. With Owner.com, there are no contracts, no hidden fees, and nothing to lose. Join thousands of restaurant owners using Owner.com to grow direct online sales, save thousands in third-party fees, and simplify their online presence all-in-one.Book a free demo today at owner.com/ and see why Owner.com is the #1-rated Restaurant Marketing Software. Restaurant Systems Pro - Join the 60-day Restaurant Systems Pro FREE TRAINING. This is something that has never been done before. This 60-day event is at no cost to you, but it is not for everyone. Fred Langley, CEO of Restaurant Systems Pro, will lead a group of restaurateurs through the Restaurant Systems Pro software and set up the systems for your restaurant. During the 60 days, Fred will walk you through the Restaurant Systems Pro Process and help you crush the following goals: Recipe Costing Cards; Guidance in your books for accounting; Cash controls; Sales Forecasting(With Accuracy); Checklists; Budgeting for the entire year; Scheduling for profit; More butts in seats and more… Click Here to learn more. Thanks for listening!
Better Edge : A Northwestern Medicine podcast for physicians
In this Better Edge episode, David J. Palmer, MD, clinical associate professor of Ophthalmology at Northwestern Medicine, and Jeff Good, chief sustainability executive at Northwestern Medicine, discuss the current and future sustainability efforts at Northwestern Medicine, and how the Ophthalmology department has integrated them into daily operations. Dr. Palmer speaks on the medical industry's impact on greenhouse gas emissions, including drug waste (in the OR and take-home medications) and environmental changes on eye health. Additionally, the guests share advice for other healthcare organizations and physicians that are looking to enhance their sustainability practices.
Reminding you why the Mississippi Gulf Coast is such a great place to live, work, and play
Host(s): Malcolm White & Joe Sherman (Guest Host)Guests: Elaine Trigiani, Jeff Good, Katie LeachTopics Discussed: Olive Oils, Cooking One Dish, All Things Italian Food, King Cakes & more.Email: food@mpbonline.org.If you enjoyed listening to this podcast, please consider making a contribution to MPB: https://donate.mpbfoundation.org/mspb/podcast. Hosted on Acast. See acast.com/privacy for more information.
Ep #447 (Full Show) Of The Clay Edwards Show On 103.9 WYAB 02/09/2023 1. The power of unanswered prayers 2. Me and Anson Walker discuss the benefits of Testosterone Replacement Therapy (TRT) 3. Anson Walker joins the show for our weekly "Walker Lifestyle" segment, this weeks topic is about living like a top "5%'er" 4. I discuss the open worship of the Devil during the Grammy's and explain that it's hard for me to act too outraged when I grew up on Motley Crue, Marilyn Manson, Three 6 Mafia and other devil themed musicians in the 80's & 90's 5. Jackson businessman Jeff Good comes in against HB1020 bill that would expand the CCID and help save jxn, I take Jeff & some callers to task over his comments. Check out my website & all of my social channels by clicking my link tree at www.solo.to/clayedwards
Clip From Ep #447 Of The Clay Edwards Show On 103.9 WYAB 02/09/2023 1. Jackson businessman Jeff Good comes in against the HB1020 bill that would expand the CCID and literally help save jxn, I take Jeff & some callers to task over his comments. Check out my website & all of my social channels by clicking my link tree at www.solo.to/clayedwards
Happy holidays everyone! The end of the year is fast approaching and boy oh boy has 2022 been something else! Tune into this special little audio snippet that has Henry and Lillie reflecting on the show rebirth, reinvention, and release into the wild and weird world of 2022! From answer questions of whatever happened to episodes that were recorded but never aired, to invention of the commentaries, to the show you know and love and what the future holds; we want to take this time to say special thanks to the whole cast of characters that make this show the special work that it is today! Happy holidays and merry new year everyone! Special thanks to: S.A Blalock Arts , Kaiju Ramen , Samia Mounts , SS Cringefest , Hia Kien , Kasey K Pham , Lisa Naffziger, Dope Pope, Angela , Blake , Johnny, Brenna of Mourning Murders , Get Out Alive Podcast , Laura , Will O'Donnell , Benny Gesserit , Talking During Movies Podcast, Taylor Sandy , Shaun Michael Keenan, Zach Lamplugh, Paul Mattingly of Matt and Mattingly's Ice Cream Social Podcast , The Scoopstronaut , Sheila, Erica Lynn , Darcy the Dandy, Awesome le Possum , The Corvid Witch, The Horror Historian,Vivian, Sasha , HotterBiscuit , Skuudo, Polly Ketcham, Rob Soto, Jirasaurus, Rob, Kaiju Conversations, TwitchyJay Games, Rigel, Will Cope aka Tyrantis Terror, Prof. Kaiju, Andrew Parker, Brandon Cahela, Monsters vs Men Podcast, Everything is Scary Podcast / The Graveyard Shift, The Horrormom, Eevee, Anna Klompen, Lora Fitkin, Jeff Good, Lauren LoGiudice, Jawsman, Derek Bourgeois, Doomsday Cupcake, Denny Roth, Jack Porter, Stephanie, Barbara PHD, Brian, Ella, Gummmy Dragon, Jurassic Jen, Krystal Star, Laura aka TheCleverfangirl, Sean Sumagaysay, Kahlid Elijah Tapia aka TheSeoulBrotha,Toni, Sparkle Fox, Kaiju Hime , Patrick Waugh ,Kiddo Cut, Almighty Rayzilla, August Northcutt and to all those who listen, support, and enjoy this podcast! We've learned our lessons and have grown to become a show that will literally rock your socks off in the coming year! Thank you all and see you all in 2023! ITS GOING TO BE BIG! CLICK HERE to learn how to follow, support and experience more of ICFAMMPodcast!
Shout to Jeto and Jeff Good Times for the special apperance
Shout to Jeto and Jeff Good Times for the special apperance
It's week 6 for #DirtyNapkins & we sit down with Dan Blumenthal & Jeff Good at their restaurant Sal & Mookies Pizza & Ice Cream Joint. #LetsGetSomeNapkinsDirty #CitywithSoul
In this episode of Mississippi Stories, Mississippi Editor-At-Large Marshall Ramsey sits down with Jeff Good about how Jackson's continuing water crisis is pushing local independent restaurants to the brink. Water is a huge part of a restaurant's operation from drinks to food preparation to hand washing to ice and when drinks and ice have to be bought, dwindling profit margins (down 75% due to inflation) are stressed. Good speaks on behalf of other restaurants in Jackson and how leadership needs to start communicating to find a solution.
Ep #327 Of The Clay Edwards Show On 103.9 WYAB 1. I go a rant about the "positive solutions only" crowd & jxn bums panhandling at major intersections 2. Jeff Good teams up with Lamar outdoor billboards to warn people not to leave valuables in their F-150's, it just got me to thinking how sad it is that business owners have to do this. 3. We're Gonna Make JXN Great Again by electing Kim Wade as Mayor of JXN in 2025!! 4. Download the new Chad Wesley album "Soul Rock" now!!! Thank me later!! The Clay Edwards Show Podcast is brought to you by my own personal business, "Auto Armour By Clay Edwards". We are central Mississippi's premiere automotive and boat detailer and ceramic coating shop. Check out our website at Www.AutoArmourMs.Com Check out my website & all of my social channels by clicking my link tree at www.solo.to/clayedwards
This Clip Is From Ep #318 Of The Clay Edwards Show On 103.9 WYAB BOILING POINT: Local businessman & very successful restaurant owner Jeff E. Good pens a very concerning facebook post calling out the mayor & city leaders over the lack of transparency concerning the city of Jackson's water woes, the misinformation on boil water notices & honestly just not telling people how bad the situation at the treatment plant really is. Check out my website & all of my social channels by clicking my link tree at www.solo.to/clayedwards
Series: The Gospel of Luke - That You May Have Certainty...
Good Friday Service 2022
Bo and Blake talk college football and the Y'all Lifestyle in the final hour of the show live in the BankPlus Studio. The guys talk Super Bowl and NFL quarterbacks as two former SEC stars face off this Sunday. ESPN college football analyst Tom Luginbill joins the show on the Bucked Up Energy guest line talking SEC coaches. Tom takes a deep dive into the chaos at Auburn as Bryan Harsin is under heavy scrutiny and could be on his way out after just one season. Tom discusses the dysfunction Auburn athletics has lived in over the last forty years, and why things seem to be coming to a head under Harsin. In the SEC Insider Hit, local restaurateur Jeff Good with Bravo, Broadstreet and Sal & Mookie's join the show on the Bucked Up Energy guest line talking food, fellowship and the Y'all Lifestyle. Jeff talks about what makes this time of year so special, the homemade King Cakes from Broadstreet Cafe. Jeff walks us through the unique journey that made them the top King Cake producer in the state, and why he loves celebrating this time of year. Jeff talks about his evolving golf game, powered by Edwin Watts Golf Shop, and what he's doing to battle the down time of the pandemic. Learn more about your ad choices. Visit megaphone.fm/adchoices
Local restaurateur Jeff Good with Bravo, Broadstreet and Sal & Mookie's join the show on the Bucked Up Energy guest line talking food, fellowship and the Y'all Lifestyle. Jeff talks about what makes this time of year so special, the homemade King Cakes from Broadstreet Cafe. Jeff walks us through the unique journey that made them the top King Cake producer in the state, and why he loves celebrating this time of year. Jeff talks about his evolving golf game, powered by Edwin Watts Golf Shop, and what he's doing to battle the down time of the pandemic. Learn more about your ad choices. Visit megaphone.fm/adchoices
Local restaurateur Jeff Good with Bravo, Broadstreet and Sal & Mookie's join the show on the Bucked Up Energy guest line talking food, fellowship and the Y'all Lifestyle. Jeff talks about what makes this time of year so special, the homemade King Cakes from Broadstreet Cafe. Jeff walks us through the unique journey that made them the top King Cake producer in the state, and why he loves celebrating this time of year. Learn more about your ad choices. Visit megaphone.fm/adchoices
Local restaurateur Jeff Good with Bravo, Broadstreet and Sal & Mookie's join the show on the Bucked Up Energy guest line talking food, fellowship and the Y'all Lifestyle. Jeff talks about the difficult process of building a restaurant and the evolution that takes place throughout a restaurant's life-cycle. Learn more about your ad choices. Visit megaphone.fm/adchoices
Local restaurateur Jeff Good with Bravo, Broadstreet and Sal & Mookie's join the show on the Bucked Up Energy guest line talking food, fellowship and the Y'all Lifestyle. Jeff gives his thoughts on the Super Bowl and talks about his evolving golf game, powered by Edwin Watts Golf Shop, and what he's doing to battle the down time of the pandemic. Learn more about your ad choices. Visit megaphone.fm/adchoices
It's a new year and we're starting it off right with one of Mississippi's most successful restaurateur's, Jeff good, President of Mangia Bene Restaurant Management Group Inc. which includes Bravo, Broad Street and Sal & Mookies. Listen as he talks about the past year, new projects and how he plans to operate another year within a pandemic. See acast.com/privacy for privacy and opt-out information.
Series: The Gospel of Luke - That You May Have Certainty...
Bo and Blake talk college football and the NFL in the second hour of the show live in the BankPlus Studio. The guys continue having fun debating the best sides for Thanksgiving dinner, and get some input from listeners on their favorite foods. Mississippi restauranteur Jeff Good joins the show on the Bell's Two Hearted Ale guest line talking about the special holiday gift card offer for the Bravo!, Sal and Mookies and Broadstreet Bakery trio. Jeff discusses the awesome three-in-one offer on gift cards and their new location in Eastover. In the SEC Insider Hit, Pro Football Focus senior analyst Steve Palazzolo joins the show on the Bell's Two Hearted Ale guest line talking NFL. Steve gives his thoughts on the bounce-back win for the Cowboys and the great first half of the season for Dak Prescott coming off last season's injury. Steve discusses the upcoming matchup with the Chiefs and Patrick Mahomes, and how the Cowboys could approach stopping one of the league's best offenses over the last few years. Steve gives his thoughts on the play of rookie quarterback Mac Jones and the Patriots, who are looking better and better with each passing week. Steve goes rapid-fire through the league discussing quarterbacks, good and bad. Finally, Steve gives his top two teams in the AFC and NFC through this point in the season.
Mississippi restauranteur Jeff Good joins the show on the Bell's Two Hearted Ale guest line talking about the special holiday gift card offer for the Bravo!, Sal and Mookies and Broadstreet Bakery trio. Jeff discusses the awesome three-in-one offer on gift cards and their new location in Eastover.
Have you ever wondered what it's like to spend a season playing against the top fantasy hockey managers in the world? On this bonus episode, the managers in the Keeping Karlsson Ultimate Patron Fantasy League's top tier reunite on air for the first time since draft day to share their winning (and losing) strategies, and revisit the big moments and big drama from the KKUPFL's biggest, most active and wildest season ever. Stat Attack's Jon Neuhold hosts as Dustin Au, our new KKUPFL Ultimate Champ(!!), lets us in on how he won both the Tier 1 regular and post-seasons to claim the title of best fantasy hockey manager in the world. Tier 1 managers Elan Dubrofsky, Ben Burnett, Lewis Ezekiel, Dave Betten, Marcas O'Callanain, Jeff Good and Tom Crowhurst also share takeaways and battle scars from their season in the world's toughest fantasy hockey league. Jon Neuhold appears courtesy of JN Software Consulting, providing professional and IT skills training, consulting, coaching and development to individuals and small businesses since 2002. We'll be back with a brand new regular episode of the Keeping Karlsson Fantasy Hockey Podcast on Monday, May 10. * * * Join our inclusive, passionate and brilliant Keeping Karlsson community by becoming a patron of Keeping Karlsson! Patrons support future episodes of the show and get all kinds of perks in return, like managing teams in the Keeping Karlsson Ultimate Patron Fantasy League (aka the KKUPFL), access to our patrons-only Discord Server, bonus monthly Patroncasts, and weekly show scripts. Keeping Karlsson is proudly presented by Dobber Hockey. Learn more about your ad choices. Visit podcastchoices.com/adchoices
#SpanningtheNeed sat down with Jeff Good, Chief Education Technology Officer - @WesternReservePBS. Join us as we talk about the 5.1 million viewers they serve, resources that they offer to the public, the education district, and how they started the trends on TV now.@WesternReservePBS: https://www.pbswesternreserve.org/#SpanningtheNeed: https://anthonyvspano.com/
Nearly two decades in the making. Henry the Host directs and produce the pilot for an upcoming Audiodrama project based on Henry's original giant monster concept APEX. "As the world looks on at a tragedy, Rick Winston lands in Singapore with a secret agenda as something unfathomable makes its way into the cityscapes of mankind." Starring the likes of Samia Mounts, Nolan Ronald, Jonathan Crocetti, Cece Cornett, Jarret Bowie, Greta Wink and Jeff Good. For more on APEX, either follow @icfammpodcast or @APEX_audiodrama on Twitter or subscribe to the ICFAMMPodcast Patreon for sneak peeks and early access to APEX news!
Bo and Blake talk football and the Y'all Lifestyle in the final hour of the show live in the Bank Plus Studio. Todd Mardis and Philip Anthony with Capital Preservation Services join the show live in the Bank Plus Studio talking about the latest in tax reform and ways to save you money. Todd and Philip discuss the CARES 2021 act and what that means for businesses, especially with the Employee Retention Credit allowing for major savings. The guys also discuss their new book coming out soon and how it simplifies a complex issue for business owners and entrepreneurs alike. In the SEC Insider Hit, local restaurateur Jeff Good with Bravo Italian Restaurant, Broadstreet Cafe and Sal and Mookie's joins the show talking National Pizza Day and their upcoming move to the District in Eastover. Jeff talks about Sal and Mookie's moving locations this spring and what that means for the Jackson food scene. Jeff also discusses the unique differences between the pizza at Bravo and at Sal and Mookie's and how they cook them. Jeff also shows off his knowledge by perfectly guessing the most loved and hated toppings for pizza, and he weighs in on whether or not pineapple belongs on pizza.
Local restaurateur Jeff Good with Bravo Italian Restaurant, Broadstreet Cafe and Sal and Mookie's joins the show talking National Pizza Day and their upcoming move to the District in Eastover. Jeff talks about Sal and Mookie's moving locations this spring and what that means for the Jackson food scene. Jeff also discusses the unique differences between the pizza at Bravo and at Sal and Mookie's and how they cook them. Jeff also shows off his knowledge by perfectly guessing the most loved and hated toppings for pizza, and he weighs in on whether or not pineapple belongs on pizza.
Local restaurateur Jeff Good with Bravo Italian Restaurant, Broadstreet Cafe and Sal and Mookie's joins the show talking National Pizza Day and their upcoming move to the District in Eastover. Jeff talks about Sal and Mookie's moving locations this spring and what that means for the Jackson food scene.
Local restaurateur Jeff Good with Bravo Italian Restaurant, Broadstreet Cafe and Sal and Mookie's joins the show talking National Pizza Day and their upcoming move to the District in Eastover. Jeff discusses the unique differences between the pizza at Bravo and at Sal and Mookie's and how they cook them. Jeff also tells a great story from when the restaurant first opened and things didn't go according to plan.
Local restaurateur Jeff Good with Bravo Italian Restaurant, Broadstreet Cafe and Sal and Mookie's joins the show talking National Pizza Day and their upcoming move to the District in Eastover. Jeff shows off his knowledge by perfectly guessing the most loved and hated toppings for pizza, and he weighs in on whether or not pineapple belongs on pizza.
In years to come we’ll think of 2020 as “the year of the pandemic,” the year that shifted our comfort zones in more ways than we could ever imagine and the year we were ALL a part of what will one day be told in history. So today, we’re reflecting on what we learned from 2020 and what what's next in 2021 with guests, restaurateurs, Robert St. John and Jeff Good and award-winning investigative reporter and journalist, Jerry Mitchell. For more information about the information on this episode visit:Mangia Bene Restaurant Management Group Inc. - Home - Jackson, Mississippi - Menu, Prices, Restaurant Reviews | FacebookRobert St. JohnMississippi Center for Investigative Reporting (mississippicir.org) See acast.com/privacy for privacy and opt-out information.
As a teen, Jeff Good moved to Jackson from Salt Lake City and went on to attend Millsaps College and stayed put, planting deep roots in the city. As owner/operator of Jackson restaurants BRAVO! Italian Restaurant & Bar, Broad Street Baking Company and Sal & Mookie's New York Pizza & Ice Cream Joint, Good's face and welcoming persona is one that's ever-present in the City With Soul. His most recent endeavor, a workforce training café, Refill Café, is based in West Jackson. In this episode: bravobuzz.com | salandmookies.com | broadstbakery.com | www.refilljackson.org
More than just a place to eat, local restaurants are gathering places for friends and a vital business for the local economy. Today Malcolm and Carol talk with restaurant owner Jeff Good about the affect COVID-19 had on hid business and the way he managing these uncertain times. Also with the fall season making its arrival Felder Rushing (The Gestalt Gardener) joins the show to talk about your fall vegetable garden. Let’s eat y'all! Persimmon Pudding(as mentioned by Carol during the show)INGREDIENTS4 tablespoons/56 grams butter, melted, plus more for the dish5 Fuyu persimmons (about 2 1/4 pounds), trimmed and chopped2 eggs, beaten2 cups/400 grams sugar1 teaspoon/8 grams baking soda1 cup/240 milliliters buttermilk1 ½ cups/190 grams all-purpose flour2 ½ teaspoons/12 grams baking powder1 cup/240 milliliters heavy cream¼ teaspoon/ 1 1/2 grams salt½ teaspoon/3 milliliters vanilla extract Dash of cinnamonPREPARATIONHeat oven to 325 degrees and butter a 2-quart baking dish. Purée persimmons in a food processor or blender until smooth. Strain pulp through a fine mesh strainer into a bowl, using the back of a spoon or a spatula to push purée through. Measure out 2 cups of pulp (discard remaining pulp).Combine eggs, sugar and persimmon pulp in a large bowl and beat with an electric mixer on medium speed until well mixed. Stir baking soda into buttermilk, then add to persimmon mixture and beat to combine.In a separate bowl, sift together flour and baking powder. Beat flour mixture into persimmon mixture in 3 batches, alternating with the cream, beginning and ending with the flour.Stir in melted butter, salt, vanilla and cinnamon. Transfer batter to prepared dish and bake until pudding is set, 1 hour to 1 hour 15 minutes.Link: http://nyti.ms/1tb0EGa See acast.com/privacy for privacy and opt-out information.
This episode marks the Season Two finale with Professor Pius Akumbu, an Associate Professor of Linguistics at the University of Bamenda, Cameroon, and an Alexander von Humboldt Fellow at the University of Hamburg. His research focuses on the documentation and description of Grassfields Bantu languages of Cameroon, including his mother tongue, Babanki. Additionally, Pius researches multilingualism in Cameroon as well as language planning and policy in Africa. He is an ELDP grant recipient and a depositor at the Endangered Languages Archive. He is also a member of the KPAAM-CAM project. Things mentioned in this episode:Babanki languageMultimedia Documentation of Babanki Ritual Speech (ELAR deposit)KPAAM-CAM projectNjem (Njyem) language Cameroonian Pidgin EnglishELDPFirebird FoundationFoundation For Endangered LanguagesEndangered Language FundPius Akumbu's websiteBabanki literacy classes and community-based language research by Pius Akumbu (2018)Episode 13: Jeff Good on Facilitating Language Documentation in Cameroon Get in touch: Website: https://fieldnotespod.comEmail: fieldnotespod@gmail.comTwitter & Instagram: @lingfieldnotesField Notes Support Page
BPF continues its dialogue with Jeff Good as he discusses teaming up with Jackson area leaders to form a workforce development café called the Refill Café. The young adult staff is enrolled in a 10-week work training program to help develop skills needed for entering the workforce.
