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Listen Up Home Buyers—Jeff Jackson With FIMAVictoria: Hi, I'm Victoria Ray Henderson, the host of the NABA podcast, Listen Up Homebuyers. So happy to have back for a second round of conversations, Jeff Jackson, the Deputy Assistant Administrator for the Federal Insurance Directorate. He leads flood insurance operations for the National Flood Insurance Program at FEMA. And Jeff, I want to thank you so much for being a guest again on Listen Up Homebuyers.Jeff: Thanks. It's great to be back.Victoria: So glad to have you. I'd like to start with a very general question. What should every homebuyer know about flood insurance?Jeff: The most important thing to know is then that in all but the rarest of cases, flood risk is not insured through your homeowner's insurance policy. If you want to have coverage for water that comes from the outside and comes inside your house, so not stink backups, not toilet backups. Those kinds of things, but water coming in from the outside, it requires a separate flood insurance policy. You can either buy that from the National Flood Insurance Program, which is through FIMA, or there often are a number of private flood insurance policies that you can buy as well.Victoria: So if somebody lives in an area that isn't by the coast, isn't necessarily by a creek or a river, what do they need to know about flood insurance?Jeff: Well, it floods everywhere. There have been in the last little bit under 25 years, 99% of the counties in America have flooded. So, it's happening somewhere in your county. And what I would say is it's not always readily apparent just by looking around and seeing the distance to the nearest water source, although that's an extremely important factor. Changes in our built environment, the more we see paving, the more we see development of what was traditionally green space can raise our flood risk as well. And so there can be an illusion that you don't have flood risk when in actuality, you're at least perhaps moderately risky. And that certainly is an area when you get there, you would at least want to strongly only consider buying a flood insurance policy.Victoria: Okay. So as you know, I only work for people buying homes as an exclusive buyer broker. So the first thing that we typically do when they're going to be buying a home is see how well they're qualified to obtain a mortgage. At what point should a home buyer be looking at the risk that could be potentially there in a house of interest?Jeff: I would say it's when you get that listing from your broker and you see a list of houses, it's good to go look them up on the FIMA maps to see if it's a place where you would have to buy flood insurance. And we certainly went over this the last time I was here. But for the folks who are checking in for the first time, if you are in a high-risk area, what's called a special flood hazard area, and you have a federally backed mortgage, which is most mortgages, then you're required to buy. For everyone else, it's an option to buy, and for those where it's required, certainly as you go through the lending process, that will be made clear to you.But really, getting back to the heart of your question, it's when you walk through the door of the house for the first time. It's everything from knowing if it's in a high-risk area as you go and choose to look at the listing, as well as when you walk through the property, look around and look for what are there any signs of water in this house? Are there stomp pumps? Has clearly work been done because there's a drainage issue in a basement? Many places have that. So you don't have to be scared away that it's a matter of going in and learning as much as you can about the property so that you make a decision about whether or not to purchase it, and then if you do purchase it; First, do you have to buy, have flood insurance? And then second, should you choose to buy flood insurance?Victoria: Right, I always tell people that I'm working with that when we go into a house, the first thing I'm going to tell you is everything that's wrong with it. And I go straight to the basement because we both live in the greater Washington, D.C. area, and we have a lot of wet basements, a lot of issues, along the Potomac River. Just last week, I'm working with clients in Old Town, Alexandria, and they were interested in a condominium, and I checked the flood maps, and it's in an A.E. flood map. Walk me through what your advice would be for a homebuyer in that situation if they really wanted to put an offer in on a place like that.Jeff: The first thing I would do is reach out to your insurance agent and get a quote, not just for homeowners insurance, but also for flood insurance. If you're in that A.E. zone, that's one of the zones that is required to purchase if you have a federally backed mortgage. So I would go get a flood quote and factor that in, the cost of that in, when you're determining the affordability of the house, and as you're comparing it to other properties, perhaps where you might not have to buy a flood insurance policy and make that part of your buying decision, the more you can learn about a property, including from the cost perspective. But your number one trigger should be, have your insurance agent on speed dial. So, when you see that house, you know that Saturday is coming, you're getting excited about going and looking at all these properties, you know for that one, you would have to factor in cost.Victoria: When people are looking at properties and it's zoned X, but they aren't that far from a zone A.E., you had mentioned that typical flood insurance isn't covered in most homeowners insurance. Is that correct?Jeff: That's right.Victoria: Yeah. So, if you are anywhere near an A.E., would your advice be to go ahead and look into flood insurance?Jeff: I would go ahead and do it for a couple of reasons. The FIMA flood maps are really a regulatory product designed to decide when we as a country and particularly looking out for the mortgage holders' interest, when we're going to say, hey, we need you to go ahead and purchase this insurance because your high risk. If you're just outside of the high-risk area, you're not no risk, and that's the biggest myth that we have to bust here as we teach folks about flood risk in America. You're probably at medium risk. Medium to medium high is a good way of characterizing it.What we know over time is it only takes about an inch of water that can quickly get you up to around a $25,000 cost repairing your home. So, in that circumstance, I certainly would buy a policy. It really gives you peace of mind. It is an expense and I know with housing being so expensive and insurance costs are rising, it's not exciting to add an additional expense into the household budget to be sure. But we talk to people every year who do have the coverage and who do experience a loss. And they look at, let's say, a $50,000 or $60,000 flood loss, which is pretty common.Victoria: Okay.Jeff: Not average, but common, and so if you don't have the coverage, you're looking at covering that, putting things on a credit card, taking it out of your home equity. If you just bought the property, depending upon the size of your down payment, you may not have a lot of equity, and it really can set you back. People get set back decades and don't financially or don't financially recover at all. So particularly for the people in that situation that you described, it would be a great investment. Your home is your biggest investment for most of us, and this certainly will help you protect that investment.Victoria: Is it possible to give kind of an average, and we're not going to hold you to this, but an average cost for flood insurance? So people have some idea of what they'd be looking at.Jeff: Our average cost is a little bit over $800 right now.Victoria: Okay.Jeff: But it can range and particularly for those who are just outside of a high-risk area, it's going to be a little bit more than that probably. But the average cost right now is just a little bit over $800. The National Flood Insurance Program was created because we have an insurability problem in America, as well as an affordability problem. We haven't unfortunately solved the affordability problem in all these years, but the NFIP is here and we'll sell a policy to anyone in any of the 22,600 participating communities. So that availability problem that we see with, you know, we see insurers pulling out of places like California. We see people dropping people in Florida, insurers dropping people in Florida.With the NFIP that we're going to be there and we're going to continue to sell you the insurance. It is going to be at a risk-based price. That's the affordability piece of things, and it's one of the reasons why certainly for those who can afford to do so, we encourage you to buy, and for those that can't afford it, we continue to advocate to Congress to provide some type of assistance, and we're hopeful that one day that'll be in place as well.Victoria: On this podcast, we're going to include some links so that people can learn more, from the FIMA maps and regarding the flood insurance that you're talking about. Is there anything else that you would like consumers to know and specifically, again, people who are buying homes, anything that you could share with your expertise?Jeff: One is that the FIMA flood map is a snapshot in time. It may be some vintage and certainly has to be reevaluated to make sure it continues to represent the flood picture every five years, but a lot can happen in five years. Maps get updated on a priority order. And so, it's not uncommon to see a 10-year-old map that probably is pretty close to what the risk is. But if you're expecting fine line gradations and risk, that's not really what it's designed to do. It's designed to say it's tremendously helpful for the folks in your community who manage the floodplain, particularly at the county level. It's an important technical product for them. It's important for realtors and it certainly important to help you learn if you have to buy.What it's not great at is a nuanced view of risk, and so I caution against over-reliance on the flood maps, and I think the way you look at it is the right way to think about it, which is not just, am I in or am I out of the high risk zone? But how close am I to water sources? And then give some thought and have some conversation around what have been the changes to the built environment? Say, every map will have a date on it. What's the environment? What's happened since that map was put into place? That certainly is one thing.The second thing I would say is for many years, there's been a school of thought, which is that if you don't have to buy the insurance, you don't need it, you don't need to talk about it. I caution against anybody, gives you a very dismissive, oh, you don't need that, and so we don't need to bother to talk about it. I think that's a thinking that's a little bit behind the times and is certainly not where I would want to be as a consumer in terms of getting service from whoever would be giving me that advice. So I would counsel against you don't need it. I think there are a number of great agents. There are a number of great insurance agents who will help talk you through a nuanced conversation. I think somebody who's willing to get in a conversation with you is where I would want to be as a buyer.Victoria: Yeah, I think exclusive buyer brokers like myself, and we're all over the country, one of the first things we want to do is educate and inform, which is why I have you on this podcast, because people need to know what the risks are, and then they can make a decision based on that. I live in the Washington area, and every summer, I end up flocking to the beach, just like everybody does. Sometimes I drive along that strip, that little narrow strip of Ocean City and Lewis, Delaware, and then Dewey and Rehoboth and just think, this is a pretty risky area.Jeff: Yeah, it certainly is, there's been so much evolution in the science of catastrophe modeling and learning all the flooding events that potentially could happen. The more I talk to those experts, the more that I learn is that the amount of time we're in a home is infinitesimally small. It's just minute, and you'll hear owners of homes say, I've been here for 10 years, I've been here for 15 years, and it's never flooded. So, it's probably not likely to flood. And while previous flooding experience is important, it's just such a small amount of time. I mean, the way the water patterns work, 100 years is just beginning to get to the point where you really get a keen sense of how water is moving around and what the risk is in a particular area.And then that's on top of the fact that we change things so much. I mean, we're fortunate to live in these areas where things are getting torn down and things are getting rebuilt and we need additional parking. And so, there's got to be an extra lot. And so, there's all these things that sort of hopefully will move us away from maybe the people selling us the property had it for 15 years and it never flooded there. I wouldn't let that be the end of my inquiry.Victoria: No, definitely not. I mean, it's the biggest financial commitment you're going to make in your life until you, I guess, do it again. But you don't want to make a mistake like this.Jeff: We have a great website called FloodSmart.gov. It has all kinds of information about flood insurance policies, and that's important, but also just about flood risk in America. So, it's a great resource to go out and learn a little bit. Encourage your listeners to go check that out and we've got some videos on that as well. So, go check that out.Victoria: Great. Jeff Jackson is the Deputy Assistant Administrator for the Federal Insurance Directorate. He leads flood insurance operations for the National Flood Insurance Program at FIMA. Jeff, it is such a pleasure to talk to you again about flood insurance here on Listen Up Homebuyers.Jeff: It was great to be with you. Thanks.FEMA flood insurance Listen Up, Home Buyers! The podcast offering advice and tips from true buyer agents. Host and Producer, Victoria Ray Henderson is the owner and broker of HomeBuyer Brokerage in the Washington D.C. area. Victoria is and a member of the National Association of Exclusive Buyer Agents.

Jeff Morris, VP of Product & Solutions Marketing at Couchbase, joins Corey on Screaming in the Cloud to discuss Couchbase's new columnar data store functionality, specific use cases for columnar data stores, and why AI gets better when it communicates with a cleaner pool of data. Jeff shares how more responsive databases could allow businesses like Dominos and United Airlines to create hyper-personalized experiences for their customers by utilizing more responsive databases. Jeff dives into the linked future of AI and data, and Corey learns about Couchbase's plans for the re:Invent conference. If you're attending re:Invent, you can visit Couchbase at booth 1095.About JeffJeff Morris is VP Product & Solutions Marketing at Couchbase (NASDAQ: BASE), a cloud database platform company that 30% of the Fortune 100 depend on.Links Referenced:Couchbase: https://www.couchbase.com/TranscriptAnnouncer: Hello, and welcome to Screaming in the Cloud with your host, Chief Cloud Economist at The Duckbill Group, Corey Quinn. This weekly show features conversations with people doing interesting work in the world of cloud, thoughtful commentary on the state of the technical world, and ridiculous titles for which Corey refuses to apologize. This is Screaming in the Cloud.Corey: Welcome to Screaming in the Cloud. I'm Corey Quinn. This promoted guest episode of Screaming in the Cloud is brought to us by our friends at Couchbase. Also brought to us by Couchbase is today's victim, for lack of a better term. Jeff Morris is their VP of Product and Solutions Marketing. Jeff, thank you for joining me.Jeff: Thanks for having me, Corey, even though I guess I paid for it.Corey: Exactly. It's always great to say thank you when people give you things. I learned this from a very early age, and the only people who didn't were rude children and turned into worse adults.Jeff: Exactly.Corey: So, you are effectively announcing something new today, and I always get worried when a database company says that because sometimes it's a license that is going to upset people, sometimes it's dyed so deep in the wool of generative AI that, “Oh, we're now supporting vectors or whatnot.” Well, most of us don't know what that means.Jeff: Right.Corey: Fortunately, I don't believe that's what you're doing today. What have you got for us?Jeff: So, you're right. It's—well, what I'm doing is, we're announcing new stuff inside of Couchbase and helping Couchbase expand its market footprint, but we're not really moving away from our sweet spot, either, right? We like building—or being the database platform underneath applications. So, push us on the operational side of the operational versus analytic, kind of, database divide. But we are announcing a columnar data store inside of the Couchbase platform so that we can build bigger, better, stronger analytic functionality to feed the applications that we're supporting with our customers.Corey: Now, I feel like I should ask a question around what a columnar data store is because my first encounter with the term was when I had a very early client for AWS bill optimization when I was doing this independently, and I was asking them the… polite question of, “Why do you have 283 billion objects in a single S3 bucket? That is atypical and kind of terrifying.” And their answer was, “Oh, we built our own columnar data store on top of S3. This might not have been the best approach.” It's like, “I'm going to stop you there. With no further information, I can almost guarantee you that it was not.” But what is a columnar data store?Jeff: Well, let's start with the, everybody loves more data and everybody loves to count more things, right, but a columnar data store allows you to expedite the kind of question that you ask of the data itself by not having to look at every single row of the data while you go through it. You can say, if you know you're only looking for data that's inside of California, you just look at the column value of find me everything in California and then I'll pick all of those records to analyze. So, it gives you a faster way to go through the data while you're trying to gather it up and perform aggregations against it.Corey: It seems like it's one of those, “Well, that doesn't sound hard,” type of things, when you're thinking about it the way that I do, in terms of a database being more or less a medium to large size Excel spreadsheet. But I have it on good faith from all the customer environments. I've worked with that no, no, there are data stores that span even larger than that, which is, you know, one of those sad realities of the world. And everything at scale begins to be a heck of a lot harder. I've seen some of the value that this stuff offers and I can definitely understand a few different workloads in which case that's going to be super handy. What are you targeting specifically? Or is this one of those areas where you're going to learn from your customers?Jeff: Well, we've had analytic functionality inside the platform. It just, at the size and scale customers actually wanted to roam through the data, we weren't supporting that that much. So, we'll expand that particular footprint, it'll give us better integration capabilities with external systems, or better access to things in your bucket. But the use case problem is, I think, going to be driven by what new modern application requirements are going to be. You're going to need, we call it hyper-personalization because we tend to cater to B2C-style applications, things with a lot of account profiles built into them.So, you look at account profile, and you're like, “Oh, well Jeff likes blue, so sell him blue stuff.” And that's a great current level personalization, but with a new analytic engine against this, you can maybe start aggregating all the inventory information that you might have of all the blue stuff that you want to sell me and do that in real-time, so I'm getting better recommendations, better offers as I'm shopping on your site or looking at my phone and, you know, looking for the next thing I want to buy.Corey: I'm sure there's massive amounts of work that goes into these hyper-personalization stories. The problem is that the only time they really rise to our notice is when they fail hilariously. Like, you just bought a TV, would you like to buy another? Now statistically, you are likelier to buy a second TV right after you buy one, but for someone who just, “Well, I'm replacing my living room TV after ten years,” it feels ridiculous. Or when you buy a whole bunch of nails and they don't suggest, “Would you like to also perhaps buy a hammer?”It's one of those areas where it just seems like a human putting thought into this could make some sense. But I've seen some of the stuff that can come out of systems like this and it can be incredible. I also personally tend to bias towards use cases that are less, here's how to convince you to buy more things and start aiming in a bunch of other different directions where it starts meeting emerging use cases or changing situations rapidly, more rapidly than a human can in some cases. The world has, for better or worse, gotten an awful lot faster over the last few decades.Jeff: Yeah. And think of it in terms of how responsive can I be at any given moment. And so, let's pick on one of the more recent interesting failures that has popped up. I'm a Giants fan, San Francisco Giants fan, so I'll pick on the Dodgers. The Dodgers during the baseball playoffs, Clayton Kershaw—three-time MVP, Cy Young Award winner, great, great pitcher—had a first-inning meltdown of colossal magnitude: gave up 11 runs in the first inning to the Diamondbacks.Well, my customer Domino's Pizza could end up—well, let's shift the focus of our marketing. We—you know, the Dodgers are the best team in baseball this year in the National League—let's focus our attention there, but with that meltdown, let's pivot to Arizona and focus on our market in Phoenix. And they could do that within minutes or seconds, even, with the kinds of capabilities that we're coming up with here so that they can make better offers to that new environment and also do the decision intelligence behind it. Like, do I have enough dough to make a bigger offer in that big market? Do I have enough drivers or do I have to go and spin out and get one of the other food delivery folks—UberEats, or something like that—to jump on board with me and partner up on this kind of system?It's that responsiveness in real, real-time, right, that's always been kind of the conundrum between applications and analytics. You get an analytic insight, but it takes you an hour or a day to incorporate that into what the application is doing. This is intended to make all of that stuff go faster. And of course, when we start to talk about things in AI, right, AI is going to expect real-time responsiveness as best you can make it.Corey: I figure we have to talk about AI. That is a technology that has absolutely sprung to the absolute peak of the hype curve over the past year. OpenAI released Chat-Gippity, either late last year or early this year and suddenly every company seems to be falling all over itself to rebrand itself as an AI company, where, “We've been working on this for decades,” they say, right before they announce something that very clearly was crash-developed in six months. And every company is trying to drape themselves in the mantle of AI. And I don't want to sound like I'm a doubter here. I'm like most fans; I see an awful lot of value here. But I am curious to get your take on what do you think is real and what do you think is not in the current hype environment.Jeff: So yeah, I love that. I think there's a number of things that are, you know, are real is, it's not going away. It is going to continue to evolve and get better and better and better. One of my analyst friends came up with the notion that the exercise of generative AI, it's imprecise, so it gives you similarity things, and that's actually an improvement, in many cases, over the precision of a database. Databases, a transaction either works or it doesn't. It has failover or it doesn't, when—Corey: It's ideally deterministic when you ask it a question—Jeff: Yes.Corey: —the same question a second time, assuming it's not time-bound—Jeff: Gives you the right answer.Corey: Yeah, the sa—or at least the same answer.Jeff: The same answer. And your gen AI may not. So, that's a part of the oddity of the hype. But then it also helps me kind of feed our storyline of if you're going to try and make Gen AI closer and more accurate, you need a clean pool of data that you're dealing with, even though you've got probably—your previous design was such that you would use a relational database for transactions, a document database for your user profiles, you'd probably attach your website to a caching database because you needed speed and a lot of concurrency. Well, now you got three different databases there that you're operating.And if you're feeding data from each of those databases back to AI, one of them might be wrong or one of them might confuse the AI, yet how are you going to know? The complexity level is going to become, like, exponential. So, our premise is, because we're a multi-modal database that incorporates in-memory speed and documents and search and transactions and the like, if you start with a cleaner pool of data, you'll have less complexity that you're offering to your AI system and therefore you can steer it into becoming more accurate in its response. And then, of course, all the data that we're dealing with is on mobile, right? Data is created there for, let's say, your account profile, and then it's also consumed there because that's what people are using as their application interface of choice.So, you also want to have mobile interactivity and synchronization and local storage, kind of, capabilities built in there. So, those are kind of, you know, a couple of the principles that we're looking at of, you know, JSON is going to be a great format for it regardless of what happens; complexity is kind of the enemy of AI, so you don't want to go there; and mobility is going to be an absolute requirement. And then related to this particular announcement, large-scale aggregation is going to be a requirement to help feed the application. There's always going to be some other bigger calculation that you're going to want to do relatively in real time and feed it back to your users or the AI system that's helping them out.Corey: I think that that is a much more nuanced use case than a lot of the stuff that's grabbing customer attentions where you effectively have the Chat-Gippity story of it being an incredible parrot. Where I have run into trouble with the generative story has been people putting the thing that the robot that's magic and from the future has come up with off the cuff and just hurling that out into the universe under their own name without any human review, and that's fine sometimes sure, but it does get it hilariously wrong at some points. And the idea of sending something out under my name that has not been at least reviewed by me if not actually authored by me, is abhorrent. I mean, I review even the transactional, “Yes, you have successfully subscribed,” or, “Sorry to see you go,” email confirmations on stuff because there's an implicit, “Hugs and puppies, love Corey,” at the end of everything that goes out under my name.Jeff: Right.Corey: But I've gotten a barrage of terrible sales emails and companies that are trying to put the cart before the horse where either the, “Support rep,” quote-unquote, that I'm speaking to in the chat is an AI system or else needs immediate medical attention because there's something going on that needs assistance.Jeff: Yeah, they just don't understand.Corey: Right. And most big enterprise stories that I've heard so far that have come to light have been around the form of, “We get to fire most of our customer service staff,” an outcome that basically no one sensible wants. That is less compelling than a lot of the individualized consumer use cases. I love asking it, “Here's a blog post I wrote. Give me ten title options.” And I'll usually take one of them—one of them is usually not half bad and then I can modify it slightly.Jeff: And you'll change four words in it. Yeah.Corey: Yeah, exactly. That's a bit of a different use case.Jeff: It's been an interesting—even as we've all become familiar—or at least junior prompt engineers, right—is, your information is only going to be as good as you feed the AI system—the return is only going to be as good—so you're going to want to refine that kind of conversation. Now, we're not trying to end up replacing the content that gets produced or the writing of all kinds of pros, other than we do have a code generator that works inside of our environment called Capella iQ that talks to ChatGPT, but we try and put guardrails on that too, right, as always make sure that it's talking in terms of the context of Couchbase rather than, “Where's Taylor Swift this week,” which I don't want it to answer because I don't want to spend GPT money to answer that question for you.Corey: And it might not know the right answer, but it might very well spit out something that sounds plausible.Jeff: Exactly. But I think the kinds of applications that we're steering ourselves toward can be helped along by the Gen AI systems, but I don't expect all my customers are going to be writing automatic blog post generation kinds of applications. I think what we're ultimately trying to do is facilitate interactions in a way that we haven't dreamt of yet, right? One of them might be if I've opted into to loyalty programs, like my United account and my American Express account—Corey: That feels very targeted at my lifestyle as well, so please, continue.Jeff: Exactly, right? And so, what I really want the system to do is for Amex to reward me when I hit 1k status on United while I'm on the flight and you know, have the flight attendant come up and be like, “Hey, you did it. Either, here's a free upgrade from American Express”—that would be hyper-personalization because you booked your plane ticket with it, but they also happen to know or they cross-consumed information that I've opted into.Corey: I've seen them congratulate people for hitting a million miles flown mid-flight, but that's clearly something that they've been tracking and happens a heck of a lot less frequently. This is how you start scaling that experience.Jeff: Yes. But that happened because American Airlines was always watching because that was an American Airlines ad ages ago, right, but the same principle holds true. But I think there's going to be a lot more of these: how much information am I actually allowing to be shared amongst the, call it loyalty programs, but the data sources that I've opted into. And my God, there's hundreds of them that I've personally opted into, whether I like it or not because everybody needs my email address, kind of like what you were describing earlier.Corey: A point that I have that I think agrees largely with your point is that few things to me are more frustrating than what I'm signing up, for example, oh, I don't know, an AWS even—gee, I can't imagine there's anything like that going on this week—and I have to fill out an entire form that always asked me the same questions: how big my company is, whether we have multiple workloads on, what industry we're in. And no matter what I put into that, first, it never remembers me for the next time, which is frustrating in its own right, but two, no matter what I put in to fill that thing out, the email I get does not change as a result. At one point, I said, all right—I'm picking randomly—“I am a venture capitalist based in Sweden,” and I got nothing that is differentiated from the other normal stuff I get tied to my account because I use a special email address for those things, sometimes just to see what happens. And no, if you're going to make me jump through the hoops to give you the data, at least use it to make my experience better. It feels like I'm asking for the moon here, but I shouldn't be.Jeff: Yes. [we need 00:16:19] to make your experience better and say, you know, “Here's four companies in Malmo that you ought to be talking to. And they happen to be here at the AWS event and you can go find them because their booth is here, here, and here.” That kind of immediate responsiveness could be facilitated, and to our point, ought to be facilitated. It's exactly like that kind of thing is, use the data in real-time.I was talking to somebody else today that was discussing that most data, right, becomes stale and unvaluable, like, 50% of the data, its value goes to zero after about a day. And some of it is stale after about an hour. So, if you can end up closing that responsiveness gap that we were describing—and this is kind of what this columnar service inside of Capella is going to be like—is react in real-time with real-time calculation and real-time look-up and real-time—find out how you might apply that new piece of information right now and then give it back to the consumer or the user right now.Corey: So, Couchbase takes a few different forms. I should probably, at least for those who are not steeped in the world of exotic forms of database, I always like making these conversations more accessible to folks who are not necessarily up to speed. Personally, I tend to misuse anything as a database, if I can hold it just the wrong way.Jeff: The wrong way. I've caught that about you.Corey: Yeah, it's—everything is a database if you hold it wrong. But you folks have a few different options: you have a self-managed commercial offering; you're an open-source project, so I can go ahead and run it on my own infrastructure however I want; and you have Capella, which is Couchbase as a service. And all of those are useful and have their points, and I'm sure I'm missing at least one or two along the way. But do you find that the columnar use case is going to disproportionately benefit folks using Capella in ways that the self-hosted version would not be as useful for, or is this functionality already available in other expressions of Couchbase?Jeff: It's not already available in other expressions, although there is analytic functionality in the self-managed version of Couchbase. But it's, as I've mentioned I think earlier, it's just not as scalable or as really real-time as far as we're thinking. So, it's going to—yes, it's going to benefit the database as a service deployments of Couchbase available on your favorite three clouds, and still interoperable with environments that you might self-manage and self-host. So, there could be even use cases where our development team or your development team builds in AWS using the cloud-oriented features, but is still ultimately deploying and hosting and managing a self-managed environment. You could still do all of that. So, there's still a great interplay and interoperability amongst our different deployment options.But the fun part, I think, about this is not only is it going to help the Capella user, there's a lot of other things inside Couchbase that help address the developers' penchant for trading zero-cost for degrees of complexity that you're willing to accept because you want everything to be free and open-source. And Couchbase is my fifth open-source company in my background, so I'm well, well versed in the nuances of what open-source developers are seeking. But what makes Couchbase—you know, its origin story really cool too, though, is it's the peanut butter and chocolate marriage of memcached and the people behind that and membase and CouchDB from [Couch One 00:19:54]. So, I can't think of that many—maybe Red Hat—project and companies that formed up by merging two complementary open-source projects. So, we took the scale and—Corey: You have OpenTelemetry, I think, that did that once, but that—you see occasional mergers, but it's very far from common.Jeff: But it's very, very infrequent. But what that made the Couchbase people end up doing is make a platform that will scale, make a data design that you can auto partition anywhere, anytime, and then build independently scalable services on top of that, one for SQL++, the query language. Anyone who knows SQL will be able to write something in Couchbase immediately. And I've got this AI Automator, iQ, that makes it even easier; you just say, “Write me a SQL++ query that does this,” and it'll do that. But then we added full-text search, we added eventing so you can stream data, we added the analytics capability originally and now we're enhancing it, and use JSON as our kind of universal data format so that we can trade data with applications really easily.So, it's a cool design to start with, and then in the cloud, we're steering towards things like making your entry point and using our database as a service—Capella—really, really, really inexpensive so that you get that same robustness of functionality, as well as the easy cost of entry that today's developers want. And it's my analyst friends that keep telling me the cloud is where the markets going to go, so we're steering ourselves towards that hockey puck location.Corey: I frequently remark that the role of the DBA might not be vanishing, but it's definitely changing, especially since the last time I counted, if you hold them and use as directed, AWS has something on the order of 14 distinct managed database offerings. Some are general purpose, some are purpose-built, and if this trend keeps up, in a decade, the DBA role is going to be determining which of its 40 databases is going to be the right fit for a given workload. That seems to be the counter-approach to a general-purpose database that works across the board. Clearly you folks have opinions on this. Where do you land?Jeff: Oh, so absolutely. There's the product that is a suite of capabilities—or that are individual capabilities—and then there's ones that are, in my case, kind of multi-model and do lots of things at once. I think historically, you'll recognize—because this is—let's pick on your phone—the same holds true for, you know, your phone used to be a watch, used to be a Palm Pilot, used to be a StarTAC telephone, and your calendar application, your day planner all at the same time. Well, it's not anymore. Technology converges upon itself; it's kind of a historical truism.And the database technologies are going to end up doing that—or continue to do that, even right now. So, that notion that—it's a ten-year-old notion of use a purpose-built database for that particular workload. Maybe sometimes in extreme cases that is the appropriate thing, but in more cases than not right now, if you need transactions when you need them, that's fine, I can do that. You don't necessarily need Aurora or RDS or Postgres to do that. But when you need search and geolocation, I support that too, so you don't need Elastic. And then when you need caching and everything, you don't need ElastiCache; it's all built-in.So, that multi-model notion of operate on the same pool of data, it's a lot less complex for your developers, they can code faster and better and more cleanly, debugging is significantly easier. As I mentioned, SQL++ is our language. It's basically SQL syntax for JSON. We're a reference implementation of this language, along with—[AsteriskDB 00:23:42] is one of them, and actually, the original author of that language also wrote DynamoDB's PartiQL.So, it's a common language that you wouldn't necessarily imagine, but the ease of entry in all of this, I think, is still going to be a driving goal for people. The old people like me and you are running around worrying about, am I going to get a particular, really specific feature out of the full-text search environment, or the other one that I pick on now is, “Am I going to need a vector database, too?” And the answer to me is no, right? There's going—you know, the database vendors like ourselves—and like Mongo has announced and a whole bunch of other NoSQL vendors—we're going to support that. It's going to be just another mode, and you get better bang for your buck when you've got more modes than a single one at a time.Corey: The consensus opinion that's emerging is very much across the board that vector is a feature, not a database type.Jeff: Not a category, yeah. Me too. And yeah, we're well on board with that notion, as well. And then like I said earlier, the JSON as a vehicle to give you all of that versatility is great, right? You can have vector information inside a JSON document, you can have time series information in the document, you could have graph node locations and ID numbers in a JSON array, so you don't need index-free adjacency or some of the other cleverness that some of my former employers have done. It really is all converging upon itself and hopefully everybody starts to realize that you can clean up and simplify your architectures as you look ahead, so that you do—if you're going to build AI-powered applications—feed it clean data, right? You're going to be better off.Corey: So, this episode is being recorded in advance, thankfully, but it's going to release the first day of re:Invent. What are you folks doing at the show, for those who are either there and for some reason, listening to a podcast rather than going to getting marketed to by a variety of different pitches that all mention AI or might even be watching from home and trying to figure out what to make of it?Jeff: Right. So, of course we have a booth, and my notes don't have in front of me what our booth number is, but you'll see it on the signs in the airport. So, we'll have a presence there, we'll have an executive briefing room available, so we can schedule time with anyone who wants to come talk to us. We'll be showing not only the capabilities that we're offering here, we'll show off Capella iQ, our coding assistant, okay—so yeah, we're on the AI hype band—but we'll also be showing things like our mobile sync capability where my phone and your phone can synchronize data amongst themselves without having to actually have a live connection to the internet. So, long as we're on the same network locally within the Venetian's network, we have an app that we have people download from the Apple Store and then it's a color synchronization app or picture synchronization app.So, you tap it, and it changes on my screen and I tap it and it changes on your screen, and we'll have, I don't know, as many people who are around standing there, synchronizing, what, maybe 50 phones at a time. It's actually a pretty slick demonstration of why you might want a database that's not only in the cloud but operates around the cloud, operates mobile-ly, operates—you know, can connect and disconnect to your networks. It's a pretty neat scenario. So, we'll be showing a bunch of cool technical stuff as well as talking about the things that we're discussing right now.Corey: I will say you're putting an awful lot of faith in conductivity working at re:Invent, be it WiFi or the cellular network. I know that both of those have bitten me in various ways over the years. But I wish you the best on it. I think it's going to be an interesting show based upon everything I've heard in the run-up to it. I'm just glad it's here.Jeff: Now, this is the cool part about what I'm talking about, though. The cool part about what I'm talking about is we can set up our own wireless network in our booth, and we still—you'd have to go to the app store to get this application, but once there, I can have you switch over to my local network and play around on it and I can sync the stuff right there and have confidence that in my local network that's in my booth, the system's working. I think that's going to be ultimately our design there because oh my gosh, yes, I have a hundred stories about connectivity and someone blowing a demo because they're yanking on a cable behind the pulpit, right?Corey: I always build in a—and assuming there's no connectivity, how can I fake my demos, just because it's—I've only had to do it once, but you wind up planning in advance when you start doing a talk to a large enough or influential enough audience where you want things to go right.Jeff: There's a delightful acceptance right now of recorded videos and demonstrations that people sort of accept that way because of exactly all this. And I'm sure we'll be showing that in our booth there too.Corey: Given the non-deterministic nature of generative AI, I'm sort of surprised whenever someone hasn't mocked the demo in advance, just because yeah, gives the right answer in the rehearsal, but every once in a while, it gets completely unglued.Jeff: Yes, and we see it pretty regularly. So, the emergence of clever and good prompt engineering is going to be a big skill for people. And hopefully, you know, everybody's going to figure out how to pass it along to their peers.Corey: Excellent. We'll put links to all this in the show notes, and I look forward to seeing how well this works out for you. Best of luck at the show and thanks for speaking with me. I appreciate it.Jeff: Yeah, Corey. We appreciate the support, and I think the show is going to be very strong for us as well. And thanks for having me here.Corey: Always a pleasure. Jeff Morris, VP of Product and Solutions Marketing at Couchbase. This episode has been brought to us by our friends at Couchbase. And I'm Cloud Economist Corey Quinn. If you've enjoyed this podcast, please leave a five-star review on your podcast platform of choice, whereas if you've hated this podcast, please leave a five-star review on your podcast platform of choice along with an angry comment, but if you want to remain happy, I wouldn't ask that podcast platform what database they're using. No one likes the answer to those things.Corey: If your AWS bill keeps rising and your blood pressure is doing the same, then you need The Duckbill Group. We help companies fix their AWS bill by making it smaller and less horrifying. The Duckbill Group works for you, not AWS. We tailor recommendations to your business and we get to the point. Visit duckbillgroup.com to get started.

