Podcasts about titrate

Before You Take Ozempic, Wegovy, or Mounjaro Listen to This! The challenges for people taking GLP-1s. (1:10) GLP-1s do NOT cause muscle loss. (3:10) The under-muscled epidemic. (5:48) The way GLP-1s work and what they do. (7:45) Obesity vs. under muscled. (11:12) Losing muscle is bad. How do you stop that from happening when on a GLP-1? #1 - Titrate the dose if too strong. Why you should go through a compound pharmacy. (13:30) #2 - Eat high protein. (16:49) #3 - Lift daily. (20:32) #4 - Drink ½ to 1 gallon of water daily. (24:18) #5 - Use essential amino acids, creatine, electrolytes, HMB. (25:42) Related Links/Products Mentioned Special Promotion: MAPS GLP-1 50% off!! ** Code 50OFFGLP1 at checkout ** Visit Seed for an exclusive offer for Mind Pump listeners! **Promo code 25MINDPUMP at checkout for 25% off your first month's supply of Seed's DS-01® Daily Synbiotic** Changes in lean body mass with glucagon-like peptide-1-based therapies and mitigation strategies Muscle Mass and Glucagon-Like Peptide-1 Receptor Agonists: Adaptive or Maladaptive Response to Weight Loss? Visit Transcend for this month's exclusive Mind Pump offer! ** 25% off all GLP-1s – This includes the GLP-1 probiotic which people can order through their specialist. ** Mind Pump #2360: What You Need to Know About GLP-1 With Dr. Tyna Moore Mind Pump #2110: Ozempic the Miracle Fat Loss Peptide: The Truth With Dr. William Seeds Mind Pump #2410: How to Maximize Fat Loss & Preserve Muscle on GLP-1s (Introducing MAPS GLP-1) Mind Pump #2432: The Truth About Essential Amino Acids with Angelo Keely HMB benefits, dosage, and side effects - Examine Mind Pump Podcast – YouTube Mind Pump Free Resources    

For more information, visit https://thecirsgroup.com Today we have a special guest! Dr. Dayan Goodenowe is a researcher that has unlocked the power of plasmalogens and thankfully, this is something that can be a real game changer for people struggling with CIRS, or Chronic Inflammatory Response Syndrome. We cover what they are, where they come from, how to try them for yourself, and more. Check out the time stamps and links below, and for more information, support, and resources in your own CIRS healing journey, visit TheCIRSGroup.com TIME STAMPS: 0:00 Intro and disclaimer 1:28 What are plasmalogens? 6:20 What do plasmalogens do? 10:20 How Dr. Goodenowe started working with plasmalogens 13:10 Glia and Nuero: what are the differences? 16:47 Titrate up slowly and carefully 18:40 Jacie's experience with plasmalogens, and how plasmalogens help even in exposure 23:30 Getting to baseline to build resilience 26:45 Side effects to look out for when starting out 21:10 Blood test to determine your needs/deficiencies 38:24 How to work with Dr. Goodenowe or purchase his products HELPFUL LINKS MENTIONED: Dr. Goodenowe's website: https://drgoodenowe.com/ His Prodrome website to purchase plasmalogens: https://prodrome.com/ The CIRS Summit: https://thecirssummit.com/ The CIRS Group: Support Community: https://thecirsgroup.com Instagram: https://www.instagram.com/thecirsgroup/ Find Jacie for carnivore, lifestyle and limbic resources: Instagram: https://www.instagram.com/ladycarnivory YouTube: https://www.youtube.com/@LadyCarnivory Blog: https://www.ladycarnivory.com/ Pre-order Jacie's book! https://a.co/d/8ZKCqz0 Find Barbara for business/finance tips and coaching: Website: https://www.actlikebarbara.com/ Instagram: https://www.instagram.com/actlikebarbara/ YouTube: https://www.youtube.com/@actlikebarbara Jacie is a Shoemaker certified Proficiency Partner, NASM certified nutrition coach, author, and carnivore recipe developer determined to share the life changing information of carnivore and CIRS to anyone who will listen. Barbara is a business and fitness coach, CIRS and ADHD advocate, speaker, and a big fan of health and freedom. Together, they co-founded The CIRS Group, an online support community to help people that are struggling with their CIRS diagnosis and treatment.