BPF continues its conversation with Jeff Good to talk about 3rd party delivery services, customer service and how Mangia Bene continues to grow its business, as well as diversify.
BPF talks with Jeff Good on his start in the restaurant business here in Jackson, MS with partner Chef Dan Blumenthal. Jeff talks about upscale dining, farm-to-table, the Jackson market and how they’re still making it happen through the highs and lows.
Welcome to Season Two! This is the first episode of Season Two on Field Notes. Although we are living in strange times and fieldwork is not currently possible due to the COVID-19, Field Notes will continue publishing weekly episodes this season to share information and experiences from the field which will hopefully benefit our listeners in the future (when fieldwork is possible again). Until then, hang in there, we are all in this together.This episode's guest is Jeff Good. Jeff is a professor and chair of the Department of Linguistics at the University of Buffalo in New York. Jeff is a typologist and his research focuses on lesser-documented Batoid languages in the lower Fungom region of Northwest Cameroon. In this episode, Jeff shares how he started working in the lower Fungom region and how he now works with scholars in Cameroon to facilitate language documentation and research from his base in Buffalo.Things mentioned in this episode: Jeff's websiteBantoid languages KPAAM-CAMZoom Q8 video cameraRode NTG2 microphoneMarantz audio recorderZoom H4n audio recorderTopics in Language Documentation Seminar reading listSaramaccan (Atlantic creole) on WikipediaEpisode 4 with Hugo Cardoso (focusing on creoles) Get in touch: Website: https://fieldnotespod.comEmail: fieldnotespod@gmail.comTwitter & Instagram: @lingfieldnotes
The COVID-19 Healthcare Crisis has effected the entire world in so many ways and businesses are feeling the wrath of the coronavirus pandemic more than ever. Today we will speak with three guests from three different lines of business to discuss how they are navigating through this “New Normal”. Bishop Brian Seage from the Episcopal Diocese of Mississippi, Jeff Good, President of Mangia Bene Restaurant Management Group and professional Singer/songwriter Seth Power. Visit the links below for more information about our guests and updates on curb-side takeout for Mangia Bene Restaurant Management Group Episcopal Diocese Of Mississippihttp://bravobuzz.com/http://broadstbakery.com/http://salandmookies.com/http://sethpowermusic.com/ See acast.com/privacy for privacy and opt-out information.
It's the final week of Pride Month 2019. The guys wish everyone celebrating World Pride in NYC a wonderful time. Jeff talks about being homesick for New York and missing playing hockey. Pose's early season 3 renewal is praised. Will talks about the special Masterwork Experiment happening on The Story Grid Podcast where they are breaking down and analyzing the story structure of Annie Proulx's Brokeback Mountain. Jeff and author/blogger Lee Wind have an extended interview in which Lee discusses his debut YA novel, Queer as a Five Dollar Bill and how he's become engaged in discovering queer history. They also talk about the YA book blog I'm Here. I'm Queer. What the Hell Do I Read? that Lee began over a decade ago. Lee also recommends a couple of his favorite YA books and the queer history project he's trying to jump start on Instagram. Complete shownotes for episode 194 along with a transcript of the interview are at BigGayFictionPodcast.com. Interview Transcript - Lee Wind This transcript was made possible by our community on Patreon. You can get information on how to join them at patreon.com/biggayfictionpodcast. Jeff: Lee, welcome to the podcast. It is so great to have you here. Lee: Thank you so much. I'm really excited to be here, Jeff. Jeff: Now, I recently read your debut novel, "Queer as a Five-Dollar Bill". In fact, I reviewed it back in Episode 189. And absolutely love it. Now, tell people in your own words what this YA novel is about. Lee: So it's all about the fact that I don't have a time machine. When I went...in 2011, I went to a game in summer camp kind of weekend. And there was a guy talking about the letters that Abraham Lincoln wrote Joshua Fry Speed that convinced him that Abraham was in love with Joshua. And I just thought he was full of it. Like how could that have been possibly been true? It's the first time I heard about it. And I went to the library, and I got the letters and I read them and because the emotions Lincoln speaks about are the same emotions I experienced when I was closeted in dating girls and sort of judging it the right thing to do, but not feeling it, I had this moment of sort of goosebumps, and I was like, "Oh my gosh, I think maybe Lincoln was in love with speed." And I thought, "Oh, if I had a time machine and go back and tell my 15-year-old self that the guy on Mount Rushmore, the guy on the $5 bill, the guy on the penny, was maybe in love with another guy, I think it would have changed my whole life. I don't think it would have taken me until I was 25 years old to fully come out. I think it would have been a game changer. But I don't have a time machine. So "Queer as a Five-Dollar Bill" is my paying it forward. I'm a writer, I wanted to write the story about a 15-year-old who's closeted and bullied and dating a girl because he kind of judges it's the right thing to do, but he doesn't feel it. And then he's assigned a book report on Lincoln and he gets the same book that I got from the library, he reads the actual letter, where Lincoln is asking his best friend, after the best friend has gotten married to a woman, "Are you now, in feeling as well as judgment, glad you're married as you are? From anybody but me, this would be an impudent question not to be tolerated, but I know you'll tolerate it for me." And he ends the letter saying, "Please tell me quickly, I feel very impatient to know." And we don't have Joshua's answer, because Mary Todd burned all the letters on that side of the correspondence. But we do know it was only four weeks later that Abraham had married Mary. So to me, it felt like wow, that, like what would happen if a kid today found that out and decided that he wants the world to know? Because everyone loves Abraham Lincoln in our country. And he thought, "Well, okay, so if he tells - the main character, Wyatt - if he tells the whole world that Abraham Lincoln was in love with another guy, he thinks it's going to change how everyone feels about gay people, cue the songbirds and the rainbow and happy ending." I do think if in our culture today if someone was to go really viral with the information that Abraham Lincoln was, wrote these letters and was in love with Joshua Fry Speed, I think there would be a huge conservative backlash and media firestorm. And that's really that what I wanted to show in the novel, how this Wyatt, how Wyatt, this main character makes his way through this incredible maelstrom of fury that he's ignited by just sharing what actually is part of American history. And then to kind of ratchet the stakes up even further, I wanted to make it, like, how was it important for a teenager today? Why is Abraham Lincoln important? So I kind of situated him in Lincolnville, Oregon, a town I kind of made up. His parents own the Lincoln Slept Here Bed & Breakfast. And when the economy of the town kind of starts to tank and they're threatened with losing their business, they bring in a civil rights attorney to help and she has an openly gay son and sparks fly between the two teens. But the main character Wyatt can't do anything about it. Because gay kids saying Lincoln is gay is really different than a straight kid saying Lincoln is gay. And he's faced with his choice, does he follow his heart and see if something might be happening with this guy, Martin? But the cost of that is letting this secret fade back into history, and nothing will ever change in our world. Or does he sort of sacrifice himself and his own happiness, and persist with the story that Lincoln was indeed in love with another guy and see if he can change the world a little bit, even though it won't change for him? So that's the story of "Queer as a Five-Dollar Bill". Jeff: And I feel like even before I read this book that I had heard, you know, some of the rumblings that Lincoln may have had a relationship, may have been gay. So I think it kind of dances around the edge of what some people know, because I can't even begin to tell you where I heard it or anything else, just that it had been kind of back there somewhere in the memory of I don't know, something. Does that even make sense? Lee: Well, it's been a big thing on "Will & Grace", the revived series. They've been doing a whole run on jokes about Jack doing a one-man play called Gaybraham Lincoln, which is sort of all about Lincoln being gay, which I think has been good on the one hand, because it's letting more people know that this is something that people are talking about, but it's also doing so as if it's a farce, as if it's not true at all, and completely made up in a complete flight of fancy on the part of this bigger than life character. When in fact, if you read the letters, it is remarkable how to me it feels so clear that Lincoln was in love with Joshua. Jeff: What was your process for researching the history? Because there's more in here than just the letters themselves. There's a lot of Lincoln history, there's comparisons drawn between Lincoln and Martin Luther King Jr. In my review, you know, I kind of likened it a little bit, you know, you go see "Hamilton" and you get this big infusion of history, while you're wildly entertained. What was kind of your process around gathering all the pieces you needed? Lee: Well, first of all, thank you for comparing it to "Hamilton." That is like the best compliment ever. I need to embroider that on a pillow or something. I did a lot of research. I started out with the letters and then I realized that I just didn't know enough. I looked around and I live in Southern California. And it turns out in Redlands, California, there is an Abraham Lincoln Memorial shrine and museum. And it's like a three-room edifice that has display cases and a gift shop. And so many of the things that ended up being part of the bed and breakfast that Wyatt's parents own were kind of taken from that real-world experience of going to this place and seeing that they actually had, you know, civil war chess sets. And they had, you know, little teddy bears that were gray or blue. And they had, you know, Confederate Flag and a Union Flag. And that was hugely helpful. And then just starting to dig in deeper to some of the things I discovered there, there's a whole sort of subplot about how Wyatt feels that there's no one he can actually talk to. And so he's developed this strange internal dialogue with this image of a soldier in the background of one of their display cases. And I actually have a photo of it from when I went to this Lincoln shrine. And it was there, it was behind all these ammunitions. And I don't know that my gaydar works 150 some years later, but definitely, there's somebody in that, they're one of the soldiers in that photo does look like he could be gay. And I thought, "Wow, what if this was the only way that Wyatt felt that he could have somebody that recognized who he was, and how sad that was that he didn't really have a friend?" And that was why I was excited to create the character of Martin so he had somebody. Jeff: Were you a history buff all along? Lee: No, I hated history. And I'm sure that they're all these teachers that are like hitting their foreheads in shame right now. But like, honestly, I never had a history teacher that kind of got me excited about the stories of history, because I really feel like the way we teach history today, and my daughter's in 10th grade right now and her history textbook could have been my history textbook from the 1980s, where basically, it's the stories of rich, white, straight, cis-gendered, able-bodied men from Europe. And, you know, history is more than that. There are the stories of disabled people and people of color and women and men who loved men and women who loved women and people who looked outside gender boundaries in history. And I kind of feel like, we have to crack that facade of that false facade of history and let people know that that there's all this amazing light and you can see yourself in history. And, you know, Lincoln and Joshua are just sort of like the tip of the iceberg. There's, you know, Eleanor Roosevelt and Lorena Hickok, there's Mahatma Gandhi and his love for this German Jewish architect, Hermann Kallenbach. There's the pharaoh Hatshepsut in Egypt, there is Safa, there's so many stories that impact us today. But we don't really know them because they don't get taught, or when they are taught, they're not taught in a sort of, queer inclusive or respectful manner. So I kind of feel like now I love history. And in fact, I wrote this novel, but as I was writing the novel, there was so much history, there was so many things that came up, so many more pieces of evidence, so many more pieces of the pie, things that made me surprised, like, I didn't really know that Lincoln was sort of a racist, even though he's credited with freeing all the slaves, he had this whole plan that he signed off on with Congress at that time to sort of, you know, explore shipping all black people back to Africa. And I didn't know that. And the deeper I dug, when I found a piece of information that kind of contradicted what I knew, I really wanted to find a way to include it in the story. Because I feel like that's what we should be doing when we find things that show that history is complex, and that people are not black and white, that it just makes it all so much more real and so much more relatable. And if we can see reflections of ourselves in the past, like if we know that there were men who love men in the past, then we can believe that we have a place at the table today. And if we know that we have a place at the table today, we can envision a future that is sort of limitless. And I want that for everyone that doesn't feel like their history is included. I want it for all the women and all the people of color and the disabled people and the women who love women and the people who lived outside gender boundaries, too. Because that's, you know, we call it LGBTQAI+ or QUILTBAG or whatever. But really, the job is about being an ally to other people. And me as a gay man, I have to think, "Well, how can I be an ally to everybody else?" And hopefully, they're thinking the same thing. And that's how we start to create societal change. Jeff:: That is wildly profound. And especially, given that this episode of the podcast is dropping in the last week of June, as you know, the queer community celebrates Stonewall 50. Lee: Oh, yeah. Well, you know, I love that we're celebrating Stonewall, I love that the gender non-conforming people that were there, the transgender people, the drag queens are getting some respect now that they were part of that and they were in fact, the leaders of standing up to the police finally. But for many, many years, Stonewall had a banner, the Stonewall Inn had a banner outside that read "Where Pride Began". And I think that's really misleading. And we talk in the queer community in America as if that's where pride began, right. Like, pride, "Hey, we're celebrating 50 years of Stonewall, Hooray." But wait a minute, Karl-Maria Kertbeny came up with the word homosexual 100 years before Stonewall. Right? Like Lincoln and Speed were writing these letters to each other 20 years before that. You know, you can go back thousands and thousands of years and there's this beautiful story from China before China was unified, where the State of Wey that the guy that ruled it, his name was Duke Ling and he had a guy he loved his name is Mizi Xia. And they were walking through the orchard one day and Mizi Xia picks a peach off a tree and starts to eat it. And halfway through, he stops because it's so delicious. He wants to share it and he gives the half eaten peach to the Duke and the Duke makes a really big deal out of it. Like, "I can't believe your love for me is so profound that you would sacrifice your own happiness to give me the peach." And something about that moment captured the imagination of people in that pre-unified China. And for over 1,000 years, the way in Chinese that they said gay love was love of the half-eaten peach. Like we have this amazing, amazing history. And we just need to kind of breakthrough that facade and let all this amazing rainbow light shine through. So that's kind of what I feel my mission is to kind of let people know that we have all this amazing history, and we can start to dive into it. Jeff: Is this all history? Because you mentioned earlier that you're not, you weren't a history buff and you hated history. Have you gathered up all of this new knowledge since you were researching to write "Queer as Five-Dollar Bill"? Lee: Yeah. So while I was writing "Queer as a Five-Dollar Bill," like I mentioned, there was just so much stuff that came up, so much evidence that I was like, "I can't really cram all this into a novel, because at the end of the day, the novel is really about a kid today." And I didn't want it to feel like a historical novel. I wanted it to be this page-turner. So I realized that maybe it was two books, maybe there was the novel. But what if there's a nonfiction book as well that presents the primary source materials, like a popup video thing on MTV or VH1, whatever it was, helps interpret, or at least how I interpret the thing? So like, there's all this talk about Shakespeare's Sonnets, and how, while they're very rarely taught, over 100 of the sonnets, Shakespeare wrote to another guy. And these are love sonnets that include really, really famous lines that we all recognize, like, "Shall I compare thee to a summer's day. Thou art more worthy, yet more temperate." That's a line that Shakespeare wrote to another guy. For hundreds of years, they had changed the pronouns of that in one of the folios. So it ended up being that for hundreds of years, people thought that Shakespeare wrote all those poems to a woman, to the Dark Lady. But when "The Riverside Shakespeare" came out, the editor of that section, he talked about how, "Well, we've restored the sonnets to their original, you know, pronouns, but you shouldn't mistake that, you know, the affection men felt for each other in the 1500s was nothing like the homosexual attraction today." He wrote this in 1970s. And I'm like, "Really? Really?" Because, you know, "A man in hue all hues in his controlling, Which steals men's eyes and women's souls amazeth," it sounds pretty romantic to me. So what I realized what I wanted to do is to create a book that wouldn't be just a book about Lincoln and Speed, but it would be a book about the broader thing, about men who love men and women who love women and people who lived outside gender boundaries. So there's 15 chapters. One is about Lincoln and Speed, one is about Shakespeare. And then there's, like, you know, a bunch of other amazing people in history, and it really presents the primary source material. And I'm really excited because today - that we're recording this - is the day that I'm signing the contract for that book with a publisher. Jeff: Oh, that is exciting. Congratulations. Lee: Thank you. It's been a long journey, long and crazy journey. Because the book originally was set up at one of the big five publishers, and I worked on it for a year and a half with them. It was approved, we were talking cover design. And then two weeks after our current president was elected, they canceled the book. I think they were concerned that it was going to be too controversial. They just didn't have the courage to proceed. And that was really devastating. And it took a long time to find a new home for it. There were a lot of shenanigans, a lot of plot twists. The agent I had had at the time turned out to be a criminal who, well, she was telling all her clients she was submitting things and that they were having all these pending book deals. She was lying. And the book was never submitted anywhere. Even after it was returned, the rights were returned to me. And the novel, "Queer as a Five-Dollar Bill" ended up getting crowdfunded because I thought that I was being, well, stonewalled by the children's book industry and they didn't want word to get out about Lincoln and Speed so much so that no one would even respond to the submissions. So I crowdfunded it. I have a blog, I think we're talking about that a little bit later. But I have a bunch of people that know who I am and what I was trying to do, and they all supported me to not just publish the book professionally, but also, what I wanted to do is raise enough money to donate at least 400 copies of the novel to LGBTQ and allied teens, and the Kickstarter funded in six days, it was amazing. And then it went on for another 24 days. So we ultimately raised enough money to give away 910 copies. So that's been really, really gratifying. Jeff: That's incredible. I mean, it's really one of the great things about publishing today is that there's really no more gatekeepers out there. Anybody can publish, get it on Amazon, get an audiobook done, etc, and get their messages out there. Lee: There still is the thing, though, that being with a traditional publisher, you generally can reach more, especially when we're talking about like middle grade, you know, or books, where you go into libraries, which I think that this nonfiction book really is a, you know, hopefully, it'll sell like hotcakes. But also, I do think that to get it adopted more broadly into schools and into libraries, I think that coming from an established publisher is really useful and really helpful. So I'm excited about that. I do think that yeah, that there are many, many fewer boundaries than there used to be - or barriers than there used to be. But at the same time, we have the additional challenge that while access to the marketplace has never been easier, the marketplace has never been bigger. So getting noticed in a marketplace, where there's over a million books that are published every year now in the U.S., is a challenge. And that's why it's so important to have safe places to find out about these things, like your podcast, and my blog. Jeff: Yes, absolutely. To spin back on "Five-Dollar Bill" a little bit and talk a little bit more about it. What were your inspirations for both Wyatt and Martin and the type of teenagers they would be? Lee: When I was growing up, or when I was coming out, I think it felt like you couldn't be gay if you lived anywhere except for one of the big cities like San Francisco or New York. And I really wanted to have a character that felt connected to nature. And that one of the thematic subplots would be, 'Could he be himself where he was? Could he be himself in small town America, in a rural community, was there a way through for him to be successfully himself and authentic?' I feel like I spent so much of my life being inauthentic, that I want to do everything I can to help teens be authentic now. So on the one hand, Wyatt was the study of a kid that was on a journey to be authentic and Martin was the flip side of that. Martin was the character that already was authentic, and was already reaping the benefits of that level of confidence. And you know, as soon as you, for me, when I came out, it was like this huge burden off of me. And suddenly, I realized the weight of it was on everyone else, right? Like, if they had a problem with it, that was their problem. But it wasn't me hiding or holding back, or pretending or acting, which I did for so long. My husband and I have a joke, where when you go to a Starbucks or something, they're