Jeff Jordan is President and Executive Creative Director of Rescue: The Behavior Change Agency. Rescue offers a broad range of marketing services for government agencies (public health departments, state and federal agencies) and non-profits seeking to promote positive changes in public health related behaviors.  Jeff started his agency when, as a high school student, he volunteered for his local health department's youth-targeted anti-tobacco program. He transitioned from volunteer to contractor, tweaked the anti-tobacco program to approach teens in an innovative way, and grew the agency through “a lot of referrals.” He opened his first office while he was in college and continued his focus on behavioral change for social good.  In this interview, Jeff tells us that marketing tactics that are used to sell products don't necessarily work in changing “fundamental behavior.” His team has to be expert, not just in marketing, but also in behavior change theory, psychology, and sociology . . . and know how to appeal to different subsets within targeted cohort groups. Jeff says that it can take years for a consistent message to bring measurable change, and although there is nothing equivalent to “sales data” to gauge message impact in “real time,” he has found there are some measurable interim “markers” on the path to behavior change. Tracking and measuring specific behavior-related attitudes or beliefs or pieces of knowledge over time can predict subsequent behavior changes. About 7 years ago, Rescue won a $150 million FDA youth tobacco prevention contract. These funds allowed the agency to increase in size from 50 to 150 employees in 3 years. Today, Rescue's 175 employees work out of 6 offices around the country. They serve government agencies and nonprofits in 30 states. Rescue creates programs for these organizations, but also has a library of campaigns that can be licensed. Over the years, Jeff has learned to say “no” to opportunities that are not right for his agency. Budgets that are too small can limit a campaign's success . . . . and blame for poor results will invariably fall on the agency . . . not on the tight budget. The smaller a client is, the more they tend to demand. Jeff has observed that agencies end up over-servicing smaller accounts to keep them, tie up senior personnel in servicing these smaller clients, and underservice their larger accounts. Jeff warns that really small accounts can hold an agency down. Jeff applauds the move away from condemning people who choose unhealthy behaviors and the increasingly broad awareness of underlying lifestyle situations that contribute to these behaviors. Jeff's agency attracts employees who want to do something good in their careers. He describes the agency as “responsibly rebellious,” and explains that is manifested in the way the agency encourages clients to take risks in a responsible way. Jeff can be reached on his company's website at: Rescueagency.com. The agency runs what Jeff describes as a “pretty robust YouTube Channel” at: youtube.com/rescueagency. Transcript Follows: ROB: Welcome to the Marketing Agency Leadership Podcast. I'm your host, Rob Kischuk, and I'm joined today by Jeff Jordan. He's the President and Executive Creative Director at Rescue: The Behavior Change Agency. Welcome to the podcast, Jeff. JEFF: Thanks so much, Rob. ROB: It's excellent to have you here. Why don't you kick us off by telling us – it's right there in the title, a little bit – Rescue: The Behavior Change Agency. But tell us a little bit about Rescue and where you excel. JEFF: We are a public health behavior change-focused agency. What that means is that we exclusively work for campaigns that strive to change health behaviors for social good. Almost all of our clients are public health departments, state and federal agencies. When we say behavior change, we refer to actually changing a fundamental behavior that a person is performing. So rather than changing what we would describe as a brand preference of someone who drives one car, changing them to drive a different brand of car, we're looking to change that fundamental behavior of actually driving the car and converting them to ride a bicycle instead. Or in other health arenas, things like quitting smoking or eating healthier, etc. ROB: Perfect. Is that something you've actually engaged in? Encouraging people to ride a bike instead of driving a car? JEFF: Not that one. [laughs] But it's an example people tend to understand. ROB: What are some examples, digging a little deeper, of campaigns? You mentioned smoking cessation. There's probably some other interesting things you've worked on. What are some examples? JEFF: We work from simple behaviors like quitting smoking or not using drugs or not vaping and things like that to more complex behaviors like healthy eating, where we're actually promoting specific types of foods, specific changes to what they eat, as well as mental health behaviors that are even more complicated – trying to get people to reduce stigma and recognize when to seek help, when to do something about the feelings they're having, and whatnot. ROB: Very interesting. You mentioned brand preference; in some cases, I think people think of brand preference as being kind of pliable. Maybe it is just as difficult to change as some health behaviors. How do you think about, or how do your clients even think about, measuring these behaviors over the long term? I imagine the feedback loop on one of your campaigns might be rather long in some cases, given the research required to gather those results. Or maybe there's something unexpected I'm not thinking of. JEFF: You're absolutely right. Behavior change, we usually say you need a couple years at least of consistent campaigning to really see a measurable change. Unfortunately, we don't have sales data to look at to see what's happening in real time, so we rely on self-reported surveys and things like that that either our clients perform or that we help them perform to see what people are saying about the behavior. You do have some interim steps that you can measure on the path to behavior change. Whatever your underlying theory is of what you think is changing in order to change the behavior, such as specific attitudes or beliefs or pieces of knowledge about a behavior, you can measure those, and then those can be pretty predictive of a behavior change later down the line. ROB: One benefit it seems like you might have in your industry – is the behavior change industry perhaps a little bit more open about what works and what doesn't than maybe some particular vertical market, like marketing soda or something? JEFF: I think it's a double-edged sword there. It's more open in the sense that you can survive on theory for a longer period of time. In the commercial world, you can have a great theory, but if it doesn't turn around sales in a quarter, you're kind of out of luck there. In public health, you can survive on theory for a few years. So that does allow you to explore more options. But that also allows bad work to remain for a long time. We see that there's a lot of mistakes and common pitfalls that clients fall into, usually when they work with traditional agencies, that just happen over and over again because it works to sell a product, but it doesn't work to change a fundamental behavior. ROB: What about openness in terms of tactics? In some cases you have organizations like the UK's famous – I may be misattributing it, but their Nudge Unit there. You have probably published research in some cases around behavioral change. How much of your work is synthesizing and adapting those things to a community and to availability of resources versus cooking up something completely out-of-the-box and new? JEFF: There's a lot of theory and approaches already within public health behavior change. I think the UK is interesting in that they tend to have movements that occur there within behavior change. 10-15 years ago, they were really social marketing, and then it switched to Nudge, and they seem to all move a little bit more cohesively, maybe because it's a smaller country. Here in the U.S., we don't see as much cohesiveness in the approaches. The latest and greatest CDC strategy or FDA strategy, those do have a big influence on the work, but a lot of states are making decisions for themselves and applying the theories and approaches that they're comfortable with – everything from states that might still be using hardcore scare tactics like the '90s in their drug prevention work, all the way to other states that are more open-minded in realizing things like adverse childhood experiences influence how people make decisions about risk behaviors later in life. That's something that the state of California is really looking at. You have a really wide range of approaches and comfort level with those approaches. One of the things that we have to do that is kind of unique to our industry is we often have to share some of that education and some of those case studies from other states with potential clients so that they can understand, these are your options. You don't have to just do the scare tactics. That's not the only thing out there, and actually it often doesn't really work. So, we have to be the experts not just in marketing itself, but in behavior change theory, psychology, sociology, all these things that go into it. ROB: It sounds like there's a difference of tactics, a difference of outcomes. Are you seeking cessation? Are you seeking some sort of treatment? Are you just seeking a reduction of use in something that is now legal in certain places? It sounds like you are able to pool that expertise and help – in the ways that many agencies are, but you don't think about it so much in public health – bring those best practices and learnings from other clients. That makes me want to pull back and dig in. You're in a very unique area of focus. I think we've done probably 120 or so episodes right now, and we have not been in a conversation with an agency owner who is in public health and behavioral change. You mentioned you've been in the agency, at least, for 20 years. Did you start off with that area of focus? How did Rescue come to be? JEFF: We are definitely a unique agency. I actually started the agency when I was in high school. I was a volunteer for my local health department's anti-tobacco program. That was a youth program. They worked with a local agency, and after volunteering for about a year, I noticed that the kids we were reaching, the teenagers we were appealing to, were not current smokers, and they were never going to be smokers, whether we existed or not. These were good kids. They were leaders. They wanted to put this on their college application. There was really no change I could see that we were causing, even though we were successful from the sense that there was a lot of youth involvement and we were doing a lot of things. Fortunately, we had an advisor at the health department that was also pretty savvy in terms of youth culture. I like to joke that she was a break dancer when she was in high school, and she was maybe 7 years older than me. So, she was still pretty connected with what high risk youth culture might look like versus low risk youth culture. I said, “Why are we spending all our money on these youth?” She was open to allowing me to move from being a volunteer to being a contractor to start to provide some of these services that would change who the program appealed to. That continued for the next year or so in high school, and very quickly we started to innovate in a way that just wasn't happening in public health, particularly with teens. That turned into a lot of referrals. While I was in college, we grew a lot through referrals and got our first office when I was in college and things like that. So, we really grew organically, and from Day 1 have been exclusively focused on public health. ROB: What does the team look like today? What are some of the scale points and key hires to where the team of the agency is now? JEFF: Today we have about 175 employees, six offices around the country. We are the largest marketing agency in San Diego, but most San Diego businesses can't hire us. [laughs] Our work, though, is spread around the country. We don't have a specific geographic footprint. There's not one place where our clients are clustered. We work with about 30 different states and with the federal government, with the FDA, as well as Veterans Affairs and others. Some of the big scale points that have occurred – there's been a few. The biggest one was about 7 years ago, when we were about 40 or 50 people at the time and we won a contract with the FDA to do youth tobacco prevention. That contract was a $150 million contract for an agency of 50 people. We very quickly grew thanks to that contract. We brought on our CEO, Kristin Carroll (who's still with us today), at that time, who helped us grow quickly. Within a matter of 3 years, we went from about 50 people to 150 people. But in that time, we've continued to grow with other clients as well. Some other notable wins are the California Department of Health's nutrition campaign as well as some other states that have brought on larger contracts. ROB: You mentioned that many San Diego businesses probably can't work with you. Does that reflect a change in the overall deal size that you've pursued? JEFF: No, no, that's just mainly because we don't do commercial marketing. You have to be a public health oriented campaign. We work with the local county health department, we work with the local school district, and we also work with the district attorney's office. So, we work with a lot of local government agencies, but we don't have any commercial customers here or anywhere else. ROB: I see. Once many agencies scale, and especially north of 100 people, I think a lot of times they become very focused on just the FDA size deals. How do you manage that different granularity of client size within one organization and not become really fixated on hitting those homeruns? JEFF: That has definitely been a problem of scaling up. There aren't that many FDA size deals in our space, so we're forced to continue our more modest deal size – which we're very happy with. But I think the biggest challenge that has occurred is being careful not to try and apply universal lessons to the entire agency. Some things that we do for our largest client don't necessarily apply to our smallest clients. We've gotten in trouble sometimes in starting to do things for our smaller clients the way we do it for our larger clients and then going over budget and overcomplicating things when they don't need to be. And vice versa, also making sure we don't get too simple with our biggest accounts. We have to operate in this limited budget standpoint for some of our accounts and then a more open budget to explore different things with our largest accounts. That's probably the biggest thing we have to remind ourselves of and be cautious with. Really, we're operating like two different agencies within one. ROB: We are chatting here right in the middle of the spring 2020 COVID-19 epidemic. How has that changed your mix of business? Do you have clients that are working within – do you have some stay home campaigns running and that sort of thing as well? I imagine any work you've done, you've had to learn very quickly. JEFF: Surprisingly, we haven't gotten into any stay at home work, mainly because we tend to focus on long-term campaigns so that we can measure these long-term changes. It does affect COVID because a lot of the reasons that people are passing away because of COVID is because of preexisting conditions that we're trying to prevent with some of our other behaviors. So in a way, they're all connected. But when there's an emergency like this, communications get out pretty quickly and go viral pretty quickly. You don't really need the traditional long-term campaign to figure it out. The one thing that has changed the most for us is the production of new creative and new messages. Right now we're focused almost exclusively on creating animated work and infographics and things like that. Our clients still want to produce the work, still want to put new messages out there. Right now, people are consuming media more than ever before, so we're still cranking away new stuff. ROB: That's excellent. Jeff, you've been at this for a little bit; you've built the largest agency in San Diego, which is quite a thing. What are some things that you've learned along this journey that you might do a little bit differently if you were starting Rescue all over again? JEFF: There's so many lessons you learn, but you almost need to learn them in order to grow from them. I think that one of the things that we learned was not to be afraid to say no to an opportunity if that's not the right opportunity. I have to teach this lesson to every new business development person we bring on or client service person we bring on. It might feel weird to say no to a small client, but keep in mind that if they don't have enough funds for us to do a good job, they won't blame the budget; they will blame us for not doing a good job. And without fail, the smaller the client, the more they ask for. Oftentimes I've seen a lot of agencies get stuck in this world where they are over-servicing smaller accounts to keep them and underservicing their larger accounts, and it's usually top-heavy. It's usually more senior people that are servicing these smaller accounts, who are now not able to go out there and pursue bigger work. So, you really have to be careful of the really small accounts holding you down. ROB: How do you think about positioning and communicating the scope with the small accounts so that their expectations are aligned? Or have you found it's hard to manage them and you just have to pick the right ones and let someone else have the ones that are going to ask for the full buffet for 5 bucks? JEFF: We definitely let someone else have those. [laughs] It's about being transparent upfront and saying, “Look, this is what it takes to do good work, and this is why. These are all the components that need to go into something.” We have found ways of being able to accept smaller accounts with different strategies. For example, something that's completely unique to our space is we actually license campaigns. We have about four different preexisting campaigns that governments can license from us and that are reused over and over again across the country. That has allowed us to open the door to some smaller – not the smallest, but some of the smaller accounts that don't have the funds to create new campaigns, but do have enough funds to implement a licensed campaigns. That's something that could never happen in the commercial world; no one would ever want to share anything. But in our space, the government loves to share, and they actually love the reduced risk that comes with knowing this has already run somewhere else. ROB: Right. I can see you coming with some results, and they can see what the campaign looks like out in the world. They can probably even go and visit and see in some other place how this campaign looks in the wild, which you can't do, to your point, for most businesses. Maybe you could get away with it in – I don't know, if you were just serving one lawyer per market, or one plumber, or something crazy like that. But even then, they probably wouldn't want to share. JEFF: Right, exactly. There's so many things that we do here because we are focused on this space that would just not be possible if we were a generalist agency. And that's part of our argument for potential new clients: look, you can hire your local ad agency that everyone has heard of that has done all the car dealerships and local banks and things like that, or you can hire a specialist in public health. What's going to happen if you hire a specialist in public health is you're going to get all this institutional knowledge about how public health marketing is different from commercial marketing and be able to be more effective, more efficient, and have all this research and tools at your disposal. ROB: Jeff, at 175 people, you're up above that 150-person Dunbar number that many people talk about as that maximum number of people you can be in relationship with, or people might phrase it differently. How have you thought about structuring, organizing, and persisting culture as you break through dozens and then triple digits and then over 150? JEFF: We had a pretty strong culture before I knew that company culture was a thing. It comes from the culture being embedded in the work. A lot of times, folks try to put this layer of culture on their organization that doesn't really have anything to do with anything. That's where culture tends to fail or feel shallow. Where culture is really strong and real is where it manifests through the work. For example, one piece of our culture is that we describe ourselves as “responsibly rebellious.” What that means is that we want to push our clients to take risks within a responsible way. That is manifest through a lot of decisions that we make for our clients, things that we present to our clients, ways that we approach how we work with our clients. Then, when we say that's a part of our culture, it's true. It is a part of our work. It's part of what we do. When we talk about being science-based, we have a giant in-house research team that does presentations for us that is then infused in the creative and in the strategy. So, I think the best way to maintain culture is to just have an identity that is real and that you truly apply every single time you do the work. ROB: It almost seems like some of the culture would be self-selecting. Not to say that people might not view Rescue as a very attractive place to work, but it seems like an odd company to sign up for unless you have a real interest in messages of public health and in helping people and helping communities. Do you find that in the interview process? JEFF: Yeah. This millennial generation that's now dominating our workforce, we are the ideal kind of company to work for. They want to cause social change. They want to have an impact, and we can allow them to have that impact. So, definitely the people that come in are people who have an interest in doing something good with their career. And that helps. Everybody in the agency wants to have a good outcome from that campaign on a deeper level than just simply delivering for a client. ROB: That makes sense. Jeff, what's coming up for Rescue that you are excited about? Or maybe it's even something in terms of either broad messages that you're seeing trends in, or even tactically? JEFF: One thing that's pretty exciting is that we're seeing a broad awakening of the underlying lifestyle situations that lead people to choose unhealthy behaviors. The best example of this is what's happening in California with the new – California has a Surgeon General for the first time, and she is focused on infusing adverse childhood experience understanding, which is this area of health research that talks about if you had these really, really big things happen to you when you were a kid – things like divorce or a parent dying or domestic violence or mental health in the family, these heavy things – those things set you on a trajectory to take on much higher risks later in life. And if you can embed an understanding of who people are and where they come from in your work, you can be more effective with these populations. So, an understanding of that, an understanding of mental health, an understanding that people don't do risky things in isolation. They do them from a complicated equation of everything that's happened in their life. That was just not existent for the past 20 years, particularly in things like drug and alcohol prevention, where it's like “people who use drugs are just making a bad choice, they're just stupid, they're just bad and they need to be told to stop doing bad things.” [laughs] That's just not how it works. It's really nice that a lot of public health is moving away from that perspective and instead moving towards a deeper understanding of the complexity of human identity. ROB: Absolutely. It brings to mind for me – you have a responsibility; the messages you're putting out there are not messages for any particular – you probably work with governments of every political party possible. JEFF: That's right. ROB: But we live in a world where – what you're saying even hearkens back to partisan politics. How do you think about putting messages out into the world that have to transcend politics and party? JEFF: I think we all suffer, across industries, across topics, from talking to ourselves and not understanding someone who's different. One of the things I like to say that I feel makes this so different is applied empathy. It's not just that we have more empathy than someone else, but that we actually apply that empathy to how we create our messages and can articulate, when we're going to create a campaign for rural men, why that campaign has to be so different from a campaign, for example, for African American women. What is different about their life experience, their attitudes, their worldview, their values that will change the way we communicate to them – but also change what we're saying. A great example of this is that we do a ton of tobacco prevention work, still, with teenagers, and you can talk to an alternative teen in an urban area who listens to rock and things like that – you can talk to them about the evilness of the tobacco industry and all the horrible things they've done, and they will get fired up. They'll say, “I don't want to support an industry that's destroying the world and manipulating people.” So, you can motivate them not to smoke just by talking about the tobacco industry to them. But then you take a rural teen, a country teen who maybe is a younger version of the right side of our political spectrum, and you talk to them about the tobacco industry and it just doesn't even faze them. They're like, “Well, that's their right as a company and you have the right to choose what you're going to do, whether you do that behavior or not. It's all about personal responsibility.” If you don't know that difference and if you don't know that they are processing information differently and caring about different things, then you're just speaking to yourself. You're just speaking about what you care about. And that can apply to so, so many different things. Within politics, its' so interesting to see people just yell within their bubbles about things that they care about and are baffled by why no one else cares about them or why the other side doesn't care. All you have to do is just spend a little bit of time on the other side and you'll understand why they don't care about what you're talking about. ROB: It's a great thought for all of us on meeting people where they are instead of where we think they are. Jeff, when the audience wants to get in touch with you and with Rescue, where should they look for you? Where should they find you? JEFF: Yeah, definitely. Rescueagency.com is our website. There's contact information there for different folks. But also, if you're just interested in what I was talking about and learning more about public health marketing and behavior change and things like that, we have a pretty robust YouTube channel, youtube.com/rescueagency. Lots of actual workshops and videos that we've done explaining our approach and research and some examples of the work. ROB: Perfect. Jeff, thank you for joining us. Thank you for the thoughtful work that you do. We're grateful for it, and look forward to a lot more of it in the future. Congrats on all the success. JEFF: Thank you. Thanks for having me on. ROB: Thank you for listening. The Marketing Agency Leadership Podcast is presented by Converge. Converge helps digital marketing agencies and brands automate their reporting so they can be more profitable, accurate, and responsive. To learn more about how Converge can automate your marketing reporting, email info@convergehq.com, or visit us on the web at convergehq.com.