In this episode, we discuss the art of helping clients navigate physical discomfort safely and effectively. We look at the practice of titration, a technique to manage challenging body sensations without overwhelming clients. Annabelle shares her journey into yoga and somatic practices, insights on recognizing signs of dysregulation, and practical yoga-based techniques for fostering body awareness and resilience. We also discuss trauma-informed care, the importance of play and creativity in therapy, and offer a grounding orientation practice to connect with one's surroundings. We look at valuable tools for therapists interested in integrating somatic approaches and yoga into their practice, ensuring safe and transformative client experiences.MEET Annabelle CooteAnnabelle Coote is a seasoned somatic therapist who loves weaving together the art and science of therapy. She helps both clients and therapists discover the joy and fulfillment of creative and experiential work. A licensed mental health therapist, board-certified dance/movement therapist, and certified Sensorimotor Psychotherapist, she is the founder of Movement Matters Integrative Psychotherapy. Annabelle is the author of book chapters on depression, trauma, and telehealth and is a frequent presenter at conferences and summits. She offers individual and group consultation to help therapists integrate somatic approaches in their work. Her interests include mindfulness, neurobiology, trauma, anxiety, women's issues, life transitions, cultivating creativity, and therapist resilience. She is known for her humor, quirky metaphors, spontaneous creativity, kind compassion, and the conviction that profound transformation happens in very tiny steps.Find out more at Somatic Matters and connect with Annabelle on TikTokUnderstanding Titration in TherapyChallenges of Body Discomfort in TherapyTrauma-Informed Somatic PracticesPractical Techniques for Managing DiscomfortTitration in Yoga PracticesHandling Overwhelm and Sensation in ClientsConnect With Me Instagram: @chris_mcdonald58Facebook: Yoga In The Therapy PodcastJoin the private Facebook Group: Bringing Yoga Into the Therapy RoomTikTok: @YogaChris58Rate, review, and subscribe to this podcast on Apple Podcasts, TuneIn, and SpotifyHow To Build Competence and Confidence in Integrating Yoga Into the Therapy RoomSelf-Care for the Counselor: A Companion Workbook: An Easy to Use Workbook to Support you on Your Holistic Healing...

Evoking thoughts of tribal gatherings and mystical experiences of the past and future, Berlin based artist, Refracted taps into his ritualistic side through his latest release titled, ‘In Veil'. Forth-coming on the London imprint Titrate, the release spans six tracks that seem to stretch time and space, enveloping the listener in field recording and drone driven journeys. Initiation brings forth an atmosphere of introspection as subdued bongos start and a steady drone fills the air. The energy turned inwards, the thoughts of a listener calm, meditative tones and melodies play throughout. Giving space and warmth as field recorded textures swirl amidst the musical backdrop. Initiation and the remainder of Refracted's ‘In Veil' release will be out on the 25th of January. @refracted-music @titraterecords www.instagram.com/refractedmusic/ www.instagram.com/titraterecords/ Write up by @huedj Follow us on social media: @itsdelayed linktr.ee/delayed info@delayed.nyc www.delayed.nyc www.facebook.com/itsdelayed www.instagram.com/_____delayed www.youtube.com/@_____delayed