always like, "What's your name?" And every time my husband changes his name. Like he just makes up different names every single time. And they ask me and I'm always Lee because it took me 25 years to even start to like myself and to accept myself. And I finally got here. And I'm like, "Yeah, I'm not anybody else. I am me. I am Lee." It's funny. I take a spin class and as a motivational thing the spin instructor does, "Who do you want to be today?" I'm always like, "Me, I want to be me." I spent so long being other people. And then also, it was really cool when I was creating Martin's character, to think about him being African American. And that being an opportunity for me to talk about the complexity of Abraham Lincoln and him not being so perfect and explore those themes a little more. And it's funny because I hear from a lot of people how much they love Martin. And yeah, he's pretty lovable. Jeff: Yeah, I really liked them both in their individual ways. For sure Wyatt...I grew up, I spent like middle school, high school, college in Alabama. So I could totally relate to where Wyatt was in his journey like he knows, but there's no way he's telling anybody. And I didn't have a Martin for a best friend. So I also loved Martin, because he was the ideal friend to have for Wyatt in the moment to show him what could be. Lee: Yeah, exactly. Jeff: What do you hope the audience takes away from this kind of history/fiction mashup? Lee: So I think a lot about words, you know, being a writer, and I think that the word homosexual isn't helping us. I think that if we, because we're so reactive and weird in our culture, in America about sex, and we are obsessed with it, and we don't want to acknowledge it. And especially we don't want to talk about it to teens. So when we talk about homosexual rights and homosexual history, all straight people are hearing, you know, to paint with a broad brush, is they're thinking about sex and that we have sex differently than they do and how do we have sex. And I just don't think that's particularly helpful. And I think that if we talked about love as sort of the binding element that makes me and my husband and our teenage daughter a family, or the love between you and your husband, if we talked about HomoLOVEual rights and HomoLOVEual history, I think we'd have a very different cultural conversation. So what the tagline of my book is, "What if you knew a secret from history that could change the world?" And I love this because it gets a little meta. But it's the challenge that Wyatt faces, right? He finds out the secret about Abraham Lincoln writing these letters and maybe being in love with Joshua Fry Speed. And he decides that he's going to tell the world because it could change the world. And then it's the same challenge that I faced because I knew the secret from history and I thought this drumming sense of responsibility, like I had to share it, I had to get it out in the world. And because I wasn't getting anywhere with traditional publishing, I thought, "Okay, well, I'm going to crowdfund it, I'm going to get it out in the world, myself." And then what I am really excited about is that it's also the challenge that the reader faces. Because when you've read the book, or you even heard me talk about the book, you know that there is something more to the story of Abraham Lincoln that has been taught to you. And it's that first crack in that facade of history. And it makes you think, "Well, wait a minute, when you see the picture of Mount Rushmore, or when you pick your kid up at the Lincoln middle school, or you're driving on Lincoln Boulevard, you know, does it occur to you that, you know, our culture has not shared that part of who Lincoln is? And does it make you feel a little more pride about the fact that you know what, we do have history, queer people, and we need to lean into it? And we have the opportunity to because there are hundreds of years of historians that are going to argue with us and that are going to say, "Yeah, yeah, it's not true. It was very typical for men to share beds on the frontier." Not that Springfield, Illinois was the frontier. But for four years, you know, Abraham and Joshua shared a bed long after Abraham could afford his own bed. "Well, it was cold." Okay, yeah. But they shared a bed for four years. It's not proof. But it's interesting. And I think that as all those things add up, we can all make our own determination of what we think, you know. Is it important for me that I convince the world that Abraham Lincoln was in love with Joshua Fry Speed? No. I think a lot about Anne Lamott, she's a writer, and she writes about writing. She has a beautiful book called "Bird by Bird". And in that book, she talks about lighthouses, and how they don't run all over an island looking for boats to save, they just sort of stand there and they shine. And I think a lot about that. Like, I need to be a lighthouse. Like I found out this amazing, cool stuff about history, and how it relates to today, and how empowering it is. And I just want to shine. And if people are interested, they can come closer to the light. And if they're not interested, no worries, you know, watch out, there's some rocks over there. Jeff: Any chance of a sequel? Because I know I would love to see more of Wyatt and Martin at some point Lee: I haven't really come up with a good angle on a sequel, I had this funny idea for...one of the other pieces of history that really struck me was Mahatma Gandhi and the story of his love for Hermann Kallenbach. And we talk a lot about Gandhi having this sort of breakthrough where he talked about it doesn't matter whether you pray facing left and I pray facing right - I may have that reversed. We're all praying to the same God. Like he had this huge breakthrough, not just in terms of, you know, a peaceful protest, Satyagraha. He changed our world in such profound ways. And at the same time, he was in love with this German Jewish architect named Hermann Kallenbach. And if he was in love with a Jewish guy, like that's actually really interesting and really germane. Like maybe that's why he had that inspiration, that insight about it doesn't matter who you're praying to, because it's, we're all sort of bonded by this sense of spiritual connection. Like, that's really exciting. And I feel like there's so many stories like that, like Eleanor Roosevelt and Lorena Hickok. Eleanor Roosevelt was the woman that after, you know, her husband died, she went to the UN and became this advocate for the Universal Declaration of Human Rights. And would she had done that if she didn't have this experience of being in love with another woman, and feeling that sort of outsider status, while at the same time being this empowered woman in our world? History starts to open up like a flower. So I don't have an exact idea for a sequel for Wyatt and Martin, but I will put it in the hopper as ideas. Reason I brought up Hermann Kallenbach and Mahatma Gandhi was that I thought, that would be an interesting thing to talk about a kid finding out about that, and how that would have changed their life. And then about, "Wait, that's the exact same story over again, I don't need to do that. I already wrote that." So for now, I'm going to focus on the nonfiction piece and some other fiction writing that I want to get to that, actually, I'm very inspired by your book too, by the "Codename: Winger" series, because I love the idea of mashing up a gay teen with a sort of spy thriller. Jeff: And I can't wait to read what you might do with that. So please, bring that to the marketplace. Lee: Thank you. I keep thinking, "Is there a way I can get gay history in here somehow?" I haven't figured that either yet. But, you know, I'll work on it. Jeff: You'd mentioned earlier that you've got your blog, which I was so excited to find right around the same time as finding the book. You've been a YA blogger for more than a decade now. I believe you said it'll be 12 years in September. And the blog is called "I'm Here. I'm Queer. What the Hell do I Read?" What led you to starting that? Lee: Thanks. Yeah, there was no safe space to find out what were the books with queer characters for kids and teens. And I remember, there was a review on Amazon for a really sweet picture book called "The Family Book" by Todd Parr. And it's sort of a cartoon-y book. And there's like one page, it says, "Some families look alike." And it's a bunch of dogs that they all have similar features. "Some families look different." And it's a tree with all these different kind of animals in it. "Some families adopt children." And it's a bunch of ducks. And on the back of one duck is a penguin. And then you turn the page and it's, "Some families have two moms or two dads." And it's a picture of two women and two men. And then it continues, and there was a review, pretty high up that said, "If you tear out the page with the two moms and dads, then this is a lovely book on diversity." And I thought, "Wow, way to miss the entire point of what diversity is." And I got so upset and so hurt, you know, because I'm a gay dad. And I thought this was an amazing book for my daughter, but also for all of my daughter's classmates to see and recognize, "Yeah, yeah, you know, some families do have two moms and two dads." And to Amazon, that wasn't hate speech, it didn't violate their terms of service, it was just somebody's opinion. Albeit kind of, you know, nasty, or at least I interpreted as nasty. And it got me thinking about how there really needed to be a safe place online, where a kid could go and find out what are the books that were out there. And when I started, there were maybe 30 books total that were inclusive of LGBTQ characters and themes for kids and teens. And what's happened over the years is that by keeping this curated safe space, where I'm not vetting all the books, but I'm making sure that no nastiness is happening on the site. We have over 500 books now in many, many categories. And it's been really exciting to see that sort of explosion of content. And yet, it's that sort of similar problem again. Like now, suddenly, there's so much content, how do you make your way through it? How do you find the things that you want? So the idea behind it was to post about the books, what's queer about the books, and then let readers add their own reviews. There hasn't been a lot of review, there's just too many places for people to leave reviews these days. So I don't see a lot of that. But I also didn't want to make it, you know, "Lee's favorite book site" because I think that that has a limited value, I thought that there was more value in it being a site that felt really comprehensive. And that's what I aim for. And then it just became a place where I could talk about the stuff that I really care about, that I want queer and allied teens to know about. And over the years, what I've discovered is that the readership is split into thirds. There's about a third, queer teens and queer and allied teens on it. There about a third of librarians and teachers and people that work with LGBTQ teens. And then there's a whole bunch of adults that are sort of reading the books for themselves and sort of healing their inner teen. And I think that there is a healing that happens. Every time I read a queer book that has a happy or even a hopeful ending, there's a healing that happens. And I think maybe that's part of why romance as a genre is so popular. I know Will was saying in a previous episode that people get on his case for like ruining the ending, but it's all romance, you know it's going to be a good ending. And I think maybe that's why people turn to it. So I know how empowering it is for me when I read something where I see a reflection of myself, and it's a positive thing. Because when I was growing up, there was nothing to read, nothing positive. The only queer characters were like evil pedophile villains, it wasn't particularly helpful. Jeff: Yeah, that's, unfortunately, the case in the history that you and I have from that era when we were growing up. In the decade-plus that you've been running the site, other than just more YA, how have you seen it all evolve? Lee: There's more, and there's better and there's deeper, and there's less preachy and there's room for it all. It's funny, there was a kind of push a few years back for...well, maybe we're beyond the coming out story. And I kind of got my dander up a little bit on that. And I felt like, "Well, we're never going to be beyond the first love story when it's, you know, a straight romance. So, Andrew Solomon has this great book that he wrote called "Far From the Tree" and it's a nonfiction piece. And he talks about how, you know, when your identity is...where you're the apple that does fall far from the tree, or falls from the tree and rolls across the, you know, down the hill and across the orchard, when you're queer, most likely your parents were not. And so you have this moment where you have to find your sense of community outside of the family that you grew up in. A lot of other identities, you share that. Like, usually, like me, I was raised Jewish and so I would, you know, my parents were Jewish. So I sort of shared that identity. For all of our identities, we sort of are either sort of close to the tree or far from the tree. And when you're far from the tree, there's more work involved. So coming out, I think is going to continue to be this universal thing. Because just like, you know, my daughter has two dads, but she's straight. So in a funny way, she's going to have to, you know, she had a bit of a coming out where she had to tell us, sort of, you know, abashed, hoping that we'd be okay with it, that she was straight. And we had a good laugh about it. Because it's not that big a deal for us. We just want her to be her authentic self and to be happy. So we do want to have coming out books, and we also want to have books where being gay, like your character Winger, Theo, where it's the least interesting thing about him. I loved when you said that in your interview. Because yeah, we want those stories, too. It's like in acting, right? In improv, the rule is yes/and. So we want these books, and we want those books. We want the fantasy, we want the romance, we want the science fiction, we want all of it because truly, if you look at the numbers of books that are published - traditionally there about 5,000 books published a year for kids and teens. And then, if you look at the world of self-publishing, let's say that 5,000 are doing it really beautifully. And the books are indistinguishable with the quality of that from traditional publishing. That's 10,000 books a year, a year. And you have all those years going back too. So what we want is the opportunity to sort of have all of those books and right now we still only have like 500. So we have a long way to go. We need lots more books, we need lots more voices, we need people writing their own voices, stories, we need more diversity included in everybody's stories because truly, you're not going to have a classroom today that doesn't include someone that's LGBTQ, we need it all. Jeff: That's very true. Given that you had the blog, did you always see yourself eventually writing the YA novel that you did? Or did that just kind of manifest itself because you have the story to tell? Lee: I've always been a writer. I've written...I remember one summer when I was like between 9th and 10th Grade in high school, I was like, "I'm going to write a novel." I sometimes think of those poor characters still trapped in the broken space station that was orbiting the Earth. And I'm like, "Oh man, I have to do something with that someday." I don't think I will. I've always written. I think that for the last 14 years, I've really focused on writing for kids and teens. I also write picture books and middle grade. And when I found out this thing about Lincoln and Speed, it really inspired me to focus on writing that as a novel. I think that the blog has been a way to have my voice heard in a more direct way, and not wait for somebody to tap me on the shoulder and say, "Okay Lee, we're ready for what you have to share." So that's been really empowering. I remember, when I started the blog, there were very few people reading it, and I would get all excited, I'd be like, and I'd tell my husband, "Hey, 15, people went to my blog today." And I was so, so excited. And now, all these years later, we passed 2.6 million page loads. I get between, you know, 15,000 to 25,000 page views a month. It's remarkable, and humbling, and also a really cool responsibility to continue to maintain this safe place. And at the same time, I'm trying to keep writing and work on the new stuff, which has been really a good thing, because balancing the day job and the blogging, there's a lot but I have stories I want to tell. And I'm going to keep trying to tell them. Jeff: Good. Yeah, keep putting it out there. Because we always need more, to be sure. For people who haven't seen the site yet, and we're certainly going to link to it in the show notes. It has an amazing hero image across the top of the superhero. Where did that come from? And where did the name come from? For folks who might question the name too, because I have a pretty good idea where the name came from. But let's hear it from you. Lee: Sure. So "I'm Here. I'm Queer. What the Hell do I read?" is a play on words of something we chanted in Act Up in the '80s and '90s. The chant was "We're here. We're queer. Get used to it." And I thought, well, my issue is a little more "What the hell do I read?" Because I felt so starved for any books that included somebody like me. I mean, you know, I grew up and I really and truly thought I was the only person in the world that felt the way I felt about other guys. And which was super ironic, because I have an older brother, who's five and a half years older, and he's gay too, but we never spoke about it. We are the children of immigrants and when my parents came from Israel, they sort of brought all their homophobia with them. And the American culture at the time was super homophobic, especially where we lived outside Philadelphia. It was not a safe place. And it's so amazing to think that you can grow up and feel like you're the only person and everything I read, I was obsessed with the series by Anne McCaffrey called the Dragonrider series. And there was this super between the lines, sort of thematic thing that you could maybe interpret that there was gay stuff happening in that world, but you had to really stretch for it. And looking back, I think, well, maybe that's why I was so obsessed with that book, with that series, because there was some faint, not even mirror reflection, but like the gleam of a tarnished piece of silverware. I was like, "Wait, wait, maybe that's me." So that's where "I'm Here. I'm Queer. What the Hell do I read?" came from. The image happened a few years later. I had been running the site for about two years, it had been doing really well. And I realized I wanted to have a customized image. And yet, it's a pretty wordy title. So I realized I needed an image that didn't have any additional words to it. So I contacted someone I knew, an artist I knew, Jim DeBartolo. And, I said, "Look, I need an image that says empowerment." And he came up with this sort of superhero moment of like ripping the denim shirt off. And there's this sort of T-shirt underneath with the sort of superhero logo, which is the website, which is leewind.org. And it was funny. We tried to play with the sort of partial face that you see, we tried to, you know, could we make it a person of color? Could we do some things with you, know, the physique? But ultimately, it was sort of an avatar of me, and it took me years to admit it that's sort of what of course it is, it's an avatar of me, but I don't have that good a jawline. But at least in my mind, I think that it's been this sort of symbol of empowerment. And that's really what I hope that people get from visiting the site, from reading anything I write. I want them to feel empowered. Jeff: I like that. That's a great story behind that. Lee: Thanks. Jeff: So relying on your...I'm going to call it a YA expertise because of the site that you run. What are three or four titles of current YA that you would recommend our audience to take a stab at? Lee: Sure. So I have to start with "Carry On" by Rainbow Rowell. I know it's not super recent. But this is the gay Harry Potter book that I wanted so badly. And I was so frustrated that JK Rowling didn't include Dumbledore as being gay in the canon. It sort of was outside the books that that revelation happened and you can go back and sort of, you know, read subtexts and stuff. But I really was hoping that there would be some sort of, you know, on the page, queer love or something, and it didn't happen, there was really nothing. And, you know, Rainbow Rowell, she wrote two books, one about the girl that writes the fan fiction, which is called "Fangirl", which is really good. And then there was this book, which was the fan fiction, that ended up being a huge success on its own, called "Carry On". And I don't want to say too much, but it is absolutely brilliant. And if you are queer, or love queer stories, and you had any connection to Harry Potter, and that sort of world of magic, you've got to go read this. It's just wonderful. Jeff: Excellent. Her books have been on my TBR forever. And I actually need to take the leap and read them. Lee: Read this one first. It's just you will be so happy you did. Jeff: So you mentioned the nonfiction that you've just signed the contract on and other stuff noodling around in your head... anything else you want to shout out that's coming up soon for you? Lee: So there are a bunch of things percolating. But nothing has come to full boil yet. So I will let you all know when it does. Jeff: That is fair. I can't wait to hear what they are. Because I think that, yeah, having read the one book from you, I'm looking forward to reading so much more. So where can people keep up with you? There's leewind.org as we talked about, which is the "I'm Here. I'm Queer. What the Hell do I read?" site. Anyplace else people should be looking for updates? Lee: Yeah. I mean, I'm playing around with Instagram. I'm trying to do this thing. I had the idea that we could do a #queerhistoryiseverywhere. And I wanted people to upload photos of Abraham Lincoln or the word Lincoln wherever they saw it and just start posting it on Instagram. It hasn't exactly caught on yet. But I still like that idea. Jeff: Maybe our podcast listeners will play along with that. Lee: Oh, yeah, that would be really fun. And also, I mean, as, you know, more queer history happens. I was speaking at the Bay Area Book Festival recently and someone came up after my panel and they said, "Did you know that Bābur from the Bāburnāma when he was a teen he was in love with another boy?" I was like, "Really?" Totally, I have sitting on my desk right next to me right now the "Bāburnāma" and indeed, when he was 18, he was in love with this other boy. And it's so exciting to find out this stuff. So I feel like because it's been hidden, the more we can crowdsource this information and share it and then all amplify each other. I think it's very, very exciting. Jeff: Very cool. So we will link to all that stuff, the books we talked about - everything else - in our show notes. And Lee, I'm so glad we got the opportunity to talk, spread the word a little bit more about this book and the website and thank you for all you're doing to get more out there about YA literature too. Lee: Thank you, Jeff. I really want to say thank you to you and to Will. I'm really a fan of the podcast and getting to be on it as a real thrill. So thanks.
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)
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.