我们从小就知道，别人问How are you？你要回答 I am fine，thank you . And you？这样的回答方式早已经在我们的心中形成了条件反射。那么，不同情境下都要用这一个回答吗？未免也太死板了吧！在英语中，这么基础的口语对话你能张口就来吗？今天一起来学习一下，回答“How are you？”都有哪些方式吧！有的时候，别人问你How are you ？他们并不是真的想知道你过得好不好、最近到底做了什么事情，只是表面上嘘寒问暖一下。那么，我们首先来学习一下，这样嘘寒问暖的句型都有哪些：01“how”系列句型，有以下这么多种：How are you?How are you doing?How's everything?How's it going?How's your business? 02此外呢，也有几个what 引导的句型可以用来提问：What's happening?What's going on?What are you up to?What's new? 面对上面的句子，我们可以回应“不错、还可以、凑合、还行”等。可以分为以下这几类：状态不错，充实忙碌Couldn t be better.非常好，太好了Keeping busy.一直挺忙的。一般一般，马马虎虎Can t complain.没什么可抱怨的，挺好的Been getting by.没什么特别的，就是在过日子最近生活不太如意Not so good. 不怎么好I ve had better days.I ve been better.不是很好（之前有过更好的阶段）回应完“不错”后，还可以感谢一下对方的关心，说 thanks，或 thank you，或 thanks for asking. 然后可以反问一下：And you ? 你呢？下面我们就来看两组例句：Hey, Jeff. I haven't seen you for days. How are you doing?嘿，Jeff。有段时间没见你了。你怎么样？Not bad ,just busy as usual. 还不错吧，和之前一样忙。Nancy ，long time no see ！How is it going with you， Nancy?Nancy，好久不见了。你怎么样？Pretty good！很好。

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta. This month, we are tackling a topic for which the literature continues to rapidly change - we’re talking about the ED management of patients taking direct oral anticoagulants or DOACs, previously called novel oral anticoagulants or NOACs. Nachi: Specifically, we’ll be focusing on the use of DOACs for the indications of stroke prevention in atrial fibrillation and the treatment and prevention of recurrent venous thromboembolisms. Jeff: This month’s article was authored by Dr. Patrick Maher and Dr. Emily Taub of the Icahn School of Medicine at Mount Sinai, and it was peer reviewed by Dr. Dowin Boatright from Yale, Dr. Natalie Kreitzer from the University of Cincinnati, and Dr. Isaac Tawil from the University of New Mexico. Nachi: In their quest to update the last Emergency Medicine Practice issue on this topic which was published in 2013, they reviewed over 200 articles from 2000 to present in addition to 5 systematic reviews in the cochrane database, as well as guidelines from the American Heart Association, European society of cardiology, and the american college of cardiology. Jeff: Thanks to a strong literature base, Dr’s Maher and Taub found good quality evidence regarding safety and efficacy of the DOACs in relation to warfarin and the heparin-based anticoagulants. Nachi: But do note that the literature directly comparing the DOACs is far more limited and mostly of poor quality. Show More v Jeff: Fair enough, we’ll take what we can get. Nachi: Well, I’m sure more of those studies are still coming. Jeff: Agree. Let’s get started with some basics. Not surprisingly, DOACs now account for a similar proportion of office visits for anticoagulant use as warfarin. Nachi: With huge benefits including reduced need for monitoring and a potential for reduced bleeding complications, this certainly isn’t surprising. Jeff: Though those benefits are not without challenges - most notably the lack of an effective reversal agent and the risk of unintentional overdose in patients with altered drug metabolism. Nachi: Like all things in medicine, it’s about balancing and finding an acceptable risk/benefit profile. Jeff: True. Let’s talk pathophysiology for a minute - the control of coagulation in the human body is a balance between hemorrhage and thrombosis, mediated by an extensive number of procoagulant and anticoagulant proteins. Nachi: Before the development of the DOACs, vitamin K antagonists controlled the brunt of the market. As their name suggests, they work by inhibiting the action of vitamin K, and thus reducing the production of clotting factors 2, 7, 9, and 10, and the anticoagulant proteins C and S. Jeff: Unfortunately, these agents have a narrow therapeutic window and many drug-drug interactions, and they require frequent monitoring - making them less desirable to many. Nachi: However, in 2010, the FDA approved the first DOAC, a real game-changer. The DOACs currently on the market work by one of two mechanisms - direct thrombin inhibition or factor Xa inhibition. Jeff: DOACs are currently approved for stroke prevention in nonvalvular afib, treatment of VTE, VTE prophylaxis, and reduction of major cardiovascular events in stable cardiovascular disease. Studies are underway to test their safety and efficacy in arterial and venous thromboembolism, prevention of embolic stroke in afib, ACS, cancer-associated thrombosis, upper extremity DVT, and mesenteric thrombosis. Nachi: Direct thrombin inhibitors like Dabigatran, tradename Pradaxa, was the first FDA approved DOAC. It works by directly inhibiting thrombin, or factor IIa, which is a serine protease that converts soluble fibrinogen into fibrin for clot formation. Jeff: Dabigatran comes in doses of 75 and 150 mg. The dose depends on your renal function, and, with a half-life of 12-15 hours, is taken twice daily. Note the drastically reduced half-life as compared to warfarin, which has a half-life of up to 60 hours. Nachi: The RE-LY trial for afib found that taking 150 mg of Dabigatran BID had a lower rate of stroke and systemic embolism than warfarin with a similar rate of major hemorrhage. Dabigatran also had lower rates of fatal and traumatic intracerebral hemorrhage than warfarin. Jeff: A separate RCT found similar efficacy in treating acute VTE and preventing recurrence compared with warfarin, with reduced rates of hemorrhage! Nachi: Less monitoring, less hemorrhage, similar efficacy, I’m sold!!! Jeff: Slow down, there’s lots of other great agents out there, let’s get through them all first... Nachi: Ok, so next up we have the Factor Xa inhibitors, Rivaroxaban, apixaban, edoxaban, and betrixaban.As the name suggests, these medications work by directly inhibiting the clotting of factor Xa, which works in the clotting cascade to convert prothrombin to thrombin. Jeff: Rivaroxaban, trade name Xarelto, the second FDA approved DOAC, is used for stroke prevention in those with nonvalvular afib and VTE treatment. After taking 15 mg BID for the first 21 days, rivaroxaban is typically dosed at 20 mg daily with adjustments for reduced renal function. Nachi: The Rocket AF trial found that rivaroxaban is noninferior to warfarin for stroke and systemic embolism prevention without a significant difference in risk of major bleeding. Interestingly, GI bleeding may be higher in the rivaroxaban group, though the overall incidence was very low in both groups at about 0.4% of patients per year. Jeff: In the Einstein trial, patients with VTE were randomized to rivaroxaban or standard therapy. In the end, they reported similar rates of recurrence and bleeding outcomes for acute treatment. Continuing therapy beyond the acute period resulted in similar rates of VTE recurrence and bleeding episodes to treatment with aspirin alone. Nachi: Next we have apixaban, tradename Eliquis. Apixaban is approved for afib and the treatment of venous thromboembolism. It’s typically dosed as 10 mg BID for 7 days followed by 5 mg BID with dose reductions for the elderly and those with renal failure. Jeff: In the Aristotle trial, when compared to warfarin, apixaban was superior in preventing stroke and systemic embolism with lower mortality and bleeding. Rates of major hemorrhage-related mortality were also nearly cut in half at 30 days when compared to warfarin. Nachi: For the treatment of venous thromboembolism, the literature shows that apixaban has a similar efficacy to warfarin in preventing recurrence with less bleeding complications. Jeff: Unfortunately, with polypharmacy, there is increased risk of thromboembolic and hemorrhage risks, but this risk is similar to what is seen with warfarin. Nachi: And as compared to low molecular weight heparin, apixaban had higher bleeding rates without reducing venous thromboembolism events when used for thromboprophylaxis. It’s also been studied in acute ACS, with increased bleeding and no decrease in ischemic events. Jeff: Edoxaban is up next, approved by the FDA in 2015 for similar indications as the other Factor Xa inhibitors. It’s recommended that edoxaban be given parenterally for 5-10 days prior to starting oral treatment for VTE, which is actually similar to dabigatran. It has similar levels of VTE recurrence with fewer major bleeding episodes compared to warfarin. It has also been used with similar effects and less major bleeding for stroke prevention in afib. In the setting of cancer related DVTs specifically, as compared to low molecular weight heparin, one RCT showed lower rates of VTE but higher rates of major bleeding when compared to dalteparin. Nachi: Next we have Betrixaban, the latest Factor Xa inhibitor to be approved, back in 2017. Because it’s utility is limited to venous thromboembolism prophylaxis in mostly medically ill inpatients, it’s unlikely to be encountered by emergency physicians very frequently. Jeff: As a one sentence FYI though - note that in recent trials, betrixaban reduced the rate of VTE with equivalent rates of bleeding and reduced the rate of stroke with an increased rate of major and clinically relevant non-major bleeding as compared to enoxaparin. Nachi: Well that was a ton of information and background on the DOACs. Let’s move on to your favorite section - prehospital medicine. Jeff: Not a ton to add here this month. Perhaps, most importantly, prehospital providers should specifically ask about DOAC usage, especially in trauma, given increased rates of complications and potential need for surgery. This can help with destination selection when relevant. Interestingly, one retrospective study found limited agreement between EMS records and hospital documentation on current DOAC usage. Nachi: Extremely important to identify DOAC use early. Once the patient arrives in the ED, you can begin your focused history and physical. Make sure to get the name, dose, and time of last administration of any DOAC. Pay particular attention to the med list and the presence of CKD which could point to altered DOAC metabolism. Jeff: In terms of the physical and initial work up - let the sites of bleeding or potential sites of bleeding guide your work up. And don’t forget about the rectal exam, which potentially has some added value here - since DOACs increase the risk of GI bleeding. Nachi: Pretty straight forward history and physical, let’s talk diagnostic studies. Jeff: First up is CT. There are no clear cut guidelines here, so Drs. Maher and Taub had to rely on observational studies and expert opinion. Remember, most standard guidelines and tools, like the canadian and nexus criteria, are less accurate in anticoagulated patients, so they shouldn’t be applied. Instead, most studies recommend a low threshold for head imaging, even with minor trauma, in the setting of DOAC use. Nachi: That is so important that it’s worth repeating. Definitely have a low threshold to CT the head for even minor head trauma patients on DOACs. Basically, if you’re on anticoagulation, and you made it to the ED for anything remotely related to your head, you probably win a spin. Jeff: I suspect you are not alone with that stance... There is, however, much more debate about the utility of follow up imaging and admission after a NEGATIVE scan. Nachi: Wait, is that a thing I should routinely be doing? Jeff: Well there’s not great data here, but in one observational study of 1180 patients on either antiplatelet or anticoagulant therapy, a half a percent of them had positive findings 12 hours later, and importantly none required surgical intervention. Nachi: Certainly reassuring. And for those with positive initial imaging, the authors recommend repeat imaging within 4-6 hours in consultation with neurosurgical services or even earlier in cases of unexpected clinical decline. Jeff: Interestingly, though only a small retrospective study of 156 patients, one study found markedly reduced mortality, 4.9% vs 20.8% in those on DOACs vs warfarin with traumatic intracranial hemorrhage. Nachi: Hmm that actually surprises me a bit with the ease of reversibility of warfarin. Jeff: And we’ll get to that in a few minutes. But next we should talk about ultrasound. As always with trauma, guidelines recommend a FAST exam in the setting of blunt abdominal trauma. The only thing to be aware of here is that you should have an increased index of suspicion for bleeding, especially in hidden sites like the retroperitoneum. Nachi: And just as with traumatic head bleeds, a small observational study of those with blunt abdominal trauma found 8% vs 30% mortality for those on DOACs vs warfarin, respectively. Jeff: That is simply shocking! Let’s also talk lab studies. Hemoglobin and platelet counts should be obtained as part of the standard trauma work up. Assessing renal function via creatinine is also important, especially for those on agents which are renally excreted. Nachi: Though you can, in theory, test for plasma DOAC concentrations, such tests are not routinely indicated as levels don’t correspond to bleeding outcomes. DOAC levels may be indicated in certain specific situations, such as while treating life-threatening bleeding, development of venous thromboembolism despite compliance with DOAC therapy, and treating patients at risk for bleeding because of an overdose. Jeff: In terms of those who require surgery while on a DOAC - if urgent or emergent, the DOAC will need to be empirically reversed. For all others, the recommendation is to wait a half life or even multiple half-lives, if possible, in lieu of level testing. Nachi: Coagulation tests are up next. Routine PT and PTT levels do not help assess DOACs, as abnormalities on either test can suggest the presence of a DOAC, but the values should not be interpreted as reliable measures of either therapeutic or supratherapeutic clinical anticoagulant effect. Jeff: Dabigatran may cause prolongation of both the PT and the PTT, but the overall correlation is poor. In addition, FXa inhibitors may elevate PT in a weakly concentration dependent manner, but this may only be helpful if anti-fXa levels are unavailable. Nachi: Which is a perfect segway into our next test - anti-factor Xa level activity. Direct measurements of the anti-Fxa effect demonstrates a strong linear correlation with plasma concentrations of these agents, but the anticoagulant effect does not necessarily follow the same linear fashion. Jeff: Some labs may even have an anti-FXa effect measurement calibrated specifically to the factor 10a inhibitors. Nachi: While measuring thrombin time is not routinely recommended, the result of thrombin time or dilute thrombin time does correlate well with dabigatran concentrations across normal ranges. Jeff: And lastly, we have the Ecarin clotting time. Ecarin is an enzyme that cleaves prothrombin to an active intermediate that can be inhibited by dabigatran in the same way as thrombin. The ECT is useful for measuring dabigatran concentration - it’s not useful for testing for FXa inhibitors. A normal ECT value could be used to exclude the presence of dabigatran. Nachi: So I think that rounds out testing. Let’s move into the treatment section. Jeff: For all agents, regardless of the DOAC, the initial resuscitation follows the standard principles of hemorrhage control and trauma resuscitation. Tourniquet application, direct pressure, endoscopy for GI bleeds, etc... should all be used as needed. And most importantly, for airway bleeding, pericardial bleeding, CNS bleeding, and those with hemodynamic instability or overt bleeding, those with a 2 point drop in their hemoglobin, and those requiring 2 or more units of pRBC - they all should be considered to have serious, life threatening bleeds. This patient population definitely requires reversal agents, which we’re getting to in a minute. Nachi: A type and screen should also be sent with the plan to follow standard transfusion guidelines, with the goal of a hemoglobin level of 7, understanding that in the setting of an active bleed, the hemoglobin level will not truly be representative. Jeff: Interestingly, in the overdose literature that’s out there, bleeding episodes appear to be rare - occurring in just 5% of DOAC overdose cases. Nachi: Finally, onto the section we’ve all been waiting for. Let’s talk specific reversal agents. Praxbind is up first. Jeff: Idarucizumab or Praxbind, is the reversal agent of choice for dabigatran (which is also called pradaxa). According to data from the RE-LY trial, it reverses dabigatran up to the 99th percentile of levels measured in the trial. Nachi: And praxbind should be given in two 2.5 g IV boluses 15 minutes apart to completely reverse the effects of dabigatran. Jeff: As you would expect given this data, guidelines for DOAC reversal recommend it in major life-threatening bleeding events for patients on dabigatran. Nachi: Next up is recombinant coagulation factor Xa (brand name Andexxa), which was approved in 2018 for the FXa inhibitors. This recombinant factor has a decoy receptor for the FXa agents, thus eliminating their anticoagulant effects. Jeff: Recombinant factor Xa is given in either high or low dose infusions. High dose infusions for those on rivaroxaban doses of >10 mg or apixaban doses >5 mg within the last 8 hours and for unknown doses and unknown time of administration. Low dose infusions should be used for those with smaller doses within the last 8 hours or for last doses taken beyond 8 hours. Nachi: In one trial of 352 patients, recombinant factor Xa given as an IV bolus and 2 hour infusion was highly effective at normalizing anti-FXa levels. 82% of the assessed patients at 12 hours achieved hemostasis, but there were also thrombotic events in 10% of the patients at 30 days. Jeff: And reported thrombotic events aren’t the only downside. Though the literature isn’t clear, there may be limited use of recombinant factor Xa outside of the time of the continuous infusion, and even worse, there may be rebound of anti-Fxa levels and anticoagulant effect. And lastly, the cost is SUBSTANTIAL. Nachi: Is there really a cost threshold for stopping life threatening bleeding…? Jeff: Touche, but that means we need to save it for specific times and consider other options out there. Since this has only been around for a year or so, let’s let the literature play out on this too... Nachi: And that perfectly takes us into our next topic, which is nonspecific reversal agents, starting with prothrombin complex concentrate, also called PCC. Jeff: PCC is FDA approved for rapid reversal of vitamin K antagonist-related hemorrhagic events and is now being used off label for DOAC reversal. Nachi: PCC comes in 3 and 4 factor varieties. 3-factor PCC contains factors 2, 9, 10 and trace amounts of factor 7. 4 factor PCC contains factors 2, 9 10, as well as purified factor 7 and proteins C and S. Jeff: Both also contain trace amounts of heparin so can’t be given to someone with a history of HIT. Nachi: PCC works by overwhelming the inhibitor agent by increasing the concentration of upstream clotting factors. It has been shown, in healthy volunteers, to normalize PT abnormalities and bleeding times, and to achieve effective bleeding control in patients on rivaroxaban, apixaban, and edoxaban with major bleeding events. Jeff: In small studies looking at various end points, 4 factor PCC has been shown to be superior to 3 factor PCC. Nachi: Currently it’s given via weight-based dosing, but there is interest in studying a fixed-dose to decrease both time to medication administration and cost of reversal. Jeff: Guidelines currently recommend 4F PCC over 3F PCC, if available, for the management of factor Xa inhibitor induced bleeding, with studies showing an effectiveness of nearly 70%. As a result, 4F PCC has become an agent of choice for rapid reversal of FXa inhibitors during major bleeding events. Nachi: Next we have activated PCC (trade name FEIBA). This is essentially 4Factor PCC with a modified factor 7. Though traditionally saved for bleeding reversal in hemophiliacs, aPCC is now being studied in DOAC induced bleeding. Though early studies are promising, aPCC should not be used over 4factor PCC routinely as of now but may be used if 4Factor PCC is not available. Jeff: Next we have recombinant factor 7a (trade name novoseven). This works by activating factors 9 and 10 resulting in rapid increase in thrombin. Studies have shown that it may reverse the effect of dabigatran, at the expense of increased risk of thrombosis. As such, it should not be used as long as other agents are available. Nachi: Fresh Frozen Plasma is the last agent to discuss in this section. Not a lot to say here - FFP is not recommended for reversal of any of the DOACs. It may be given as a part of of a balanced massive transfusion resuscitation, but otherwise, at this time, there doesn’t seem to be a clear role. Jeff: Let’s move on to adjunct therapies, of which we have 3 to discuss. Nachi: First is activated charcoal. Only weak evidence exists here - but, according to expert recommendations, there may be a role for DOAC ingestions within 2 hours of presentations. Jeff: Perhaps more useful than charcoal is our next adjunct - tranexamic acid or TXA. TXA is a synthetic lysine analogue with antifibrinolytic activity through reversible binding of plasmin. CRASH-2 is the main trial to know here. CRASH-2 demonstrated reduced mortality if given within 3 hours in trauma patients. There is very limited data with respect to TXA and DOACs specifically, so continue to administer TXA as part of your standard trauma protocol without modification if the patient is on a DOAC, as it’s likely helpful based on what data we have. Nachi: Next is vitamin K - there is no data to support routine use of vitamin K in those taking DOACs - save that for those on vitamin K antagonists. Jeff: Also, worth mentioning here is the importance of hematology input in developing hospital-wide protocols for reversal agents, especially if availability of certain agents is limited. Nachi: Let’s talk about some special circumstances and populations as they relate to DOACs. Patients with mechanical heart valves were excluded from the major DOAC trials. And of note, a trial of dabigatran in mechanical valve patients was stopped early because of bleeding and thromboembolic events. As such, the American College of Cardiology state that DOACs are reasonable for afib with native valve disease. Jeff: DOACs should be used with caution for pregnant, breastfeeding, and pediatric patients. A case series of 233 pregnancies that occurred among patients on a DOAC reported high rates of miscarriage. Nachi: Patients with renal impairment are particularly concerning as all DOACs are dependent to some degree on renal elimination. Current guidelines from the Anticoagulation Forum recommend avoiding dabigatran and rivaroxaban for patients with CrCL < 30 and avoiding edoxaban and betrixaban for patients with CrCl < 15. Jeff: A 2017 Cochrane review noted similar efficacy without increased risk of major bleeding when using DOACs in those with egfr > 30 (that’s ckd3b or better) when compared to patients with normal renal function and limited evidence for safety below this estimated GFR. Nachi: Of course, dosing with renal impairment will be different. We won’t go into the details of that here as you will probably discuss this directly with your pharmacist. Jeff: We should mention, however, that reversal of the anticoagulant in the setting of renal impairment for your major bleeding patient is exactly the same as we already outlined. Nachi: Let’s move on to some controversies and cutting-edge topics. The first one is a pretty big topic and that is treatment for ischemic stroke patients taking DOACs. Jeff: Safety and efficacy of tPA or endovascular therapy for patients on DOACs continues to be debated. Current guidelines do not recommend tPA if the last DOAC dose was within the past 48 hours, unless lab testing specific to these agents shows normal results. Nachi: Specifically, the American Heart Association suggests that INR and PTT be normal in all cases. ECT and TT should be tested for dabigatran. And calibrated anti-FXa level testing be normal for FXa inhibitors. Jeff: The AHA registry actually included 251 patients who received tpa while on DOACs, which along with cohort analysis of 26 ROCKET-AF trial patients, suggest the risk of intracranial hemorrhage is similar to patients on warfarin with INR < 1.7 and to patients not on any anticoagulation who received tpa. However, given the retrospective nature of this data, we cannot exclude the possibility of increased risk of adverse events with tpa given to patients on DOACs. Nachi: Endovascular thrombectomy also has not been studied in large numbers for patients on DOACs. Current recommendations are to discuss with your stroke team. IV lysis or endovascular thrombectomy may be considered for select patients on DOACs. Always include the patient and family in shared decision making here. Jeff: There are also some scoring systems for bleeding risk to discuss briefly. The HAS-BLED has been used to determine bleeding risk in afib patients taking warfarin. The ORBIT score was validated in a cohort that included patients on DOACs and is similarly easy to use, and notably does not require INR values. Nachi: There is also the ABC score which has demonstrated slightly better prediction characteristics for bleeding risk, but it requires high-sensitivity troponin, limiting its practical use. Jeff: We won’t say more about the scoring tools here, but would recommend that you head over to MD Calc, where you can find them and use them in your practice. Nachi: Let’s also comment on the practicality of hemodialysis for removal of the DOACs. Multiple small case series have shown successful removal of dabigatran, given its small size and low protein binding. On the other hand, the FXa inhibitors are less amenable to removal in this way because of their higher protein binding. Jeff: Worth mentioning here also - dialysis catheters if placed should be in compressible areas in case bleeding occurs. The role of hemodialysis for overdose may be limited now that the specific reversal agent, praxbind, exists. Nachi: In terms of cutting-edge tests, we have viscoelastic testing like thromboelastography and rotational thromboelastometry. Several studies have examined the utility of viscoelastic testing to detect presence of DOACs with varying results. Prolongation of clotting times here does appear to correlate with concentration, but these tests haven’t emerged as a gold standard yet. Jeff: Also, for cutting edge, we should mention ciraparantag. And if you’ve been listening patiently and just thinking to yourself why can’t there be one reversal agent to reverse everything, this may be the solution. Ciraparantag (or aripazine) is a universal anticoagulant reversal agent that may have a role in all DOACs and heparins. It binds and inactivates all of these agents and it doesn’t appear to have a procoagulant effect. Nachi: Clinical trials for ciraparantag have shown rapid and durable reversal of edoxaban, but further trials and FDA approval are still needed. Jeff: We’ve covered a ton of material so far. As we near the end of this episode, let’s talk disposition. Nachi: First, we have those already on DOACs - I think it goes without saying that any patient who receives pharmacological reversal of coagulopathy for major bleeding needs to be admitted, likely to the ICU. Jeff: Next we have those that we are considering starting a DOAC, for example in someone with newly diagnosed VTE, or patients with an appropriate CHADS-VASC with newly diagnosed non-valvular afib. Nachi: With respect to venous thromboembolism, both dabigatran and edoxaban require a 5 day bridge with heparin, whereas apixaban and rivaroxaban do not. The latter is not only easier on the patient but also offers potential cost savings with low risk of hemorrhagic complications. Jeff: For patients with newly diagnosed DVT / PE, both the American and British Thoracic Society, as well as ACEP, recommend using either the pulmonary embolism severity index, aka PESI, or the simplified PESI or the Hestia criteria to risk stratify patients with PE. The low risk group is potentially appropriate for discharge home on anticoagulation. This strategy reduces hospital days and costs with otherwise similar outcomes - total win all around. Nachi: Definitely a great opportunity for some shared decision making since data here is fairly sparse. This is also a great place to have institutional policies, which could support this practice and also ensure rapid outpatient follow up. Jeff: If you are going to consider ED discharge after starting a DOAC - there isn’t great data supporting one over another. You’ll have to consider patient insurance, cost, dosing schedules, and patient / caregiver preferences. Vitamin K antagonists should also be discussed as there is lots of data to support their safety outcomes, not to mention that they are often far cheaper…. As an interesting aside - I recently diagnosed a DVT/PE in an Amish gentleman who came to the ED by horse - that was some complicated decision making with respect to balancing the potentially prohibitive cost of DOACs with the massive inconvenience of frequently checking INRs after a 5 mile horseback ride into town... Nachi: Nice opportunity for shared decision making… Jeff: Lastly, we have those patients who are higher risk for bleeding. Though I’d personally be quite uneasy in this population, if you are to start a DOAC, consider apixaban or edoxaban, which likely have lower risk of major bleeding. Nachi: So that’s it for the new material for this month’s issue. Certainly, an important topic as the frequency of DOAC use continues to rise given their clear advantages for both patients and providers. However, despite their outpatient ease of use, it definitely complicates our lives in the ED with no easy way to evaluate their anticoagulant effect and costly reversal options. Hopefully all our hospitals have developed or will soon develop guidelines for both managing ongoing bleeding with reversal agents and for collaborative discharges with appropriate follow up resources for those we send home on a DOAC. Jeff: Absolutely. Let’s wrap up with some the highest yield points and clinical pearls Nachi: Dabigatran works by direct thrombin inhibition, whereas rivaroxaban, apixaban, edoxaban, and betrixaban all work by Factor Xa inhibition. Jeff: The DOACs have a much shorter half-life than warfarin. Nachi: Prehospital care providers should ask all patients about their use of anticoagulants. Jeff: Have a low threshold to order a head CT in patients with mild head trauma if they are on DOACs. Nachi: For positive head CT findings or high suspicion of significant injury, order a repeat head CT in 4 to 6 hours and discuss with neurosurgery. Jeff: Have a lower threshold to conduct a FAST exam for blunt abdominal trauma patients on DOACs. Nachi: Assessment of renal function is important with regards to all DOACs. Jeff: While actual plasma concentrations of DOACs can be measured, these do not correspond to bleeding outcomes and should not be ordered routinely. Nachi: The DOACs may cause mild prolongation of PT and PTT. Jeff: Idarucizumab (Praxbind®) is an antibody to dabigatran. For dabigatran reversal, administer two 2.5g IV boluses 15 minutes apart. Reversal is rapid and does not cause prothrombotic effects. Nachi: Recombinant FXa can be used to reverse the FXa inhibitors. This works as a decoy receptor for the FXa agents. Jeff: Vitamin K and FFP are not recommended for reversal of DOACs. Nachi: Consider activated charcoal to remove DOACs ingested within the last two hours in the setting of life-threatening hemorrhages in patient’s on DOACs. Jeff: Hemodialysis can effectively remove dabigatran, but this is not true for the FXa inhibitors. Nachi: 4F-PCC has been shown to be effective in reversing the effects of the FXa inhibitors. This is thought to be due to overwhelming the inhibitor agent by increased concentrations of upstream clotting factors. Jeff: tPA is contraindicated in acute ischemic stroke if a DOAC dose was administered within the last 48 hours, unless certain laboratory testing criteria are met. Nachi: Emergency clinicians should consider initiating DOACs in the ED for patients with new onset nonvalvular atrial fibrillation, DVT, or PE that is in a low-risk group. Jeff: So that wraps up Episode 31! Nachi: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Jeff: And the address for this month’s cme credit is www.ebmedicine.net/E0819, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month!