Send a Text Message. Please include your name and email so we can answer you! Please note, this does not subscribe you to our email list, it's just to answer if you have a questions for us. Since introducing our new fan mail feature, we've had some fantastic questions rolling in, and this week, we're tackling a common concern: Should you increase your dosage of anti-obesity medication, even if it seems to be effective?Join me as I delve into this listener's question and explore the complexities of titrating up. While it might appear logical to boost your dosage for better results—especially when you're experiencing weight loss and improved health markers—there are important considerations to keep in mind.In this episode, we'll discuss the delicate balance between medication dosage and your nutritional needs, the risks associated with increasing medication too much, and how insurance companies can influence these decisions.ReferencesFor more detailed questions that can't be covered on the podcast, click below to schedule a non-medical personal consultation with Dr. Rentea:30 min consult 1 hour consult Join the January cohort of The 30/30 Program to rediscover your joy for food and movement in just 6 weeks while cultivating a flexible, open mindset for lasting change.Payment Options:3 monthly payments of $199One time payment $599Audio Stamps00:30 - Dr. Rentea discusses the challenges and rewards of attending two back-to-back conferences, highlighting the value of in-person connections.03:03 - Dr. Rentea addressed a listener's question about increasing the dosage of an effective anti-obesity medication, emphasizing the complexities of weight management.06:23 - We learn how insurance companies often force patients to increase their anti-obesity medication dosage despite its effectiveness, revealing a gap between clinical practice and insurance policies.08:40 - For questions that are too detailed for the podcast, Dr. Rentea suggests scheduling a consultation for personalized guidance on general medical topics.Quotes“If someone already is having great fat loss percentages, they're not having urges and cravings, they're able to get all the healthy food, they feel like they're in a great flow, why would we go up on the dose?” - Dr. Rentea“You're shamed if you go up, you're shamed if you don't. And ultimately, my answer is how about we just focus on what the data is doing. How are you feeling? What are the symptoms looking like?” - Dr. Rentea“If you're doing really great and you go up too much, you actually start under-eating. You start not losing as much.” - Dr. Rentea“There's this fine line between being in a calorie deficit and getting the food that you need versus being so suppressed, you don't even want to get the fiber in anymore.” - Dr. RenteaAll of the information on this podcast is for general informational purposes only. Please talk to your physician and medical team about what is right for you. No medical advice is being on this podcast. If you live in Indiana or Illinois and want to work with doctor Matthea Rentea, you can find out more on www.RenteaClinic.com

Sometimes we need help from someone and sometimes we need to help someone one. This week the Bow Tie Guy looks at two instances from this past week where family helped family. Check out a special video clip of Jon Foreman singing with his daughter at a recent Switchfoot concert here: https://www.instagram.com/reel/C_ZCHOPybw_/?igsh=MzRlODBiNWFlZA==

Imagine a tent with only one pole – it would collapse, right? The same principle applies to storytelling, where tentpole scenes provide the essential structure and support. This is true for fiction as well as memoirs and documentaries. In this episode, Cristen Iris discusses how tentpole scenes help you identify an intellectual and emotional arc for your story as well as the difference between creative nonfiction and memoirs.   Great Moments in the Episode 4:45 – 8:48  Disconnect between creativity and your environment, and the danger of time-blocking for some authors. 9:32 - 12:02  If you're stuck in a project, here are questions that will help you determine whether you should move forward or pause. 12:22 – 17:10  Definition and examples of how to use tent pole scenes in memoirs. 17:11 – 21:18  How tentpole scenes help you organize supporting scenes in your memoir. 21:19 – 23:43  An explanation of the difference between an intellectual arc and an emotional arc. 23:44 – 26:05  How to think about a story arc in your memoir. 26:06 – 29:19  How to establish the status-quo of the protagonist at the beginning of your book so that readers can see themselves in the protagonist and emotionally connect to your character's transformation. 29:21 – 33:42  How to impart wisdom through your memoir writing. 33:44 – 38:49  What it really takes to write a compelling and commercially viable memoir. 38:51 – 45:09  Difference between memoir and creative nonfiction, and how to determine what approach to take with your writing.   Words of the Episode  Brown study (n): refers to a state of deep, melancholic absorption or meditation. Titrate (v): to measure the volume or concentration of (a solution) by titration.   Connect with Cristen Cristen's Website: https://cristeniris.com/