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
Toby Mathis and Jeff Webb of Anderson Advisors are here to answer all sorts of tax-related questions that focus on everything from applications to forms and QuickBooks. Do you have a tax question? Submit it to Webinar@andersonadvisors.com. Highlights/Topics: Will income earned by lending money to real estate investors reduce Social Security benefits or increase taxes on them? Income vs. earned income; until full retirement age, benefits are reduced; when full retirement age, it doesn't matter what you make How do I get the 20% deduction from Trump's Tax Plan? The 199A Deduction is a 20% deduction on qualified business income, but you need a pass-through entity; QBI 20% deduction vs. 20% of taxable income are compared, and you get whichever is less When you make a contribution out of your own account to your LLC as a member, are you taxed on contributions? No. It’s a contribution to an entity that becomes your capital and money you can take back out tax-free, if you haven't used it to recognize losses What is the best business structure recommended against asset, structure, and personal protection? With any passive activity, use a passive entity - LLC taxed as a partnership/limited partner; whomever has control of entity decides what's distributed What is the best way to set up QuickBooks when I have a Wyoming Holding LLC and several other LLCs holding real estate in other states? Create one set of books with Wyoming LLC as the primary; do a classified income statement for other states What are the tax forms for 501c3? Use Form 1023 to apply to be an exempt charitable organization; yearly recording forms include 990-N If someone has rentals in their self-directed IRA, how are they impacted as UBIT - does it make a difference on the number/dollar amount? No UBIT, if it's a rental; UBIT is for an active business inside an IRA; passive income is almost always exempt Can I have recourse debt in a 401K or IRA? Can I have non-recourse debt? You can’t have recourse debt, but you can have recourse debt What are my options to re-distribute funds from one LLC in several entities to separate investments? You can always move it from one to another with no tax implication Can I write off costs for rehabbing out of the country? Yes. Worldwide profits; if it's income-producing property, you report it to the United States I lent money to a real estate flipper. She gave me a promissory note, but it wasn’t recorded with the deed of trust. Now, she is in default. Can I foreclose? Document it because you can’t foreclose until you file your secured interest Is there anything I can do to reduce my taxable income? Yes. There are lots of things you can do - make contributions to qualified retirement plans, charities, and C Corp I purchased a new computer that cost less than $2,500. Is that a straight expense in the current tax year or some weird depreciation thing? Section 179 deduction; you can buy up to $1 million and write it all off For all questions/answers discussed, sign up to be a Platinum member to view the replay! Resources U.S. Social Security Administration Trump’s Tax Plan 199A Deduction QuickBooks Tax-Wise Workshop 501c3 Unrelated Business Income Tax (UBIT) 990-T 990-N Section 179 Deduction 1244 Election Kiddie Tax Anderson Advisors Tax and Asset Prevention Event Toby Mathis Anderson Advisors Full Episode Transcript: Toby: Hey, guys. This is Toby Mathis with Jeff Webb again. Jeff: Good afternoon. Toby: If you don't know, Jeff Webb's a tax manager here, and I am one of the partners. I'm not an accountant but I'm an attorney. Jeff is actually a CPA. This is Tax Tuesdays. If you've never been on Tax Tuesdays before, all we do is answer all sorts of questions. Let me see here whether I've got the right question field up. Look at that. We've got a bunch of people asking questions. Let's see. We'll get to all your questions, making sure you can hear us in the question and answer part. Just say, "Yes, I can hear you loud and clear," to make sure that we're getting through to everybody. If you do that, then we appreciate it. There we go. I'm getting a whole bunch of "loud and clear", "loud and clear", "loud and clear". All right, if you don't know the format if Tax Tuesday, it goes like this. We answer a whole bunch of questions. We answer the questions that people ask via the email that I'll be giving you at the end of the webinar, and we grab a whole bunch of them, and we just start answering them. If we can't answer the question or the question that you ask is too complicated, too specific, too long, then I grab it and kick it off to a staff or we answer it the following week, depending on how cool a question it is. That being kind of the overview, this is where we're at. We're going to go through these and we're going to make sure that we're answering all the questions. Let's see if I can actually make these slides advance. Look at that. That's weird. I didn't even know what that W there is. It's kind of cool. "Will the income I earned by lending my money to my real estate investors reduced my social security benefits or increased my taxes on them?" That's an interesting question. There's, "How do I get a 20% deduction?" I'm picking these literally from people's emails so don't yell at me for the typos. "When you make a contribution funds to your own account to your LLC as a member, are you taxed on contributions that you contribute to an LLC?" "What is the best structure–" and that is the weirdest thing I've ever had. "What is the best structure recommended against asset, structure and personal protection for a Multi-Family Home Investor acquiring and holding rental properties, especially if working–" and I'm going to go through each one of these. "What is the best way to set up QuickBooks when I have a Wyoming Holding LLC and several other LLCs holding real estate in various other states?" Those are our opening questions. We have a few more. We're going to go through a ton of them, and I'm already getting a bunch of questions on the Q&A portion. We will get to those but, first, we're going to knock these ones out. The first question: "Will the income earned by lending money to real estate investors reduce my Social Security benefits or increase my taxes on them?" The first thing is there's the benefit itself. In this particular question, I looked it up and I believe there were 61, so they're receiving Social Security benefits before they reach the full retirement age. Full retirement age varies between 65 and 67. The reason this is important is because, once you reach that age, it doesn't matter what you make. Until you reach that age, you will have your benefits reduced on what you're receiving. When you're pulling out Social Security early, 50 cents on the dollar once you get over $17,080.Of course, it's indexed for inflation, but it's a little bit over $17,000. I think this year it's $17,080 or something like that. What that means is, if you are lending money, then that would be counted as income. However, if you're under the full retirement age, they only count earned income. The question here is, "Until you're at full retirement age, will the income earned by lending money to real estate investors reduce my Social Security benefits or increase my taxes on them?" The answer is a big, resounding, "No." This will not hurt you in any way. Once you hit full retirement age, now we have to be worried about how much of your social security becomes taxable. When they look at your tax ability of the benefit, now we're looking at all sorts of income, everything that you make, and it's going to push it up. That's the one where it's not that you reduce the benefit but it becomes taxable. Jeff: Fairly quickly, additional income starts making your Social Security benefits taxable. They're never going to be more than–85% of your benefits are never going to be taxable. I'm saying this totally backwards. Toby: What it means is that the most they're ever going to tax your benefits is 85% of them. If you're getting $20,000 of benefit, the most you'll ever pay tax on is $17,000. You'll still get $3,000, tax-free. The sad part is you didn't get, really, a deduction when they took it out the first place. That's the old double tax that you hear about with Social Security. Anything else you want jumped into? This is kind of stuff. It makes your brain go numb so you're doing it right. You're actually asking good questions. Jeff: Just the matter of when you should take Social Security is such a huge question. Toby: Because you can start taking it. When is the earliest, is it 64? Jeff: I'm going to say 62, but maybe it's earlier depending on their age. Toby: It does depend on their age. There is a before-a-threshold and after-a-threshold. Now, I forget what the threshold is. What you do is you go to the Social Security Administration and you run your scenarios and they'll give them all to you, or you can contact us. We have folks we could send you out to that have software because it is complicated. Depending on what month you were born in and all that stuff, how many days–all of this gets factored in as to what's the earliest you could start receiving benefits. Once you start receiving the benefit, they let you receive that benefit only so long as your income is low and it's your earned income. If you're trying to get the benefit when you're 62 and you make too much money, you're going to lose a bunch of the benefits. If you start making–if you're 62, start pulling out the benefit and you have passive income, not that big of a deal; it doesn't reduce it so that's really cool. Enough of that. It makes my head hurt, Social Security. Do not rely on Social Security. There, I said it. Yeah, Social Security is one of those things that, when it was set up, the average life expectancy of people on Social Security was two years. It was really there to catch you if you're really old and didn't have any other benefits. Now, we use it almost like it's a retirement plan that's not what it was intended for. That's why it doesn't work to do it. Here's the next one. "How do I get the 20% deduction from Trump's Tax Plan?" First off, it's not Trump's Tax Plan. It's the Tax Cut and Jobs Act and it was passed by our wonderful Congress because, technically–though, they seem to forget this–Presidents don't write laws. Now that we got that out of the way, they did put this thing called a 199A Deduction, which is a 20% deduction on qualified business income from pass-through entities. Follow me here. The first thing we need to have–and I'm going to write these up–is we need to have a pass-through entity, and you can be an LLC taxed as–this is a 1065 that's partnership, a sole proprietor or as an S Corp. Those are your choices. Technically, it could also be a trust. Then, you look at other entities, S Corps and just flat out partnerships, including limited partnerships, all that fun stuff. It's passing through; it doesn't pay its own tax. Then, you need qualified business income. I'm just going to call it QBI, which just means income. Generally speaking, it's active income, but they also include real estate, if you are making money on real estate in which you participate in some fashion. The only type of real estate that's not included as far as we can tell–because they're still giving us regulations on it, but the proposed regulations make clear that real estate, rental real estates included, is if you have a commercial building and triple-net leases that you're giving out where you're not really taking on much of the risk, then they're not going to let you have the qualified business income. Then, they compare that qualified business income 20% deduction versus 20% of your taxable income, whichever is less. Why is this important? Because if I'm a sole proprietor–let's say I have $50,000 that I'm making–that I would get a $10,000-deduction under the QBI. Let's say that I take and contribute into my retirement plan–a husband-and-wife sole proprietor is still the same thing, and they both put in–what's a good number–let's just say $10,000. Then, my taxable income is actually $40,000 because I rode off–I made tax-deductible contributions into my IRA of $10,000 so I would take the lesser of that. Then, they do this wonderful thing, is they then say, "Well, if it's a special service company, we're going to put a cap on how much QBI you can actually make." It's not really QBI; it's actually your taxable income, and they say, "We'll only let you ride off so long as your taxable income is below a threshold." If you're single, that threshold is $157,500, and there's a phase-out for the next $50,000. To make your head spin, it goes from $157,000 to $207,500. That's the easiest way to look at it. If you're married, filing jointly, those numbers are $315,000 to $415,000. Jeff: What's an example of a special service? Toby: Special services are something that it is you and your skill that makes the money, and they use–it's going to be doctors, lawyers, accountants, engineers, real estate agents who are solo, somebody who–it's their skill so like a carpenter who doesn't have a bunch of staff. That's going to be a special service. If you get above those thresholds, you are done. Somebody's asking a question which is pretty interesting. A single-member LLC counts. You have a flow under you so that's when you're sole proprietor or just going under your tax return that's passed through entity so you're fine. The interesting here is that you can control your taxable income. Even on those thresholds–and when we teach this in the class, we actually go through a learning chart where we say, "If this, then this. If this, then this." If you're a special service, we just need to make sure that we can control your income, and the way you control your income is by splitting it with tax-free, tax-exempt or separately-taxable entities. Let me give you an example. If I have a C Corp and it makes a bunch of money, great, that's not income to me. I don't want to pay myself a whole bunch of money and make whatever my other business is that is or where I'm going to meet the threshold taxable because I'm losing that 20% deduction. Let's say I have $200,000 coming in. As an individual, I can get some donations and deductions into a retirement plan and I get myself underneath that $157,000 and I have another $200,000 in C Corp that I pay myself. If I leave the $157,000 as is and I don't take any money out of the C Corp, I'm going to get a 30-something thousand dollar deduction. It's just going to come off the top. It's a 20% deduction so almost like I spent. If I took the money out of the C Corp–and, by the way, that C Corp is a flat 21% tax rate now so it's going to pay 21% so it's not horrific. If I paid myself that money, I push my taxable income over the threshold, now I get 0 deduction on my qualified business income. That's why it's important. If it is not a special service, then those thresholds trigger something else. It takes us to an area where we can write off up to 50% of the W2 income or 25% of the W2 income for the business plus 2.5% of the assets. Jeff: No, you're right. I'm just jumping ahead of you. Toby: Yeah, so what we're looking at, then, is you better have a regular business that actually has salaries. If you, for example, as a sole proprietor, single, are making–what would be a good example–$200,000 and you're over the threshold, you're phasing out, you'd have to go to the second test. You're over the 157 and the second test is now pushing you at 50% of W2 wages, and you have zero so your deduction is going to be zero. You're going to get literally nothing. You might get a few dollars because you're not quite at the 207, which is the top line of the actual phase-out so you'd be phased out about 90% plus of the benefit. Now, let's say you converted that sole proprietorship to an S Corp and, instead, you paid yourself a salary, so same situation, $200,000. Let's say I paid you $75,000 of salary. Then, the QBI or the monies that's flowing through is actually the net income and net profit, so you'd subtract the 75 off. It would be $125,000. You compare 20% of that number, which I should grab the calculator, whatever that number is. Jeff: It'd be 25,000. Toby: Yeah, 25,000, and we would compare it to one-half of the W2 income, which would be 37,500. You'd get the lesser of the two. You'd get a $25,000-deduction just because of the type of entity. That's the one I have to do. Somebody just said, "I have almost 300K in real estate and other income. Is there anything I can do?" A single person? Yeah, there's something you can do because, remember, it depends on whether you're special service and then it depends on the business, and there's one last thing: It always comes down to your taxable income. "What other ways can I use to control my taxable income?" The most obvious is I split it with a C Corp, I give it to charity–and it could be my charity–or I deduct it by putting it into a tax-deferred retirement plan. For example, same situation, I'll use the $200,000 and they do a 401K. They put a husband and wife each–they're under 50. They each contribute 18,500–or, actually, the example I used was a single person so I would have to say I put 18,500 and in, and they get a 25% deduction on the 75,000. They would put in–again, I'm using crazy numbers so what would that be? About $18,750 or whatever that is–around under $19,000. I can put, in essence, about $37,000 right into the 401K, and that reduces my taxable income. The taxable income goes from 200 down to almost the threshold, and now I don't have to worry about it. It makes my life so much easier. I'm just going to get a nice big, fat deduction and I'm happy as a clam. That's how this stuff works, but if you don't do it before the year ends, you're toast. This is going to be my–this is why you need to have some sort of somebody doing tax planning. How do I get the 20% deduction from the new tax act? Very deliberately. You make sure that you have the income flowing under your return and then you make sure that, if there's a disqualifying factor that would cause you to lose it, that you look and say, "What's better? To just walk away from it and not worry about it or would I be better to take a couple of actions to allow myself to take advantage of the deduction?" It's a freebie, guys. If I make $20,000 in real estate, that rental real estate–that's my net after all my depreciation–I get a $4,000-deduction. I'm only recognizing 16,000 under this taxable income so that's a nice little benefit especially if I'm a high-income person so that's what I'd be looking at. Jeff, do you want to do this one because I'm […] barding the answers again? Jeff: No, that's alright. "When you make a contribution out of your own account to your LLC as a member, are you taxed on contributions that you contribute to the LLC?" No, actually, you're not. That is a contribution to an entity that becomes your capital, your owner's equity–we can call it a lot of things–your owner's capital in that company. That's actually money that you can take back out also tax-free assuming that you haven't used it up to recognize losses or maybe other things like that. Toby: We get that a lot. I'll give you a real-life example. Some guys were doing a syndication on apartment buildings and they were telling people, "Hey, we're going to return your capital out of the profits and you're not going to have to pay any tax on the money that you receive up to your investment." I said, "Hey, that's not really the case." Here's how it works: I can always get back my contribution, and it's tax-neutral; it means nothing. If the company makes zero, no profit, it can always give me back my money and I pay no tax, but if the company makes money, I'm taxed on my portion of that gain no matter what even if they're giving me extra. I was like–what they were doing was they were saying, "Here's a little thing. We'll make some profit. We'll just give you your money back. You want to pay tax on it?" I was like, "No, that's not how it works. You actually have to pay tax on the profit in proportion to your ownership, and it's a little bit funky." Jeff: This is a case that, sometimes, we see where a client will tell us, "I had deposits of $100,000 into my business," and what they fail to tell us is that 50,000 of it was their own money. We want to make sure that we're able to differentiate what the owners are putting into the company versus what income they're making in the company. Toby: There's a couple of questions. Somebody says, "My head is spinning." We do record this. If you're platinum, you're going to get a recording of it in your little platinum area. Somebody asks, "Is this pre-recorded?" No, it's not. We're doing it live but I'm answering the questions that people have emailed me first and, yes, we have about 50 questions that are in the queue that we're going to go through here in a second. Jeff: We don't have a three-second delay or anything? Toby: No, I don't think so. I could give you a 10-second delay. All right, "What is the best business structure recommended against asset, structure and personal protection?" I don't know what that means. I'm going to assume they mean to protect the business–for a Multi-Family Home Investor acquiring and holding rental properties, especially if working as a team member with other investors? Here's what I'm going to say: Anytime you have a passive activity–that is, when you buy the property or the cash flow and the appreciation–you're going to want to use a passive entity, meaning an LLC taxed as a partnership or a limited partner. Don't do anything else. That's it. There's maybe some really weird exceptions but I'm going to say, 99% of the time, you're going to end up using an LLC, and it's either going to be disregarded even if you have other people in or it's going to be a partnership. If anybody does anything differently, they're doing some weird stuff. If you have other investors, then it depends on your relationship with those investors. I'm not going to going to get into securities, Reg Ds and all that but, generally speaking, you're going to have it taxed as a partnership, but the most important consideration is always going to be control, who has control of that entity, because that's who decides what's distributed. That partnership agreement or the operating agreement of the LLC is really going to be important. You do not want to do this stuff half-arsed. You want to make sure that you're actually really addressing this stuff. At Anderson, we tend to be very protective of the manager, meaning we want you to have control. If it's your project, we don't want people to force you to do stuff and, on the flip side, if you're investing and you're a client, we're always going to say, "You don't want to be forced to kick in more capital against your will." Those are the things we always look at. Where does that one go? Here we go. "What is the best way to set up QuickBooks when I have a Wyoming–" and this is going to be so you, Jeff, because Jeff loves QuickBooks. "What is the best way to set up QuickBooks when I have a Wyoming Holding LLC with several other LLCs holding real estate in various other states?" I'm going to draw this. There's my Wyoming LLC. It's either going to be a 1065 or disregarded, and it holds all these cute little LLCs in other states. Let's say this is Texas LLC, Washington LLC, Nevada LLC, Georgia LLC, and they're all going to flow up to that Wyoming. I want to keep my books straight because, if you know QuickBooks, they will sell you QuickBooks for this one, this one and this one. You'll end up with four sets of QuickBooks and you'll drive yourself crazy. What do you do, Jeff? Jeff: Here's what we like to do: We like to create one set of books with the Wyoming LLC at the top being the primary set of books. Then, what we do is what we call a classified income statement where each of these four LLCs below the Georgia, Nevada, Washington and Texas where they're all kind of their own set of books within your Wyoming LLC books. All this income is going to flow from those bottom four up to the top one anyway and, while we need to keep the entities separate so we can report them that way, ultimately, what we're reporting is what's coming through the whole kit and caboodle. Toby: Yeah, we only need to worry about setting up QuickBooks for this guy right here, and then we set up these guys as classes. All that means is we have one set of books. Jeff: Yeah. You can still pull an income statement for your Georgia LLC or your Texas LLC to see what's just in that but, all in all, you still have one set of books. It makes it easier and you don't have all these inter-company transfers that you have to track. Toby: Oh my god. I'll tell you, we're horrible on that. He's giving me the look. See, here's the problem, is if you have different companies with different sets of books, you've got to close out the previous sets of books and then open up the new company. It's a process and it takes a few minutes and it's really annoying when you're trying to enter stuff into it. It's going to save you a whole bunch of time to use one set. Jeff: Yeah, then you don't run into things like, "Well, I transferred money from Georgia, the taxes that I did it, I record it in both companies." When you record them on one, you end up re-recording it in both. Toby: Yeah, and there's some fun stuff. Some of them just ask for a basic QuickBooks question, jump in the line. It's hard to set up classes in QuickBooks, not horribly, but if you don’t want to learn–QuickBooks is one of those things where you're going to spend some time with it. You just have a bookkeeper do it. Anderson does that if you want. All right. If you have questions–you guys, I know you do because there's a ton of them already in the little queue here. Here's how it works: If you want to ask a more detailed question, if you have a question that you didn't hear answered on the webinar, you can just email them on in to webinar@andersonadvisors.com, and, that way, we can put it in that queue and we can answer it just like we just did. We're going to break those out. Those will be separate little videos, each one of those, so that you get your answer. Somebody was saying, "My head was spinning about 199A." You can go back and listen to that. Better yet, you can come to some of our other webinars or come, actually, to the Tax-Wise Workshop and we go through this stuff. Spend some time with us. If you invest a little bit of time in taxes, it will pay off in spades. Other questions–some people just answered this stuff. "Can you go over the tax forms for 501c3? Jeff: There's a couple of forms for the 501c3. To apply the BF 5O1c3, there's what's called the Form 1023. It's the application to be an exempt charitable organization. Then, there's several different yearly recording forms. The 990 is the primary one where you report, among other things, what your income was, what your balance sheet looks like, your plan, your purpose, who you've dealt with. What were you going to say? Come on. Toby: Basically, if you're making less than $50,000 in your 501c3, you're doing a 990 post-note card. You're just doing a real basic here. Literally, it looks like a postcard. Jeff: They don't do that anymore. Toby: I thought they're still– Jeff: All these old people still call it postcards, but it's a… Toby: They do that in the 10… Jeff: But it's a 990N and it's filed electronically. Toby: Yeah, I know but it's the same thing. Jeff: It's still close. Okay. Toby: It's a postcard. Oh, my god. Yeah, you do it electronically now but it's really simple. You go above that, then you're going to be filing a little more detail. You get about 250, you're filing very detailed. Never do it yourself. Just hire an accountant to do it, and those guys–we do them. They're not horrifically complicated unless you have a huge void that everybody's taking money. You go American Red Cross, you can go look at the actual tax forms that everybody files because they're all public record. You can go in there and take a look at anybody and see just how complicated it is. What you'll realize is that the more the stuff they're doing, the more complicated it gets, and not doing ton it is pretty simple. We have ones that are $5 million non-profits and it's a few pages. Then, you have ones that are $1 million but they've got everybody and their mother with their hands in the thing, and you're doing a lot of reporting. That one might be more complicated. If you're a church, you don't file anything. If you're religious and you're a religious organization, you don't file anything; you file zero tax forms. Jeff: When you have an accountant do these 990s for you, they're going to ask you a lot of questions because there's a lot of questions on the form that they don't have the answer to, basically about what it is the non-profit does and things like that. Toby: All right. "If someone has rentals in their–" basically, again, if you have those tax forms, this is one other thing, is that's the tax compliance on an annual basis. If you're setting up a 501c3, you are doing–more than likely, 501c3 is an application called a 1023. If you're doing a 501C6 or some of these others, that's a 1024. Jeff: Wow, I'm impressed. Toby: Yeah, sorry. It's stuck in my head. Those are the applications for exempt status. Your business, your non-profit, is in existence and it's considered exempt from Day 1. Even though you haven't gotten your exemption approved, you actually have 28 or 29 months to get approved, and it relates back to the day that you started. You can actually do a 501c3 and be up and running in a matter of weeks if you want to. All right, from Lisa: "If someone has rentals in their self-directed IRA, how is it impacted as far as unrelated business income tax (UBIT) and does it make a difference on the number or dollar amount?" You want to do this one or would you like me to? Jeff: Why don't you do this one? Toby: All right. Self-directed IRA and it has real estate? You have no UBIT if it's just rental. That's not unrelated business income tax. Unrelated business income tax is when you're doing an active business inside an exempt organization, inside an IRA, or church, or something else, and you're running a mini-mart then they tax you on it because it's unrelated business income so not related to your exempt purpose so they tax you on it. Passive income's always going to be–I shouldn't say "always"; it's almost always exempt. I guess there's possible–if you have some royalty stuff, it's possible, if you're advertising, that the exempt organization tax, but for your IRA for rentals, don't worry about it. Here's what you worry about when you're doing an IRA with rentals: It's usually the case–this is what we've seen–is that people will oftentimes want to lever that real estate. In an IRA, you have something called–I'm