In today's podcast Mason chats to Jeff Chilton. Jeff has been working in the medicinal mushroom industry since 1973 and is an absolute specialist in his field. Jeff is the founder of Nammex, the leading supplier of organic mushroom extracts in the world today. With over 40 years of mushroom growing experience, Jeff was one of the first people to bring mushroom extracts to the North American market. All you medicinal mushroom nerds out there make sure you catch this episode, Jeff is a deep reservoir of knowledge and insight!   The gents wax lyrical over: The ins and outs of mushroom harvesting. The difference between products made from mushroom mycelium as opposed to their fruiting body.  Cordyceps Cs-4. The inferior nature of grain grown medicinal mushroom products. The nature of the medicinal mushroom industry at large, and what to look out for in regards to quality and authenticity. Following your passion in business. Retaining your integrity in the mushroom industry. Polysaccharides and betaglucans. China as a superior source Who is Jeff Chilton ?   Resources  Q: How Can I Support The SuperFeast Podcast?   A: Tell all your friends and family and share online! We’d also love it if you could subscribe and review this podcast on iTunes. Or  check us out on Stitcher :)! Plus  we're on Spotify and Soundcloud!   Check Out The Transcript Here: Time to talk tonic herbalism people. Maybe some medicinal mushrooms and philosophy for longevity, so pour yourself a tonic and get ready to get super human, baby. Let's start the show!   Mason: Hello everybody. Welcome back to the podcast. Got one that, I've been really looking forward to doing this interview. Jeff Chilton, I'll go into a little breakdown now, rather than just jumping ahead to why I'm really into his work. He's been in the mushroom industry since 1973. When it comes to mushroom cultivation, back then, he was really pioneering. Especially, a lot of the mushrooms that we have available today via cultivation in the west.   Mason: He had a lot to do with the developing the manufacturing of those. Then in 1989, switched over to the manufacturing of medicinal mushroom extract, so he's OG in this medicinal mushroom world. There was no real trending back then. And I, like him, we met two years ago at a herbal symposium in Oregon. That's when I really ... super aware of him and just how he was just via just his own integrity and just educating the market.   Mason: He became this internal watchdog of the industry. Just in the sense of just calling out real bad practices that are going on in the medicinal mushroom industry, and still today, and educating people, so you can spot a product on the market which is telling fibs, and really doesn't have the good stuff that we have all come to know and love about medicinal mushrooms.   Mason: So NAMMEX is his company, also Real Mushrooms, and I love the fact that we can sit down as colleagues, offering medicinal mushrooms, having more at it from the Taoist perspective and Jeff just rocking gin that specialization of mushrooms and especially being such an originator of the entire industry. I really love to be able to sit down, talk with him and ask him about the history, especially he's really been shining in educating people about the difference between growing medicinal mushrooms on wood and on mycelium. And we dive into nuances of that.   Mason: Basically we talk about the industry and we talk about setting up relationships in China and just how amazing it is to be able to source really incredible, the most high quality mushrooms that you're gonna be able to get in the world outside of a wild cultivated situation. Where we are talking about medicinal qualities. Getting those from China and being able to educate people about the beauty of getting them from China. We talk a little bit about that.   Mason: Also what it's taken for us to develop the relationships with growers and farmers and so I think you'll find it really interesting hearing me from 2011, Jeff from 1989 really navigating the difference in our stories. As well we go into organic because Jeff has pioneered in getting the first certified organic mushroom supplement in the US which is really amazing. We go a little bit into that, I share my two cents on where I see organic is at. More so the reason why I like Jeff is because he's not like most companies that just think the be all and end all is paying for this little sticker, jumping through a couple of hurdles and getting the sticker on your product.   Mason: But what we call going beyond organic. And Jeff does that with the organic certification and I share my two cents on where I'm at with that whole thing. But mostly just how much I love that he's non-stop out there educating people. Not just trying to flog a product, not just trying to grow this crazy big business. But I think that's kind of inevitably happening, it's just a nice slow growth of a business. Because it has a lot of trust and it has a lot of consistency in its messaging. And we talk a lot about that and have a lot of laughs and get a couple of stories about the history of the mushroom kingdom and those mushroom people back in the day. We talk about mushroom conferences and a bunch of other things. I think you'll really enjoy it, I hope as much as I did, here's Jeff Chilton from NAMMAX.   Mason: Jeff, thanks for joining me, man.   Jeff: Hey Mason, thanks a lot for having me.   Mason: Absolute pleasure, so remind me where are you again in the world?   Jeff: I am in British Columbia, Canada. I like on Vancouver Island out on the West Coast. You and I are actually connected by the Pacific Ocean.   Mason: Vancouver Island especially, for some reason that just keeps on calling in. I keep on having friends, awesome friends and now you. You're waiting there. And I'm like "What is the pull?"   Jeff: Yeah. You have gotta come. Definitely come in our summer time because otherwise you'll just be hit by all of those things you don't like, which is rain and all the rest.   Mason: Well, it brings mushrooms, yeah?   Jeff: It's true.   Mason: When is it really on for you there? What months is it on for mushroom harvesting?   Jeff: Mushroom season is really going strong in October. First couple weeks in November still happening but then things cool off too much then it slows down and there's nothing happening. We get rains in August, which really primes things then in the last couple weeks in September we could see things starting to pop up.   Mason: All right, I love it. October, that sounds good to me. Let's dive in a little bit because we met maybe we were chatting it must've been two years ago.   Jeff: At the American Herbalist Guild Conference in Oregon, which was just awesome.   Mason: That was amazing, I mean, we were in Silverton? Is that right?   Jeff: Silverton, exactly, yeah, that's where we were.   Mason: But apparently not the witch one. No, I think that's on the other side. Tony was looking at Silverton but that's where all the witches were.   Jeff: Oh, ah   Mason: That's a different Silverton. I can't remember the name of the hotel but their grounds rolling in and the ginkgo trees, big ginkgo trees as well lining it. And then all the herbalists who came and did their herb walks were just frothing at how much they were able to go and show everyone how to forage, how to identify. Because the array of herbs there was incredible. That place is designed.   Jeff: It was absolutely designed. It was a huge property and they put in all sorts of different plants, herbs and different kinds of trees. It was a beautiful venue there are a great place to have that. Even on the Saturday night when they had a band playing and everybody was dancing. I had a great time.   Mason: That's so good, yeah. I imagine that place gets a lot of herbal symposiums going through it. And man, the best thing, the fig tree was kicking. Did you get up there and face on the fig then, during that symposium? That was the best part of it. Right next to the pine.   Jeff: Oh my goodness, no. I hardly had a chance to get outside which is back to my place where I was staying on the grounds and then down to the venue. But I was locked into my booth most of the time and talking to people. And then in the evenings it was nice. It was a fun thing. And I know you said you had a chance to get to hear Christopher Hobbs while you were there. That had to have been really great because I always enjoy seeing Chris. I know he was really busy in fact, funny thing was Chris told me, he said "God, I'm sorry I didn't spend more time with you. I ran into an old girlfriend."   Mason: Oh, right, I'm happy for him.   Jeff: Me too.   Mason: You're like, 100%, I can't contend with that. So '86 Hobbs wrote the book. Were you aware when his book 'Medicinal Mushrooms' came out, because when was NAMMAX first created?   Jeff: I started the business in 1989. I'm trying to remember whether I knew Chris at that point in time or not, but he was part of the whole herbal industry, so to speak, and Herbalist Guild and all of that back then. I wasn't nearly as much in touch with herbalists until I started my company. Before that it was just pretty much just mushroom people and all the people that were in the mushroom world over here. There are a lot of them. Mushrooms really happening. Long before the herbal industry figured it out and got wind of it.Chris was one of the first because he was an herbalist but also was interested in fungi. So that was really cool.   Mason: Yeah, I think he studied and formally became a mycologist as well.   Jeff: Well, no, he was a botanist, definitely a trained botanist and a history orf botany in his family. Herbalists and things like that. And now he went on and he got a PhD in molecular genetics.   Mason: Okay, he's going down that route. I like that book because he was really able to balance the mystical aspects of the mushroom herbal kingdom especially and then dive deep down into the science. It's something that only him and Steven Hardliner. Steven is the master at going down deep, molecular how a particular compound is interacting with a particular viral passade. And then blowing into full throttle Earth poetry in the next paragraph. It's a real gift. Going back to the 80s, you were running with the mushroom clique in America. Yeah, tell us the story.   Jeff: The thing was in the 70s... Well, first of all in the late 60s magic mushrooms were really great interest. That was one of the things that I was really studying at university. I had this interested in mushrooms in the 60s and I reading all about a man named Gordon Wasson. Are you familiar with Gordon Wasson?   Mason: Just the name and loosely, but not really.   Jeff: Yeah, so Gord Wasson was a New York banker with a Russian wife. He learned about mushrooms being used deep in the mountains of Mexico by Curanderez and went down there in the 50s and spent the next five summers down there. He classified a whole bunch of different psilocybes during that period because he took a French mycologist with him. And so, five summers. But he basically opened up this whole world of Look! Still today after thousands of years there are people in the world that are still using these psychoactive mushrooms in their healing practices. Man, that was a mindblower.   Jeff: So I was reading Watson and other people that were involved in that and they had published these books that were incredible books. I mean Watson went on to publish a book called 'Soma: Divine Mushroom of Immortality.' He published that in 1968.   Jeff: Then somebody came along a man named John Allegro came and published a book called 'Sacred Mushroom and the Cross,' which talked about mushrooms in early Christianity. So, Mason, listen, think about it for a second. In 1968 two books are published. One says that a mushroom is at the root of Christianity. The other one says a mushroom is at the root of the Hindu religion.   Jeff: And then all of a sudden from there it just... You get going forward and you find that mushrooms, you see symbols of them and you start to hear stories about them used through all sorts of different groups throughout history. Pre-history actually, because as that came out people started looking and discovering this. That was really part of my study in university because I was studying anthropology. And mycology on the side.   Jeff: Going into the 70s in Olympia, Washington where I lived and worked on this big mushroom farm there was a whole core of people that were interested in mushrooms. It was an amazing group of people. Paul Stamos is one of those people. Ultimately he and I wrote the book called 'The Mushroom Cultivator' in 1983. We even had a group. We had four people, Paul and I and two other people, where we had four different mushroom conferences. These conferences were so ... You would have enjoyed it so much. We had people there that were speaking about how to identify mushrooms. I was speaking on cultivation of mushrooms, speaking on the anthropological aspect of mushrooms. We had great people there speaking. There was Andre Wyle was at our conferences. And it was just a great time had by everybody, right? You can imagine. All these mushroom people coming together. 200 people coming together for a weekend. Amazing.   Mason: So good. I mean, it's different, you got this original crew, there's always something special when you've got the original crew.   Jeff: Yeah.   Mason: There's a medicinal mushroom symposium every year that moves around the world. It was in Colombia a couple of years ago and then in Italy. Do you know that one?   Jeff: You're actually talking about the International Medicinal Mushroom --   Mason: Conference?   Jeff: Society IMMS and you know what? And that was more of a scientific group that was formed much later. I know the principles of the group. It started somewhere around 1999. They're having a conference in China on the 18th of September this year. You should come. I'm gonna be over there at this conference. I know lots of other people are gonna be there as well. It's gonna be an interesting time. I'm gonna be giving a paper there, which will be fun. There will be lots of other people too. I don't know what time of year you go to China.   Mason: Yeah, I go in September. I think this year we've got our staff retreat in September. I'm gonna check the dates, but otherwise I've been wanting to get along anyway. I've been trying to revolve it around going to Wudang mountain and doing some Taoist training as well. This is where I've been tossing up this year, what time to get over there. But that sounds a bit serendipitous.   Jeff: Yeah, well, the conference is I believe the 18th to the 22nd of September. That's normally kind of early for us. We like to go over more in November. We go every year. November's really harvest time for a lot of mushrooms like Shiitake, Maitaki, Wood ear. A little bit later is Hericium, Lion's mane. In September it's the Reishi harvest.   Mason: Yeah, Reishi harvest is normally for us in September. Where's your Lion's mane growing? Which region?   Jeff: It's growing in Fujian province.   Mason: Okay. Ours is a little bit earlier, in September as well. In Heilongjiang. In the northeast.   Jeff: Okay, yeah, because in Fujian province it is late, late November when it's quite cold. It's back to the mountains, quite cold. Maybe up in Heilongjiang it's colder in there right?   Mason: It's chilly.   Jeff: (laughs)   Mason: That's spoken like a true Australian.   Jeff: Let's fly in and start up north there and step off. I just can't wait to get to Yunan province.   Mason: (laughs)   Jeff: I can't wait to get down into that tropical vibe. Although, nothing beats that crisp air.   Jeff: Well that's good. I'm at that point where -- I don't know when your periods of this business growth have been -- but I've been real head down, bum up in the business. Not really been in that space of upgrading my information. Of course, I'm always reading and everything, doing all these things. I feel like that's like, you're at a point in your business where you are traveling around and you're educated. You're back at that point where you're free to go and educate and then go and educate yourself non-stop, constantly, which is really nice. I'm nearly back there.   Jeff: Yeah, you know what it's like. We are so swamped right now. We've got so much demand for the product right now. We're growing and over the past two years we've hired four people, two people for lab and another person for regulatory and, can you imagine, we've got one person that's strictly regulatory affairs and deals with all the paperwork that we have to deal with. The paperwork is really monumental. We get forms from companies that are 220 questions!   Mason: Companies that you're doing business with and they wanna know, looking at purity or is it you getting stocked with them that they want all those questions answered?   Jeff: No, they qualify their suppliers. And so this is all about GMPs for the most part and how your product is manufactured. They want to know that everything is according to the GMP, quality, and the standard operating procedures and all the rest.   Mason: I think that's where Real Mushrooms. Was it your son that created Real Mushrooms?   Jeff: Real Mushrooms, yeah. Sky created Real Mushrooms in 2015 as part of NAMMAX so it's just one division of the company. He runs Real Mushrooms as well as other things because he's in training to allow me to go fishing and he can stay and do all the work.   Mason: Great. NAMMAX is providing more providing bulk for people that are putting it into products and stuff?   Jeff: We're a business to business. We sell the raw materials and then Real Mushrooms is retail products and mostly sold online. Maybe getting it into the stores at some point, but right now an online business. But we're business to business where we sell to companies that then put the raw materials out under their own brand.   Mason: Does NAMMAX do... I'm increasingly aware because I think NAMMAX... we get a lot of people asking at SuperFeast but we don't really specialize in that B2B space. But one thing I want to talk a little bit about later is a lot of people who, like NAMMAX has bridged it and made it really accessible. Especially with you and the middlemen not having to deal straight with trying to... I'm still appreciating, it took me quite a few years but you'd know the in's and out's beyond what it's like developing relationships, critiquing, getting the authenticity on the testing. Also developing a relationship based on integrity and qualifying on that level takes so long. I feel like NAMMAX has really made it possible.   Mason: I know a lot of people in Australia who are like "Ah, great, I can just go and NAMMAX can just do it all for me." Which is really great, because there's a lot of people. I like it because there's a lot of people jumping onto the bandwagon, and Australia has got this nice buffer. We don't have too much shit here, which is really good. And that's something that's nice for me to be able to say about my competitors as well. Australian community doesn't need to be as wary, I think, as the U.S. world because the U.S. is a bit...I didn't realize it's a shit fight. I know talking to you a lot back in the day, I don't think I presented that I was from SuperFeast. We were just talking about mushrooms and I was just learning a bunch off you and learning about your history.   Mason: As a company when I started out it was an absolute no-brainer that we weren't gonna use fillers, that I wasn't going to be using mycelium product myself. We'll talk about that, it has its place. Of course, growing on good-quality wood. In Australia we're just small companies. I started in Mum's spare room getting products for me and Mum. Then talking to you I was like... and then reading your blogs and really falling off the back of it just like that. Wow, because you actually really inspired me after that talk going, "Well of course, I do talk about the fact that we don't use fillers and we don't grow on grains." And all these kinds of things, but it was getting to that point I didn't realize people really needed to know the in's and out's of your product and be able to ...   Mason: After seeing what happened in America with how much trickery there is and the percentages of polysaccharides there is, lets' go into it a little bit now. You've been watching it and been the internal watchdog of the industry, which I really like. When did that first start cropping up? When did people start jumping on the mushroom bandwagon and fibbing about the levels of polysaccharides and active ingredients?   Jeff: The interesting thing was that having been in the supplement industry since 1989, the key thing for me was that I was a mushroom grower by trade. So i spent ten years as a commercial mushroom grower on a very big, big farm. Not a hobbyist growing in my basement or a closet or something like this. A commercial mushroom grower, large farm. Millions of pounds of mushrooms every year. So I knew how it all worked, I knew the economics of it all. I realized back in the late 90s, for example. Or even the early 90s that you couldn't actually produce mushrooms in North America and turn them into a supplement, because it's a dry powder it's not a fresh product. Once you dry that thing out it's 90% water you gonna get ten times as much money for that pound of mushrooms. It doesn't work in the supplement world.   Jeff: That's where going to China and I went to farms, I went to factories, I went to research institutes, I went to conferences. The 90s was just amazing to see what was going on. I went north to south, east to west. Yunan province all the way up to Jilin province. It was all over China seeing this industry and seeing the research. One of the things, you talked a bit earlier about quality how do you know. Here I am visiting these companies going to all of these conferences. I'm having people coming up to me all the time saying, "Will you buy my product? Here it is." And they just show me a brown powder and I'm just like, it's a brown powder, I don't know what it is! How can I really know what that is. And then getting to know companies and people that were genuine and you could go to their factories and see what they were doing. Especially if they were only producing mushroom products and then building the relationships to that.   Jeff: Then I turned around and back in the United States here are these companies that come along and they start to produce mycelium on sterile grain. The worst part about it is they sell it as a mushroom.   Mason: Some people might not know what, so, we're talking about the fact, which you alluded to, which I completely agree with, that the only way to make a viable super high-quality product that's a powder is doing it in China. Based on the fact that, say you have 10 or 20 kilos worth of raw product that's gonna then give you a kilo of the powdered product in the end, it's not viable in the U.S. so to make it viable in the U.S., the way it generally works is that it's grown on a grain substrate, like rice, brown rice, oats, this kind of thing.   Jeff: Yeah, and the thing is, what people need to understand is that a mushroom is just one part of this fungal organism. So the other parts would be a spore, the spore germinates in to a fine filament, those filaments come together, they create mycelium, which is the actual body of the fungus. Which normally if you're out there hunting mushrooms you never see that because it's in the ground or it's in the wood. So most people are unaware of that. But that mycelial network amasses nutrients. When the conditions are right it produces the mushroom. That's what we see because up it comes and it's like "Wow, look at that thing there!" And then that matures, it produces spores, and then we have a complete life cycle.   Jeff: The interesting part, Mason, is that growing mycelium, which is the vegetative part of this organism, on sterile grain as a mushroom grower, what that is and what that was developed as mushroom spawn. Which is like the seed that is used to grow mushrooms. Because mushrooms don't have seeds they have spores. You don't plant spores when you grow mushrooms, you plant live mycelium. The mushroom growing world, what they developed is "Okay, we'll take that live mycelium and we'll put it onto some kind of a carrier. Then that carrier we can spread into our compost or whatever it was that they're growing their mushrooms in. If you take a gallon of grain, you've got maybe thousands of grains in there you coat that with mycelium, and then you take those thousands of grains and you can mix them into a big pile of straw or compost or something. Each one of those mycelium grows off of and it grows into this thing. So that myceliated grain actually was developed in the 1930s as mushroom spawn or essentially seed to grow mushroom.   Jeff: It's an easy process, it's done in a lab and people in the United States, we can't grow mushrooms. Why don't we just take that process, we'll grow out the mycelium. Mycelium in and of itself it's got beneficial properties because it is a fungal hyphae that has beta glucans in its cell walls. If you grow it in a certain way like in liquid or something it can produce certain medicinal compounds. But when you grow it on grain and then you don't separate it out from the grain at the end of the process you end up with mostly grain powder. That's what companies started to do. They started to grow the mycelium on grain. At the end of the process they would dry it -- just like you're drying a mushroom, but -- they'd dry it, they would grind it to a powder. No mushroom there at all. No mushroom, it's just myceliated grain, and it's mostly the grain powder. Finally, the worst part about it is then they call it mushroom when they sell it.   Mason: I definitely know I've been surprised, because my first trip to the States I went and bought all the different brands. I was floored by some of the grainy non-mushroom powder that I was buying. That was like white powder, it's in your face.   Jeff: Yeah, white powder and you taste it and you're like, "How's it supposed to taste like mushroom? It tastes kind of like flour."   Mason: Yeah, it's like flour, sawdust. So are there companies doing a mycelial growth that are more on the ethical spectrum, that they're not doing a full grain wash and that they're growing on a particular grain that they're able to separate out a lot of the mycelium? I know that a lot of the mycelium is embodied grain. That's just a reality that you're not gonna be able to get rid of. But I'm trying to play that... is that possible in your experience?   Jeff: In China they grow mycelium in large tanks of liquid.   Mason: Like Cs-4 Cordycep, yeah.   Jeff: Yeah, Cs-4 Cordyceps. They've been doing that for 50 years. But the thing is that it takes a lot of money to put in a big facility that can grow and these tanks are huge and you have to have a steam generator. It's a big investment but to actually grow out the mycelium on sterilized grain does not take a lot of money, it doesn't take a lot of expertise. It's a very simple process. Anybody can do it. In my book that I published in 1983, it tells you how to manufacture mycelium on grain at home in your kitchen. It's not difficult so it's very easy and ultimately, the stuff is so cheap to produce. And these people are selling it as mushroom and making a fortune doing it. It's really immoral in my opinion, and unethical. And especially if you're calling it mushroom.   Mason: I think because we sometimes maybe look at the market and what we subconsciously are looking for when we want a mushroom and most of the studies have been on if you're like... Most of the time we're looking for a fruiting body. That's the mushroom. It's the unspoken that we know that we're talking about is the fruiting body there? And I guess there are some companies that have been quite averse or trying to sign typically validate the mycelium. When I was first kicking around all this there were people going "Look, just have it all. Have the fruiting body, have the mycelium, have all these..." and I very quickly, before I had a company was like "Mmm, no." I'm not in this to justify a particular aspect of the market or go for ease. I'm in it personally, and especially in the beginning, being a dreadful romantic, trying to connect to a herbal system, particularly Taoist tonic herbalism for me.   Jeff: Exactly. The people who grow those products and they say "Oh, we want to have all parts of this. We want to have the spore, we want to have the mushroom, we want to have the mycelium." It's like they say "It's full spectrum." Well, the problem is that they leave out the fact that (A) there is no mushroom in it, and (B) the grain! How can it be a full spectrum product if they've got all of this grain in the product? That's what they don't like to talk about. They don't like to talk about the fact that it's mostly grain and all of this other stuff about "Oh, you know, the fruit body's in there and the spore's in there." Absolutely not. It's really a lot of smoke and mirrors.   Jeff: That's what's so hard to take is that when there are people out there actually espousing that and claiming that they've got a full spectrum product when in fact it doesn't take much in the way of analysis to prove what they do and they don't have. We've run analysis and what's really interesting is if you analyze it, for example, with a proximate analysis, which is proteins, carbohydrates, fats, ash, minerals. Those products line up perfectly with the grain they're grown on.   Mason: Are there exceptions to that?   Jeff: No. All of these products and there, it's the myceliated grain products. If it's grown on brown rice it lines up with brown rice. If it's grown on oats it lines up with oats. Literally the two lines run together. The way I like to think about it too is I talk to people and I tell them what they're growing is tempeh. And they say what tempeh is, it is cooked soybeans with fungal mycelium grown on it. If you look at that tempeh and it's all white that's the mycelium but if you look at tempeh and you cut it open you can see it's mostly the soybeans. And if you were to dry it out, look, Mason, mycelium is 90% water. Just like a mushroom. The soybeans are 50% water. When you dry that tempeh out the mycelium just goes "Fffft!" Just tell me, where's the mycelium? And you've got all of these dried soybeans and you're like, well, it's mostly dried soybeans, that product.   Mason: I'm sure you get it a lot as well. Yours, there's obviously a few brands in the U.S. becoming more aware of the others. I didn't go looking for them but as you move into a market. SuperFeast, I spoke to you about it the other day. We've got so many people ... like [inaudible 00:29:50] story. I've realized in business a lot of the time it's like, same with you, I like the people. I like the unique stories. People are like "Bring SuperFeast over, there's no one doing that like what you're doing over there!" I like, yeah.   Jeff: (laughs)   Mason: And it's the same. When you're upfront about the nuances although there's a lot of companies doing medicinal mushrooms like yourself and Taoist herbs like us, medicinal mushrooms. There's nuances there and the sourcing and there's nuances in the story. What I like is, which is going to get to the polysaccharide claim, and the full spectrum claim for the people growing the mycelium. Because people are in an egoic, competitive make money mentality a lot of the time. They think they have to be everything to everyone. Versus just being very upfront. I'm always quite upfront, I don't really look at that. I don't try and standardize color or anything in any way. I don't try and standardize the constituents. I don't even sell on the percentages of constituents. I don't focus on it. I'll move more in that direction because more and more people want to be satiated. I can say yes, we test for percentages of the active ingredients to ensure that they're in alignment with the Chinese cornucopia and ensure that they're actually active. And all that kind of stuff.   Mason: But going over into the States now and hearing about all these other brands and I'm with you whenever it's growing on grain I can't get behind it. Not to be disrespectful, and I'm always trying to be really amicable in my talks. There's a place for it, but less and less can I find that place.   Jeff: And I understand what you're saying too because if a person is genuine. For example the herbalists, who are at an American Herbal AHG conference. These are people that want to provide good products, they want to provide a body of knowledge to help people. That's who you wanna be, that's who I wanna be. I'm not in this to make a lot of money. I'm not in this to build some big company and go Oh, gee, isn't this great? Because I'm selling $20 million a year of this or that. That does not excite me at all. That has no meaning for me. What has meaning for me is that I'm producing a quality product that I've been working on for years and I can tell you the product is what I say it is and I want it to help you. I want you to be able to take this product and feel confidence that you're getting what the Chinese have used in traditional Chinese medicine for thousands of years. That's what I want.   Jeff: I don't want to sell you something that is not what it really is and is a placebo and expect you to buy the product from me and I walk away going "I'm managing this great at my company. I'm making so much money and it's wonderful." No, I'm sorry, that's not me. I'm not interested. Those people turn me off. It's like the difference between being in a group of people that really understand mushrooms or herbs and being in a group of people that are just talking business and numbers and all that kind of stuff. And I don't give a shit about that.   Mason: Yeah. I think it's interesting. Watching your business I can see in the beginning it probably would've started out that everyone knew Jeff and knew your level of integrity and how you just wanted a good product. In that little circle it was like 'Great, we'll just go and get Jeff's product.' Then as you grow I think what you've done really well ... just to put it as an example of why I'm bringing this up, we're getting to this point where we're growing as a company where it's beyond Mason at the markets and everyone knows that Mason has the badass tonic herbs. Or people are coming along to the talks and all the health clique. We've started emerging.   Mason: I think you would've gone through this years ago when you emerged beyond the health clique. And it's very dramatically people aren't associating directly with you or the founder, it's the company. They don't even know or care who the founder is and therefore you need to have these things in place. We're getting to the point where everyone who's a SuperFeast customer is just like, "Yeah, we don't even care about organic, we know what you guys are doing," and we're going on that old philosophy and we're documenting that and there's all those other checks in place like independent testing for pesticides and metals and all that in place and available.   Mason: But it's getting to that point now where the people on the very outside... I still don't know if we're really gonna shift because I still personally don't care and I don't change my company for perception's sake. But you can see Wow, that organic would be really, really useful for those people on the outside. Or the testing to know what percentage of what's going on inside and being able to present that. I think we'll move in that direction. I think you've done that really well and really maintained the trust in the brand of course, and in yourself. But maintaining you there as the one that's rolling this along and not then just relying, you know, the organic certification or the percentages.   Mason: I think that's what I find really commendable, because most people then they rest on their laurels. Once they change over into, not standardizing but testing for minimum constituents like beta-glucans or organic. they then rest on that. Whereas that means nothing to me at all. Being able to talk to you I'm like, Yeah, because organic, I don't know what your take on that. I know there's some terrible organic products out there. Just the fact that we know we can go organic there's five different companies we can go to, so you just go and find the company that suits you. We can go with the company that's the hardest to jump through.   Mason: I won't go into the details of what's going on, why we're probably not going to go in that direction. For us there's so many little micro-farms that we're being nimble with whom we're working with. When we're beyond mushrooms we've got a lot of other herbs going on. We need to cut that farm out if they need to move on and do something else and we'll go and we've got that team to go around and constantly go and find these people. So every time we want to nimbly adapt and go down a different direction when someone's doing a little more traditionally than the other person, all right, get the organic certify up. Or lie, which is what I think a lot of people are doing. They get the organic certification, then when they change up those little farmers, because we're dealing with independent farmers as well, not a company that can provide the organic certification. I don't know why I went on that rant. So that's why we're not going on down that route.   Mason: It's something I see. I know there's a bunch of companies who are coming to NAMMAX, which I think is just been so good for the Australian industry. For people to know that they're very quickly going to be introducing a really good quality. You can tick off the organic but I hate it when it's just organic that they are going for and not just an incredible product with a story behind it as well. So I really commend you for offering that out.   Jeff: I've always really believed in chemical-free food. Organic is more than just chemical-free it's how it's grown. When you're growing out of soil it's building the soil and not just depleting it. For me organics is a holistic way of looking at things. I've always considered that to be very important and I support that type of agriculture no matter what it is. A lot of these companies that are producing myceliated grain, they're organically certified!   Jeff: It doesn't necessarily mean that it's going to be a great product. These companies have what I call all sorts of merit badges. 'We're big and we're organic, we're kosher, we're this, we're that,' which ultimately means nothing at all. There's a lot more to it than just that. The one thing I really like about what you're doing too is that you're introducing the philosophy of it and that's something that you really believe in. That to me is important and that's what people look at. They look at who's behind the company and what that person has to say, is that person ethical, righteous, person or not. You're not up there as a smooth talking business salesman or anything like that, right?   Mason: You should see me try and sell something I don't like. I'm a bumbling mess. I think I told you that back in the markets people used to say god-made...you could sell ice to the Eskimos. But I'm terrible if I'm not talking about herbs or philosophy behind it.   Jeff: That's because you're doing something you believe in. That's where everybody should be. Not everybody has that opportunity, but if you can have that opportunity. I was lucky enough that I followed my passion and I didn't do that because I wanted to be rich. I did it because I loved it. I always say to people, if you really like to do something, whatever it is, just do it. Follow your passion. Maybe you're going to be poor for a long time. Make something that you feel good about.   Mason: Honestly, and I really mean it not just because you're on the podcast talking it up or trying to flatter you. But when I met you, you had a happy disposition to be in business that long. In the beginning I was trying to escape the business side of things. Quite scared about having a business and not coming out the other end alive. You have a sunny disposition and you still have control of your company and the standards and you're still educating about the same thing that you're educating, of course it's evolved, but you were educating about beforehand. And there's something that I've learned a bit about in that. There's something humbling and nice about not being in that pursuit for aggressive growth while still growing at a nice, sustainable rate. But staying true to what you were doing in the first place. I educate about basics of herbalism and medicinal mushrooms in the beginning and then I'll move on and doing other things. The more I go along the more I want to settle back into doing what I did all along.   Mason: I've got a weird thing about going back to the organic, I'll almost shy away from something if it's organic because I see it as a marketing ploy a lot of the time. And I think it is a lot of the time. With little things. When growing Lion's mane there's a lot of people who will use organic fungicide because they don't pick when they're watering out to the Lion's mane. I like to use this example because we don't have a plastic covering, it's just a straw and a hut to keep it nice and dark and it gets watered. That's the only part that gets watered. And one of the things I talked about in the beginning with Lion's mane, I just heard about it through the grapevine, that fungicide is needed if you're watering straw a lot of the time in order to, all right, we know why fungus grows. But found someone who wasn't doing that and found people who were doing organic Lion's mane who were using organic fungicide on the huts. Little things like that they get me so dejected about the marketing ploy behind it. But I think you're the one organic product that I would be over the moon to use.   Mason: And the other example is Ron Teeguarden. I think we talked about him. He was such a rogue in the industry herbally. You were telling me about the acupuncture when he was offering acupuncture because he's a barefoot herbalist and all the acupuncture's guilds are like "Screw you, you need to be regulated." And he's like "Hey."   Jeff: I know, it might've been somebody when you were in LA but it wasn't me. I don't know Ron that well. He's been around a long time. He's done his own thing, he's not out at the shows or anything like that. He's very well-known and in a sense he's been the herbalist to the stars. He's in Los Angeles, right? A lot of people in Los Angeles that are into herbal medicine and living properly in term of what they eat and things like that. They would go to Ron and Ron has one of the very first herb bars where you can walk in and have this type of a drink or that type of a drink. He was really in it very early and doing stuff that nobody else was. He was an outlier in that sense. I don't think he really needed to go into the industry proper. He's done a little more now that before. He didn't have to.   Mason: He, on the level of sourcing philosophy. I bumped into him years ago. I was at that place where I was starting to grow, people are asking why I'm getting my herbs from China and people asking me if I'm organic and all these kinds of things. I want to keep on doubling down on my philosophy, what I'm doing here. One thing that I drew from yourself as well and then be proactive and educating the market. Not in pushing your own product, just generally being happy about the market being educated as well. And Ron was like...In fact I talked with him for about five minutes. More or less he was like "Listen, if you have that spark," I remember, "do not deviate from that sourcing philosophy." And it really stuck with me and from that day I did. I doubled down and I was not going to try and... I'm going to continue to not worry about what's going on and just do me. It's a lot of fun. I was at Dragon Herbs Tonic Bar about three weeks ago. I frequent the Hollywood one when I'm in L.A.   Mason: Before we go too far off the mycelium grown, one of the things you've really educated, not only the market, but businesses in the market around medicinal mushrooms in the market, is how to identify a true polysaccharide read on medicinal mushrooms. Rather than people including 60% polysaccharides or even 30%, yet when you go down into the class of beta-glucan it's actually been tested you've been hoodwinked and they've gone dry from age or whatever. Can you talk a little bit about that?   Jeff: This is something in the herbal industry too that you learn right away, and I learned it back in the 90s, was that so many herbal extracts, when you make the extract they oftentimes need some kind of a stabilizer. Otherwise they can get gummy, they can jut come together if it's a powder. Putting a carrier with a lot of extracts was pretty common. What happened was sometimes companies would cheat a little bit. The next thing you know instead of 10% carrier it was 50% carrier or 80% carrier. And they're not revealing that to anybody. You think you're getting an herbal extract, not just mushroom extract, an herbal extract and it ends up being mostly maltodextrin or dextrose or something like that, and they're not telling you, then it is really deceptive. So there's a lot of companies that were doing that in the industry.   Jeff: As I went along, the whole time that I'm working with people in China I'm like, "Look, I want extracts where we aren't using any carriers. It has to be made in a certain way," because I'm looking for the pure essence. In traditional Chinese medicine they take the herbs and they throw it in a pot and they boil it up and pour it out and "Here, drink this!" There's no carriers in there.   Mason: That's right, not sliding agents.   Jeff: That's right. If you have to put something in a capsule you've got 150 milligrams of different types of fillers and binders and flow agents. Putting it into a pouch is so nice because then you don't have to put those things in with it. It's just the pure herb. Early on in the 90s everybody's testing for polysaccharides and nobody's testing for beta-glucans. And beta-glucan is a polysaccharide. Unfortunately all these carriers are polysaccharides too. A lot of people can hide that from you that you've got carriers on their product. No, no, we don't use carriers, it's 100% mushrooms, stuff like that. That's where with any kind of supplier you have to build up a level of trust. Like I say, they show you a brown powder and say. "Here's our product, it's shiitake mushroom extract. Isn't it great?" You can test it.   Jeff: This is the thing, Mason, it's not like you can take a mushroom product other than a reishi extract, consume it, and then a few hours later or a day later go, "Wow, yeah! Did I ever get a kick out of that!" No, it doesn't work that way. You can organoleptically, I can taste the shiitake extract and I can tell you yeah, that's definitely essence of shiitake. Or with reishi it's so bitter I can taste all those bitter notes in that reishi extract, that is an awesome extract.   Jeff: I used to give a reishi extract to a friend of mine who was a deep herbalist making his own liquid extracts and a big business ultimately. He'd taste some of my extracts in the beginning and he'd go, "Not bad, but it tastes a little bit burnt." And I'm like, "Oh shit." When it was dried it was maybe in the oven a little longer, and he could pick up on it. I thought that tastes pretty good. That was in the early days when I didn't know any better. I thought it's great and high triterpenes and all this. He'd go "Yeah, it tastes a little bit burnt." Those kind of things teach you a little bit about, okay, how's it made. Let me tell you, in the 90s the facilities that were making herbal extracts were nasty. They were old facilities   Mason: Not too much GMP regulation back in those days.   Jeff: It wasn't like stainless steel everywhere, no. Everywhere was dark from all the herbs they'd been cooking for who knows how many years. Now all that's been torn down and you see nothing but brand new factories in China. Everything is stainless steel and it's beautiful and there's none of that anymore. But back then, actually, it wasn't until we got the megazyme test and I started using that. And that was in 2012 or 2013. Up until that point I thought, well, the polysaccharide number was high, that's great. Then we starting testing the products and that's where we really pulled back the curtain. My main supplier, awesome! The test results we got from that. Beta-glucan and alpha-glucan and the alpha-glucan, that was where any of the carriers were revealed.   Jeff: And then another company that was supplying me with some products, only a few, not many, fortunately. And was swearing up and down they never used any carrier. Jesus, their alpha-glucan level was way up there. I was shocked and really upset because I thought their product was good because occasionally I'd test it for polysaccharides it was 50-60% and I was thinking, great product. I could taste it, it tasted okay. Nothing but mushrooms they were producing. But here they were. They were putting them on a carrier and telling me they weren't. That's the kind of thing that you face when you're over there.   Jeff: How do you qualify these products? You can go to the factory. They can show you around, you can look at all the mushrooms in their warehouse, you can look at them cooking these things up, the final products. They don't show you the bags and bags of maltodextrin that are hidden back in the warehouse somewhere that they're using as a carrier for the liquid extract. That literally pulled back the curtain and I went and confronted that with them. They claim no. Finally they actually admitted it and I'm like, okay, see you later. I'm not buying another product from you because you lied to me. Fortunately it was a secondary supplier. They weren't my main supplier at all, but I needed a secondary supplier. I visited them and it was all mushrooms that they were doing and they were in the heart of mushroom country and it was nothing but mushroom. Yet they had all these carriers in there. I was really upset not only with them but with myself because I got taken in by it too. And that's what you have to do.   Jeff: Look, Mason, have you ever been at Ali Baba and looked at all the mushroom products being sold?   Mason: It's always funny, and as you know, everyone's jumping onto the bandwagon right now. You can see people trawling through Ali Baba going "Oh, just tell me which one is awesome." I haven't been in there in a long time. I got curious, to be honest. I think we were in the office having afternoon drinks and seeing what was on Ali Baba. It is insane.   Jeff: It's totally insane. So many companies selling mushroom extracts. Sometimes they're selling at prices where you're like, "No, wait a minute, you can't sell me that extract for $20 for a 10:1 extract. That's impossible. You load it up with starch, that's quite possible, right? That's where analysis, for me, has been very helpful. Especially the beta-glucan analysis because that gives me that alpha-glucan which is the whole carrier. That's what unmasked all of those myceliated grain products. There's definitely a place for analysis. There's also a place for getting to know the grower. I don't believe in organic pesticides. I don't give a shit. Don't use whatever it is, you have to grow this. I know it's more difficult but you have to grow this without sprays and all that.   Jeff: The thing about China is that when you're traveling through China and I've been back in the mountains in all these different places and you go back and you look down and this little valley and here's this beautiful rice fields down there and you're going "Oh, isn't it great, back here. Everything's idyllic." And then you see somebody walking through the rice field and they've got a backpack sprayer. And they're going along spraying chemicals on this rice crop. I'm like, "Ugh, shit. Really? Do you have to do that?" And I think to myself, even the smallest growers out there are using some chemicals. That's where I'm like... And I want to be sure. And that's where we test and test to make sure that everything is staying on track because these things can slip in. Somebody can cheat. You have to ride herd on the whole thing. Otherwise it can slip right through your fingers.   Jeff: That's been good for me in the sense of having an organic product that has meant that we put these constraints on the people that we work with. We say look if your product shows one of these things in there I'm sorry we're not selling it. If you and if you shipped it over to us and we find it in there after you've done the testing that's all good and we find it in there it goes the landfill I'm sorry, we can't sell it. That has been a really good quality, that's how we keep that quality up. In that sense I kind of believe in it all and think it's important. It helps us keep the product a little bit more real.   Mason: As you say said there's all these things that can go by... even though it is organic, you can get organic pesticides and all this kind of stuff. I have taken your product and of course I really love it. You know that you're going to go that extra mile with it. It's a trip around it, there's a stigma around China is isn't that whole thing polluted?   Jeff: Well, that's the other side of it right now, Mason. People are so afraid of anything coming out of China that this gives them a little bit more confidence in it. They can say what they want about organic and all but we've got pesticide tests that can demonstrate what it is and of course the always have to do heavy metals and micros and all of that.   Mason: Alpha-toxins   Jeff: For us, especially as a raw material supplier to companies large and small we have to be able to give them confidence because you know they're selling a Chinese product that they buy from us and lot of people are just like you know when it comes to China it's like no no no no it's like not going to do it so I have to talk to a lot of people. And I say, well, hey look. There's products in the United States that are absolutely full of chemicals. So it doesn't matter where it's grown. It matters where it's grown but it's not this country or that country. You can grow good, clean products anywhere in the world if you're doing it properly.   Mason: It's so good. Of course people are realizing that the ultimate Chinese herbs and medicinal mushrooms are going to be coming out of China. I really like how it's still dominating and making it really easy for people to get One thing that's organic and Two very quickly have all those things to provide so enough people are going to be able to go, Oh, okay, so it's from China and we can trust it. That's something that makes it really easy, because people are going to jump on the mushroom bandwagon. We found it as well, a similar thing. People want to come, they're like okay, tell us about Chins. Okay, tested three times for pesticides before it comes to market, each batch. Plus here in Australia the TGA facility and heavy metals and alpha-toxins and microbes. At some point people go "Hmm, shit, okay." And testing of the water. And when we can going and doing radiation testing in the areas. And then going live and seeing pictures of you at your reishi farm is magic.   Mason: When I was going live around China going, you know we're still going up while we're outside the mountains going to the fields where the eucommia bark trees were grown or up in Yunnan. Just drove five hours in the middle of nowhere to get to the poria farm, where there's wild pine and people are going "Holy shit! Look at that land! The land of the dragon. It's calling me. It's real." All of a sudden popping that thing that first of all, yes, you just need to be vigilant, that's absolutely number one. I've only changed suppliers once. In the beginning I found someone I had really enjoyed their product. And then what I've decided was one of my areas in going forth is I need someone that could absolutely school me. If I'm requesting things and they weren't able to "bang" school me on that immediately, then I'm not going to be able to do business.   Mason: And it got to this point where I was confirming no municipal water. Only springs, only well water. Only creek water in the area. Nothing from the tap every touching the crops. At one point "Okay, sometimes that's a bit hard." I was like "All right, I'm gonna change now." That's when I started going down that route and ended up... developing relationships, developing a friendship first, understanding the intent behind the philosophy behind the business, understanding who owns the business that you're going to be dealing with and what their motives are and what their history is. These are the things where people don't realize what goes into it. People go "Can you tell me your supplier?" And you're like   Jeff: (laughs)   Mason: At this point it's not about me being scared about you having access to that supplier but so much has gone into this relationship. It's not just about finding someone and sourcing off them. Although, it's nice and easy to do that. If I was beginning right now I'd love to be buying just from suppliers on NAMMAX because it's cool. All the certificates, all the independents, and then all the years of vetting and tweaking that leads to this point where trust is inevitable and you become even more switched on to what to look for if anything ever comes up. If anything slips or changes you know the questions to ask and where the slip in quality could possibly be. And large ways you know how to put things in place that would stop that from ever happening to begin with. It's an interesting industry.   Jeff: We go there every year and we'll do an audit. We'll visit farms, the factory we'll be sure we confer with our partners to make sure everything is good. This year we're at the point where we're hiring someone to be on the ground in China that will do a lot of checking and stuff for us on a regular basis. More regular than us going over there once a year. It's gotten to a point where we really need that coverage of somebody right there that we can say "Can you go out to this farm or this factory?" Also, communications because sometimes communications... although some of our partners speak English but some of them not so well and then they have to use a go-between and that's not always the best. So we're gonna have somebody now that's right there in China and can do that for us. Can you imagine going to China and traveling around without having somebody with you to help you through the liaise and talk?   Mason: I have the best intentions of getting my Mandarin up to scratch and as soon as I'm out of it, it all slips out of my head. I haven't fully entered into that poetic language realm. The language is sticking. Can you speak Chinese?   Jeff: No, I speak Spanish, but Sky's learning Chinese. He has three classes a week, an hour each class with a Chinese speaker he does it over Zoom or something like that. He's very diligent about it. We get over there. He's speaking with them in Chinese and they love it. He's learning more, but unless you actually go and live somewhere for a while it's always tough. I've been thinking about it. You go over and spend two weeks, three weeks, whatever, then you leave. That's nothing in terms of really getting in and learning a language. That's swimming on the surface.   Mason: I gotta get onto it because I'm gonna do some Taoist training there.   Jeff: Yeah, that'd be really cool. You're young enough that you still can do that. I'm way beyond doing anything like that.   Mason: Come on, they'd love you up in the temple.   Jeff: Not only that, where I love to be is in Patagonia   Mason: Dude, that's the other place my heart lies, down in Patagonia. I want to become an old Argentinian man. I want to become a cowboy.   Jeff: Exactly, I know where we can get some horses, Mason, so let me know.   Mason: All right, that's it. That's on. China this year, maybe Patagonia next year.   Jeff: Yeah, two years ago Andrea and I went out and spent the day with, we had a gaucho that took us out. We went all over this one area. It was a hot day too. We were on horseback the whole time, cruising through, very slow. Slow living at its best, right?   Mason: Yeah, that's it. Drinking, eating a lot of meat, drinking a lot of yerba mate.   Jeff: Yeah, when you're on a horse you're not going to go very fast. You're going to cruise along. It's life in the slow lane.   Mason: I love it. So before we finish up is there anything that is coming up now that's exciting you about educating people about this market and about this industry with medicinal mushrooms?   Jeff: People really still need a lot of education with mushroom. Part of what I do too which I really like is I talk about the nutritional value of mushrooms. My thing too is eat mushrooms. I think mushrooms may be the missing link in terms of food. A lot of people are like, fungus, never eat it, right? And I'm like, "Dude, you've gotta get on and eat mushrooms, it's a fabulous food. They've got great benefits, you get medicinal benefits as well as nutritional benefits." That's the key for me, I'm pushing that really hard when I talk to people, saying "No, it's a fabulous food." And in China they have this whole thing of food is medicine.   Jeff: That's in Ancient Greece too. Food as your medicine. Everything that you take into your body should be something that is beneficial. And medicine as a very loose way in terms of it's feeding you and keeping you healthy. And that's what we should all be thinking about. What we consume is keeping us healthy and we should look at our food as that. That's providing me with all of these benefits. I say if you want a supplement, you feel you need more, that's great. You can supplement. But definitely use mushrooms for food. That's a big category for me.   Jeff: As a mushroom grower, can you imagine? I'm working on an agaricus farm. For ten years every day I'm going in I'm going through the rooms and each room ultimately is producing 20,000 pounds of mushrooms. There's mushrooms everywhere around me growing and I'm stoked. I love this. I've got mushrooms that I'm eating all the time. I've even got small beds of mushrooms that I bring stuff home and I'm growing them in my house because it's so interesting to me. The farm I was on it wasn't just an agaricus, we had a scientist that was growing shiitake and maikitake and oyster mushrooms. Back in the 70s when those weren't even on the markets anywhere. And I had access to these mushrooms. Besides the wild mushrooms that we were navigating. I'm like, make them part of your diet because it's a wonderful food.   Jeff: That's my message to people is this is a forgotten food, bring it home.   Mason: I love it so much. Thanks for reaching out, I really appreciate you reaching out and having you on here. It's not only do I admire you as a person, admire what you've done and your business. I spoke to you a little bit about it. I like talking to the other people who are perceived competitors. There's so much room in this market and everyone's doing their own thing and has their own story. This whole red ocean we have to fight over a scrap of people who are going to be buying mushrooms and not focusing on educating together is absolutely ridiculous. It's always awesome to meet people who trail-blazed that attitude in the industry. Calling out people that are bullshitting and then coming together and educating together and getting the world healthy together in our little way. There's something really nice about that that makes it possible to be in business for so much time, for so long, see so much shit yet still have such a positive attitude about it.   Jeff: That's absolutely right. I really love what you're doing too and I love the whole Taoist part of what you're taking to people and bringing to people. That philosophy is really awesome. That's what brings something really unique. When I hear you talking about mushrooms up around, what's the lake up there in the mountains?   Mason: Mumbai   Jeff: Yeah, that was so cool and you're hanging out there, talking about the mushrooms really excited about it all. That is really special. I love your energy, Mason, I'm really happy that we've been able to get together and have these meet-ups, speak and let's carry it on, let's keep doing it and stay in touch for sure.   Mason: Absolutely. We'll get some videos in another podcast together, 100%. I'll go check out these dates, see if I can swing a   Jeff: I'll send you the info on it so that you can check it out. If you can come you'll have a ball because there's gonna be lots of mushroom peop

Show Notes Jeff: Welcome back to EMplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Nachi: With no gold standard diagnostic test and with complications ranging from simple ectopic beats to fulminant cardiac failure and death, this isn’t an episode you’ll want to miss. Jeff: Before we begin, let me give a quick shout out to our incredible group of authors from New York -- Dr. Eric Morley, Dr. Bryan English, and Dr. David Cohen of Stony Brook Medicine and Dr. William Paolo, residency program director at SUNY Upstate. I should also mention their peer reviewers Drs. Jennifer Maccagnano and Ashley Norse of the NY institute of technology college of osteopathic medicine and UF Health Jacksonville, respectively. Nachi: This month’s team parsed through roughly 1200 articles as well as guidelines from the eastern association for surgery in trauma also known as EAST. Jeff: Clearly a large undertaking for a difficult topic to come up with solid evidence based recommendations. Nachi: For sure. Let’s begin with some epidemiology, which is admittedly quite difficult without universally accepted diagnostic criteria. Jeff: As you likely know, despite advances in motor vehicle safety, trauma remains a leading cause of death for young adults. In the US alone, each year, there are about 900,000 cases of cardiac injury secondary to trauma. Most of these occur in the setting of vehicular trauma. Nachi: And keep in mind, that those injuries don’t occur in isolation as 70-80% of patients with blunt cardiac injury sustain other injuries. This idea of concomitant trauma will be a major theme in today’s episode. Jeff: It certainly will. But before we get there, we have some more definitions to review - cardiac concussion and contusion, both of which were defined in a 1989 study. In this study, cardiac concussion was defined as an elevated CKMB with a normal echo, while a cardiac contusion was defined as an elevated CKMB and abnormal echo. Nachi: Much to my surprise, though, abnormal echo and elevated ck-mb have not been shown to be predictive of adverse outcomes, but conduction abnormalities on ekgs have been predictive of development of serious dysrhythmia Jeff: More on complications in a bit, but first, returning to the idea of concomitant injuries, in one autopsy study of nearly 1600 patients with blunt trauma - cardiac injuries were reported in 11.9% of cases and contributed to the death of 45.2% of those patients. Nachi: Looking more broadly at the data, according to one retrospective review, blunt cardiac injury may carry a mortality of up to 44%. Jeff: That’s scary high, though I guess not terribly surprising, given that we are discussing heart injuries due to major trauma... Nachi: The force may be direct or indirect, involve rapid deceleration, be bidirectional, compressive, concussive, or even involve a combination of these. In general, the right ventricle is the most frequently injured area due to the proximity to the chest wall. Jeff: Perfect, so that's enough background, let’s talk differential. As you likely expected, the differential is broad and includes cardiovascular injuries, pulmonary injuries, and other mediastinal injuries like pneumomediastinum and esophageal injuries. Nachi: Among the most devastating injuries on the differential is cardiac wall rupture, which not surprisingly has an extremely high mortality rate. In terms of location of rupture, both ventricles are far more likely to rupture than the atria with the right atria being more likely to rupture than the left atria. Atrial ruptures are more survivable, whereas complete free wall rupture is nearly universally fatal. Jeff: Septal injuries are also on the ddx. Septal injuries occur immediately, either from direct impact or when the heart becomes compressed between the sternum and the spine. Delayed rupture can occur secondary to an inflammatory reaction. This is more likely in patients with a prior healed or repaired septal defects. Nachi: Valvular injuries, like septal injuries, are rare. Left sided valvular damage is more common and carries a higher mortality risk. In order, the aortic valve is more commonly injured followed by the mitral valve then tricuspid valve, and finally the pulmonic valve. Remember that valvular damage can be due to papillary muscle rupture or damage to the chordae tendineae. Consider valvular injury in any patient who appears to be in cardiogenic shock, has hypotension without obvious hemorrhage, or has pulmonary edema. Jeff: Next on the ddx are coronary artery injuries, which include lacerations, dissections, aneurysms, thrombosis, and even MI secondary to increased sympathetic activity and platelet activity after trauma. In one review, dissection was the most commonly uncovered pathology, occurring 71% of the time, followed by thrombosis, which occured only 7% of the time. The LAD is the most commonly injured artery followed by the RCA. Nachi: Pericardial injury, including pericarditis, effusion, tamponade, and rarely rupture, is also certainly on the differential. Jeff: In terms of dysrhythmias, sinus tachycardia is the most common dysrhythmia, with other rhythms, including PVC / PAC / and afib being found only 1-6% of the time. Nachi: And while conduction blocks are rare, a RBBB is the most commonly noted, followed by a 1st degree AVB. Jeff: Though also rare, commotio cordis deserves it’s own section as its the second most common cause of death in athletes < 18 who are victims of blunt trauma. Though only studied in swine models, it’s hypothesized that the impact to the chest wall during T-wave upstroke can precipitate v-fib. Nachi: Aortic root injuries usually occur at the insertion of the ligamentum arteriosum and isthmus. Such injuries typically result in aortic insufficiency. Jeff: And the last pathology on the differential requiring special attention is a myocardial contusion. Again, no standard definition exists, with some diagnostic criteria including simply chest pain and increasing cardiac enzymes, and others including cardiac dysfunction, ecg abnormalities, wall motion abnormalities, and an elevation of cardiac enzymes. Nachi: Certainly a pretty broad differential… before moving on to the work up, Jeff why don’t you get us started with prehospital care? Jeff: Prehospital management should focus on rapid identification and stabilization of life threatening injuries with expeditious transport as longer prehospital times have been associated with increased mortality in trauma. Immediate transport to a Level I trauma center should be the highest priority for those with suspected blunt cardiac injury. Nachi: In terms of who specifically should be transporting the patient, a Cochrane review evaluated the utility of ALS vs BLS transport in trauma. There is reasonably good data to support BLS over ALS, even when controlling for trauma severity. Moreover, when airway management is needed, advanced airway techniques by ALS crews were associated with decreased odds of survival. Regardless of who is there, the message is the same: focus not on interventions, but instead on rapid transport. Jeff: And if it does happen to be an ALS transport crew, without delaying transport, pain management with fentanyl is both safe and reasonable and preferred over morphine. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. Nachi: And if the prehospital team is lucky enough, or maybe unlucky enough, i don’t know, to have a credentialed provider who can perform ultrasound for those suspected of having a blunt cardiac injury, the general prehospital data on ultrasound is sparse. As of now, it’s difficult to conclude if prehospital US improves care for trauma patients. Jeff: Interestingly, the system I work in has prehospital physicians, who do carry US, but I can’t think of a major trauma where ultrasound changed any of the decisions we made. Nachi: Right, and I think that just reinforces the main point here: there may be a role, we just don’t have the data to support it at this time. Jeff: Great, let’s move onto ED care, beginning with the H&P. Nachi: On history, make sure to elucidate if there is any chest pain, and if it’s onset was before or after the traumatic event. In addition, make sure to ask about dyspnea, fatigue, palpitations, and lightheadedness. Jeff: And don’t forget to get the crash details from the EMS crew before they depart! As a side note, for anyone taking oral boards in a few months, don’t forget to ask the EMS crew for the details!!! Nachi: A definite must for oral boards and for your clinical practice. Jeff: In terms of the physical, tachycardia is the most common abnormality in blunt cardiac injury. In those with severe injury, you may note refractory hypotension secondary to cardiogenic shock. But don’t be reassured by normal vitals, especially in the young, who may be compensating well despite being quite ill. Nachi: Fully undress the patient to appropriately inspect and percuss the chest wall - looking for signs of previous cardiac surgeries or pacemaker placement, as well as to auscultate for new murmurs which may be a sign of valvular injury. Jeff: Similarly, as concomitant injuries are common, inspect the abdomen, looking for ecchymosis patterns, which often accompany blunt cardiac injury. Nachi: Pretty standard stuff. Let’s move on to diagnostic testing. Jeff: Lab testing should include a CBC, BMP, coags, troponin, lactate, and T&S. In one retrospective analysis, an elevated troponin and a lactate over 2.5 were predictors of mortality. Nachi: Additionally, in patients with chest trauma, a troponin > 1.05 was associated with a greater risk for dysrhythmias and LV dysfunction. Jeff: And it likely goes without saying, but an EKG is a must on all trauma patients with suspicion for blunt cardiac injury in accordance with the EAST guidelines. New EKG findings requires admission for monitoring. Unfortunately, on the flip side, an ECG cannot be used to rule out blunt cardiac injury. Nachi: Diving a bit deeper into the data, in a prospective study of 333 patients with blunt thoracic trauma, serial EKG and troponins at 0, 4, and 8 hours post injury had a sensitivity and specificity of 100% and 71%, respectively. However, of those with abnormal findings, all but one had them on initial testing, leading to a negative predictive value of 98%. Jeff: Well that’s an impressive NPV and has huge implications, especially in the era of heavily monitored lengths of stay... Nachi: Definitely. In terms of radiography, a chest x-ray should be obtained as rib fractures, hemopneumothorax, and mediastinal free air are all things you wouldn't want to miss and are also associated with blunt cardiac injury. Jeff: Keep in mind, however, that the chest x-ray should not be seen as a test for pericardial fluid as up to 200 mL of fluid can be contained in the pericardial space and remain undetectable by chest radiograph. Nachi: Which is why you’ll have to turn to our good friend the ultrasound, for more useful data. The data is strong that in the hands of trained Emergency Clinicians, when parasternal, apical, and subcostal views are obtained, US has an accuracy of 97.5% for pericardial effusion. Jeff: Not only is US accurate, it’s also quick. In one RCT, the FAST exam reduced the time from arrival in the ED to operative care by 64% in the setting of trauma. Nachi: That’s impressive -- for expediting patient care and for managing ED flow. Jeff: Exactly. The authors do note however that hemopericardium is a rare finding, so, while not the focus of this article, the real utility of the FAST exam may be in its expanded form, the eFAST, in which a rapid bedside ultrasonographic lung exam for pneumothorax is included, as this can lead to immediate changes in management. Nachi: And assuming you do your FAST or eFAST and have no management changing findings, CT will often be your next test. Jeff: Yeah, EKG-gated multidetector CT can easily diagnose myocardial rupture, pneumopericardium, pericardial rupture, hemopericardium, coronary artery insult, ventricular septal defects and even valvular dysfunction. Unfortunately, CT does not perform well for the evaluation of myocardial contusions. Nachi: This is all well and good, and certainly accurate, but let’s not forget that hemodynamically unstable trauma patients, like those with myocardial rupture, need to be in the operating room, not the CT scanner. Jeff: An important point that should not be understated. Nachi: And the last major testing modality to discuss is the echocardiogram. Jeff: The echo is a fantastic test for detecting focal cardiac dysfunction often see with cardiac contusions, hemopericardium, and valve disruption. Nachi: And it’s worth noting that transthoracic is enough, as transesophageal, despite the better images, hasn’t been shown to change management. TEE should be saved for those in whom a optimal TTE study isn’t feasible. Jeff: Great point. And one last quick note on echo: in terms of guidelines, the EAST guidelines from 2012 specifically recommend an echo in hemodynamically unstable patients or those with a persistent new dysrhythmia without other sources of ongoing hemorrhage or neurologic etiology of instability. Nachi: Perfect, so that wraps up testing and imaging for our blunt cardiac injury patient. Let’s move on to treatment. Jeff: In terms of initial resuscitation, there is an ever increasing body of literature to support blood transfusion over crystalloid in patients requiring volume expansion in trauma. There are no specific guidelines for transfusion in the setting of blunt cardiac injury, so stick to your standard trauma protocols. Nachi: It is worth noting, though, that there is literature outside of trauma for those with pericardial effusions, suggesting that those with a SBP < 100 have substantial benefit from volume expansion. So keep this in mind if your clinical suspicion is high and your trauma patient has a soft but not truly shocky blood pressure. Jeff: Operative management, specifically ED thoracotomy is a heavily debated topic, and it’s next on our list to discuss. Nachi: The 2015 EAST guidelines conditionally recommend ED thoracotomy for moribund patients with signs of life. The Western Trauma Association broadens the ED thoracotomy window a bit to include anyone with no signs of life but less than 10 minutes of CPR. The latter also recommend ED thoracotomy in those with refractory shock. Jeff: Though few studies exist on the topic, in one study of 187 patients, cardiac motion on US was 100% sensitive for predicting survivors. Nachi: Not great data, but it does support one's decision to stop any further work up should there be no cardiac activity, which is important, because the decision to pursue an ED thoracotomy is not an easy one. Jeff: And lastly, emergent pericardiocentesis may be another option in an unstable patient when definitive operative management is not possible. But do note that pericardiocentesis is only a temporizing measure, and not definitive for cardiac tamponade. Nachi: Treatment for dysrhythmias is standard, treat in accordance with standard ACLS protocols, as formal randomized trials on prophylaxis and treatment in the setting of blunt cardiac injury do not exist. Jeff: Seems reasonable enough. And in the very rare setting of an MI after blunt cardiac injury, you should involve cardiology, cardiothoracic surgery, and trauma to help make important management decisions. Data is, again, lacking, but the patient likely needs percutaneous angiography for appropriate diagnosis and potentially further intervention. Definitely hold off on ASA and likely nitroglycerin, at least until significant bleeding has been ruled out. Nachi: Yup, no style points for giving aspirin to a bleeding trauma patient. Speaking of medications, the last treatment modality to discuss here is pain control. Pain management is essential with chest injuries, as appropriate pain management has been shown to reduce mortality in pulmonary related complications. Jeff: And in line with every acute pain consult note I’ve ever come across, a multimodal approach utilizing opioids and nonopioids is recommended. Nachi: Perfect, so that sums up treatment, next we have one special circumstance to discuss: sternal fractures. Cardiac contusions are found in 1.8-2.4% of patients with sternal fractures, almost all of which were seen on CT and not XR according to the NEXUS chest CT study. Of these patients, only 2 deaths occured, both due to cardiac causes.  Thus, in patients with isolated sternal fractures, negative trops, ekg, and negative cxr - the patient can likely be discharged from the ED, as long as their pain is well-controlled. Jeff: And let’s talk controversies for this issue. We only have one to discuss: MRI. Nachi: The fact that MRI produces awesome images is not controversial, see figure 3. It’s role, however, is. In accordance with EAST guidelines, MRI may be most useful in differentiating acute ischemia from blunt cardiac injury in those with abnormal ECGs, elevated enzymes, or abnormal echos. It’s use in the hyperacute evaluation, however, is limited, in large part owing to the length of time required to complete an MRI Jeff: What a time to be alive that we even have to say that MRIs may not have a hyperacute role in trauma - absolutely crazy... Nachi: Moving on to disposition: any patient with aortic, pericardial, or myocardial injury and hemodynamic instability needs operative evaluation and likely intervention, so do not hesitate to get the consults coming or the helicopter in the air should such a patient arrive at your non-trauma center. Jeff: And in those that are hemodynamically stable, with either a positive ECG or a positive trop, they should be monitored on telemetry. There is no clear answer as to how long, but numerous studies suggest a 24 hour period of observation is sufficient. For those with persistent ekg abnormalities or rising trops - this is precisely when you will want to pursue echocardiography. Nachi: And if there are positive EKG findings AND a rising trop, they should be admitted to a step down unit or ICU as well -- as ⅔ of them will develop myocardial dysfunction. Similarly, those with hemodynamic instability but no active traumatic bleeding source - they too should be admitted to the ICU for a STAT echo and serial enzymes. Jeff: But in the vast majority of patients, those that are hemodynamically stable with negative serial EKGs and serial tropinins, they can effectively be ruled out for significant BCI after an 8 hour ED observation period, as we mentioned earlier with a sensitivity approaching 100%! Nachi: Though there are, of course, exceptions to this rule, like those with low physiologic reserve, mobility or functional issues, or complex social situations, which may need to be assessed on a more case-by-case basis. Jeff: Let’s wrap up this episode with some key points and clinical pearls. Cardiac wall rupture is the most devastating form of Blunt Cardiac Injury. The sealing of a ruptured wall may lead to a pseudoaneurysm and delayed tamponade. Trauma to the coronary arteries may lead to a myocardial infarction. The left anterior descending artery is most commonly affected. The most common arrhythmia associated with blunt cardiac injury is sinus tachycardia. RBBB is the most commonly associated conduction block. Commotio cordis is the second most common cause of death in athletes under the age of 18. Early defibrillation is linked to better outcomes. Antiplatelet agents like aspirin should be avoided in blunt cardiac injury until significant hemorrhage has been ruled out. An EKG should be obtained in all patients with suspected blunt cardiac injury. However, an EKG alone does not rule out blunt cardiac injury. Serial EKG and serial troponin testing at hours 0, 4, and 8 have a sensitivity approaching 100% for blunt cardiac injury. An elevated lactate level or troponin is associated with increased mortality in blunt cardiac injury. Perform a FAST exam to assess for pericardial effusions. FAST exams are associated with a significant reduction in transfer time to an operating room. Obtain a chest X-ray in all patients in whom you have concern for blunt cardiac injury. Note that the pericardium is poorly compliant and pericardial fluid might not be detected on chest X-ray. Transesophageal echocardiogram should be considered when an optimal transthoracic study cannot be achieved. CT is used routinely in evaluating blunt chest trauma but know that it does not evaluate cardiac contusions well. In acute evaluation, MRI is generally a less useful imaging modality given the long imaging time. There is evidence to suggest that a patient with an isolated sternal fracture and negative biomarkers and negative EKG findings can be safely discharged from the ED if pain is well-controlled. Trauma to the aorta, pericardium, or myocardium is associated with severe hemodynamic instability. These patients need surgical evaluation emergently. Hemodynamically stable patients with a positive troponin test or with new EKG abnormalities should be observed for cardiac monitoring. Nachi: So that wraps up Episode 26 on Blunt Cardiac Injury! Jeff: Additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Nachi: It’s also worth mentioning for current subscribers that the website has recently undergone a major rehaul and update. The new site is easier to use on mobile browsers, has better search functionality, mobile-friendly CME testing, and quick access to the digest and podcast. Jeff: And as those of us in the north east say goodbye to the snow for the year, it’s time to start thinking about the summer and maybe start planning for the Clinical Decision Making conference in sunny Ponta Vedra Beach, Fl. The conference will run from June 27th to June 30th this year with a pre-conference workshop on June 26th. Nachi: And the address for this month’s credit is ebmedicine.net/E0319, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at EMplify@ebmedicine.net with any comments or suggestions. Talk to you next month! Most Important References 7.* Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-S306. (Guideline) 22.* Schultz JM, Trunkey DD. Blunt cardiac injury. Crit Care Clin. 2004;20(1):57-70. (Review article) 23.* El-Chami MF, Nicholson W, Helmy T. Blunt cardiac trauma. J Emerg Med. 2008;35(2):127-133. (Review article) 27.* Bock JS, Benitez RM. Blunt cardiac injury. Cardiol Clin. 2012;30(4):545-555. (Review article) 34.* Berk WA. ECG findings in nonpenetrating chest trauma: a review. J Emerg Med. 1987;5(3):209-215. (Review article) 64.* Velmahos GC, Karaiskakis M, Salim A, et al. Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury. J Trauma. 2003;54(1):45-50. (Prospective; 333 patients) 73.* Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. (Randomized controlled trial; 262 patients)

He's a libertarian, anarcho-capitalist. He hosts the biggest conference, Anarchapulco, for anarcho-capitalism. He's The Dollar Vigilante. Originally from Canada, hailing from Mexico. Jeff Berwick   Stefan: Ladies and gentlemen, welcome to the show, Respect The Grind, with Stefan Aarnio. This is the show where we interview people who achieve mastery and freedom through discipline. We interview entrepreneurs, athletes, authors, artists, real estate investors, anyone who has achieved mastery and examined what it took to get there. Today on the show, I have a very special guest out of the norm, Jeff Berwick. He's a libertarian, anarcho-capitalist. He hosts the biggest conference, Anarchapulco, for anarcho-capitalism. He's The Dollar Vigilante. Originally from Canada, hailing from Mexico. Jeff, good to have you on the show today. Respect The Grind, my friend. Jeff: It's a pleasure. Thank you. Stefan: Yeah. I really appreciate having a guest like you on the show, because we normally talk about like business and making money, and real estate. A lot of people listening to this show, they want financial freedom for themselves, and they're trying to make money. They're trying to invest, whatever that means. It's cool to have a guy like you on the show. We had a mutual friend of ours, John Sneisen, on the show a little while ago, and I love talking to guys like you, because we end up talking about the money system. We talk about freedom in the free world, free speech, all this kind of stuff. For the people at home who don't know you, Jeff, can you introduce yourself in your own words? Who are you, and why is this a relevant conversation for us to be speaking? Jeff: Sure. Yeah. Actually, it's a totally relevant conversation that's everything that I talk about. I've been doing that for about nine years now, since 2010, with The Dollar Vigilante, which is a anarcho-capitalist financial newsletter talking about how to free yourself. Not just financially, but in every way possible. Of course, for people that don't understand the word, "anarcho" means anarchy, of course, and that's a Greek word which means "an," without, "archy," ruler. I just believe that no one should have a ruler and no one should be a slave. I don't know why that's controversial at all, but that's the government indoctrination camps that people have had for about 12 years that most people have been forced into. Jeff: Then the capitalist part, a lot of people actually misunderstand that word, too. They think that what you have in the U.S. today is capitalism. There is a small part of capitalism still remaining, and that's why the U.S. is still standing, but it's mostly fascism, and crony capitalism, and what I call crapitalism. Really, when I say "capitalism," I just mean free market. I've been, and completely free market, so no government involvement whatsoever, no taxation, no regulation, no central banks, and no fiat currencies and things like that. I've been doing that for about nine years. Jeff: I also do a podcast called Anarchast. I've been doing that for about seven years, and it's grown quite a bit. It's nothing too huge, but it's actually spawned an entire conference now called Anarchapulco, as you mentioned. It's now the world's premier liberty and freedom event held in Acapulco, Mexico, every year. It's coming up in February 14th to 17th. We're expecting about 3,000 people, because the freedom, the idea of it is actually growing, believe it or not. I've been doing all that stuff for about, as I said, about eight or nine years now. Stefan: That's tremendous, Jeff. People like you, I really got to salute a guy like you, because it's not easy. It's not easy going against the grain. It's not easy speaking out about this stuff. It's not a popular table topic at the Thanksgiving table or the Christmas table. I remember when I was telling my family years ago about the money system at like at Christmas dinner or Thanksgiving dinner. Everybody got up and left. The average person doesn't want to hear about how they are enslaved. They don't want to hear about the money system. I remember years ago when I was 21, 22, I read a book called Atlas Shrugged by Ayn Rand, and that's the capitalist bible. The communists have Karl Marx, Das Kapital, and then the capitalists have Ayn Rand's Atlas Shrugged. It's number two most influential book in the United States. Stefan: Can you explain to the people at home, that's where I've first heard the word "libertarian." What's a libertarian? Because people, we're from Canada, or I'm from Canada, in Winnipeg, today, and people hear "libertarian," and they think libertarian is liberal, because it's L-I-B. They don't know the difference between the two words. What's a libertarian? Jeff: That's interesting you're up there in Winterpeg. I'm originally from what I call Deadmonton, so up in Canada. Stefan: Dude, that's the other Winnipeg. I'm giving that a gong. Bang. Just gonged it up. Deadmonton and Winterpeg. Jeff: Yeah, so the word "libertarian," I actually didn't even really know the word until about 15 years ago. It's become quite popular. It's become fairly popular since Ron Paul ran for president in 2008. Really, what the word means is, well, it's pretty simple word, "libertarianism." What it means is that if you're a libertarian, then you hold as one of your highest principles liberty or freedom. If you truly hold that as one of your highest principles, then you should actually be a anarchist, because an anarchist believes in complete freedom. It believes in the freedom of the individual that no one has the right to enslave and say they own another person. Of course, whenever you have a government, you're just born somewhere, and they go, "Well, you're ours now," especially in the U.S., where every baby born today in the U.S. has a quarter of a million U.S. dollars worth of debt and liabilities overhanging it from the government that it's supposed to pay off. Stefan: My God. Jeff: That's absolutely criminal and absolute tyranny and slavery. That's what we have in every country today, as well as Canada and every other country. A true libertarian truly believes that no one should be ruled or owned by anyone without their permission. Of course, there's a lot of people who don't mind being owned or being slaves. They're called statists, and if they want to do that, that's fine. I have no problem. As a libertarian or as an anarchist, do whatever you want. Just don't aggress against me. The only problem is, when they get these governments going, they always seem to include us and seem to think that, "Well, you are now owned by whichever government in whatever area you're in." I just completely disagree with that. Stefan: Yeah. I saw Jordan Peterson. You're probably familiar with Jordan Peterson, right? Jeff: Yeah. Stefan: I saw Jordan Peterson speak in the summer. He was speaking here in Winnipeg, Winterpeg, at the Burton Cummings Theatre, and he said something interesting that I thought something that I think people need to hear more often. He said, "The human race for most of history has lived under tyranny. We used to have monarchies. We used to have feudalism. For most, most of the human race, we've had tyranny, and for very brief times, we've had democracies or republics, but democracy lasts for about 250 years. Then it turns into a tyranny, usually, and then after that, turns back into a monarchy." Why do you think monarchies and tyrannies have existed throughout history, and why does it always seem to consolidate power like that? Why can't we just stay as a democracy or republic all the time? Jeff: Well, first of all, I'm not so sure about human history. I think most things we're told about history are lies, and so really, anything beyond a couple of hundred years ago, I really have doubts about what really happened. I really don't know what happened, but I don't trust anything that we're told by the media, or the governments, or the schools, which are all sort of the same sort of people running those sort of things, but what I understand happened is, a few hundred years ago, there was things like kings and queens, and they were doing that quite a bit. They were going around doing similar things that governments do today and say, "Hey, you were born here, so now you have to pay us a certain percentage of whatever you make," and that sort of a thing. Jeff: Really, a few hundred years ago, and it sort of seems to have happened in France, which is kind of interesting, because there's a bit of an uprising happening there again right now, is a lot of people said, "This is crazy. Just because you're born, this whole idea of kings and queens is so insane." I love the Monty Python, I think it was in the Holy Grail one, where the king's walking around, and he's like, "I'm your king." They're like, "You're who?" He's like, "I was born of this mother," and everyone's like, "What?" He's like, "I found a sword in the lake, and therefore I'm your king." They're like, "You're crazy," but for whatever reason, people kind of fell in line with that. Jeff: Of course, a lot of these monarchies were really tyrannical, and they would really, if you didn't pay them, they would kill you, that sort of a thing. That's very similar to governments. A few hundred years ago, people kind of woke up from it, and they said, "Well, this is stupid." The people who were in control at the time really realized they're going to lose a lot of power, and so they came up with an absolutely ingenious idea. That ingenious idea was democracy, which is a totally heinous, evil system of mob rule. If you have 51% of people decide that legally they can kill the other 49%, then everything's fine. Jeff: It's absolutely insane and just keeps people battling each other, but it's absolutely ingenious, because they've managed, through the government indoctrination camps, and through the media, the mainstream media, television, propaganda programming, to tell people that, "Oh, when you have a democracy, then you are the one who rules yourself, and you get to rule yourself by voting once every four or five years. You get to tick a box," and then some guy goes somewhere, and he makes decisions about what you're going to have to give up and how much they're going to extort you and things like that, but it's absolutely an ingenious idea. It's worked now for a few hundred years, and people have really fallen for it, but they're starting to wake up to it. That's what we're starting to see across the world, really. Jeff: We're starting to see that in France right now. Again, they're starting to realize, "This is absolutely insane that we have people ruling us without our permission, and taking our money, and things like that." Even Donald Trump, in the U.S., was to an extent an awakening of people going, "This system is horrible. We've got this total political class that is totally ruling us and just totally enslaving us." Jeff: What they thought was, "Well, we have democracy, thank God. We have democracy, so we can elect someone else," so they elected a kind of a bit of an outsider, Donald Trump, who's best friends with the Clintons and has been involved with central banks and with the Bush family for decades. His family's been very involved with the Bush family, so he's been very involved in the political class, but he came in as sort of an outsider, and you kind of see a lot of people saying, "Oh, he's an outsider, so he can fix things." He's not an outsider whatsoever. It's another sort of ruse in the whole democracy game, but really, that's what we've got today. Jeff: Now, what we've got at The Dollar Vigilante, I cover how bankrupt all these nation states are, how the central banks are printing money until we're going to be, hit hyperinflation very soon, so we're very near the end of this sort of system of these big nation states, of these big welfare states, warfare states, Big Brother nanny states, where everything is controlled, and regulated, and extorted, and taxed, and that sort of a thing. It's all going bankrupt right now, so even if people didn't wake up to what I'm talking about, we're still going to go through a massive amount of change in the next few years as all these systems all go down because they're all bankrupt. Stefan: Yeah. Well, there's a ... Man, Jeff, you said a mouthful there, man. I don't even know where to start, but I'm going to try to weigh in on what you said there at the end. Now, I wrote a book here called Hard Times Create Strong Men. I'm holding it up here for the camera for the people at home, and the cycles of history, as I understand it, goes like this. Hard times create strong men. Strong men create good times. Good times create weak men. Weak men create hard times. That whole cycle takes about 80 years, and every 80 years, there's a major war, a major crisis, a major reset. 80 years ago was World War II. 80 years before that was American Civil War, and you can trace this back in history. 80 to 100 years, every 80 to 100 years, is a major reset. Now, if you trace that out to the future right now from World War II to now, 2020 is the next "hard times create strong men." Stefan: That's what the book's about is, the men are becoming weak. When men become weak, the backbone of society falls apart. The family falls apart. The churches and the freedom of that falls apart, and what we end up with is some sort of major crisis. Would you say something like that's coming up? Jeff: Oh, absolutely, and I think those cycles are very true. If you just look at anyone who's like a rich kid, so his father most likely worked really hard his entire life and amassed a fairly large fortune, and then the kid comes along, and he's just pampered, and he never does anything. He never learns how to do anything. He never has to learn anything about life, and they usually become idiots, and they actually end up usually wasting or losing most of their money. This is a very natural sort of a cycle that can happen if you're not smart, if, as a father, if you make a lot of money, you don't just give it to your kids. That's absolutely ridiculous. Talk about a really great way to destroy your children, but the big problem with that cycle that you just mentioned that's been going on now for centuries is the government. Jeff: When you get the government involved, it's not just people who are destroying themselves through the cycle of people having to have hard times to get better and actually learn skills and work hard, and then they get soft afterwards, and then their kids get really soft and that sort of thing. That happens all normally, but when you add the government into it, it gets way worse, because then what, that's exactly what we're seeing today in a place like the U.S., which used to be quite capitalist. It has been fully capitalist, really, since its inception. It hasn't been, definitely has not been capitalist since 1913 when they first put in the Federal Reserve and the income tax acts in the same year, which is no coincidence whatsoever. It's been kind of a mix of the socialism, and communism, and fascism since then. Jeff: About what you've seen because of the capitalism, because of the free markets, there was quite a bit of free markets in the U.S. There isn't any more, but there used to be quite a bit. You build up all this wealth, and when you have a government, it always seems to skew to these people going, "Well, now that we have quite a wealthy place, we should be quite giving." Yeah, that's great. Give, but what they're talking about is, the government should steal money from everyone, extort everybody, and then give some of it to some people, which is absolutely heinous, and evil, and destroys everything. Jeff: Even the welfare system destroys the people on welfare, but as I was mentioning, like that whole cycle would happen probably quite normally unless people start to wake up and realize what they're doing, but the fact that we have governments today makes it so much worse, because that's what we're seeing in the U.S. You even see communism is really catching on in the U.S., because you've got all these pampered little kids. They sit there on their MacBook Pro at Starbucks ranting about how evil capitalism is and saying they want communism, and they don't even look up the last 100 years of what communism has brought a lot of places, like the Soviet Union, or Cuba, or Venezuela, and places like that. Jeff: They just, because they're so soft, and they've never really done anything, that's why they call them little snowflakes and things like that, and they become social justice warriors. Really, they're just non-player characters, NPCs, but yeah, the big problem with that whole cycle is government. If we can get government out of the way, then you'd have families destroying themselves over time over and over and not realizing the problems that they keep creating for themselves, but they wouldn't force it all on the rest of us through government. Stefan: Yeah. Wow. I mean, this is some really good stuff, and the snowflake thing, the snowflakism's a reason why I wrote Hard Times, because I had some of these snowflakes in my company. I have a company. I got 13 employees, and these little snowflakes were crying, "Oh, you're mean, and I don't love this. This isn't my dream job, and you make me feel like a piece of shit," and I had people showing up late. Just snowflakism all day, and I said, "Where does this come from? Where does the snowflakism come from?" I started writing this book Hard Times, and it's interesting, because what you said is absolutely true. Stefan: We've had some communist subversion come in from the Cold War into our schools, into our churches, into our militaries, everything, and we got this virus in our brain that thinks that communism is going to save inequality, but in history, communism has never worked. It has never worked once. It ends in massive, massive killing and massive death. There's something like 100 million people slaughtered in the last 100 years with communism. It's something brutal. It's the biggest cause of unnatural death, and every 80 years, we think it's going to work somehow. Somebody somewhere's trying communism. Stefan: As an extension, I've been studying communism, I was watching a show with Stefan Molyneux on Freedomain Radio, and he was talking about how feminism actually spawned out of communism when they started talking about equality, and men and women are equal, and next thing you know, in communist Russia, in 1917, when they switched over to communism, you had all sorts of major problems, where there was one crazy stat was, more babies were aborted than were born. You think about that, it's just a big, crazy, evil system. Why do we get this idea that we think that communism's going to save us from our own poverty? Like why does that idea keep coming in every 80 years into different societies around the world? Jeff: Yeah. That's a good question. I wish I knew the real answer, because it makes no sense. Obviously, these people don't look at actual history. As you pointed out, there's never been one ... It's not like there's been one that really worked out well, and they're like, "Oh, we screwed it up a few times." It's like every single one turns into disaster. It actually makes total sense why, because of human nature. For someone like yourself who's read books by Ayn Rand, you kind of understand the individualist sort of a thing, and that people will always do what's in their best interest. That just makes total and normal sense as human being. When you have this system that comes in and you say, "Okay, the guy at the top decides everything that we're all going to do," you don't keep anything from your work, so that makes it so a lot of people don't really want to work anymore, because why would you work if all the incentives go away to ... Jeff: I don't know about you, but when I do work, it's because I know I'm going to get something from it. I'm not just doing it because for no reason whatsoever. A lot of these people, especially ... Well, what's really happened in the West is that they've really pumped it up in the government indoctrination camps. That's why I say to people, "Get your kids out of the government schools. There's nothing that can be worse than that than having government actually teaching you ... " Not teaching, actually indoctrinating your child for like 12 of its most important years of its building of its sense of self, of its intelligence, of everything. Even Vladimir Lenin, of all people, said, "Give me your child for four years and the seed I plant will never be uprooted." Jeff: It starts a lot there, and then you go home in places like the U.S., or Canada, or a lot of places, and you turn on the television programming, and it's called programming for a reason. You get pro-cops, and pro-presidents, and, "The government saved us today," and turn on the news, which is total fake news. It's just government propaganda, and they're like, "Well, we saved this today," and all that sort of stuff. With the cycles that you're talking about, and we're in the snowflake cycle now of sort of this millennials that have never seen anything hard their whole life. To them, the hard thing they've seen is like when there's a long line at Starbucks or something like that. Stefan: No Wi-Fi on the plane. There's no Wi-Fi on the plane today. Darn. Jeff: Yeah, like that's the hardest times they've seen. Because they've gone through this indoctrination and that they're really, I actually stay away from colleges and universities, because it freaks me out to hang around, like they're all zombies, and they're the stupidest people I've ever met in my life. They're all indoctrinated and programmed. You go there, and half the classes are talking about communism and socialism, so they've got them in this sort of thing, and they're all going out there now. We've seen that ... What's that, there's that U.S. politician, some young girl, is just complete and total moron who's just got selected or elected into Congress. It's called Congress because it's a con game, and it's called the Constitution because that's also a con, and all that sort of stuff. Jeff: You've got those people out there pushing this stuff, and these kids just go out, and they think, they don't know anything better. It's very unfortunate, but that's why it's really important that we continue to push out what we push out, which is more free market stuff. A lot of people do catch on to it. It's not as bad as it seems. The worst place that it really is in the world today is the U.S. They've got everyone ... Not everyone, but most people, they're so indoctrinated, and so brainwashed, and so propagandized, but you go to a lot of other places like Mexico here, and a lot of people are pretty free market. They don't like government and things like that. That's why they make Mexico look so bad on the news. That's on purpose, because it's a lot more free market down here. Stefan: It's amazing. I mean, you moved to Mexico. I have this prediction that Russia right now is a freedom-growing country. They're getting more freedom over there. It's like the 1950s U.S. over there, and then over here, it's like we're a freedom-losing country in Canada and the U.S. It's interesting with, you're talking about the universities being scary. When I get a stack of résumés, and I'm hiring, I throw the ones with degrees in the trash. Yeah, they don't- Jeff: Yeah, me too. Stefan: The people can't think for themselves. I remember I went out with this 18-year-old girl, and she wanted a job, so we went out for lunch, and I said, "Okay, look. What do you want to do?" She goes, "I want to start a social media company." I'm like, "Great. Start it." We're eating lunch. I said, "Great. Start it." She says, "Well, I'm in the business school, and I'm going to get my MBA, and I don't think I can start, because I don't know how," and I said, "Well, go google that. Just start." "Oh, I don't think I know how. I'm not qualified." The school system literally disabled her mind from figuring out how she could just start a social media company. Stefan: I mean, I got some guys running my social media. They're 18, 19 years old, and I just met them at a restaurant. Boom, they're banging out my social media like crazy, doing a great job, but this same girl in the government indoctrination camp, as you say, the universities and the schools, can't think for herself. I also think it's interesting in the colleges and universities right now, the number one read book on economics is Karl Marx. That's just like, that just doesn't make sense. Why don't you tell me a bit, Jeff, why does Karl Marx as the number one economics book not make sense? Jeff: Oh, my God. First of all, he knows nothing about economics. He was a homeless guy who had no money, and he wrote a ... If I was around when he wrote the book, I would have given it a few minutes, or even maybe a few days, maybe even a month or two, of thought, because it sounds really good. Right? Like what is the communist sort of slogan? It is, "Give to-" Stefan: Seize the means of production? Jeff: No, but they have this slogan like, "Someone's needs ... " Stefan: Oh, "To every man's need," or, "To the best of his ability and every man's need," or something like that. Jeff: Something, but basically what it's saying is ... See, that's how stupid it is. I don't even memorize the stupid quote, but basically, it sounds nice. It sounds like, "Yeah, if people can't do things, then you help them." It's like, "Yeah, sounds great," but the way they're talking about is, you have this giant government. They come around. They steal things from people, and they decide who gets your money, essentially, and things like that. Yeah, and it's shocking that ... It's really mostly caught on in the U.S. Like obviously, if you go to the ... You brought up Russia. If you go to Russia, no one wants to read Karl Marx. They'd probably burn that book if they saw it, just because they'd be so angry at it. Jeff: Anyone who's actually lived through communism, a lot of the old Soviet Union, the Eastern Bloc, Poland, and a lot of those places, even Germany to an extent, they still remember a lot of that. That's all you need to know about communism is live through it, and you realize it. That's one thing that I always thought that's funny is, you have all these people like Bernie Sanders and all these people, and they're so pro-communism and socialism and all these sort of things. It's like, have you ever even just gone to Venezuela even for a weekend? Because I was there like a year and a half ago, and it was pretty bad. Jeff: I remember being there about 15 years ago, and it was really nice. In fact, you can look up Venezuela back in the '60s and '70s. It looked just as nice as what you see in the videos of the U.S. People got around in nice cars, looking all nice. Everyone's looking good and happy, and they have lots of food and all that sort of stuff, and now it's just a complete and total disaster, so ... Yeah, you have some people still ... It's mostly in the U.S., though, I have to say [inaudible 00:23:04]. Jeff: I meet a lot of people from the U.S., and they say, "Man, this whole world's going to hell." It's like, actually, it's not too bad. Most of the world is pretty good. It's really the U.S. is like, and Canada is almost just as bad now, and when you go to the