just going to blank on it–unrelated debt financed income. There we go, UDFI. Unrelated debt financed income means–or just call it debt finance income–the portion of the profits that are coming from the debt. If I have a piece of property, I have a 50% loan on it, then 50% of its income is going to be taxable to the IRA. It's not allowed to have that type of loan and not pay tax on it. A 401K is allowed to have that type of loan, and it doesn't pay tax on it. It's one of those weird things where you're like, "Hey, should I be an IRA or 401K?" More often than not in our world, you're going to want to be the 401K. It has different rules, and one of the big ones is the ability to use debt. Now, here's something for you. I think I had poll questions on this. This is fun. I'm going to send a poll out to see whether you guys are listening. You guys can answer this, and what it is, "Can I have recourse debt in a 401K or IRA?" Let's see about that. Isn't this kind of cool? Jeff: It is cool. Toby: We're going to see whether or not you can have recourse debt in a 401K or IRA. For those of you who don't know what recourse debt, recourse means, "I can go after you. I have recourse, and I can go–" basically, a personal guarantee, personal guarantor. We got a lot of people voting. I will share the results with you once we're there. Jeff: What if Lisa is flipping instead of renting in an IRA? Toby: Then, we don't have any cases on it. Jeff: Great. Toby: What we always say is do five at a max. Here's the thing: If you disqualify an IRA, the whole thing's disqualified. What I want to do is if I'm flipping in a self-directed IRA, I want to make sure only that money is in that IRA so if I have a disqualifying event, it's only for that one little IRA. So, I may have two or three IRAs. Good news: People are listening. That's always good news. We have about–50% of you guys voted. I'm going to go ahead and close this thing in about a few seconds. Let's see. There, I closed it and now I'm going to share it with you. Do you want me to tell you the answer? You cannot have recourse debt. 36% of you guys just disqualified your plans, and you have a 10% penalty plus it's all taxable. Sorry to say that you just destroyed your plan, but you cannot have recourse. This is half the fun. What's the next question I could ask you? I could throw up another poll at you. Let's see. Get out of there. Let me see if I can do this. All right, what's the next one? Here's a better one: Now that you know you can't have recourse debt, I'm going to launch a new poll. "Can I have non-recourse debt in an IRA or 401K?" This is where accountants and tax lawyers have– Jeff: Disagreements? Toby: No, this is where it's so much fun. Are you kidding? Let's see. Somebody's saying, "No." What is non-recourse? Non-recourse means you can't hold the person responsible. There's no personal guarantor. You can only go after the property so the property is truly asset-based lending. There's nobody on the hook for that loan if it goes south. A typical non-recourse loan in a plan–this is kind of cheap because it's going to give you the answer–is they're going to look at the other plan assets and so they're going to secure the other plan assets. They're going to make sure that they're not over-leveraged. In other words, they're not going to give you a 99% loan to value; they're going to give you a 60% loan to value or 50% loan to value. We'll see if you guys still get the answer even though I just basically gave it to you. This is fun. I'm just going to stop this one and I'm going to share it because the numbers are pretty done. It looks like 86% of you said, "Yes." Can I have non-recourse debt? 86% of you are correct. You can have recourse debt. Here's the trick: In an IRA, that non-recourse debt creates debt finance income so you have to pay tax on the portion that you're making but it doesn't disqualify your plan. In a 401K, you do not pay the debt finance income, and some of you guys are not too pleased with me for that, but I'm getting giggles out of it. That's enough with polls. I could have polls all day long and we would have a lot of fun. Last one: "I hold some assets in LLC–"and, by the way, this is the last one from people that have shot it in but it says, "You don't pay tax until withdrawal, correct?" No, if you have debt finance income, you're paying it in the year in which the debt finance income–you actually file a 990 T. You actually have to report it. "I have some assets in an LLC that is a day-trading entity." You're brave. "If this generates sizable profits–" I just love traders. "What options are out there to re-distribute funds from one LLC in several entities to the separate investments?" You can always move–if it's yours, it's like–an LLC is a safe so I can always move it from one safe to another, no tax implication. This is one of the questions we had earlier. I can always put money in, take it out. Somebody was talking about an opportunity zone. The opportunity zone's awesome. It's where you take capital gains and invest them in the opportunity zone. It's actually called the growth opportunity zone, and you defer the tax on that income. The max amount you can defer that tax is until 2025 right now. Then, you get a portion of that as non-taxable. Then, the growth–if you leave it in the opportunity zone for 10 years, all that growth and the gains on the investment itself are tax-free, and that's pretty interesting. Growth opportunities, we'll be talking about that as they give us more information. Somebody says, "Can you take the poll down?" I thought I did. I'll make sure polls, hide. There we go. Sorry about that, guys. Everybody's telling me, "Flip off the poll." I'm flipping it off. I like your opportunity zone discussion, and think about a bank, and loan out funds to other LLCs you use. You could do that. Then, it's interest unless it's all you. In which case, you don't charge yourself interests. "I am told that funds in an LLC are much like funds in a savings account. I pay taxes on the gains my funds make, and funds can be withdrawn at any time." That is true as long as it's disregarded or taxed as a partnership. I want to make sure that we're very clear. LLCs that are partnerships are disregarded. Yes, you can do that. If it's an LLC taxed as a corporation or LLC taxes in S Corp, little bit different. An S Corp probably has a huge difference. Jeff: Yeah. You can even pull securities out–even if it's a partnership–pull securities out and put them somewhere else. Like what Toby's saying, if it's an S Corporation or corporation, if you pull securities out of a corporation, you have to recognize gain immediately. Toby: It sucks. Appreciated assets is considered wages, right? Use an example here. Jeff: We had a client who had a couple of $100,000 of securities in a corporation, wanted to move it somewhere else, and we tried to explain to him that if he pulls securities out that are now worth 250 and he's only got a basis of $100,000, he's going to have capital gains of $125,000 in that corporation. The corporation will pay gains and then, for you to take it out, that's got to come from somewhere else, so either a salary, roan repayments or dividends. It doesn't work out well. Toby: No Bueno. The other one is people that real estate in an S Corp and then they need to take it out to refile it or something. All that appreciation is wages. It's horrific and so we have oftentimes say, "Hey, if you're going to do this S Corp, it's cool." The capital gains still flow down to you; it's just that you can't take it out. You've got to leave it in there. Jeff: Can we re-running into that more and more where the banks are running to take it out of the LLCs and stuff? Toby: They got horribly hosed during the downturn of people doing weird stuff. What happened is I would do a financing in an entity. Say I'm the owner, and then I would sell Jeff my ownership and the entity and the bank had no idea that I'm no longer the guy that they were dealing with that they gave the loan to in their mind and had sold his interests. They had no idea. One day, Jeff comes back in and says, "By the way, I'm the owner of this LLC, not the guy that you loaned the money to." No Bueno. They don't like that. All right, we got a lot of questions to go through so if you have questions, you can always email them in. I'm going to start going out through these things, and we have questions from almost an hour ago. People were asking questions before we even started. "I did a cash-out refinance from my residence to invest in private lending or to buy rentals. California only allows 150,000 to deduct interest expense for residence." That's actually the new federal rule. "For the portion that is more than 750, can I deduct the interest as investment expense?" All right, so here's the rule–and, Jeff, I'm [...] barding, but I deal with this stuff all the time. Your new limit is–unless you owned your house prior to–during 27 and perhaps during the first quarter of 2018 if your loan was already in process before December 15th of 2017, don't try to remember this stuff; just know that if you're in that weird period, you may qualify, then you're up to a million, but it has to be for acquisition indebtedness. Acquisition indebtedness means, "I bought the house," or, "I improved the house." That's for the mortgage person to be deductible on your Schedule A, which is your itemized deduction. If you're using the money for something else, then it has to be deductible on that something else. For example, if I am buying rental real estate, then the interest–you'd be writing off the interest on your Schedule A, essentially, against the income from that rental real estate. You are no longer writing off your mortgage interest personally as the individual residing in it; you are now writing it off as part of an investment. Anything you wanted to add on that? Jeff: No. If we're talking about buying a piece of investment property like you're just going out and buying more land, hoping that it'll go up in value, then it would be considered investment interests and go back on Schedule A. Typically, we want to keep it–if it's in a business interest or rental property, something like that, we want to keep it there. Toby: Again, the Canadians have been dealing with this for a lot longer than us guys. You cannot write off interest if it's not for your home in Canada unless it was used for an investment. People actually have to go re-file their houses, they get all the cash they could, pay down their house, re-file it so they could show that they used it for an investment so they could actually write off the interest. I think it was called Scotts transactions. It's weird. Hey, I'm not Canadian. This is another question: "Say I deducted a newsletter subscription in 2017 but received a refund for it in 2018. Do I need to add this back as income in 2018 or no?" If you wrote it off and it means your basis is zero, give you the money back, what does that sound like? Jeff: Income. Toby: Income. It is income. At the same time, I see people saying, "Hey, what if I reimburse myself from my cell phone out of two companies?" Now, each reimbursement represents–I said, "Well, you can reimburse yourself up to your expense. Anything above that is income so it becomes taxable." Fun stuff. Yes, you would report it, but only–your cash basis tax first. You report it in the year that you received the money back. "You've saved me so much money. I call y'all my friends." I love that when I get stuff like that. That's not really a question but I'm going to repeat it because it's better than, "Flip off the poll." Not that I had too many of those, but I had a few. "Can I write off costs for rehabbing out of the country?" This sounds like something for Jeff. Can you write off? US taxes. Jeff: Yeah, you do have investment in another country. Toby: Worldwide profits, baby. Yes. Jeff: If it's income-producing property, you're going to be reporting that to the United States. Any expenses you have on that property will go towards that also. Toby: If you're rehabbing a property, it sounds like dealer activity and active business. I may be little interest–I probably want to be looking at structures in the Bahamas if that's where it is. I'd be looking at something that's taxable there so you don't get into treaties and all sorts of fun stuff. "Do I have to pay $800 off the top to the franchise tax board when we start our corporation?" Jeff: No, California has an exemption to corporations that are first year only. Toby: Yeah, and that $800–this is, if you like tax cases, there's Veritas 1, there's Veritas 2, there's Northwest Energetic Services, there's Bakersfield Mall, and they're all versus your friendly–what is it called? Not the franchise tax. No, it's whatever. I forget what they're called. Jeff: We know what it's called. Toby: Yeah. Anyway, I'll remember it as soon as I could. I'm trying to think about it, but they keep suing the Board of Equalization, the BoE. It's $800 and they say that's the minimum tax, but they say, really, it's a fee because if it was a tax, then it'd be an unconstitutional tax because it's not attached to the income. They keep trying to call it a fee. They lose and then they change it a little bit and they lose again. That's just an aside. California is kind of evil. "We live in Washington. We have a Nevada C Corp which fully owns a watch and LLC and employs the kids. What are the recommended strategies to optimize for college tuition?" Wow, so you're doing a great thing. You are going to run them through payroll. When you're applying for things like scholarships, if it's going to be based on income, you're going to show that income. You're going to show those returns, but those kids should–most of that income is going to probably be underneath the standard deduction. Right now, it's $12,000. They're going to pay zero and they're going to pay very little on any amount over that. Plus, if you're smart, you're putting some of that money in a Roth IRA and they're never going to pay tax on that. It's smart to do this with your kids. If I paid tuition out of my tax bracket, it's coming out of my highest tax bracket. If I'm in the highest tax bracket, that's 37%. If my kids pay for their tuition and are working for the company, and they have to do something, then they pay at a third tax bracket, which, quite often, is zero. I do this with my own daughter. Last year, I think we paid $500 in taxes total for the year when it cost me $8,000 if I was doing it, but she has to do something. She has to actually work for the company and do stuff for the company. Other stuff you could do to optimize is dump it into–defer it into a retirement plan. If you want to do a 401K, they can put the first 18,500 of their income and they can defer it. You're still reporting it. I'm not sure it'll have an impact on scholarships or not. I have not seen it have much of an impact, but that's what I'd be doing, is the benefits far outweigh anything with this on the scholarship side. It is huge. Here's one: "I lent money to a real estate flipper. She gave me a promissory note, but it was not recorded with the deed of trust. Now, she is in default. Can I foreclose?" When you loan money to a flipper with no deed of trust, that's called a gift. I'm just kidding. You need to make sure that you're documenting it. You cannot foreclose until you actually file your secured interest. You got to have it filed and then, yes, you can actually start foreclosure proceedings if you want, if they don't pay it. You definitely want to make sure that, when you're giving notes–there's something called "first in time, first in right". You want to make sure you know it's recorded and you have your deed of trust against that house. Otherwise, somebody else could go slap theirs on first. There's also places where they get priority. In Nevada, for example, the HoAs get super liens. They actually step in front of the primary lender. It sounds weird but it's true. You want to make sure that you're documenting your loan and covering yourself as best you can, make sure that you're getting a personal guarantee and, if they have any other assets, you may want to slap a lien on those, too. All right, "With a new company, there's quite a lot of expense reimbursements. Since I don't have a lot of revenue yet, I haven't paid it back. Is it okay to carry it over a year or should I go ahead and pay it back even though I'm still in the red?" Jeff, this sounds like you unless you're zoning out there. She has a new company, she has lots of expenses, she doesn't have any money that she's made yet, so should they pay it back, carry it forward? "Can I pay myself, reimburse myself in the future year?" The answer is yes, you could reimburse yourself whenever. The question really becomes, "Do I want to capture all my startup expenses in the first year?" Jeff: Yeah, I think you do. You want to capture as many expenses as possible even if you're not getting directly reimbursed right away. Toby: Yeah, you have two choices whenever you fund a company. You can fund it with your cash and then it's going to have a loss and it's going to carry that loss forward if it's a C Corp. If it's an S Corp, you can actually take that loss. I've contributed $20,000. That's my basis and it loses 20,000 and, technically, I'd have a $20,000-loss with an S Corp. Usually, we're seeing this in C Corps, and you just carry it is a payable and a receivable. It's payable to you, you would say, "Hey, it owes me some money. It's kind of like this." I always use Krispy Kreme in my examples. I go out for Anderson and I bring in 12 dozen Krispy Kreme for a meeting or something, and the others say, "Hey, I'll pay you back but we don't have the money right now." It doesn't mean that it goes away; it means that I'm sitting there, waiting for them to pay me back. If they pay me back in two years, all it means is they can't write that off as a deduction until they pay me back so they're not going to have a loss if I'm carrying it as an IOU. If I give them the money to buy the doughnuts and they buy the doughnuts, they get the loss right away even though they haven't returned my money to me. They could return that money to me at any time. For me, it's always going to be tax-neutral. "Do I need to be on payroll with my real estate income or can I just take distributions from my LLC?" This is regarding Trump's 20% deduction on the plan. If it's investment real estate, you never have to take a seller as long as it's rental real estate. If it's flipping and it's in an S Corp, then you would have to take some salary if you're taking distributions. I don’t want to twist it. This sounds like it's just an LLC with rental property. You do not have to take it. The 20% is for 2018 onwards. If they think that it has a sunset clause, the end of 2025. Is it the end of 2025 that it ends? Jeff: Yeah. Toby: Yeah, so 2025. Here's a really long one. Boy, this is a really long one. Let me see if I can condense this. "I have a Wyoming LLC that is the sole member of a second LLC that is disregarded entity. I funded the Wyoming with 8,500 and the Wyoming funded the other bookkeeping QuickBooks balance sheet shows an owner equity 100% of 16,500. This is offset a balance sheet with capital contribution. While this does end up with net equity of 85, it gives the impression of the equity, which is incorrect. Is there a different way of handling?" Do you see what they're doing? Jeff: This is what we call–anytime you have combined financials or tax returns, you're going to have a–you may have a payable from one to the other where you've lent money to the other company, but when you do the combined financial or tax return, this is what you call an eliminating entry. If you lent $8,500 to one, those two entries are going to offset each other and it's going to be zero on your tax return. Toby: He's looking at it and saying, "Hey, they took the eight that I put into the second and added it to the 8,500 that I put in the first," and it's only 8,500 and then 8 went to the second LLC. Jeff: Yeah, I think you just need to clarify that it was the same money that– Toby: We're doing it and we'll take a look at it. We'll grab that name and, when we can, I'll print this out. "Can SMLLC, single-member LLC, disregard an entity under an MMLLC, which is a multi-member LLC taxed as a partnership, be converted to a single, multi-member LLC taxed as if–" you guys are killing me, "And would the tax changes be implemented?" What you're really saying, Billy, is, "Can I spin off a single-member LLC, make it into a multi-member LLC and change it to an S Corp?" The answer is yes. We just have to make sure that we follow the S Corp rules, which means there's got to be natural persons owning it, resident aliens–if it's somebody from out of the country, that they reside in the United States in certain trusts and even certain single-member LLCs. All right, to the question about–this refers to qualified business income. Sorry for lack of a better–no, Janet, you've already got it. "Since rental real estate is included for the 20%, are you also required to be a rep for that to be true?" No. You automatically get it. "High-tech network engineer, does it qualify as special services?" If you're not a network engineer and it's just you, then I would say probably yes. If you have a company and it's not so much you but your company has its own–like it's lots of people and it's just known, then the answer is no. Then, you're not. Jeff: Yeah, there were some specific carve-outs. I think the architects got a carve-out of this, but there's a few industries that have been specifically exempted from those specialized industries. Toby: I'm not sure but software engineer–I would say that if it's just you, chances are going to be under the special services. "When I file taxes, the taxes for the rental property show up on my tax showing a schedule form that is Schedule E. I almost $300,000 with my real estate and other income as a single woman." I think we already talked about this one. "Is there anything I can do to reduce my taxable income?" Yes, Janet, you can make contributions to qualified retirement plans. You can make contributions to charities, including your own. You can make contributions to C Corp if it has a business relationship. There are lots of things you can do or, if you have anybody that you need to pay salaries to like kids or somebody that's working with you, that would be something else you could do to lower the taxable income. "If you were writing out another slide, it's not showing up on my computer." Sorry, Sir. I think that's where all they go. "What about an IOL as a tax-deferred compensation for my property management income?" That would not work. An IOL is tax-neutral although you can do tax-deferred compensation where it's taxable to the entity and it's not taxable to you under certain circumstances. If I do tax-deferred income like, "Hey, I'm taking deferred compensation," I need to be at a losing. Usually, non-compete is going to be the thing that makes it work. We use these especially in the non-profit world where somebody says, "I don't want to be paid; I want to work, but I do want to get paid eventually for all the work I'm doing now. Rather than pay me this year, pay me when I'm 65 and maybe I wipe it out or not, but as long as I have a non-compete with that–" it's saying, "Hey, basically, if you go work for somebody else in a competing industry, you lose all that deferred compensation." You should be good. "I purchased a new computer that cost less than $2,500. Is that a straight expense in the current tax year or some weird depreciation thing?" Dean, it's called a Section 179 deduction. You can buy up to $1 million, you're good. You can write it all off. Otherwise, that would be depreciated. They also have 100% bonus depreciation, so we're going to catch it no matter what. Bonus depreciation is, if it's less than a 15-year property, you can write it off this year. You're not required to. Somebody says, "Is 199A or that 20% a 20% tax deduction or a 20% reduction?" No, it's a 20% deduction against your qualified business income. The net effect could be much more than 20% depending on your tax bracket. If you're not in a high tax bracket, then the net effect won't be huge. If I'm in the highest tax bracket in a state that's taxing me where I'm at 50%, that 20% deduction could be worth a ton. It could be worth significant amounts especially if I'm in a company that's not a specialized service and I meet the requirements. I could have hundreds and thousands of dollars of qualified business income being exempted, and that could be worth hundreds and thousands of dollars to me from a tax standpoint. We already did this one. Somebody who had their spinning left. You can go in bite-sized pieces, guys. We're going to break these things down, and I understand that we're going through fast, but that's half the fun. We're not dwindling around here. "My self-directed IRA received a K1 for net rental loss for a passive investment of $50,000. Do I need to file a 990 T to show loss? Does the IRA custodian sign the return or can I sign?" Jeff: Here's what happens: If your IRA is a partner in a partnership, that partnership is required to issue a K1 to all of its partners. That doesn't mean you have to do anything with the K1 in your IRA. You're not going to recognize any taxable income until you actually start taking money out of the IRA, especially since this is a rental property we're talking about. Toby: Cool. Hey, this is a really good one. By the way, if you ever do a 990 T and it says self-directed IRA, your custodian does have to sign, and they like to charge you for that. "401K, 401K." "I have a C Corp with accumulated losses and would rather close it than repurpose it. Is there a way to direct the loss of my personal taxes? Is it possible?" The answer is yes. It's called a 1244 election. It should have been made when you issued your stock. If Anderson did your C Corp, we already did that because I do it with every single corporation. You can then write off as a single person up to $50,000 or up to $100,000 if married, filing jointly, and then it could be used to offset even your W2 income. Jeff: Going back to one of the earlier questions, this is one reason we want to start recognizing reimbursements and stuff as early as possible to establish those debts to you early on. Toby: Yeah, I had this happen and we actually had–the one time this was ever audited was because this accountant refused to give him a $67,000-deduction. It was one of our clients who was a trader who was ready to launch and go into his business and then his employer made him an offer he couldn't refuse and gave him a whole bunch of our money. He took a $67,000-loss. He had never made a dollar in the corporation. We went under audit. We won. Yay. It took two seconds because it was a single letter and we gave him the law, and it's a statute. The IRS is just a policing agency. If there's a statute that's clear, they don't sit there and fight with it. I think it was a $38,000-reimbursement–what do you call it–refund. Awesome first-timer. We love first-timers. Thank you for joining us. "I want to receive an invite, a reminder to a different email." We can give you that. You can always use this when you register for the Tax Tuesday. Just put in your other email. "Interested doing sandwich lease options. What is the best business structure and what document can you provide to protect myself from sellers suing me if a tenant or buyer stops paying rent or if a tenant or buyer trashes the home?" That's a tough one. You're literally leasing it and then re-leasing it with the right to buy. Let me think about this one. How am I going to do this? I'm going to be doing that through an entity. The way you protect yourself is to keep very little amounts of asset in that entity so that if you're sued, it's not you; it's the entity itself, and the entity doesn't have much to lose. That's a tough one. I tend to stay away from stuff like that. I want to buy the property and then you do a lease option in an LLC. Jeff: Make sure you have insurance. Toby: Yup, make sure you have insurance, too. That could happen so the tenant trashes the place and somebody else says, "Hey, wait a second." That's why there's always risk. What you do is you just keep it to a low. "Is it hard to set up classes in QuickBooks? Does Anderson do this?" It's not hard and, yes, we do it. "How long does it take to set up a class in QuickBooks?" Jeff: No, you'd have to ask bookkeepers. Toby: Jeff's such an accountant. Yes, it's actually very easy. Jeff: Actually, the bookkeepers are really good at it. They do it all the time. Toby: It's literally all you're doing, is setting up another class. It's almost like a revenue class so you might have revenue that comes in from plumbing and then selling products in your plumbing business and then, "Hey, I have one that's a consulting," and that might be another class. It literally takes two seconds. "What if the Wyoming LLC owns a C Corp which owns an LLC?" I don't know what that means, but what we mean is–I imagine for the 199A. We're just going to look at it is the C Corp owns an LLC that's not going to be qualified for the 20% deduction. The LLC that owns the C Corp, if it's doing other activities, might qualify for the deduction. Here's the problem: In the qualified business, the part I didn't tell you about is what is qualified business income. Dividends, interest, capital gains are not included in that definition so if you're issuing interest from a C Corp to the LLC that flows under your return, you're not going to be getting the 20%. "If you set up QuickBooks with a single entity and use class as a separate income, can you also print a balance sheet by class?" Jeff: Yes, you can do it if the balance sheet is also classified. Toby: Okay. See, we're good. We're getting there. We only have about 200 more questions to go. I'm just teasing you. We've gone through about three-quarters of them. "What is Jeff's last name?" Webb. "I have a rental company. This will be my first year doing taxes. What can I expect to pay on my capital gains? What are some determining factors?" Isaac, if you're a rental company and you're selling–like if you have capital gains, it's going to be depending on whether you sold it within a year or after a year. If it's less than a year, it's going to be ordinary income to you. If it's over a year, it's going to be taxed with either 0%, 15% or 20%. If you make over 250,000, you're going to get to add no another 3.8% and then whatever your state tax is. What are the determining factors? How much you make. If you're married, filing jointly less than 77,000, your capital gains rate is zero. All those things come into it. You can always write us at webinar@andersonadvisors if you want to ask specific questions. "I'm in the process of setting up QuickBooks account for my C Corp. I have a construction business and a hair salon that are DPA-ed as C Corp. I am flipping single-family residents in Wyoming LLC? I have sub-expense and sub-income accounts for those." This is getting long. This one, we may want to answer next week because this is kind of cool. It's talking about sub-accounts. I'm just going to table that one unless you want to jump on it. Jeff: No, I think there were a couple of issues in there. Toby: Yup, "But you don't pay tax until the withdrawal, correct? That was just with regards to the IRA." Steve, you do need an account and, yes, you don't pay the tax until you withdraw, add up in IRA. If you have unrelated business income tax or debt finance income out of an IRA, you'd pay it in the year that it was generated. "Can I set up an entity to receive W2 income and max out top […]?" Yes, but you can't do it out of a self-directed IRA. The reason being is that you are a disqualified person so you cannot do that unless you do something called a ROBS transaction, and that's going to be a major topic for another day. That's if your IRA invests in a C Corp that you set up and there are ways to do it and then you could actually pay yourself, so there. "I recently rolled over a 401K to equity trust IRA account, lending funds to other investors charging interest. Is interest income taxable to the IRA?" No, you can do that all day long, and equity trust is having to sign all your docs. My recommendation would be to set up your own 401K so you can sign the loan documents. Somebody says, "How many times a year can you roll over from 401K to IRA or reverse rollover?" It depends on whether you're doing a direct rollover. Jeff: You can do a trustee to trustee every day if you want, meaning you're going from TDM trade to Bank of America. You can do those as long as it's directly being transferred. You can pull the money out once to yourself once every 12 months, and it's a rolling 12-month period. If I pulled it out today, then I wouldn't be able to do it again until next October. Toby: Somebody asks, "Can I roll individual stock holding into Roth trading account if the current value is under the 550 limit, and how?" The answer would be, really, no; you're going to have to liquidate the holdings, open up a new account in the Roth IRA and then contribute the 5,500. It's a pain in the butt, I know, but I don't make the rules. It's this whole Bank Secrecy Act and all this stuff since they flew planes into trade centers. "Is the old rule dead on personal residences two out of five years?" No, that's still the rule, and we still use it like crazy. That's exception 121. Jeff: Yeah, they were talking about making it five out of eight years, and that got thrown out so it's still the old two-out-of-five rule. Toby: Yup. "Do my startup costs carry over two years if my net was negative?" It's actually 20-something years. Jeff: 15 years. Toby: 15 years now? Nate, you can carry forward your startup costs. Is it 15? Jeff::Yeah. Toby: "Hey, wait a second. I have an S Corp. They keep charging me the 800 fee ever