universities, as you pointed out, and I do the same thing, I have only hired one university graduate ever, and it turned into the biggest disaster I've ever had. He was actually a producer at CNBC, I hired him in 1999 to head up a video department of a internet company I had, and he was a total disaster. He was an MBA, and I had all the, all that stuff, and I ended up having to pay him out like two years' salary to get him to leave, that sort of- Stefan: Oh, my God. Jeff: But yeah, so I just stay away from the universities. As you pointed out, if I ... I've got a number of businesses myself, so if someone's interested in working with us, I'll ask them what they do, and if they go, "Well, I just spent the last eight years in university," I'm like, "Well, you don't make very good decisions, do you? You [inaudible 00:24:00]-" Stefan: Bro, I'm going to give you a gong for that. Boom. I want you to instant replay that for the kids at home. "If you're hanging out in university the last eight years, you don't make very good decisions, do you?" Tell me why that's a bad decision in 2019. Jeff: Well, I'm sure there's probably a couple courses you could take in college that make some sense somehow. I've never seen them, though, but I ... There must be a couple, but the reason that it makes no sense in 2018, 2019, is because we have the internet now, and all information is on the internet. You don't have to pay $100,000 a year to go sit in a room with probably a unionized teacher who's never done anything his whole life, that's why he's a teacher, he doesn't know anything, and sit there with a bunch of other idiots like you, because you don't know anything, they don't know anything, and learn about socialism-type stuff pumped into you. It's a complete and total waste of time. Really, the best- Stefan: You mean it's a virgin sex therapy class, so the guy teaching, it's a virgin, but he's teaching sex therapy to everybody? Jeff: Yeah, that's one good way to put it, but yeah. It's just a waste of time. I think trade schools or something, where if you're going to become a mechanic, so you have to work on cars, so you can't really do that over the internet, I think that makes some sense, but 90-percent-plus of what you go to college for is just a complete and total waste of time that you could just totally learn much better stuff on the internet. It actually just came out, I don't know if you heard this, but Google and Facebook just said that they've removed university education as one of the requirements to work there. I think they're really slow and late to do that, but I think they're starting to realize, it's like, "Man, the people we're getting from the schools are just brainwashed idiots, whereas the young guy who's sitting at home just hacking away, and going on the internet all day, and figuring everything out, those are the kind of guys you want." Stefan: Yeah. I got a policy in my office, and when people come to me and ask for stuff, I say, "Google it, or handle it." Those are the two things, handle it, google it. Google and ... I think it was Google, Apple, Facebook, they don't need degrees anymore. I think that's been going on for some time, but it's an official statement now. Right? That's like super, super official. Jeff, let's go back to collapse of society and things like that. One thing that's common in history, and I've studied it over and over again when these collapses happen, it's usually, the people can't buy bread. The nonsense can keep going on. The ... Stefan: I've got the numbers in my book here, Hard Times, about minimum wage, and minimum wage in 1968, indexed to gold, is 103,000 dollars U.S., so you work at McDonald's, you made one cheeseburger, one hamburger, French fries, Coke, and a milkshake, you made 103 grand in purchasing power back then, indexed to gold. Same guy today making a cheeseburger, hamburger, French fries, well, he has to make 150 items down at McDonald's. They got a crazy menu. Stefan: Same guy at McDonald's makes 13,000 a year, so he's lost 90% of his purchasing power indexed to gold, and this shenanigan with the money system where the banks and the government rob people through inflation every year, and then suddenly, at some point, it keeps going, going, going, going until the average man can't buy bread. That's when the Russian Revolution happens. That's when the French Revolution happens. Why does that pattern keep happening over and over again? Jeff: Well, first, let me just mention that the reason that these jobs have gone so far down in value is because of the central bank. It's because of money printing and inflation, and that's why you pointed out those numbers in inflation terms. You have a lot of people out there today who are like, "We need to raise the minimum wage," which is, what you're saying is, "We need these people who extort us, called the government, to go out with guns and force businesses to pay us more because we can't afford to live." Well, the reason you can't afford to live is because you've had most of your stuff stolen from you by the central bank, and the central bank, by the way, is a tenet of communism, and that's why I say the U.S. is nothing even close to capitalism today. Jeff: Actual communism has already destroyed most of these people. You ask about revolutions, and yeah, it seems that people, this is one thing you can say about anarchy, a lot of people think about anarchy, "Well, if there was not government, it'd just be chaos, and horrible, and everyone would just kill each other." It's actually not true. Your average person, and this relates to your question, your average person just really doesn't want to do too much. They want to have a nice little life. They want to have a family or whatever, or they don't, but they want something nice, and that's about it. They don't want to go out and rock the boat too much. Your average person just does not want to rock the boat, and that's what ... Jeff: That's one of the problems we have today is, we have the statist system, and most people are just too scared to change it, but it appears, at some point, when you finally run out of even just food, and you can't even eat anymore, that's when finally people start to wake up, and stand up, and demand some sort of change. When I say demand, the problem is, they're demanding from the government change. What they should really realize is, the government caused it, the central bank caused it, and just break away from this system and stand up and become their own person and not be a slave to the systems, but yeah, it's unfortunate that your average person, for whatever reason, will wait until they're basically starving before they actually face the real problems in the world. Stefan: It's interesting in history, I think Putin kicked out the central banks. Is that right? Jeff: I'm not sure if Putin did, but the ruble basically collapsed. I don't think they had a central bank, definitely, at the start there. Stefan: Well, I've heard Putin's kicked out the central banks. I think it's interesting is, Hitler did that back in the day. I guess Germany was so poor, and they were so messed up, and they couldn't make their war reparation payments. They just couldn't pay, and that's how World War II started is, a bunch of people, super poor, couldn't pay their payments, boom, world war starts. It's interesting, because somehow, in the system, the political system, they go right versus left, and the right versus the left, and the left versus the right. Really, it's the same kind of thing. Nobody points the finger at the central banks. Stefan: One thing I love about America that still stands is, there's 300 million guns in the States and 300 million people, and they keep that gun amendment in there because they know that tyranny's going to come at some point. They left that in there, and if people can't buy bread, or they're really hungry, that's where those 300 million people with guns are going to rise up. Do you think we're going to see something like that in our lifetimes? Jeff: Yeah, definitely, because the U.S. is going to collapse in the next few years. It's not going to be decades, because it's so bankrupt. We have 22 trillion dollars' worth of debt now, so we're basically ... I said when I started The Dollar Vigilante that the U.S. dollar will collapse by the end of this decade, so we've got about a year left. I think we're pretty close to on track. That's how close we are to the end of this system. Yeah, we're definitely going to see collapses anyway. As far as people in the U.S. having guns, I think all people should have the right to defend themselves, obviously. I don't think anyone should be able to say, "You can't have this," if you're not hurting anyone else, and that's what government does, of course. It's very good. That's the only thing left in the U.S. that is keeping it from being complete and total carnage is that the people still can protect themselves, so the government has to be very careful about how they enslave everyone, but they've done an incredibly good job of enslaving people. Jeff: When you think about how the U.S. started, it started over the Tea Party, where it was a tax from England on tea, and that was it. It wasn't a tax on everything else, income tax, and capital gains tax, and smoking tax, and hotel tax, and food tax, and all this sort of stuff. It was just a little tax on tea, and that started the so-called American Revolution. Now you have people in the U.S. today where you have taxes that are over 50%. It's probably closer to 60 or 70% when you add up all the taxes, because literally every single thing in the U.S. is taxed today, including death. Death has a tax, and so when you die you get taxed. You still don't have people wanting to revolt. It's because, again, people are fairly, if they have a decent life, they don't tend to want to change things too much. You look at the U.S. and your average person, even poor people have a television. They probably even have a car. Even poor people have cars in the U.S. Jeff: That's how much free markets, even the poorest people are still ahead of a lot of other people in the world, and so because of that, they don't really want to have a revolt or anything like that. Plus, they don't even ... Because of all the years of government indoctrination and all the war propaganda about how they're trying to save the world by spreading freedom by bombing the entire world in the War on Terror, war of terror. It's absolutely insane, but your average person just doesn't seem to want to even break out of this system. Jeff: What's going to probably happen is, that system's going to collapse on its own because of all the debt and go into hyperinflation. Then hopefully, and you brought up about how Russia's become much more free market now. That's what happens. The same cycles that you mentioned before when you have countries, they usually start off quite small and poor. Even the U.S. was like that when it first started. Because it had a lot of freedom, it becomes quite rich. Then they get soft because of that and because of government and statism, they start doing socialism and all these sort of things which start to destroy everything. They start putting kids into the government schools and all that, and they get worse and worse until they eventually totally collapse, like the Soviet Union. Once it has a total collapse, then you can actually have free markets again. The U.S. actually, once this collapse happens, and after a few weeks or months, and that's sort of what happened in the Soviet Union as well, it takes a little bit of time, like weeks or months, definitely not years, then you can start to rebuild immediately again with free markets. Jeff: We've seen how the free markets, if you just allow people to be free, you just have to look at places like Hong Kong. That was a fishing village like 200 years ago. Look at it now. I don't know if you've ever been there. It's amazing to even go there. Singapore, even 100 years ago, was a fishing village. It's now one of the most luxurious, wealthy places in the world. Dubai was just desert. They just started doing like low-tax, no-tax sort of stuff, and all of a sudden, there you got like indoor ski parks in the hot, 150-degree desert. Once you have like all this tyranny, it will eventually collapse. Then once it collapses, you have freedom again, and then things take off again. Jeff: Really, that's the whole point of what I do at The Dollar Vigilante is, that's our actual tagline, which is, "Helping you to survive and prosper during and after the dollar collapse," because if you can hold on to some of your assets, and if you can get through this collapse that's coming, we're going to go on to amazing, prosperous times again, but if you have no assets, you'll have to work a lot harder to get back up, but if you have kept some of your assets and things like precious metals or cryptocurrencies, once everyone else gets wiped out, and all the banks close, and the currency becomes worthless, you'll be one of the richest guys around, and then you can start rebuilding the new free market. Stefan: Yeah. There's two cycles that are coming to an end. I wrote about this in my book, Hard Times. One is the 2020, which is that 80-year cycle of war. That's an important one to watch. Hard Times Create Strong Men. Then the other one is the 250-year cycle of democracy. Democracies only last about 250 years, so if the U.S. was born in 1776, it's going to be dead by 2026, so somewhere between 2020 and 2026, we know there's probably going to be an end of democracy, probably usually goes democracy into tyranny, and then tyranny back into monarchy usually is what happens. We'll see something happen. Do you think it's going to go back to tyranny and monarchy, or do you think it's going to go just to open freedom? Jeff: Yeah. A really good question. I don't know how it's going to play out. I could definitely see the tyranny part coming after this. What will likely happen, and probably be Trump will be in, his regime will be in as this collapse happens. As everyone's gets wiped out, as the banks close, as it's complete, way worse than 1929, Great Depression, someone like Trump will become sort of like Hitler-like in that sense, in that he will be the strongman who will lead the country out of this. Because of that, we're going to need more laws, and of course, Trump has been pro-asset, civil forfeitures, having the police just take whatever they want. He even came out recently and said that he's okay if the cops go and just take everyone's guns and then figure out if they did the right thing afterwards and go to court in that afterwards, so no due process and things like that. Yeah, I could totally see that we have this collapse in the next couple years. Jeff: It leads into a very sort of like Nazi Germany like sort of like tyranny type thing, and perhaps war, because the U.S. does have a massive amount of military just sitting there, and of course, if you're desperate, and if you're broke, and if your people are all crying out for something to be done, and of course, what do they always say on the news, the television programming? "Well, it's always Russia. Russia's always messing with us." Russia's not doing anything to the U.S. whatsoever, but they've been putting this into place, and they also mention China a lot. Yeah, they'll probably go into some sort of major war at some point. The key for people like us will be to stay outside of it and let them all go through this, again, if they want to go through this again, which is unbelievable. Jeff: There's lots of stories of people surviving through all of these, World War II, World War I, the Great Depression, and coming out way ahead afterwards, and even surviving quite well through it. A lot of them would go to places like Argentina or whatever for a few years, wait till all the craziness dies down with their assets and things like that. That's really the key, and to me, it's, we can't change everyone else. I wish we could, but we can't. Jeff: Actually, I don't wish I could. That'd be a huge responsibility, to change everyone else, but I wish that they would be a bit more able to see what's going on, but if they can't, really all that's left for us to do is to take care of ourselves and to keep spreading this information the ways that we can do it, but if they're going to go ahead and destroy the whole world with their statism, and their craziness, and their communism, and socialism, and fascism again, then it's really just up to us to survive and prosper through it and then try to be there to help rebuild once they get through doing it all again. Stefan: There's two interesting things that come to mind when you say that. There's the Hitler-Trump connection, which I think is super interesting. There's two things I want to allude to. There's the Hitler-Trump connection, and then there's another one, an Abraham Lincoln and Trump connection. When you look back in history, so if we go back 80 years to World War II, Germany was one of the most advanced civilizations on the planet, probably actually was the most advanced in science and medicine. They were so broke, they were so poor, they were so hungry, they were so messed up that the Nazis became popular, because Hitler was offering them a better life. He said, "Look, here's a better life. We can have a better way." People got behind that, the most sophisticated, probably, society on the planet went into absolute terror at that time. Stefan: I think there's a similar thing going on in the U.S. You've got a huge amount of people on food stamps. People are poor. People are pissed off, so they elect a strong leader. It's not ... It's interesting, like if it wasn't Hitler back in World War II, it probably would have been somebody else leading them, because the people were so poor and so messed up ... I like what Jordan Peterson said in the summary. He said, "You don't have an idea. An idea has you." That idea had Nazi Germany. I think there's a similar idea in the Brexit right now. There's a similar idea in the United States, and then that's the 80-year cycle. Stefan: If you go back 80 years before, you got the Civil War, the American Civil War, and Abraham Lincoln got shot. It's interesting, because Lincoln was a guy that wasn't totally popular with half the country. He got assassinated, and those things are all kind of floating around. You got a Trump, Trump-Hitler-like ruler there. I mean, I actually like Trump, personally, but at the end of the day, there's a sentiment in the country and a feeling around that that's Hitler-like, and then there's also an Abraham Lincoln kind of feeling where do you think he could get assassinated? Jeff: Look, I think it's possible. I think most of those sort of things, they're all actually orchestrated. JFK, for example, I believe that was Lyndon B. Johnson and the CIA who took him out. Ronald Reagan, that was the first Bush, the one who just died, George W. Bush, or sorry, George Bush, who was behind the assassination attempt, so-called assassination attempt, on Ronald Reagan. It's usually like an inside sort of a thing. It's really controlled. It's really theater. They actually keep all these things, including Putin, including little Kim in North Korea. They're all controlled by the same people, and it's just this big theater to keep people just mesmerized and watching their CNN and, "Oh, what did Trump say today," and all that. It's just no different than people in North Korea like, "What did little Kim say today? What are we supposed to do today?" Jeff: That sort of a thing, but anything is possible, but it is pretty tough to assassinate the president, as an outsider, but as an insider, it's not that hard, but they also seem to have some sort of weird like almost like protection around them. Like even George W. Bush, when he was in Iraq and the guy stood up at the media thing, and he was very mad, because Bush had been destroying his country and killing his family and all that sort of stuff, and he threw one shoe, and Bush just did the little dodge and just missed him, and then threw another shoe, and he just ... It's like, I don't know what it is with these people. They're kind of like, I don't know what it is, but it seems like he can't really get to them that way, not physically violent sort of thing. I think the only way we get rid of all of this is for people to wake up and realize that these people don't own you, and start to move away from these systems, and these people just go away and have to get real jobs. Stefan: I think one of the problems with human nature and people, I mean, you were talking about human nature and communism, where human nature doesn't work inside of communism, and then there's also another side of human nature, which is, I think humans have a hero worship, innate hero worship ability where we see someone, we see a leader, and we just want to worship them, and we want them to handle our problems. We want to have a personal Jesus. We want to have somebody we can just give it all to. Somehow, that's going to be the easy button. It'll all be solved, and then we don't have to think or deal with anything. Would you say that's true? Jeff: Oh, absolutely. That's exactly what government, it really is. That's what government always does. You look at every election. They come up there, and they give all these promises. "I'm going to solve this for you. I'm going to solve that." They never solve anything. They're just extorting you and destroying everything in the process, and making everything worse in the process, but yeah. That's absolutely the case is, your average person just won't take responsibility for themselves and just say, "I don't need this person to run this entire country for me. I can run myself," and that sort of a thing. Of course, it gets a little interesting how that would all, we've been in statism now for hundreds of years, so to actually break away from it's going to be difficult. Jeff: That's actually why we're starting up numerous sort of countries across the world now, so we've started Liberland in Europe, which is near Croatia and Serbia, which is a new sort of anarcho-capitalist country that's just being started, and there's some few others working on buying some islands, and we're going to start some totally anarcho-capitalist free sort of places there. We're also seasteading, so we're trying to start up in the ocean, start up our own little, what you call countries. None of them are really like countries, because there's no real government, but it's a place that we're going to start up that it's going to be completely free. Then through that, hopefully we could show the world, because they've never really seen it, what life would be like in a true free market. Jeff: If, all evidence seems to point to when you have a totally free market that it's incredibly good for most people. It just increases the wealth dramatically, as we've seen, as I pointed out, in places like Hong Kong, Singapore, Dubai. Whenever you have a lot of freedom, everything gets a lot more prosperous. The only sort of question a lot of people have is, "What if you have total freedom? What would happen?" We don't really have any good examples for that yet, so we're hoping to start do that in the next couple of years and try to show the world the light that, really, this governmental sort of statism system with central banks, and all these sort of things, are just absolutely terrible. The best thing for all humanity is to get rid of those sort of things and not have a belief in their authority. Stefan: Sounds like a page out of Atlas Shrugged right now. You got all the productive smart people wanting to go start their own country or start their own island. This is, it's just human nature. It's all written down in the book. It's all happened before, and here's a thought, Jeff. I don't know if you thought about this. At some point, there probably was some nice, true freedom in the Wild West, maybe, Wild West America or some place, and then at some point, the people organized themselves. At some point, there's a government. At some point, there's a king. At some point, there's a good king. He dies, and then you got his son, the bad king. Stefan: Do you think we've had freedom in history at some point, like true freedom, and then it just got consolidated into power? Because it seems to me that whether you look at a market like a real estate market, or you look at a Monopoly board, or you look at anything in life with humans, it seems that there's like always a consolidation going on. There's a consolidation at some point where somebody just ends up taking over, and we just end up in that over and over again, and the dominoes fall down at some point. We reset. Do you think we can actually exist as free people, like truly, or do you think someone's going to seize power at some point? Jeff: Well, the thing is, if you have enough people who actually believe that freedom is the way to go, and they want to do that, then no one can seize power, because there's nothing there to seize. You pointed out rightly that over history, it appears that people have always been okay with giving away their power to someone else and hoping this guy takes care of them all, and that never works out for the best, just like communism, it just never works out well. Jeff: Yeah, that's actually been the case over time is that people seem to have always sort of gravitated into these sort of things, but at the same time, when you think about life even today, we actually live in a state of complete anarchy right now. It just so happens that there's a lot of governments on earth which you can just consider to be criminal organizations who are stealing and extorting people, and kidnapping people, and forcing them to do things they don't want to do, but we actually live in a state of anarchy. Jeff: Your average person, actually, every single day of their life, pretty much lives in anarchy. When you're in your home, or you're talking to your friends, or you go to work, that's just anarchy. That's just day-to-day life, and there's no one there telling you what to do, except for a street cop or whatever, a road pirate who might try to extort you if he thinks you're going a little too fast over a arbitrary speed limit or things like that, but generally kind of already live in anarchy. Really, the important thing to understand is that the word "government," what it really means, "govern" is, the word "govern" comes from the Latin [Latin 00:46:24] which means to control, which makes a lot of sense, and the word "ment." Jeff: There's a lot of different sort of where that came from, but I lived here in Mexico, Spanish, [Spanish 00:46:34] is mind, so really, government is mind control. It's controlling people's minds to make them believe that this thing has authority over them and that it's sort of taking care of them as well. This is where we get into Stockholm syndrome and things like that, where people actually begin to really adore their kidnapper, the person who has basically kept them enslaved. I see [inaudible 00:46:56]- Stefan: I wanted to give a gong. At some point, you got to stop for me to give you a gong. I didn't know that "government" meant mind control. It's really interesting, because if you control the information, you control the thoughts, and if you control the thoughts, you control the stories. You control the stories, you control the beliefs. If you control the beliefs, you control reality. It's almost like ... In Hard Times, I talk about we almost live in a 1984 future from George Orwell, and some of it's like Brave New World, Aldous Huxley, which was Orwell's mentor. We got half of our stuff is the American Aldous Huxley Brave New World future with orgies, and synthetic music, and all these women with narrow hips that don't bear children anymore, and we have alphas, and betas, and gammas, and deltas and all that stuff, and epsilons. Stefan: Then the other part of our world is like the 1984 future where there's three gigantic powers that are always at war with each other, and it's like a Stalinist future. What do you think about those two books right now, Jeff, like 1984, Brave New World, and what we got going on right now? Jeff: Yeah. Both those guys, both, I think they went, both went to Oxford or one of those major schools. They hung out with the same people like the Bush crime family and all those, so they hung out with what you could call the elites, or some people call them the Illuminati or whatever words you want to put to these sort of secret societies that mostly sort of are in these schools like Oxford and stuff like that. They were actually good friends, as you pointed out, and it's really amazing that that long ago, what is it, like 60, 70, 80 years ago, they wrote- Stefan: It was 1945- Jeff: ... these books. Stefan: ... I think. It was like right after World War II the books came out. Jeff: Yeah, so I can't do the math. I went to government schools, but 70 years ago, whatever it was, and they've really just roadmapped the exact both ways that we're going. Actually, they're both happening at the same time. The Aldous Huxley, Brave New World, that was a lot of bread and circuses. The people would be too dumbed down, which we're seeing, through fluoridization in the water, through all the government indoctrination camps, through the television programming, all that sort of stuff. People are just watching the Kardashians and all that. Jeff: The sports, so the sports ball games, and that sort of thing, so people, that's what Aldous Huxley was saying is, people would be too dumbed down and too into these things like sports and entertainment to even notice that they're enslaved. That's what we have today, especially in the U.S. Then on the other side, there was Orwell went the other way with a bit more it's like a hard, top-down dictatorship. You can't say anything. Everything's the opposite of what it means in political speak, which is what we have today. You brought up about how there's these certain sectors of the world that always at war. East Oceania's always at war with whatever the other one was. That's what we have today. It's like, who's at war with who? This War on Terror, it's a war on a feeling. It's a war on, it's like terror is a feeling. It's like, "I was terrified when I saw that. We need a war against that." It's like- Stefan: Well, we got the- Jeff: ... "Who are you [inaudible 00:49:47]" Stefan: ... War on Drugs which doesn't work. We got the War on Terror that doesn't work. You got the War on Cancer that doesn't work. You got all these wars. They keep just funneling money into a couple dudes' pockets, and the War on Drugs makes drugs worse. The War on Cancer makes cancer worse. The War on Terror makes terrorism worse. It's pretty scary how those things just simply don't work. Jeff: Yeah, and it's all by design, like the people who really do these things know this is what's going to happen. It's just sad that people keep falling for it, but people are slowly waking up thanks to the internet. Yeah, I even saw like, who's that blonde, fairly not attractive, woman on U.S. TV who's like a really mean, nasty sort of ... Anyway. She just came out, and she just said all these wars are just stupid. They're just like, like we shouldn't be doing them. She was like a total war sort of a person. This just came out. Jeff: People are starting to wake up, but the biggest issue is, they don't know what the answer is, and so that's why they keep going back to what you pointed out, which is this false left-right paradigm, which they tell everyone that's all there is. There's left or right or somewhere in the middle and there's nothing else, but that's a very narrow range of political spectrum. That's basically statism right there, and you can have left or right in statism, but there's a whole other spectrum of just not having governments whatsoever that could really free a lot of people. It's really growing, actually, like when we first started Anarchast, Anarchapulco, Anarchapulco started five years ago. It was 150 people. We're now expecting about 3,000 people. It's doubled every year. Stefan: Wow. Jeff: My show, Anarchast, a lot of people said no one had ever watched the show, but anarchy, that's crazy. They think anarchy is throwing bombs and all this sort of stuff, but it's catching on. People are catching on to a lot of this stuff now, so we're going to see what happens. We're at an amazing time in human history, because all these things are coming to a head all at the same time. All these governments are bankrupt. The central banks are about to go into hyperinflation. Then we have people waking up and starting to realize what's going on, and then you still have all these people in the universities who think that communism's the way out, so they'll probably try to push for that. Jeff: It's just amazing, incredible time, and there's going to be so much change in the next 10 years. I don't think anyone will believe what happens over the next 10 years. I couldn't even imagine what will happen, but I know it's going to be mind-blowing what happens. It's going to be that much change. Stefan: Yeah. It's unbelievable. Now, Jeff, I got to wrap up the show, but I want to ask you a couple questions I ask every guest, because I think they're cool. If you can go back in time to, let's say, 15-year-old Jeff and give yourself a piece of advice, what's a piece of advice you'd give yourself? Jeff: Oh, man. That's a good question. I would say work on yourself. I really just started working on myself over the last couple of years. I'm like 48 years old now, and it's changed my life dramatically. I didn't deal with a lot of my past issues, childhood issues, a lot of the programming that we get from our cult, our culture they call it, but our cult, through our younger years. That still stays in your head. I think if I would have, if I could go back, I'd say, "Buy Bitcoin as soon as you hear about it," and I'd- Stefan: [inaudible 00:52:55]. Jeff: ... say, "Work on yourself," like- Stefan: [inaudible 00:52:57] man. Jeff: I'd probably also say, "Don't go to the bars that much. Don't be having a lot of drunken sex. It's a total waste of time. Try to find a good girlfriend. Try to fix yourself and work on yourself more than anything." That's what I'd tell him. Stefan: Wow. Great answer. Top three books that changed your life. Jeff: A good question again. We talked about G. Edward Griffin earlier. The Creature from Jekyll Island was one of the first books that got me looking into all this stuff that I talk about today. That was a really important to my life. I'd say The Lord of the Rings is, I read it when I was very young. I used to love to read. I was probably like 12 or something. This giant book, it's even bigger than your book there. What I didn't realize about The Lord of the Rings that is interesting, I love the book, and I loved everything about it, and it wasn't until a couple years ago I realized that that ring of power was actually a metaphor for government power. I actually looked- Stefan: Wow. Jeff: ... into it a couple years ago, and J. R. R. Tolkien, who wrote the book, called himself an anarchist, so that entire book was an allegory about the problems caused by government. Those two books are pretty good. I guess the third book that I thought was really interesting, and it's like a pamphlet. You can read it in about two hours. It's called The Market for Liberty. You can actually find it online for free in PDF format, and it shows what the world could be like without government. When I read that book, it just blew my mind, because I'm sure if you even read it, you'd go, you'd be like me, you'd be like, "Wow, I never thought things could work that way or that ... " Jeff: They actually thought about how things would work without government, so there'd be like private security companies. Well, how would that work? Well, there'd be insurance as well, so the insurance companies ... For example, like people go, "Well, how would you put out fires without the government?" Which is kind of funny, because the government rarely puts out fires [inaudible 00:54:34]. Stefan: Fire insurance. Jeff: Yeah. Fire insurance, and then the insurance companies have all this insurance money, and they'll have to pay out a ton if there's a giant fire, so they actually put out fire stuff, and fire stations, and all that kind of stuff so it can all work in the free market. I think that book really, in just such a small amount of time, can really just show how the free market can handle everything. Stefan: Yeah. Well, that's great. I always, people say, "Well, who's going to pay for the roads?" Well, you just tax cars and gasoline. If you got a car and gas- Jeff: Not even tax, right, but like the businesses would own the roads. You would never put up ... Let's say you're Walmart, and you want to put up a Walmart somewhere and there's no road there. You're going to build the road, because you want people to get to your thing. Plus, not to mention there's already all roads. All roads that already exist. I don't know why people think they'll just disappear, but obviously like gas stations would have a giant interest to making sure there was roads, so they would probably do something. The gas stations would all work together and say, "Okay, let's take 10% of all of our money that we make every month and put it into maintaining the roads." Right? It's fairly basic sort of stuff. Stefan: Right. All right. Second last question today, Jeff. What's the one thing that young people need to succeed these days? Let's talk to the snowflakes. Let's talk to the millennials, the guy with the MacBook Pro at Starbucks. What's something you want to say to h

Jeff Neumeister, Founder and CEO of Neumeister & Associates, joins us today to talk about cryptocurrency taxes, a confounding area of tax law (what isn’t?) and one that you should master if you are an investor in digital currency. Because what you don’t know could have an adverse impact on your pocketbook. That’s what happened to one U.S. college student in 2017 who invested $5,000 in Ethereum and somehow would up owing the IRS $400,000 in taxes. Yes, you stand to benefit greatly from understanding how the IRS views crypto (Hint: It’s in the same category as your house). And you’ll learn the cardinal rule of crypto taxation: The buck stops with you.   This is specially important this year after the 2018 market crash since many investors are selling their cryptocurrency and fleeing the market, without full knowledge of the tsunami of capital gains liabilities that these transactions may be triggering.   A forensic accountant by trade, Jeff brings great credibility to the task of walking us through the minefields of crypto taxes. He offers practical tips on everything from what constitutes a taxable event to what makes crypto taxes so challenging and how mined coins are taxed. That’s just a few of the questions Jeff answers in this episode. You’ll come away feeling a lot more confident about understanding your tax burden as you stagger into your tax prep marathon.     Topics Covered in this Conversation with Jeff Neumeister   What makes crypto taxes so challenging. What constitutes a taxable event? What is the difference between short-term and long-term gains? How are mined coins taxed? What happens if I give some coins as a gift, or someone gives me crypto? Do I have to pay tax on coins that were hacked? What happens if I lose some coins? What are the acceptable ways to report coin gains? What are the biggest obstacles to easily filing crypto taxes? Increasingly, there are charities that accept crypto. Is that something that would be helpful at tax time?  How are exchanges doing in terms of making it easy for investors to file taxes? Can crypto losses be balanced against traditional fiat capital losses. What’s the craziest thing you’ve ever seen or heard with it comes to filing or not filing crypto taxes. Let’s step back a bit and look at the process involved - let’s look at two scenarios: Scenario A: Let’s say you are Sally Fey, a beginner investor in 2017 and you got all caught up in the buying and selling during the Bull Market and you didn’t track all the coins you traded across multiple exchanges nor did you jot down the buy/sell price  for each transaction. Now your taxes are looming and you have your head in your hands. How do you regroup? Scenario B: Unlike Sally Fey, you are Matt Jones -- a beginner investor in 2019 and it’s a Bear Market and you’ve been told now is the time to buy. You’re starting with a clean slate. You’ve set up your exchange accounts, you are ready to trade. What’s good tax hygiene you should follow from Day One and on to Day 365 to simplify your tax headache for the year? Can you get away with NOT paying crypto taxes? What are the penalties for non-compliance? Any closing thoughts on how to make our crypto tax lives easier?   Questions and Comments? chasingunicorns@gem.co   Guest Contact Information Jeff Neumeister Website | LinkedIn | Twitter Resource Links: 3 Ways the IRS Is Taxing Cryptocurrencies Taxes and crypto Turning your 2018 Bitcoin and Crypto Losses into Tax Savings What You Don’t Know About Crypto Taxes Can Hurt You Tax Nightmare: Student Invested $5k in Ethereum & Now Owes $400k in Taxes 4 things to know about your cryptocurrency at tax time Year-End Tax Tips And Strategies For Cryptocurrency Investors IRS Guidelines Transcript: Interview with Jeff Neumeister Interview Recorded On: November 12 Topic: Crypto Taxes Chitra: Hello, and welcome to Running with Unicorns, your portal to the world of cryptocurrency. I'm Chitra Ragavan, Chief Strategy Officer at Gem. It's that time of year again, and your crypto taxes are looming. Here's what you can do about it. Our guest today is going to walk us through the ins and outs of crypto tax filing. Jeff Neumeister is CEO and Founder of Neumeister & Associates, an LA-based tax advisory firm with a growing practice in crypto taxes.   Jeff, welcome to the program.   Jeff: Thank you.   Chitra: What makes filing crypto taxes so challenging?   Jeff: It'd be probably because there are so many different things that are happening in the crypto world. It's not just mining coins or just trading coins, but there are forks, airdrops. There's just a lot happening. Because it's a new space, it's a lot that the taxing authorities are still trying to wrap their heads around.   Chitra: Let's start with the basics. What constitutes a taxable event in cryptocurrency?   Jeff: A taxable event is anything that results in a tax obligation or a potential tax obligation. That could be selling something, it could be generating income, it could be incurring a expense.   Chitra: Is it different than in regular taxes? What are the differences and similarities?   Jeff: It's similar in concept, except with cryptos there's just, again, so much more going on. Normally, if someone is just, say, a W2 earner, they have a paycheck, and that's the sole source of income that is subject to tax. With cryptos, however, if you're mining and trading in the ICO world, there's so many things that are happening that you're constantly subjected to different types of taxes.   Chitra: One of the basic things one needs to know is short-term and long-term gains. How does that work?   Jeff: Short-term gains just refer to anything, anytime you hold an asset or a piece of property for less than 12 months. Long-term is anything above that. Now, they also come along with different taxable rates. With long-term capital gains, it could be anywhere from 0 to 20%, so much better than what most of us pay with taxes for our income earnings. For short-term gains, it's anywhere from 10 to 37%. Short-term capital gains are essentially the same as ordinary income tax rates.   Chitra: Let's look at different types of crypto and how they will be impacted by taxes. Let's start with if you're mining cryptocurrency. How do you account for those?   Jeff: Mining's interesting, because it's kind of two things at once. When you mine a coin, or a fraction of a fraction of a coin, you're generating ordinary income, so whatever the value of the mined coin was, or fraction of a coin was, you have to pay ordinary income taxes on that. Then, that also establishes your cost basis in the coin that you now hold. If you do something else with it later on, trade it or sell it, you'll have capital gains on top of that.   Chitra: Then, let's look at crypto gifts. If you get a gift of Bitcoin, or Ether, or EOS, how do you handle that when it comes to tax time?   Jeff: If you're the receiver of a gift, then you just need to be aware of what the holder's or the donor's cost basis was. If they acquired something for, say, $100 and gave it to you, you need to make sure that you have that down in your records that your cost basis is $100.   There's no tax owed on a gift received. However, if you're the gift giver, you might have to do a informational filing, a form 709. What that is is anytime you gift more, at least in 2018, more than $15,000, you have to file a form 709. You don't have to pay gift tax on that, but if you exceed your gift-giving of $5.6 million during the course of your lifetime, then you have to start paying gift taxes.   Chitra: If only we could all be so lucky.   Jeff: Right. Most of us will never have to worry about that, but make sure that you file a form 709, because there are penalties with not filing.   Chitra: Then, can you give crypto to charity? I see that increasingly, there are a lot of, even the Red Cross and other organizations accepting crypto. When that happens, is that a good thing to do, when it comes to tax time? Obviously, it's a good thing to do in any case, but it probably helps with taxes, doesn't it?   Jeff: Absolutely. It's just like any charitable contribution, except instead of giving clothes, or fiat, or artwork, or jewelry, you're giving cryptos, yeah.   Chitra: It's taxed similarly?   Jeff: Yes, mm-hmm (affirmative).   Chitra: Then, if you're hacked, what happens? You're losing a bunch of coins because you got hacked. Do you have to pay taxes on that?   Jeff: No, but you have to make sure that it's documented. It's the same thing as if someone came into your house and burglarized it, right? It's a casualty loss. That would be an itemized deduction. You have to make sure that you record those things. Chitra: What if you just lose your crypto? Like, they're on some exchange, you don't know where it is, or you've lost the password. Can they figure it out that you have this crypto? How do you account for the missing crypto?   Jeff: That's a little bit more challenging. If you no longer have access, say, to your key, and you'll never obtain access, then that could be construed as a casualty loss, as well. If you just say, "I don't know which exchange it's on," hopefully that won't come up if you're audited, yeah.   Chitra: And if you are?   Jeff: Then, as long as you show a good faith effort in being consistent and transparent with taxing authorities, and they could see that you're not trying to hide anything, then you should be okay.   Chitra: Do you hear of people that are trying to hide crypto by claiming losses, that they've lost it?   Jeff: Some folks, yeah, yeah. More egregious than that, though, we've had, there was one gentleman that was seeking out a CPA, who made a little over 2.5 million in cryptos, and said, "No, I'm just not going to file. If they want the money, they have to come after me."   Chitra: Did they?   Jeff: Well, that's what's going to happen over the next couple years, yeah. The IRS has started mounting a task force specialist specifically to investigate cryptocurrency filings.   Chitra: Is that going to be an easy task? Will they find people that are scofflaws?   Jeff: They will absolutely find people, right? It's going to be interesting in the tax world for the next couple of years, and tax courts, people fighting them.   Chitra: You're seeing a lot of new developments in tax filings, in tax law as a result of this?   Jeff: Not yet. Really, they're just kind of testing the waters, now. The last, about a year ago, they started issuing subpoenas to exchanges, and they were winning, to get transaction records from them, so they could see what people are trading and how much people are earning, so they could compare that with individual tax returns, to find evidence of those that are evading their taxes. They're just starting to institute those audits now and will be taking these folks to tax court as needed. There's a lot of things that will come out of it, but it hasn't happened yet.   Chitra: Because I think, particularly in the early days, there were probably a lot of people who weren't filing taxes. Is there like a statute of limitations, or does it matter if like 10 years ago you weren't filing taxes, and now the IRS is starting to think about this and starting to do these audits?   Jeff: There is a statute. It's, generally speaking, three years from the date of which a filing was due, but that's only if it was an innocent mistake. If you're intentionally evading, there's no statute on that.   Chitra: How do you report, typically, gains and losses? What's the process?   Jeff: The process is usually, you want to have everything calculated, all the transactions. Coin for coin, coin for fiat, and those will be itemized on a form 8949, and summarized on a schedule D, which are attached to the tax returns.   Chitra: Having done my crypto taxes this year, it's fairly complicated. It's just, you have to look at every single transaction. Talk a little bit about what that process is like. It's fascinating for me to see the level of detail and how you actually go about finding those records, if somebody hasn't kept those records, and being able to trace the flow of that currency from the exchange to your wallet, or if you're trading, you've got all of these multiple transactions that have taken place, hundreds, maybe thousands of them.   Jeff: Yeah, it could get very complicated. That's why a lot of our clients have come to us, to help them untangle these complex array of transactions, ranging from, if they have a few hundred coins that they're trading across multiple years, you can end up having thousands and thousands of cost pulls, because you have to trace every single transaction to its cost basis. Its cost basis depend on whether you used FIFO, LIFO, or HIFO.   Chitra: Explain that a little bit.   Jeff: Sure, yeah. Those are the manners in which you inventory the cells of different coins. LIFO, last in, first out, that's saying, when you sell a coin, you go to the last time that you had acquired that coin, and you sell it out of that pool. If you're buying and selling coins all day long, go across multiple months, you have many cost pulls, even thousands or tens of thousands of cost pulls.   FIFO, first in, first out, is where you sell your oldest coin. What that does is it will result in fewer long-term capital gains, but you're kind of eating up your tax obligation now, versus deferring it to later on.   Chitra: Let's say I'm trading, okay? I'm on exchanges, and I'm trading. I'm not really thinking about ... It's not something you think during your trading process, right? It's something you do after the fact. I'm not thinking LIFO and FIFO when I'm like, "Let me find what's my oldest Bitcoin, and let me trade that for Ether." I'm just like, trading. Am I doing the right thing? Is this something you go after the fact, and start to look through it and make those calculations?   Jeff: The easiest thing is to maintain good records, so that whoever, whether you're doing it yourself or outsourcing it to a professional like us, then they could go through those records a lot easier, because it does get complicated. As long as you have the information, it could be all untangled.   Chitra: What's the largest number of transactions you've done, filing taxes, that you've seen? Thousands, hundreds of thousands?   Jeff: Probably in the hundreds of thousands. I think our largest client had a little shy of 200,000 transactions across about 2.5 years. It was a lot. It took a massive amount of manpower, because there isn't a way to fully automate it, yet. We've established a proprietary method to semi-automate portions of it, but not the whole thing. There's still a lot of manual touches that have to be done to it.   Chitra: Were you able to do it?   Jeff: Yeah, yeah. We were able to untangle all of it. He had a massive tax obligation, but most importantly, it'll keep him compliant with the IRS. He had the cash, right? If you make a million dollars in cryptos, and if you have to pay a few hundred thousand in tax, you know, you're still coming out ahead.   Chitra: This is true. What are some of the biggest obstacles today for average investors, when it comes to filing taxes?   Jeff: I think having an understanding about how complex the tax aspect is with cryptos, if you're trading, mining, doing anything else. I think just being aware and mindful of that.   Chitra: There's also the issue of documentation, right? For example, different exchanges can give you different levels of information about your trades, so at the end of the year, some exchanges will give you a lot of information. Other exchanges give you virtually no information. How do you start to do the detective work to find all of your records?   Jeff: That's one of the tricky parts, yeah, because there isn't really any sort of regulation about what all the exchanges have to provide users. There's going to be, and it's moving that direction. For now, it's kind of up to the individual to maintain their own records. If the exchange only provides piecemeal stuff, or in the case of Bittrex that just up and deleted people's information, it's still your obligation to make sure that you're tracking things.   Chitra: What happened in that instance where the information was deleted?   Jeff: Well, they up and decided just to remove information.   Chitra: This was an exchange?   Jeff: Yeah, yeah, Bittrex. It's still the user's responsibility to maintain the records. The individuals that were subjected to that, had they downloaded their transactional information, let's say, every week or every month, they would have been okay, right, just in case something does happen to an exchange. That's something we advise our clients to do is don't wait till the end of the year to start pulling your information, even if you're using a CPA like us, right? Pull the information maybe once a month, just in case something happens.   Chitra: That's interesting. That's something I've never thought to do. It's kind of surprising that they're allowed to even delete information. Is that going to change, in the future?   Jeff: Yeah, there's definitely more pressure in regulation around what the exchanges are doing. Also, keep in mind that a lot of these are foreign exchanges, too, right? The IRS and the federal government only has so much control over what they do.   Chitra: Because this is such a global flow of money.   Jeff: Exactly. It's a global thing. Right.   Chitra: How does the US government, or how is the US government attempting to get a handle on this? Do you feel like the government is kind of playing catch up, now?   Jeff: A bit, yeah. I think there was too much downtime from 2014 to now. You know, the last time the IRS issued any formal guidance was in 2014.   Chitra: What was that initial guidance?   Jeff: It was maybe like a five-page notice, 2014-21, which pretty much just said that it's not legal tender, and to pay your tax on it. There really wasn't much guidance beyond that.   Chitra: What happened before then, like 2009 through '14? Was there any guidance?   Jeff: Nothing formal.   Chitra: What were people doing then?   Jeff: I think, at the time, IRS and other government agencies probably just assumed that this is just a fringe thing, it's a temporary thing, it's not going to last, but look at us now. There are industries being built around blockchain and crypto, and they realize that, now, and the amount of money that people have earned in the sector. They see it as, like, it's a huge nest egg waiting to be tapped.   Chitra: Build your highways and all of that stuff.   Jeff: Right, yeah.   Chitra: Now, when you're filing taxes, can your crypto losses or gains, be balanced against your traditional portfolio?   Jeff: Yes, yeah. The way it works is short-term gains and losses get netted against other short-term gains and losses, regardless of if they're crypto or not. Then, the same thing with long-term.   Chitra: Great. Now, what are the penalties for noncompliance?   Jeff: For failing to file a return, it's a flat 5% of whatever your tax obligation is. For not paying the total amount of taxes owed, it's one half of 1% per month. If it's just one month late, half of 1%, it's not a lot, but if a couple of years go by, a few years go by, it can add up really quick, plus interest.   Chitra: Can you go to jail?   Jeff: Absolutely, unfortunately. If it's deemed that it was tax evasion, like in the example that I gave you of the gentleman that was looking into using our service and decided, no, they can just come after me, a couple million dollars, if they find evidence of tax evasion, then it could be subjected to a felony, which leads up to up to five years in prison and up to a quarter million dollars in penalties.   Chitra: Now, there's a lot of money laundering also going on, right? Does that play a role at all in this?   Jeff: Not so much with the taxes, but it is something that they're mindful about, out there. I see that more in the banking sector, that being an issue. In fact, one of our clients in the crypto space, their bank account was just abruptly closed with no notice. They said, "You can't bank with us," because they are concerned about potential money laundering.   Chitra: What is their fear?   Jeff: I think because they don't know where the money is coming from, right? If you have crypto-related money, it's so easy for it to be maneuvered from overseas. I think that's the concern, because there isn't enough regulation out there yet, right? Some people are just distancing themselves.   Chitra: It seems like there's a whole bunch of areas in which the federal government and governments around the world are now grappling with, how do you make people accountable for all of this wealth that they're generating, and how do we get a piece of that action?   Jeff: Right, that's what it is. They want their cut. As long as you give them their cut, they're not going to bother you.   Chitra: Now, let's look at two scenarios. Let's say you're a Sally Fay, you're a woman investor. You're just starting out. You're super excited. It's 2017. The bull market is in full swing, and you've learned how to trade, and you're just buying and selling without any regard for keeping tabs on your cost basis or the proceeds that you're making. Then, come December, you're stuck with having done thousands of transactions, and you have no idea how to go about finding those records, because every trade that you've done is potentially taxable, correct?   Jeff: Correct.   Chitra: What do you do?   Jeff: In those kinds of situations, because it's a lot of cleanup, the best thing to do is consult with an expert like us, so we can get you cleaned up and caught up. Then, going forward, you're on the right path, right? And to be mindful just about all the tax consequences of all that trading activity.   Chitra: Do you just sort of systematically start to go back and look at every trade you've made?   Jeff: In order to calculate all the gains and losses, historically, yeah. We have to kind of start from inception. If someone started trading in 2014, right, we have to go back to square one.   Chitra: That's pretty daunting.   Jeff: It is, yeah, yeah. At least once we get you caught up, then you should be okay, right?   Chitra: Let's look at scenario B. Let's say that I am a young man, Matt Jones. I'm not in the crypto market yet. It's the bear market, and people are telling me, "Hey, now's the time to come in. Buy low, and you can sell high." I have a clean slate. I've set up my exchanges, but I haven't done any transactions. What are the kinds of things I need to put in place to have tax hygiene, so to speak?   Jeff: Some best practices.   Chitra: Yes.   Jeff: I'd say, first, be mindful that you do any sort of trade coin for coin, that's all going to be a taxable event. Have at it, but just be mindful that there could be a lot of tax compliance to deal with at the end of the year. That affects some people's volume activity.   Another thing, to make sure to pull their records on a consistent basis. We usually, we're advising our clients now to download their transactional history from each exchange they use about once a month. Just make it a month-end practice, just in case either they got locked out, the data is deleted, or something is hacked, just in case anything happens, at least you have the records.   Then, outside of transactions like that, if you're trading on an exchange, if you're gifting coins, jot down somewhere on a Excel sheet or a Word document who you gave it to, when you gave it to them, and how much you gave, right? Just in case if there's any gift tax compliance to do, we could do that as well.   Chitra: Is it advisable to have a notebook and a pen, and when you're making these trades, to actually just jot it down, or put it on an Excel sheet that on this date, I bought X amount of Bitcoin, or I sold X amount of Ether for X amount, and to have that? Is that going to be helpful at the end of the year?   Jeff: It could, but like all the transactional data within the exchanges usually is going to have all that information. If someone wants to just separately track it, and if they're not doing a lot of trades during the year, that could be just as efficient and make their process easier at the end.   Chitra: Now, tell us some war stories. What are some of the anecdotes that you tell people about folks having challenges in filing taxes, or cases that you've seen, or what the government is doing to come to terms with this new source of income?   Jeff: Sure. Probably a couple examples. We have clients that were trading back from, the oldest one is 2013, maybe about a little over $4 million, and of course, they never reported any of it. Thankfully, in contrast to the other individual I was referencing, he said, "You know what, I just want to be compliant, right?" He came to the table. We went through everything, all the records, and got him up to speed.   Going forward, if he's audited, or maybe I should say when, because it's a lot, a big amount, we have work papers in place that we could provide in response to an audit. 90% of the time, that'll just make it go away, almost immediately. As long as the IRS can see that you've made a good faith effort, that there's been due diligence in being compliant, and you have work papers and a CPA to back it up, the audit will go away, right?   Another example, well, with the IRS, it's not so much a war story, but it's come to my attention that they've selected around 1200 to 1300 cases already from the 2017 filings that they're going to move forward with audits. Now, I don't know which ones those are. That comes from a source I have within the audit community, but we suspect that those are probably the larger ones, mostly, people that have generated hundreds of thousands, if not millions.   Chitra: Is the IRS not only trying to get revenue back from these taxable events but also trying to set precedence in some way?   Jeff: Yeah. It serves both purposes, yeah. One, it's a huge amount of revenue just sitting there for the government that hasn't been tapped yet. The second is going through this process, and going through these audits, and taking some people to tax court will set precedence, so that it's clear to everyone else that, one, you need to be compliant. Don't play games with them. I wouldn't be surprised if they send at least a few people to jail over this that have evaded their taxes.   Also, it allows them to kind of establish authoritative guidance, because they're going to take everything they find. They will undoubtedly issue some pronouncements about, "Here's how you calculate this. Here's why you file things this way," which right now, we don't have.   Chitra: What about moving out of the US, like just moving abroad so you don't have to pay your taxes, or even moving to Puerto Rico. You hear a lot about that. Is that going to help you or hurt you, in the long run?   Jeff: I think for taxes, temporarily, it would help, right? But, do you really want to expatriate yourself, denounce the US, in order to just save some money temporarily on taxes? I don't know.   Chitra: Depends, I would say.   Jeff: It depends, yeah, yeah.   Chitra: On what the amount is. Are you hearing about people who are actually doing that?   Jeff: No one I know has actually done it. Some folks that we know have been debating it, and they asked to do some research on expatriation process.   Chitra: It's a fascinating area. When you're doing the forensic work, you've been asked to help, I think, with investigations and things like that. How do you go about collecting the forensic evidence on these cases?   Jeff: Really kind of the same way we do crypto calculations for our clients, right? We pull all the underlying third-party documents. In this case, transactional records. We get their narrative about what happened, hear the story, because any forensic case, anything that we do, it's not just the numbers. It's also the context. It's also what happened, the story, if you will.   With forensic cases, there's usually a lot of other moveable parts, as well, particularly like divorce cases, where people are sometimes hiding funds. Partnership disputes, where one partner is embezzling money. We see that kind of stuff a lot more often than what people realize.   Chitra: What happens in the case of a divorce? Who gets the crypto? How do you actually even split the proceeds, if that's what happens?   Jeff: Same thing with kind of like a house, right? If it was community property, assuming it's a community property state like California, then any assets would be split 50/50, unless it was bought with separate property. If you don't want to cash out the portfolio, then usually one partner would buy out the other half from the other partner, just like a house. If you don't want to literally split the house in half, one person wants to keep it, one partner would buy out the house from the other.   Chitra: Well, that actually raises an interesting question, because let's say one partner is very crypto-savvy and the other partner is not crypto-savvy. It probably is pretty easy to hide your assets in the form of crypto, because the other person has no way of finding out how much you have and where you have this.   Jeff: True. Yeah, there's an opportunity there for someone to try to take advantage. Part of the divorce proceedings process is to come to the table and be transparent with both partners. Usually, like, you're essentially signing off to the court that let the partner know 100% of the assets out there. To try to hide it is essentially perjuring with the court.   Chitra: Where do you see all of this going in the next few years, as more and more people get into the space? There is a prediction that you're going to have a billion new crypto investors, over the next five years, entering the market. Where do you see the field of taxation going?   Jeff: Yeah, definitely, I see a second adoption, as well, coming in the coming years. I think, by the time that happens, there'll be a little bit more infrastructure in place with the taxation piece. One, with the exchanges. They'll start being a little bit better about what they record for their clients and what they issue out at the end of the year. I think we'll get to a point where exchanges are very, very similar to brokerage accounts, where you just get a 1089 of, "Here's your cost basis, here's your proceeds, here's what you report on your tax," and make it much easier for folks.   Chitra: Just as the industry is growing up, the tax piece will grow up, as well.   Jeff: Yup.   Chitra: Yeah. Great. Is there anything I haven't asked or anything really important, closing thoughts?   Jeff: One closing thought, just, I think it's good for everyone to remember that almost everything is a taxable event. If the question is, "Do I have to pay tax on this?" 9 times out 10, it's yes.   Chitra: Sadly.   Jeff: Yes.   Chitra: Thank you so much for joining us. Where can people learn more about you and find out more about the work that you're doing?   Jeff: Sure. Our website is neumeistercpa.com, that's N-E-U-M-E-I-S-T-E-R-C-P-A.com. We're a full-service accounting consulting firm, but we specialize in things like cryptos.   Chitra: Great. Thanks so much for joining us.   Jeff: All right, thank you.   Chitra: That's all for now. Join us again next time for another edition of Running with Unicorns. Until then, enjoy your crypto journey, unicorns.  

Panel Charles Max Wood (twitter github Teach Me To Code Rails Summer Camp) Eric Davis (twitter github blog) Evan Light (twitter github blog) Jeff Schoolcraft (twitter github blog) Discussion Fixed bid Time and materials Give a budget to the client Scope creep Do you renegotiate the contract on scope creep? Short fixed bids can help manage costs and risk Customer management Fixed vs. Hourly is a discussion of risk Provide options for a fixed bid Multipliers for each unknown Risk is added for each new technology added to the stack Alan Weiss Start up with a courting period and then renegotiate after the courting period Shorten the scope of the project When you lower your bid, remove features (value) from the bid Charge more! Picks Find a Mastermind or Group of people who do what you do (Chuck) Heil PR-40 Microphone (Chuck) Other dynamic (Chuck) Behringer XENYX (Chuck) Roland R-05 (Chuck) Resounder (Chuck) Adobe Audition (Chuck) Million Dollar Consulting (Eric) The Consulting Bible (Eric) Peepcode Play by Play (Eric) Destroy All Software (Eric) (anti-pick) iMac Microphone (Evan) (anti-pick) Eric Davis' Internet Connection (Evan) Math Minute Additions (Jeff) Steel City Ruby Conf (Jeff) Mass Effect 3 (Jeff) Star Wars the Old Republic (Evan) Transcript CHUCK: Anyway I’ve got to hang up and get off so-- EVAN: Yeah, whatever. ERIC: Yeah you got what you need out of us. I see. CHUCK: Yeah exactly. EVAN:  At least you kiss us after you f--- us. JEFF: That has got to be the sound. CHUCK: Hey everybody! Welcome back to the Ruby Freelancer Show. On today’s panel we have Eric Davis. ERIC: Hello. CHUCK: We also have Evan Light. EVAN: Hi! CHUCK: And we also have Jeff Schoolcraft. JEFF: What's up? CHUCK: Now we’ve kind of been a quite bunch this morning, so we have to see how the show goes. So we were discussing what we want to talk about and one of the things that somebody brought up (and I’ve been asked a few times) is whether or not to take fixed bids. And I'm pretty sure I know what you guys are going to say, so if anyone wants to chime in and share their opinion on whether fixed bids or hourly, or either one or both are okay, go ahead. ERIC:   Well why don’t we start with actually defining what fixed bid is, because I see people say, don’t do fixed bids. But they actually don’t mean the same thing on someone else. CHUCK: Okay, so when I say fixed bids, what do you think? ERIC: For me, it’s basically a set cost, typically a set of features and then there will typically be like a set deadline which goes wishing by usually. CHUCK: Right, and then the other side of the spectrum is every hour I work, you pay me X amount of money right? ERIC: Yeah and some people consider that hourly. CHUCK: What else would you consider hourly? JEFF: Not government based, we will call fixed bid from fixed price and that's all the expenses everything, you are doing for whatever scope the project is, rolls up to some big number. And the other to way to do, is time and materials. So, you charge for every minute you work on that project and every pencil you buy or whatever you do to clear it up. But that is the other, I don’t know, vernacular terms I heard for those two billing concepts. CHUCK: Right. I want to see you code with a pencil, that would be fun. JEFF: Sometimes it will be faster. CHUCK: It's easier to debug. You just turn it over and use the eraser right? ERIC: Yeah I actually do it lot on index cards, when modelling or whatever, just kind of write stuff on index card. If it's not going to look like it's going to relay just throw the index card away. It’s a lot faster than removing code. CHUCK: That's true. That’s kind of an interesting planning phase or I guess modelling phase. And you can do agile, so that you are consistently updating your model as you code.

Panel Charles Max Wood (twitter github Teach Me To Code Rails Summer Camp) Eric Davis (twitter github blog) Evan Light (twitter github blog) Jeff Schoolcraft (twitter github blog) Discussion Fixed bid Time and materials Give a budget to the client Scope creep Do you renegotiate the contract on scope creep? Short fixed bids can help manage costs and risk Customer management Fixed vs. Hourly is a discussion of risk Provide options for a fixed bid Multipliers for each unknown Risk is added for each new technology added to the stack Alan Weiss Start up with a courting period and then renegotiate after the courting period Shorten the scope of the project When you lower your bid, remove features (value) from the bid Charge more! Picks Find a Mastermind or Group of people who do what you do (Chuck) Heil PR-40 Microphone (Chuck) Other dynamic (Chuck) Behringer XENYX (Chuck) Roland R-05 (Chuck) Resounder (Chuck) Adobe Audition (Chuck) Million Dollar Consulting (Eric) The Consulting Bible (Eric) Peepcode Play by Play (Eric) Destroy All Software (Eric) (anti-pick) iMac Microphone (Evan) (anti-pick) Eric Davis' Internet Connection (Evan) Math Minute Additions (Jeff) Steel City Ruby Conf (Jeff) Mass Effect 3 (Jeff) Star Wars the Old Republic (Evan) Transcript CHUCK: Anyway I’ve got to hang up and get off so-- EVAN: Yeah, whatever. ERIC: Yeah you got what you need out of us. I see. CHUCK: Yeah exactly. EVAN:  At least you kiss us after you f--- us. JEFF: That has got to be the sound. CHUCK: Hey everybody! Welcome back to the Ruby Freelancer Show. On today’s panel we have Eric Davis. ERIC: Hello. CHUCK: We also have Evan Light. EVAN: Hi! CHUCK: And we also have Jeff Schoolcraft. JEFF: What's up? CHUCK: Now we’ve kind of been a quite bunch this morning, so we have to see how the show goes. So we were discussing what we want to talk about and one of the things that somebody brought up (and I’ve been asked a few times) is whether or not to take fixed bids. And I'm pretty sure I know what you guys are going to say, so if anyone wants to chime in and share their opinion on whether fixed bids or hourly, or either one or both are okay, go ahead. ERIC:   Well why don’t we start with actually defining what fixed bid is, because I see people say, don’t do fixed bids. But they actually don’t mean the same thing on someone else. CHUCK: Okay, so when I say fixed bids, what do you think? ERIC: For me, it’s basically a set cost, typically a set of features and then there will typically be like a set deadline which goes wishing by usually. CHUCK: Right, and then the other side of the spectrum is every hour I work, you pay me X amount of money right? ERIC: Yeah and some people consider that hourly. CHUCK: What else would you consider hourly? JEFF: Not government based, we will call fixed bid from fixed price and that's all the expenses everything, you are doing for whatever scope the project is, rolls up to some big number. And the other to way to do, is time and materials. So, you charge for every minute you work on that project and every pencil you buy or whatever you do to clear it up. But that is the other, I don’t know, vernacular terms I heard for those two billing concepts. CHUCK: Right. I want to see you code with a pencil, that would be fun. JEFF: Sometimes it will be faster. CHUCK: It's easier to debug. You just turn it over and use the eraser right? ERIC: Yeah I actually do it lot on index cards, when modelling or whatever, just kind of write stuff on index card. If it's not going to look like it's going to relay just throw the index card away. It’s a lot faster than removing code. CHUCK: That's true. That’s kind of an interesting planning phase or I guess modelling phase. And you can do agile, so that you are consistently updating your model as you code.