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. This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. We have a special episode for you this month… We’ve brought Dr. Jeremy Rose, one of the peer reviewers, and a sepsis expert, on with us to talk through the content this month. Jeremy: Dr. Jeremy Rose here. Thanks for having me in on this conversation. I’m always happy to talk about this topic because it’s clearly important. There’s a great deal of confusion around sepsis and I hope that in the next couple minutes we can clarify things in a way that really help your average front line doc trying to get it right. Nachi: So Dr. Rose, before we get started, tell us a bit about your background and your interest in sepsis… Jeremy: I’m the Assistant Medical Director and Sepsis Chair at Mount Sinai Beth Israel in Manhattan. For those listening, my hospital probably looks a little bit like yours. We’re busy, interesting, and just a little rough around the edges. We like it that way. More importantly, though, we mirror the national averages regarding sepsis. Roughly half of in-hospital mortality is associated with septic in some fashion. Pretty incredible when you think about it. Half. Jeff: Sepsis chair... clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. But getting back to the article this month. This month’s issue was authored by Faheem Guirgis, Laurent Page Black, and Elizabeth DeVos of the University of Florida, Department of Emergency Medicine. Nachi: And it was peer reviewed by Michael Allison, Assistant Director of the Adult ICU at Saint Agnes Hospital, and Jeremy Rose and Eric Steinberg of Mount Sinai Beth Israel. Jeff: So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis? It seems that every month or so we have a new guideline, bundle, definition, or whatever… I think it’s best to start with the basics - At its core, sepsis is a dysregulated response to infection that can be life-threatening. Nachi: Right and it’s the combined inflammatory with immunosuppressive features of sepsis that lead to the devastating organ dysfunction and even death. Optimal management of septic patients has been a source of intense research, stemming from the landmark study by Rivers in 2001. Jeremy, can you give us a little historical context there? Jeremy: Rivers was a real pioneer. He found a 16% mortality reduction with randomization to an early aggressive care bundle. Amazing work. That being said, many components of that bundle have since been disregarded. For example, Manny Rivers would measure CVP in all of his patients, something we rarely do. Nachi: Not to cut you off and steal your thunder there, but we’ll get to the most recent updates in management shortly. Let’s first talk definitions and terminology, and specifically, diagnosis, which is definitely a big elephant in the room. As Jeff mentioned a few minutes ago, diagnostic criteria have undergone so so so many changes. Jeff: Yes it has! 1991 marked the first standardized definition. Then in 2001, sepsis-2 was introduced. In 2014, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine started a task force, and by 2016, updated definitions were out again! Sepsis-3!! A lot of this came after the realization that SIRS was just too broad and was overly sensitive and non-specific. Jeremy, why don’t you take us through Sepsis 3. Jeremy: So just to back up a little and frame this: Here’s the fundamental problem: As we likes to say, “there’s no troponin for sepsis.” And if you look at our patients, we tend not to miss the hypotensive, tachycardic, febrile patient. We know they’re septic. But how do we find the ones who don’t look as sick. Frequently elderly, possibly with normal-ish vitals and no fever. Those can be a lot harder to spot, but they may indeed be septic. Also, for research purposes we have to have a common definition, so Sepsis 3 came up with something called the SOFA score. The problem with the SOFA score is that its difficult to perform in the ED. It has parameters like bilirubin that often aren’t available when we want to screen out very sick patients. Fortunately there is the abridged version qSOFA, which identifies non-icu patients who are at high risk of inpatient mortality. So here it is, and if you get one thing from this episode, this is it: There are ONLY 3 criteria to the qSOFA. 3 Criteria. RR > 22; AMS; SBP 2. So quite a few changes! Jeff: And Jeremy, sticky topic coming up here. Center for Medicare and Medicaid Services (or CMS) quality measures - They haven’t really caught on to and adapted to Sepsis-3 yet, have they? Jeremy: The CMS mandate is based on the presence of SIRS criteria. Sepsis 3 is based on SOFA. This is definitely confusing. Part of the challenge in discussing this topic is separating out the QI guidelines from what is actually relevant to patient care based on the latest evidence-based medicine. Nachi: That seems fair. We’re really going to put you in an uncomfortable spot for a second and push you here Jeremy. Do you have any insight into why CMS isn’t interested in following the mountains of research that have led to sepsis-3? Is there a reason they are sticking to their current criteria? Jeremy: I think some of it is the slow pace of bureaucracy and the time that it takes to develop a consensus on management. Even if we can agree on who is septic, it’s really hard, if not impossible to link the care to a pay-for-performance metric which is what CMS ultimately would like to see. That’s not how Sepsis-3, or for that matter, SIRS, was designed to be used. You’re trying to take a tool which was originally designed for research and mold them into a tool used for pay for performance. Nachi: What a struggle. The CMS metrics are slightly different from the 2001 sepsis guidelines also. Take a look at Table 2 of the article for a quick comparison of sepsis-3, 2001 sepsis, and cms side-by-side. And for those on twitter, we’ll be sure to tweet this table out too for your review. Jeff: With so many different scores and definitions, I think that adequately sets the stage for the challenge this month’s authors faced coming up with real evidenced based guidelines. Nachi: Oh absolutely. And to make matters worse - this is a HUGE problem. We’re talking up to 850,000 ED visits annually in the US, and 19 million cases worldwide. Compounding this, sepsis results in death in approximately 1 out of 4 cases. Not only is it lethal, it is also very costly -- 17 billion dollars per year in the US alone! Jeff: And don’t forget importantly the 30-day hospital readmission rate. Sepsis is coming in at a higher readmission rate and cost per admission than acute MI, CHF, COPD, and PNA. Nachi: Let’s speak briefly on the etiology and pathophysiology of sepsis: we all know that sepsis is due to local infections that then become systemic. Previously, it was believed that the bacterial infection itself was the cause of the clinical syndrome of sepsis. However, we now know now that the syndrome of sepsis is due to the inflammatory and immunosuppressive mediators that were triggered by the infection. Normal immune regulatory safeguards fail and this leads to the syndrome. And interestingly, several studies have shown that critically ill septic patients experience reactivations of specific viruses that were previously limited to patients with severe immunosuppression. Jeff: Definitely something to look out for in your critically ill septic patients. We should talk briefly about the most common inciting infections that lead to sepsis. In order, these are: pneumonia, intra-abdominal infections, and urinary tract infections. No surprises there! Nachi: Yeah, that basically parallels my own experience, so that’s reassuring! That takes us to our next potentially controversial topic - blood cultures. Jeremy - we’re going to punt this one back to you Jeremy: This is another interesting topic that has received plenty of attention. CMS loves blood cultures. It’s an easy metric to track. That doesn’t mean they’re always helpful. We looked at our patients with lactates between 2.1 and 4.0 which had “severe sepsis.” These patients were normotensive though, In other words, the ones that aren’t that sick. We found that blood cultures are useful about 20% of the time. That’s not bad. So what do we do? We draw cultures before pushing antibiotics. Is that helpful? Sometimes yes, does it waste money? Debatable. Does it help us meet our metrics, yes. Jeff: And I think that gets at the crux of the problem here: we don’t want to delay antibiotics on anybody, but we must balance this with the potential harm of further increasing the drug resistant bacterial population via sound antibiotic stewardship. Remember also that there is a broad differential for sepsis, with several “sepsis mimics”. To name a few, we have PE, MI, CHF, acute pulmonary edema, DKA, thyroid storm, GI bleeds, drug intoxications, and withdrawal syndromes, just to name a few. In case that wasn’t enough check out Table 3 of the article. Nachi: And we already mentioned the leading causes of sepsis, that’s pneumonia, intra abdominal infections, and uti’s. But remember the source can be anywhere. Be sure to also think of pyelonephritis, central line associated bloodstream infections, prosthetics, endocarditis, necrotizing fasciitis, and meningitis. Jeff: I don’t think we need to dwell on this much longer - basically the differential is huge. Let’s move on to my favorite section - prehospital care. Jeremy: 20 pages of evidenced based recommendations and your favorite is the prehospital section, what’s up with that? Jeff: I’m an EMS fellow, what can I say… Anyway, on to my favorite section -- prehospital care. This is always a hot topic because the prehospital period is a special opportunity to get early interventions in for septic patients as 40 - 70% of all severe sepsis hospitalizations arrive via EMS. Nachi: And in one study taking place in a large metropolitan area, prehospital care time was over 45 minutes, and less than 37% arrived with IV access. Of course, these numbers would vary significantly based on where you practice. Jeff: So get this -- one study showed that out-of-hospital shock index and respiratory rate were highly predictive of ICU admission. So clearly early recognition and therapy may play a role here. Another study, however, showed knowledge gaps by advanced EMS providers in diagnosis and management of sepsis. And yet another study showed that only 18 to 21% of confirmed septic patients were suspected of having sepsis by EMS. Out of hospital fluids were started in only half of patients with severe sepsis. In essence, there is likely a strong role here for pre hospital protocols for identifying and treating sepsis. Nachi: In terms of pre hospital treatments though, prehospital IV fluids haven’t been shown to improve mortality, but have been associated with shorter hospital stays. Prehospital sepsis protocols have been described, but in general more research is needed in this area. Jeff: While prehospital care hasn’t yet been shown to improve the prognosis of septic patients, those presenting via EMS do have shorter delays to initiation of antibiotics, IV fluids, and early care bundles. EMS should focus primarily on stabilizing vital signs and providing efficient transport. If it’s possible to establish an IV and initiate fluids without delaying transport, EMS should do that as well. Nachi: And of course, oxygen for the hypoxic patients! Moving on to history and physical for your presumed septic patient. Jeremy, what are the big hitting things here that you always ask and check for, and that you make sure your residents are doing? Jeremy: After ABC’s and glucose, AMS is really important, it’s in the QSOFA SCORE. Unfortunately, this can be hard in many septic patients where they’re baseline mental status is less than perfect. The other thing is to try and find the source. Finding the source lets you make wise choices about therapy. Jeff: Great point about the mental status - so many of our older population have an altered baseline, but recognizing changes from that baseline is key. Nachi: Absolutely, with that in mind, let’s talk diagnostic studies, especially lactate. Where I trained, basically everybody was getting a lactate, even tired looking residents seemed to be having their lactates checked, and trust me, they weren’t looking that good... Jeremy: Brace yourself: lactate is really important in septic patients. That being said, not every cause of elevated lactate is sepsis. There is this animal called Type B lactic acidosis can come from numerous drugs like albuterol. Just because you see elevated lactate doesn’t mean you can forget about the other causes. That being said, we know that patients with sepsis do better when they clear lactate. Jeff: Seems like the evidence is definitely in favor of serial lactate testing… Jeremy: For sure. At least until you have a reasonable trend towards improvement. We know lactate clearers do better. We’ve looked at our own lactate numbers. Interestingly, the takeoff point for sepsis seems to be around 2.5. Meaning that patients with altered vitals and lactates above 2.5 tend to do worse. But, there is a broad ddx to elevated lactate. What is true, though, is that lactate is a marker for badness. If your patient’s lactate is rising, yours should be too. Nachi: I bet I’m a “lactate clearer”. I may add “lactate clearer to my CV,” sounds impressive. But I digress… Next up we have Procalcitonin. Since procalcitonin becomes elevated in those with bacterial infections, intuitively, this should be a valuable marker to assess in potentially septic patients. Unfortunately procalcitonin lacks negative predictive value so most literature supports its use in diagnosing pulmonary infections and for antibiotic de-escalation. Jeff: Good to know, I’ve seen it being used a lot more recently and wondered how evidence based this test was. Jeremy: Honestly, I don’t see Procalcitonin changing ED management at the moment. If you’re waiting for Procalcitonin to start antibiotics or fluids, you’re waiting too long. Nachi: Moving on, let’s talk imaging. Based on current studies, the authors recommend focused imaging only. In addition, they also note that our good friend, the point of care ultrasound, likely plays a role, as in one study, POCUS demonstrated a 25% improvement in sensitivity from clinical impression alone. Jeremy: I think there are two ways POCUS comes in. One, lung ultrasound can be really useful to find that occult pneumonia or differentiating pneumonia from CHF. Two, your ultrasound is your best tool for assessing volume status. I try to look at the IVC of all my septic patients and echo them when possible. Nachi: Right. So now we’ve examined, drawn labs and cultures, checked a lactate, may be obtained imaging… next up we should probably start treating the patient. Whether you like it or not, we have to discuss CMS. Jeremy: Just to clarify before we start. CMS defines “severe sepsis” as SIRS + infection with a lactate of 2.1-4.0. Septic shock is SIRS + infection with hypotension or a lactate > 4.0. That’s where we’re at. Jeff: Good point. Back to treatment: within the first 3 hours, for any patient with sepsis and septic shock, you must measure a lactate, obtain 2 sets of blood cultures, administer antibiotics, and give an isotonic fluid challenge with 30 cc/kg to patients with hypotension or a lactate greater than 4. Then, within the first 6 hours, you must apply vasopressors to achieve a MAP of at least 65, re-assess volume status and perfusion, and remeasure a lactate. Nachi: This begs the question - are these recommendations evidenced based? Jeremy…. Jeremy: I’m so glad you asked that . Let’s start with fluids. Patient’s need adequate fluid resuscitation. Interestingly there are 3 large RCT’s, PROMISE, PROCESS and ARISE, that compared a Rivers type bundle to usual care. Surprisingly, they showed no difference. But when your drill down into these 3 trials, you see that “the usual care,” now generally includes at least 2 liters of fluid. Jeff: Ok, so it seems that there is some pretty good data to support a rapid fluid challenge of at least 30 cc/kg. But how do we determine who needs more fluids and how much more they need. There must be an endpoint to all of this? Jeremy: Another million dollar question. 30cc/kg is probably a good place to start. How much is too much? I think we need to be smart about our fluids. Some patients will need less and some will need much more. So, I remind my resident’s to be smart about fluids. Sono an IVC, trend a lactate, follow a urine output, do a passive leg raise, even check JVP. I mean just because you haven’t seen a unicorn doesns’t mean they’re not real. Do something to monitor volume status. Nachi: Very important. Put your ultrasound skills to work here. They’ll only improve as you practice more. Jeff, let’s get started on the ever important topic of antibiotics. Jeff: Sounds good. Current guidelines recommend that broad spectrum antibiotics be administered within the first hour of presentation for those with sepsis or septic shock, ideally with blood cultures being drawn beforehand. In one study, every hour of delayed abx administration was associated with an 8% increase in mortality. Since this 2006 study, other studies have had mixed results - with studies showing increased odds of death with delays in abx administration and others showing only a benefit in those with septic shock with or without hypotension with no benefit to those without shock. Nachi: In terms of antibiotic coverage - you need to consider the site of infection, local resistance patterns, the presence of immunosuppression, and the patient’s age and comorbidities. Table 5 of the article is very thorough and should be kept as a quick reference. Jeremy do you have any specific recommendations for our listeners on how we should approach antibiotic usage in the septic patient? Jeremy: I like to think about antibiotics a little more simply than referencing a table. I ask a couple questions. Does my patient need MRSA coverage ? Does my patient need Pseudomonal coverage? If the answer is no and no, then narrow your coverage. You don’t necessarily have to use a bunch of Vanco, or a big gun antipseudomonal like Pip/tazo. Also, have a look at your local antibiogram. I can’t tell you how many times this changes prescribing habits for even things like simple UTIs. I’m going to stray into some controversial territory here. The benefits of sepsis protocols are measured one patient at a time, but the harms are only measured in the aggregate. What does that mean? CMS metrics have caused us to use to use more broad spectrum antibiotics. As a result, we’re seeing more resistance. My resident’s tell me to make it easy, give em VZ (that’s vanco/zosyn) and it kills me. Every time you put a Z-pack into the world a pneumococcus gets it’s wings. So think more about your antibiotics, and know your local biograms. Jeff: That’s a great way to think about it, I fear I’ve given a lot of pneumococci wings during my training… Next we’re on to vasopressors. The data is pretty clear on this one - norepinephrine is the recommended first line vasopressor for septic shock. In numerous trials comparing Norepi to dopamine, NE was far superior, with dopamine increasing arrhythmias in one trial and associated with an increased risk of death as compared to NE in another trial. Jeremy: So here’s a question I get all the time: How can I give Norepi without a central line. Let’s use Dopamine, its safe peripherally. Ok, so follow that through. We’re going to give a drug to increase blood pressure by constricting blood vessels, but don’t worry, it’s safe peripherally. What does that mean? It means it doesn’t work!! It doesn’t give much blood pressaure. Dopamine is a lousy pressor. It causes a lot of tachycardia, which is not what you want in failing septic hearts. So what do we do if we don’t have a central line? We start norepi peripherally into a large bore IV for the time it takes us to get a central line. That’s where the evidence is. There’s a mortality benefit to NE over dopaine in septic shock. Jeff: Right, this month’s authors note peripheral pressors may be safe for brief periods in settings with close monitoring. While this is commonplace in some hospitals, others haven’t yet jumped on that bandwagon. I think it’s important to mention that this is becoming more and more commonplace, even in the prehospital realm. With the service I fly for, we routinely start peripheral vasopressors without hesitation. But this isn’t limited to the air. Many ground 911 services have also adopted peripheral vasopressors in a variety of settings. Nachi: I’m sure there are many trials to come in the future documenting their safety profile, but moving on to the next pressor to discuss... vasopressin. This should be your second line vasopressor for septic shock. In the VASST trial, low-dose vasopressin was found to be noninferior to NE. In other trials, vasopressin also appeared to show a potential benefit in those with AKI and sepsis, although the subsequent VANISH trial (perhaps the best name for a clinical trial so far) failed to demonstrate a benefit to vasopressin titration with regard to renal outcomes in septic shock. Vasopressin has also been shown to reduce NE dosing when administered at a fixed dose of 0.03-0.04 units/min. Jeff: Next we have epinephrine. In one study epinephrine and NE were equivalent in achieving MAP goals in ICU patients with shock, however several of those receiving epi developed marked tachycardia, lactic acidosis, or an increased insulin requirement. The increasing lactic acidosis could confound the trending of lactates, so in those requiring inotropy in addition to some peripheral squeeze - the authors recommend adding dobutamine to norepinephrine instead of starting epinephrine. Although, keep in mind, this can lead to some hypotension so remember to start at low doses. Nachi: Phenylephrine, a pure alpha adrenergic agent, is next and should be considered neither first nor second line, but it may have a role as a push dose agent while preparing other vasoactive agents. Jeff: And lastly, we have angiotensin 2. One recent 2017 study examining the role of angiotensin 2 in those with septic shock already on 0.2 mcg/kg/min of NE found that those receiving AT2 had significant improvements in MAPs as well as cardiovascular SOFA score at 48h with no difference in mortality. Unfortunately, these benefits do not come without risk as AT2 may increase risk of arterial and venous thrombosis and potentially thromboembolism. Clearly, one study isn’t enough to change practice, but it’s certainly food for thought. Nachi: So that wraps up vasopressors. Jeremy, we’re on to corticosteroids -- another hotly debated topic. When do you give steroids in sepsis? Jeremy: Hmmm steroids, this is an age old question. No study has clearly supported the blanket use of steroids in septic shock. Several like CORTICUS and ADRENAL showed no difference. I will use hydrocortisone for pressor refractory shock. Meaning, you’ve tried everything else, so you might as well try. Also, I do tend to avoid Etomidate, given the possibility of adrenal suppression and that there are several other induction agents, notably Ketamine that don’t have this problem. Jeff: Those trials are certainly important, thanks for bringing them up - Especially with all the FOAM content out there, it’s incredibly important to look back at the data to understand where certain recommendations are coming from. Anyway… one quick note on blood transfusions before we move on to special populations - Although part of the original early goal directed therapy, thanks to data from the TRISS trial which showed no difference in outcomes with a transfusion goal of 7 vs 9, transfusions are reserved for those with a hbg of less than 7. Jeremy: One population we should make sure to mention and be careful with is end stage liver disease. In the ER, we tend to miss SBP alot. Mostly because these patients have lots of reasons to be sick and they already have elevated lactate because of their deceased clearance. My practice is to give a dose of Ceftriaxone and sent a diagnostic tap to patients who are sick and have ascites. Nachi: Alright Jeremy, let’s talk controversies in sepsis. We’re giving you all the big questions this month! Jeremy: We’ve already talked about fluids and how much to give. Just a reminder that a history of CHF doesn’t preclude proper fluid resuscitation. I think broad spectrum antibiotics for relatively well patients is a big controversy. Our national rates of antibiotic resistance are terrible, and yet we’re using more antibiotics all the time. There are very few if any antibiotics coming down the pharma pipeline and we’re going to have to face the music eventually. Finally, we need national metrics that mirror clinical evidnece. Protocols should be a tool and not a crutch. You know what’s best for the patient in front of you, so don’t let metrics or protocols make you do things you think are not in your patient’s best interest. Nachi: So how do you escape the hospital protocols and CMS and do what’s best for your patient without “getting in trouble”? Jeremy: Here’s how I deal with it as the one who reads and QI’s all of our sepsis charts. I tell my colleagues to do what’s right, and if you need to deviate from the protocol tell me why. As long as you can explain your decision, I’ll support it. Explaining your thinking is good clinical practice and is good medico-legal practice. CMS has been unable to link these metric to payment, simply because no hospital can meet them with any regularity. It’s important that we advocate for our patients or nothing will change. Make them respect you for the highly educated professional that you are, and your patients will ultimately benefit. Jeff: Preach!! And before we close out with disposition, there are a few new therapies and trials on the horizon to keep a lookout for. The RACE trail examined the role of L-carinitine. The VICTAS trial is looking at vitamin C, thiamine, and steroids in sepsis. The CLOVERS trial is looking at early vasopressors vs a crystalloid liberal strategy. And lastly, IL-7 is also being investigated. All really cool stuff that could change how we manage sepsis in the future.. Nachi A few quick notes on disposition before we close this episode out. Certainly not all patients meeting SIRS require admission, but many do. Those with qSOFA of 2 or higher represent a sick population and an ICU admission should be considered. Even for those with a qSOFA of 1 but a lacate over 2 -- they have a mortality approaching that of patients with a qSOFA of 2. Be careful just sending a patient who is on the fence to the floor because several studies have demonstrated that patients who are later upgraded have worse outcomes. Jeff: That’s in line with the general themes we’ve laid out today - definitely better to start early with aggressive care rather than play catch up later. Jeremy - in 30 seconds or less, what are the most salient points in the management of sepsis that you would like our listeners to take with them from this episode. Jeremy: Here are my take aways: qSOFA, RR, AMS SBP < 100 Norepi, not Dopamine - it doesn’t work! Be smart about fluids!! Be smarter about antibiotic use! You are the best advocate for your patient, despite what anyone else says! Jeff: Excellent, so that wraps up the October 2018 episode of Emplify. A big thanks to Jeremy Rose for joining us. Jeremy: Thank you for having me!!! It was great talking with you. Nachi: For our listeners -- 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. Jeff: And the address for this month’s credit is ebmedicine.net/E1018, 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. Nachi: 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!
Our guest today is Dawn Dugle, an award-winning storyteller and writer who travels the country teaching businesses and non-profit organizations how to tell and share their stories and she’s here today to share her new story, The Bravo Way: Building a Southern Restaurant Dynasty. We’ll speak with Dawn and find out why she wanted to tell the story of Jeff Good and Dan Blumenthal and their business. Plus we’ll talk about the latest headlines in the weekly roundup. See acast.com/privacy for privacy and opt-out information.
2X05 Jeff Good by Jackson Free Press
This episode focuses on how local restaurateur, Jeff Good, along with a team of community leaders, are making a significant and generational impact right now in Jackson, Mississippi through the soon-to-open Refill Cafe. The Refill Cafe will be a restaurant that serves up comfort food and positive experiences. Guests will enjoy quality meals made and served by local young adults as part of a life skills training program. This concept restaurant, modeled after Café Reconcile in New Orleans, seeks to link those that have difficulty finding and keeping work, due to a variety of reasons, with necessary resources to enable their success. Trainees will learn trust, commitment and worth ethic in a structured team environment and gain valuable experience in the restaurant business. The Refill Cafe is located in West Jackson surrounded by goodwill organizations whose members also sit on Refill Cafe’s Advisory Board. Connect and Learn More: Refill Cafe Refill Cafe on Facebook Jeff Good's Restaurant Establishments: BRAVO! Italian Restaurant & Bar Sal and Mookie's Broad Street Bakery Eat Y’all Website Eat Y’all on Facebook Eat Y’all on Instagram Eat Y’all on Twitter
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 Meet Ivan Delgado: Being Your Own Boss Is Hard Work and Worth It All (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 this Job Insights Extra we talk to Ivan Delgado, a Business Enterprise Program Operator from Las Vegas. How he got his start into the BEP and what being a business owner has done for him. We hope you enjoy and if you have any questions for Ivan, you can send him an email. If you are interested in becoming your own boss and want to run your own business, contact your state services, your Devision of Vocational Rehabilitation and see what opportunities they have for you. Full Transcript Below 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. Transcript [Music] Jeff: Welcome to a job insights extra where we will be talking to business enterprise program operator Ivan Delgado. [Music] He's from Las Vegas and that's where the Blind Abilities team went to get this interview at the Randolph Sheppard Vendors of America Sagebrush convention. What is the business enterprise program? It is a operation part of the Randolph Sheppard act that allows you to own an operate your own business. Check out your State Services, your DVR, and find out more about the business enterprise program. [Music] 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 extra, consisting of interviews, demonstrations, and news surrounding employment, careers, and jobs, 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. You can also follow us on Twitter at JobInsightsVIP. Right now, please welcome Ivan Delgado. Welcome to Blind Abilities, I'm Jeff Thompson, and I am at the Sagebrush convention in Las Vegas and I ran into a fairly new vendor here amongst the senior vendors. I'm talking to Ivan Delgado. How are you dong? Ivan: Alright man, how about yourself? Jeff: Good, good, just enjoying the convention and all of the busy lights and stuff, and noises I should say out there. Ivan: Nice city huh? Jeff: Yeah, and you're from Vegas? Ivan: Yeah man, welcome to Las Vegas, if anybody is listening, come and enjoy Vegas, we love your guy's money. [laughter] Jeff: I noticed that! [laughter] So what got you interested the business enterprise program? Ivan: So about 3 or 4 years ago man, finishing up, not finishing, taking a break from college for certain reasons, whether it was lack of assistive technology or books not being ready for me, I decided to take a break and my lady actually told me about this program. She had a few friends that have done it in California and other states, and she told me, you like to boss me around so you might as well boss people around and try to make money. Yep, a couple years later man, I have been fortunate enough to finally get my own site and I started, originally I started the program. I got my BEP license about 2 years ago. My first site opened February 1st of last year, we just had our one year anniversary, before that we had vending machines at the location I am in. We just, it took a while for the location, the actual location to open up. Jeff: Is there training involved when you first join? Ivan: Yeah, when I first joined, now it's a lot different man, but when I first joined it was pretty intense, what I think is intense man. It was, I want to say 9 months man, and don't quote me on that. Classes started in March and the first three months were strictly just books and learning bi-laws, and how to do PNL's, and marketing, it was pretty awesome man, for someone like me that, you know never had a business, don't have an idea, i was just used to working 9 to 5s. It was very helpful. We did a couple of course through Hadley, Hadley School for the Blind online. We did that and then we did a couple of ServSafe tests here, customer service exams that we had to get. I am fortunate and I could brag about it man, because again, I am blessed man, and I think I am one of the only vendors here in Nevada that does his own profit and loss statement. You have vendors that are paying 200 to 300 dollars to, for people to input simple numbers and again, thanks to those classes, thanks to those three months of actually putting in work man, and understanding PNL's, and little Bi-laws, and stuff like that is definitely helpful man. Jeff: You are your own accountant. Ivan: Yes sir, thank God man! Jeff: You gotta keep the profits up right? Ivan: Right right, that is one way of doing it man, saving money man, all you gotta know is how to work. We know how to work man, it doesn't matter if you are disabled or not man, it's ambition, as humans we hunger for that ambition man. We have it, it is just a matter of if we want it or not man, and a lot of the times we don't want it man, and that sucks, but we are our own worst enemies and our own best friends man, and only we can get what we want man. Jeff: So what suggestions would you have for someone who is interested in getting into the business enterprise program? Ivan: A lot of patience. A lot of patience, hard work. Here in Nevada the process is a little longer due to the lack of operators we have, you know we kind of have to prove ourselves and that is fair I think. But a lot of patience and , just because you're disabled doesn't mean that stuff is going to be handed to us, especially here in the business world man, we have just as much of a responsibility as anybody else. Just keep your head up and be strong. That's it, just stay positive and stuff could be worse and if we are here and you are listening to this podcast, obviously we have gotten this far and the sky is the limit after here. Jeff: So what does Sagebrush bring to you? Ivan: A lot of a lot of information. A lot of people like Mr. Jeff, sorry if, I am bad at names, I think that's your name [laughter] Jeff, but yeah, this man, that working, as a blind community we have to become close man and I'm, the best example man, I don't go out a lot and I don't network but it hasn't changed man, I don't believe in NFB's, and NCB's, and ACB's, I wish there was only one. I don't see for this separation between organizations when really we're all just one, and that's blind. We're all blind so I would love for us to stick together and become one. I think if we become one a lot of people would be aware of both our disabilities, of our business and the Randolph Sheppard Act, again if we advocate be strong, stay positive and network, go out to these kinds of meetings, kind of conferences, I think this could very well be accomplished. There is a lot of older gentleman and ladies that are in the program and it's time for younger generations to step up and I think this is the time. Jeff: There is a lot of wealth of information, they have been in it, they have seen it change, and that is the bigger thing that things have changed and now here you are paving your way, you know, you're two years in, pretty soon you'll probably be leading the show here. Ivan: Absolutely, and those are the plans man, and absolutely, we always have to be grateful to the people that have, that started this man you know, and we've gotten a long ways man, I mean from selling newspapers at Post Offices to you know, having places at Hoover Dam's or at airports, you know that's a huge accomplishment, and that couldn't have been done without the people that you know, are moving on or retiring now. And that is a huge gratitude to you guys, we thank you. Jeff: Well, Ivan Delgado thank you very much for taking your time away from the karaoke. You gonna sing out there? Ivan: No we already did man, I need two more shots, I think these last two shots were on you. [laughter] Jeff: Do you have an email? Ivan: Yeah man, that's ivan.delvilla@gmail.com. Jeff: Alright, well thank you very much for taking the time and just speaking on Blind Abilities. Ivan: Yes sir, have a good day! [Music] Jeff: So if you are interested in the business enterprise program, becoming your own business owner, entrepreneur, check it out with your division of vocational rehab, your State Services for the Blind and see what they can do for you. If you want to find out first hand from Ivan what it is like to be 2 years in, in the business enterprise program, shoot him an email, check it out. Links are in the show notes. So we hope you enjoyed this Job Insights extra, 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 the realities of Blind Abilities. 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.
The Boys are back!This week, our Hot Take Artist, Patrick Magnus, was called away so we have Hot Take Artiste, Jeff Good, filling in for him. The guys break down the usual stuff and also get into some Opening Action reactions, bold predictions, and much more!Suggested Talking Points- Austin Hedges is Omnipresent, Long hair on pitchers, Jeff is mean to AJ Puk, Ian refuses to be logical about the Rays, Jeff tries to not get invited back! Thanks to Carraway for the use of our shiny new theme song- Raising the Dead, off of their self-titled EP. Check them out at wearecarraway.bandcamp.com. Questions or comments- email us at dynastyguru@gmail.com !Twitter Handles-The Dynasty Guru- @dynastyguruKeaton- @thespokenkeatsJeff- @lowguppyIan- @usfhudson
The Boys are back!This week, our Hot Take Artist, Patrick Magnus, was called away so we have Hot Take Artiste, Jeff Good, filling in for him. The guys break down the usual stuff and also get into some Opening Action reactions, bold predictions, and much more!Suggested Talking Points- Austin Hedges is Omnipresent, Long hair on pitchers, Jeff is mean to AJ Puk, Ian refuses to be logical about the Rays, Jeff tries to not get invited back! Thanks to Carraway for the use of our shiny new theme song- Raising the Dead, off of their self-titled EP. Check them out at wearecarraway.bandcamp.com. Questions or comments- email us at dynastyguru@gmail.com !Twitter Handles-The Dynasty Guru- @dynastyguruKeaton- @thespokenkeatsJeff- @lowguppyIan- @usfhudson
Dave and Jeff tell you who killed Natalie Wood! They prove they're good dads and they discuss the future of the Lakers and Padres.
TVI Toolbox: Success Stories, Tools for Success - #BeMyEyes App, Meet Jeff Mihiletch Blind Abilities presents the TVI Toolbox. Where the collaboration between Teachers, Counselors, Parents, Agencies and the Students themselves help enhance the opportunities for success. Transitioning from high school to college and the workplace is a major step and the beginning of lifetime goals and aspirations. As Jeff Mihiletch, this month’s featured interview in the Success Stories portion of this podcast, puts it, “Braille is a tool he wished he would have given a better chance.” From the TVI’s to the Agency counselor’s and program specialist, working together along with parents as well, is creating more opportunities and successes for Transition age students. Sharing experiences through Success Stories, sharing programs that make a positive impact, sharing ideas, findings, upcoming events and the Tools for Success all play a part in making the transition process a natural progression and better understood by all. On The Horizon is a bulletin space for upcoming events, information and resources submitted by listeners and our staff. You can submit to On the Horizon by emailing Jessica Hodges. The Success Stories feature an experience of a Transition Student, whether they are attending college, preparing for college or are now employed, the Success Stories brings a positive and a sharing of the experience of transitioning from high school to college and the work place. Here are the links to the information we bring to this episode. Scholarships from the National Federation of the Blind Perkins Program for Students Blind, Inc Summer Programs Summer Transition Program (STP) Extended School Year Program Deb Peterson at DPeterson@916schools.org Check out your State Services by searching the Services Directory on the AFB.org web site. State Services for the Blind of Minnesota We offer tools and training for employment and for helping seniors remain independent and active. As Minnesota’s accessible reading source we also transcribe books and other materials into alternative formats, including audio and braille. We assist Minnesotans who are blind, DeafBlind, losing vision, or who have another disability that makes it difficult to read print. I hope you find what you need here. We've also created a Tips for Using Our New Website page. If you’d like to apply for services, learn more, or have more questions, just give us a call. You’ll find contact information for all of our offices on our contact page, or you can call our main office at 651-539-2300. You can submit to the On The Horizons segment by email to jessica.Hodges@state.mn.us 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. Full Transcript: TVI Toolbox: Success Stories, Tools for Success - #BeMyEyes App, Meet Jeff Mihiletch (Music) Dacia: It's your job, disability or not, to know what you bring to the table, and sell that. That's your job. Narrator: Welcome to the blind abilities TVI Toolbox. I'm Jeff Thompson. Dacia: Because they don't have any experience with vision loss, so they're thinking to themselves, "I don't know if I could do that if I couldn't see right. I'm not sure that they're going to be able to do that." That's what... there inner monologue isn't about you, it's about what they think that you can't do, and their bias. Narrator: TVI toolbox is a tool for teachers, for agencies, for clients to enhance the opportunity and the understanding of transition services. Professionals talking about the services they provide. Teachers of the visually impaired talking about topics of transitioning from high school, to college, to the work place. Students talking about their journeys, there successes, and some of the barricades and brick walls that were in there way, and solutions, tips, and tricks on how they got through it. Dasha: We try to help them develop resumes right from the beginning. We would like some body that even as young as fifteen sixteen to have a resume that they can continuously add to, to build on. It really puts in front of them a more realistic view of "Ok, well I can add this to my resume. I can do this because I can add that. This is going to bring value." It kind of gives them more of an ownership of there experience. Narrator: That's (probable spelling mistake here,) Dasha van Alstine. She's an employment program specialist at state services for the blind, working with clients, counselors, and employees, to optimize the opportunities for successful employment. Dasha: I always tell people, if you go into an interview, and you're thinking that you're not the best candidate, you're probably not. Narrator: On this episode of TVI Toolbox, we'll be talking about employment. We'll be hearing more from Dasha van Alstine, and the success story today features Jeff Mihiletch, with A BS degree in Business Administration. And Jessica Hodges with On the Horizon, where she brings you recent news and events with particular interest in the transition process with a blindness perspective. And the tools for success spotlight is Be My Eyes. It's an ap that, well, kind of speaks for itself. Now, here's employment program specialist Dasha van Alstine. Dasha, welcome to blind abilities. Can you tell our listeners what your roll is at state services? Dasha: Hi Jeff. I am a program specialist for the employment team at state services for the blind. Narrator: Tell us a little more about the employment team. Dasha: The employment team works with various counselors and customers on anything from the very beginning of how to choose a job goal, all the way up to when it's time to close your case. So are you ready, do you have everything you need, do you need additional training, we're there all along the way. Whereas a counselor looks at an entire situation, we look at everything from absolute employment Narrator: Dasha, for a transition student, what would a first meeting with the employment team look like? Dasha: That can be at any type of stage, it depends on... if somebody has done a lot of research various...market information on their own, we might not meet with any of us until later. Someone who really needs some help and some direction with trying to figure out what they want to be, and what that's going to look like, and where the doors are going to open, they might meet with us right away. Narrator: So first they work with state services, then when it comes time to think about employment, that's when they get handed off to the employment team? Dasha: Well, preferably, they wouldn't just get handed off to our team. We would want to have some sort of relationship with them from the beginning. I'll give you an example. A college student, someone who knows that they're college bound know they want to go to college to get to a career, we'll look at them right before it happens and say, "Ok, what is your job goal? What do you want to do? What are the various avenues to get there." We'll work on what is the most appropriate way from point A to point B, for you, with college in the middle there. And then, in college, a lot of times there will be some check ins. We'll check on them, hey, how's it going? Have you thought about an internship yet? Are you working during school? Do you need help finding something. You know, what can we do to assist you?" We make connections for them, and sometimes we help them find part time employment, or find there internship. A lot of times, we'll work with the school to try to figure that out with them, to try to get them more independent and not depending on us. And then, when they're getting ready to graduate, sometime before the last semester, we help the figure out, you know, it's time to start looking. Because ideally, you want a job before you graduate, you want that job to be ready for you. Narrator: Dasha: With the age of transition students, I imagine that a lot of them have not had too much job experience. Does the employment team have a component for people to learn about job interviews and filling out resumes? Dasha: It's different for each person. That begins whenever appropriate. Some people, especially our young people, We try to help them develop resumes right from the beginning. We would like some body that even as young as fifteen sixteen to have a resume that they can continuously add to, to build on. It really puts in front of them a more realistic view of "Ok, well I can add this to my resume. I can do this because I can add that. This is going to bring value." It kind of gives them more of an ownership of there experience. Every aspect of every case is so different. There are some people that need us to do the resume and then walk them through what we did. There's other people that we just give some guidance to, and they do it. you know, everything is so individualized, it's wherever it's appropriate for each individual case. Narrator: That's great. Dasha, there's a saying, don't judge a book by it's cover, but in the employment situation, in job interviews, can you tell us a little bit about first impressions? Dasha: First impressions are really important, especially if you have a vision loss, because there's a really good chance that whoever you're meeting has never met someone with a vision loss before. There's no back ground there. They're going to base whatever experience they have with you, and project that onto every other person that they ever meet in the future who has a vision loss. When you meet somebody, especially if you're going in for an interview, you want to make sure that first of all, you're nice to the receptionist, because if you're not nice to the receptionist, the person interviewing you is going to find out, and you're not going to get that job. Just saying, the receptionist, that's the barrier there. Be nice to them. And second of all, once you do meet somebody, and if you have to follow them, make sure that you're comfortable, and don't be afraid to ask for information. Left or right? Where's the room? Don't be afraid to ask those kinds of directions.. With first impressions, you want to make sure that you are well put together. You want to make sure that you don't go into a business with saggy clothes, or with dirty clothes. You want to make sure that your hair is, you know, presentable, that you're not wearing baseball caps. You also want to make sure that you can speak clearly, concisely, have some confidence, that's going to be really important to an employer. Even if you're just walking in to pick up an application. Just go to the receptionist, be nice, "Hi, you know, my name is so and so. I was wondering if you're hiring. Can I get an application? Even something as simple as that. That goes a a long way. You also want to make sure that when you do talk to somebody, especially if it's an interview, you're going to get that, "Tell me about yourself." You could even get that when you 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 an obvious disability, you want to make sure that you kind of address that in a way that makes it so they're not thinking about that, they're thinking about your skills. A lot of people make the mistake of never saying 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 if I could do that if I couldn't see right. I'm not sure that they're going to be able to do that." That's what... there inner monologue isn't about you, it's about what they think that you can't do, and their bias. So it's up to you to make sure that you sell yourself. Sell your skills. Tell how you do things. Go into it with confidence. Know what your skills are ahead of time. Know what you have to offer the employer, and just go into it that way. And this is not just with employers. This is also useful with your professors. Narrator: Dasha, I was just doing an interview with a business owner, Susan Robinson. She said that she'd never hired a person because they had sight. She always hired a person because she felt they could best do the job that she needed to get done Dasha: Yes, it's all about the what can you do for me. Employers hire because they have a job that they have to get done. They don't hire because they want to feel good. They don't hire because they want to spend a bunch of money. They do it because they have a job, and they have to get it done. So your job is to make sure that they know you can do that job, and not only that, but you can bring stuff to the table so you're the person can help them get that done. You're the best candidate, and this is why I always tell people, if you go into an interview, and you're thinking that you're not the best candidate, you're probably not. If you're going into an interview, and you can't even think of what you bring to offer to the table, the employer's not going to know. It's your job, disability or not, to know what you bring to the table, and sell that. That's your job. Narrator: Selling it!" Dasha: "Selling it." Narrator: "That's what it comes down to, selling yourself, letting the employer know that you have a set of abilities that will help their company succeed. Well, there's that sound, so let's turn it over to Jessica Hodges with On the Horizon. Jessica: "Good day to you all. There are many, many lovely events coming up on the horizon. First of all, the national federation of the blind has some awesome scholarships for students both nationally and state wide. To find out more about scholarships both in your state and at the national level, you can visit www.nfb.org. On the subject of college, Perkins has a program for college students where you live on there campus for nine months, and attend school close to them. It's a good way for college students to kind of get there feet underneath them and make sure that they are really ready, and it's a great way to get started with college. You can visit there webcite to find out more. The national braille press has a guide for those who are interested in apple watches called, "You and Your Apple Watch," by Anna Dresner. You can find that on their webcite, nbp.org. Blind incorporated, the well renown training center for the national federation of the blind in Minnesota has there summer programs coming up, and that means they are looking for both students and counselors. For more information on those, you can go to their webcite, www.blindinc.org. For the style program, ,they're looking for people from July Tenth through August fifteenth, and the buddy program is also looking for people from July Tenth through August Fifteenth. For the prep counselor positions, they are looking for people from June Tenth, to August Fifteenth. The prep is the young adult program, the style is a young adult program here in Minnesota, and the buddy program is the younger children. So, if you would like to know more about that ,visit their webcite, www.blindinc.org. Minnesota has a lovely program for transition aged students called the STP program. An extended school year program, the STP, or summer transition program, is a program designed for students between tenth and eleventh grade who are planning on working competitively and working independently. To get a brochure or have paperwork sent to your school, contact Deb Peterson, dpeterson@916schools.org. If you have any events you'd like included on the next horizon, please email jessica.hodges@state.mn.us. Thank you for staying tuned, and please listen to next time, as we'll have more events on your horizon. Narrator: Well thank you Jessica Hodges. And for more information on all the events mentioned, check the show notes. for the links. And now, our tools for success spotlight. We bring you Be My Eyes. It's an application that hooks the phone to a person that will see through your camera what you're looking at and describe it for you. It's a personal assistant. It's free from the app store, and on Android. So we're going to demonstrate the iOS device on Apple, here's Be My Eyes. Siri? Open be my eyes. VoiceOver: Be My Eyes. Call first available volunteer, button. Narrator: It's ready to go. With a single finger double tap, you're activated, and you're ready to call. But lets swipe right, single finger swipe left to right. VoiceOver: Settings, button. Narrator: Double tap here VoiceOver: Settings, heading. Narrator: Now a flick to the right. VoiceOver: Done, button. Profile, heading. Personal details, Jeff Thompson, button Narrator: Swipe to the right. VoiceOver: Change email, button. Password, button. Languages, heading. Primary language, English, button. Other languages, button. Send us feedback, button. Frequently asked questions, button. Terms and privacy policy, button. Share be my eyes, button. Rate be my eyes, button. Connect with us, heading. Facebook, button. Twitter, button. Instagram, button. Youtube, button. Version: 2.1 Narrator: So this is upgraded, and as you can see you can share this, you can go follow them on Facebook, Twitter, and all the rest of the stuffs there. But one important thing here is this. VoiceOver: Send us feedback, button. Narrator: Send us feedback. This allows you to connect up right with the developers of the app in case you have an issue. You don't have to tweet it out on Twitter and complain or anything like that on Facebook. You can just go here, and send it straight to the main office. There you go. So let's go back. I'm going to do a four finger single tap, near the top of the screen. VoiceOver: Settings, heading. Narrator: Swipe once to the right. VoiceOver: Done, button. Narrator: Single finger double tap. VoiceOver: Call first available volunteer, button. Narrator: All right, so at this point, if I single finger double tap, I'm getting online, so I'd better have something ready for them to do for this demonstration. I think it's coffee time. VoiceOver Using the rear camera. Please wait. Finding the first available volunteer. (ringing sounds) Narrator: And this is where the be my eyes app. .. VoiceOver: We are still trying to find an available volunteer. Narrator: searches for someone that speaks English, someone that's in my time zone. So it searches the world basically, and tries to come up with someone who is best suited for answering my questions. Now this time varies. I've had people pick up in twelve seconds. I've had people pick up in... oh...two minutes. But typically, it's around that thirty second mark. And for privacy reasons, I've changed the voice of the volunteer so it's not detectible. VoiceOver: Connected. Volunteer: "Hello." (there was another word there but I couldn't for the life of me make it out.) Narrator: Hello. Hi, how are you? Volunteer: I'm all right, how about yourself? Narrator: I'm all right. I have a question. I have a kurig machine here, this one. Volunteer: Yep. Narrator: And when I push this down, it's supposed to give me a choice here for ounces. Volunteer: The light is hitting in a way I can't read. I think the... ok, that's better. You have... it says it's ten ounce, and there's an arrow at the top and an arrow at the bottom. Narrator: So down here? Volunteer: Up a little hire. Right there is where it says ten ounce, yep now it's at eight ounces. You're pushing the down button. How do you want it to be? Narrator: I want it at eight. Is that it? Volunteer: Ok. Narrator: So then the other buttons up here, what are they? Volunteer: Well, that would be increasing the amount, Narrator: Ok, Volunteer: and when you're ready, then you move your finger to the left Narrator: Ok. Volunteer: And use this button to make it go, let's see what happens. (kurig noises) Volunteer: It's brewing. Narrator: Well there we go. Thank you very much. Volunteer: You're very welcome.Have a good day." Narrator: You too. VoiceOver: End call, button. Alert. Are you sure you want to disconnect? No. Yes. Yes button. Narrator: And that was a very nice volunteer. And it wasn't mini mouse, believe me. That voice was changed. And there we go. We got hot cocoa coming. All right, so after the experience is over, this is what we get. VoiceOver: Review your experience, heading.. Thanks for your call. Please let us know if you had any problems during this call, be it either technical or personal. I experienced problems, button. I had a good call, button. Narrator: And that's it. that's all there is to this free app. it's be my eyes in app store, and be my eyes on android in the google play store. And in this success story, we bring you Jeff Mihiletch, who has utilized the services of state services for the blind for many years, from elementary school, high school, college, and the work place. Jeff has found success, and is currently employed, and invited us down to his south Minneapolis office to chat with us. So please welcome Jeff Mihiletch. We hope you in joy. Narrator: Welcome to blind abilities, I'm Jeff Thompson, and I'm downtown south Minneapolis with Jeff Mihiletch, and he is employed and has used state services for the blind before. How are you doing Jeff? Jeff: Good morning, I'm doing good. Narrator: Can you tell us a little bit about your job and what you do? Narrator: I am Jeff Mihiletch. I work in the snap employment and training program, and that is about people that receive food support, snap benefits that they used to call food stamps. If you are an able bodied adult without dependants, it's mandatory now that you be job searching, and my team does the job searching orientation classes and case management for clients that are in that sector of the snap program. I was originally hired for data management, so my job is to look at the referrals every day of new clients coming in, all the different elements, who they are, nationality, when there orientation class is, location and time, and I put it all in a spreadsheet. Then I take that spread sheet, move it into a different spread sheet so it's statistically meant for the entire year, and that's my daily task that I do. I also have broadened my job duties a little bit. My team does orientation class three times a week for new people that are coming onto the snap EMt program. I help out here at the sabathanie center with the Tuesday morning orientation class. So it's a chance for me to get up in front of a group and talk, and move around, helps give my coworkers a little break, because they need to do that orientation class three times a week, and as you can imagine it gets a little repetitive, so they were totally thrilled when I decided to volunteer myself to help out with that orientation class. Narrator: So Jeff, on a daily basis, what kind of accessible devices or tools do you utilize for your job? Jeff: I use Jaws extensively. I have a little bit of vision, so I do use zoomtext sometimes, but only for spot reading, if I can't find a formula or something in my excel sheet with jaws. Primarily though, it is Jaws, almost probably ninety five, ninety eight percent of the time. Narrator: What about in your personal life. Do you use a smart phone with access to it? Jeff: Yeah, in my personal life I have an iPhone seven. I use VoiceOver, a couple different voices, one for Siri, one for the VoiceOver functionality of it. My work, I have a phone for my work, because the phone that is in everyone's laptops, the soft phone from Sisco, is not screen reader accessible, and so that's a reasonable accommodation, my employer provides me an iPhone for my work. So I feel kind of a little geekish, because I walk around with two phones when I'm at work, my personal phone and my work phone. Narrator: that's status isn't it? Jeff: I'm glad that they were able to make that accommodation and provide an iPhone for my work phone calling. Narrator: Now Jeff, when you applied here, how did you get the job? how did accommodations work for you and what was that process like? Jeff: The way I found the job was I had a friend of mien who was blind who works for the county, has been with the county for almost thirty years, and he got a phone call from someone, my boss, who was looking to fill a position, a newly created position. My job did not exist before. And she specifically was looking for someone that had a visual disability. And so she reached out to my friend who was blind and worked for the company to find out and assess any barriers that their were, to see how successful he was at doing his job, and to see how many barriers there were, and from there, he told me about the fact that she was looking for someone who was visually impaired to take this new job. I kind of jumped on that band wagon, and followed up with her, and long story short had an interview, and was hired. My job is not a permanent job. It's a two year contract. I'm a limited duration person, and the snap program, the food stamp program is federal funded. So the county writes my check, but salary comes from the feds, from the agricultural program. Narrator: So Jeff, in your career, education, did you utilize state services for the blind? Jeff: Yeah, I did. All through my education. Elementary school I had a rehab counselor that used state services for the blind all the way through that, through college went to (spelling) babija university, BS in business administration, and minor in psychology and chemical dependency. And state services for the blind helped me out with tuition and books, and that type of thing. Narrator: Great. What is transportation like for you, working in south Minneapolis here? Jeff: In he morning to go into work, I take metro mobility, because it's a relatively direct shot, although sometimes I can get to work in ten minutes, and sometimes two hours, so that's the downside of metro mobility. Going home at night, I do take a city bus. I have to go downtown, and transfer to an express. That's how I do transportation. Not looking forward to winter time, I will say. Narrator: Great. So Jeff, Being someone that has used state services, who has transferred from high school to college to the work place, what suggestions would you have for someone who is in those shoes today looking towards there future? Jeff: I would say if you are a braille user, or have the potential to be a braille user, but also use screen readers, I would really highly recommend still doing the braille thing. Narrator: You said you use Jaws and PC. Now, in the workplace, there's always the debate, you know, should people have a PC or a Mack, and I found out myself that most businesses are Microsoft based, so what would you suggest for someone who's learning technology? Jeff: The county uses PCs, HP brand. Actually, we just rolled out new laptops and we moved to Microsoft 2010 and office 2016. I mean it all depends on the work environment, but you are correct most of the time that it's PC based. Narrator: Jeff, do you want to talk about some of your past jobs? Jeff: Sure. A lot of my job history is kind of broken into clumps. The first is social service, working with developmentally delayed adults, and the second chunk of job history is kind of more customer service type. So the first part, the social service, I kind of fell into that. I moved to Minneapolis after finishing my degree at Bemidji state university, and was really-really desperate for a job, couldn't find one, and it was to the point that I couldn't afford my apartment. I took a job as a live in in a group home for developmentally delayed adults. A good chunk is a little more customer service related, I worked in a large call center for computer hardware dispatch, so I was doing in bound calls with customers and technicians out in the field. Some other jobs I had over the years. I had a really really short gig. I was a very small commodities broker. I found the job through one of the venders that state services for the blind hires. They were looking for someone to do phone work and I was hired and given the job. But the screen reader didn't work at all with their customer management web page that they had. We tried to make it work. After six weeks they let me go, just because it wasn't working out. I also worked for a guy who ran one of the vending stands in saintpaul, and I would fill in for him in the concessions stand while he was out in the field filling vending machines. Did that for a while, and some other kind of odd jobs. I actually at one time was self employed. I went to massage school, became a massage therapist, and tried to do that to make a living. It's a really hard field. It's very seasonal. So that's a little overview of some of my job history. Narrator: Sounds like you're a real go getter. people feel insecure about going into job interviews and that process. And it can be daunting to someone that hasn't done it before. What's your experience like when you go into a job interview? Jeff: The interview process itself, I mean, I'm a partial vision, and it's always difficult to know whether to disclose that up front or not. And though there were times in my life when I would disclose that on the phone up front, and then there were other times when I did not. And it's hard to know if disclosing it up front would automatically disqualify me even before I walked in, or if walking in with a white cane and bumping against a desk or a coffee table or something would have disqualified me. It's always a big debate when you're a partial whether or not to disclose it. that was the one nice thing about my current job. My boss is aware of my current disability and I did not have to deal with that disclosure type thing. I had to deal with coworkers a little bit, and that was a challenge. Again, because I'm partial, I can see to navigate a little bit, but you know, I can't figure out who people are until they say something. When you're a partial, it's harder for other people to grasp of what you can and can't see. Narrator: Jeff, did you ever go through a training center? Jeff: I did. When I was in seventh grade I did a summer school thing at fairbolt. As an adult I did a couple different stints at VLR, adjustment to blindness training program. The focus for both of those times when I went was Jaws and screen readers. But I also did cooking class, the independent skills, worked in the wood shop, which was a really eye opening experience so to speak. I'd never used a table saw. I'd never used a router, that kind of thing. And it was so cool to actually create something myself out of a chunk of wood and have the skill set to do that. Yeah, I've been to VLR a couple times, they do really good stuff. I highly recommend them. And they were the ones the second time through. They were the ones that got me to Jaws. Because before, I would really try to use zoomtext as much as I could, and it was causing headaches and back strain, because I was leaning forward too much. So the second time I went through, I said, "I really want to get to the point where I can faze out magnification and just do jaws mostly. And so they got me to the point where I could use it exclusively and functionally. Yeah, the adjustment to blindness centers were very helpful. Narrator: That's vision loss resources on Franklin and Lyndale down in Minneapolis. Well, I want to thank you for coming on to blind abilities and sharing your story, your journey, thank you very much. Jeff: You are welcome. Hopefully my perspective is useful and helpful for you young people out there, you know, in the path of education and early job searching. Good luck to you, and I wish I would have had this technology when I was going to college. It would have made my college experience much easier, much less stressful, maybe a few less gray hairs. Narrator: I don't think we can get around the hairs, we can blame it on whatever we want but... well thank you very much Jeff. Jeff: Thank you very much Narrator: It was a real pleasure talking to Jeff Mihiletch and learning about his transitional journey from high school to college to the workplace, and his experiences job to job. And you can find out more about state services for the blind and the services they can offer you on the web at https://mn.gov/deed/ssb. And in other states, be sure to contact your state services, and see what services they have for you. And be sure to check the show notes for the American foundation of the blind. They have a link to all the state services in all the states. Stay tuned next month where we bring you episode three of TVI toolbox. And a big thank you goes out to CheeChau for his beautiful music that we use for the podcast. Thank you CheeChau. You can follow Cheechau on Twitter @lcheechau. Thanks for listening, we hope you enjoyed, and until next time, by by.
Kim Smith has a special story about her dog, Wink, who almost died from an abusive incident. He lived and she tells his story! Later, restaurateur Jeff Good joins us to talk about why he chooses Mississippi to house his several restaurants. See acast.com/privacy for privacy and opt-out information.
Jeff Good is an extremely accomplished restaurateur. He spends his days running 3 of Mississippians most successful restaurants. After college, Jeff spent 7 years working as a computer salesman for a Fortune 100 technology company. After that time Jeff opened BRAVO! with his partner Dan Blumenthal in the spring of 1994. They later opened Broadstreet Bakery and Sal and Mookies. In this episode, you'll hear about the hard work and sacrifices that it takes to establish and run a restaurant. This episode is loaded with practical tips and advice that I know you will enjoy.
Jeff Good from Not Another Magic Podcast Joins us for a discussion of Vintage Artist Constructed and creating decks for new players. Jeff’s VAC Spreadsheet - https://docs.google.com/spreadsheets/d/1PijlROdisc1Ci0mNclo6lDIIhyjJ8vMUtX0wHhJlLk4/edit?usp=sharing Magic Cards Dot Info Search - http://magiccards.info/search.html Puca Trade Search - https://pucatrade.com/search Check Out Our Facebook Group – https://www.facebook.com/groups/669935343108314/ RSS Feed - http://willofthecouncilcast.libsyn.com/rss How to reach Jeff: Twitter @lowguppy Cast contact info: Contact Info – You can find the cast on www.mtgcast.com or at www.cardconfidants.com Twitter – @willofthecast Email – WilloftheCast@gmail.com Zeki can be found at - @Zektown on Twitter Brian can be found on Twitter - @inkyscholar Zeki and Brian also write for Card Confidants Eternal shout out to @BalduvianBears and Houston @TNSGingerAle . Follow them and check out their podcast - Tap N Sac Our intro/outro music “Is Good vs. Looks Good” by cast friends Loud House is available at – https://loudhousephl.bandcamp.com/releases Read more at http://willofthecouncilcast.libsyn.com/#siy2TGLjYkS1WZ7y.99
On this week's episode Keeping Karlsson Fantasy Hockey Podcast, we try something different, giving you a behind the scenes, unedited and uncut look at the Keeping Karlsson Ultimate Patron Fantrax League's Championship Division auction draft. Elan and Brian have a quick chat to open the show about lessons they may or may not have learned from their super competitive auction draft experiences. We then share the live broadcast of the KKUPFL Tier 1 auction draft, hosted by Elan and Jeff Good, which Brian repeatedly tries to join only to have to suddenly leave when players he wants get nominated. We laugh, we cry, we talk about the fantasy value of players as they're drafted, we heap criticism upon Brian's real-time decisions whenever possible. Later this week, keep an eye out for our interview with Peter Harling of Dobber Prospects Radio where we'll offer up some thoughts on which rookies are ready to make a fantasy impact in 2016-17, and then we'll be back with our next episode about all the preseason comings and goings on Monday, October 10. See the auction draft results at http://www.keepingkarlsson.com/blog, and view the live auction video on our youtube channel at http://www.keepingkarlsson.com/youtube. * * * Download this episode, subscribe, and review us on iTunes! If you enjoy the show, please support future episodes by becoming a patron of Keeping Karlsson. Keeping Karlsson patrons can join our patron-only Facebook group and take part in (and receive audio from) a monthly live, face-to-face and interactive Keeping Karlsson recording! You can also support us by telling a friend, subscribing to and reviewing Keeping Karlsson on iTunes, and following us on Twitter (@keepingkarlsson). Feel free to tweet us with your feedback, fantasy hockey questions, and topic requests for future episodes. The Keeping Karlsson Fantasy Hockey Podcast is proudly presented by DobberHockey. Thanks for listening! Want to advertise on this podcast? Go to https://redcircle.com/brands and sign up.
While you sit by the phone waiting for your Professional Tryout Offers from the Leafs, here's a brand new episode of the Keeping Karlsson Fantasy Hockey Podcast to tide you over! Elan and Brian return to once again gather and dissect all of the latest fantasy relevant tidbits regarding your soon-to-be training camp competitors and more, letting you know how the past week's developments might affect your pre-season player rankings and roster moves.On this episode, we look at a recent collection of signings, trades and training camp invites across the league, zeroing in on a pair of blue-liners looking for a boost in power-play opportunities and a couple journeymen goal-scorers hoping for the extra minutes that they may have rightfully earned.Elan also chats with Not Another Magic Podcast's (and Keeping Karlsson Patron!) Jeff Good about how to prepare for your first auction draft: nailing down player values, setting up a budget, getting the mechanics down, and more!Players discussed on this episode include Cody Franson, Johan Franzen, Curtis Glencross, Marek Zidlicky, Kris Versteeg, Artemi Panarin, Teuvo Teravainen, Marko Dano, Jiri Tlusty, Michael Grabner, Lubomir Visnovsky, Ray Emery, Brad Boyes, Martin Havlat, Derek Roy, Tomas Fleischmann, Lee Stempniak, James van Riemsdyk, Mike Cammalleri, Adam Henrique, Rasmus Ristolainen, Zach Bogosian, Johnny Boychuk, Nick Leddy, Frans Nielsen, and more.Keeping Karlsson is proudly presented by Dobber Hockey and supported by our patrons.***Download this episode, subscribe, and review us on iTunes!If you enjoy the show, please support future episodes by becoming a patron of Keeping Karlsson. Keeping Karlsson patrons can join our patron-only Facebook group and take part in (and receive audio from) a monthly live, face-to-face and interactive Keeping Karlsson recording!You can also support us by telling a friend, subscribing to and reviewing Keeping Karlsson on iTunes, and following us on Twitter (@keepingkarlsson). Feel free to tweet us with your feedback, fantasy hockey questions, and topic requests for future episodes. Thanks for listening!Want to advertise on this podcast? Go to https://redcircle.com/brands and sign up.
With the summer series coming to an end we've decided to squeeze in a bonus episode before we go back to our weekly format. Back on episode 74 Keeping Karlsson Patron and auction draft expert Jeff Good came on to share some of his auction expertise. With drafts fast approaching we decided to have Jeff back to build on last year's discussion. There's definitely lots of useful information here for anyone interested in participating in an auction draft at some point.Also this episode features the debut of our interview theme song created by the great Pat Roach.A reminder that SeatGeek is offering listeners a $20 rebate off your first ticket purchase: just head to their website or download the app, go to your profile, and enter the promo code KEEPING before buying your tickets!* * * Download this episode, subscribe, and review us on iTunes!If you enjoy the show, please support future episodes by becoming a patron of Keeping Karlsson. Keeping Karlsson patrons can join our patron-only Facebook group and take part in (and receive audio from) a monthly live, face-to-face and interactive Keeping Karlsson recording!You can also support us by telling a friend, subscribing to and reviewing Keeping Karlsson on iTunes, and following us on Twitter (@keepingkarlsson). Feel free to tweet us with your feedback, fantasy hockey questions, and topic requests for future episodes. The Keeping Karlsson Fantasy Hockey Podcast is proudly presented by DobberHockey.Thanks for listening!Want to advertise on this podcast? Go to https://redcircle.com/brands and sign up.
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