If you've ever wondered why you might not feel safe in the world after loss, don't trust people as much as you used to because of painful experiences or seem to feel “stuck” in hopelessness when you desperately want deeper trust and hope while grieving, then this conversation is going to bring you some clarity.My guest is a man with almost 50 years of experience and over 80,000 direct contact hours as a therapist that developed a practical attachment theory and human development theory that has been taught to thousands of University students. He's also the co-founder of the Gestalt Equine Institute of the Rockies.In this episode, Duey Freeman, a true elder and mentor, skillfully takes us through his attachment model, showing us why it's valuable to grasp and how it can change the way we understand grief.Whether your early childhood memories are vivid or few, you're invited to dive into how those early attachments influence your life now, particularly in how you handle grief.This is brave and courageous work. Titrate as needed.Thank you so much for listening and supporting!-RachelTW: Sexual Assault- 1:08-1:10All things Duey:Duey's Instagram, Website, and Gestalt Equine Institute of the Rockies.Free Enneagram Test through Truity!

Episode 2485 - On this Wednesday's show Vinnie Tortorich and Gina Grad discuss a study about processed foods, the ways to keep your kids healthy, and more. https://vinnietortorich.com/2024/05/keep-your-kids-healthy-episode-2485 PLEASE SUPPORT OUR SPONSORS YOU CAN WATCH THIS EPISODE ON YOUTUBE -   Keep Your Kids Healthy Gina found a study in the New York Post regarding processed foods. (2:00) The study looks at processed foods in rats and how it affects their brains. The high junk food-eating rats' memory and functioning were severely impaired. This kind of damage can be similar in the human brain. They discuss the importance of getting your kids off processed foods. (11:00) Parents complain as if they have no control over their children's choices. Titrate or wean them off processed foods, over time. Vinnie tells the story of Dr. Mary Newport and her husband. (16:45) He ties it to a story of a recent interaction that makes him wonder about people's comprehension and brain health. It is becoming increasingly apparent how sleep hygiene and processed foods show signs of damage. We are seeing more and more the effects of taking PhysEd out of schools, lack of exercise, processed foods, etc. All have an impact on our kids' overall health. (30:45) Don't forget about the NSNG® Foods promo code! Use promo code VINNIE at the checkout and get 15% off. The promo code ONLY works on the NSNG® Foods website, NOT Amazon. Gina has a new Instagram and a new website, . Go check out her socials--she posts daily. Check out Gina's book . She also co-hosts with Bryan Bishop for @LAmag on the Bryan & Gina Show, which you can find on any podcast platform and . Vinnie's rumble channel: Vinnie's X/Twitter channel: Vinnie shares an update to his website that you'll want to check out: a VIP section! Go to   to join the waitlist! [the_ad id="20253"] PURCHASE BEYOND IMPOSSIBLE (2022) The documentary launched on January 11! Order it TODAY! This is Vinnie's third documentary in just over three years. Get it now on Apple TV (iTunes) and/or Amazon Video! Link to the film on Apple TV (iTunes):  Then, Share this link with friends, too! It's also now available on Amazon (the USA only for now)!  Visit my new Documentaries HQ to find my films everywhere: REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY 2 (2021) Visit my new Documentaries HQ to find my films everywhere: Then, please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter! FAT: A DOCUMENTARY (2019) Visit my new Documentaries HQ to find my films everywhere: Then, please share my fact-based, health-focused documentary series with your friends and family. The more views, the better it ranks, so please watch it again with a new friend! REVIEWS: Please submit your REVIEW after you watch my films. Your positive REVIEW does matter!  

這週開始進入新主題：頭暈目眩找物理治療？ 透過鑑別診斷排除可能的系統性疾病或非物理治療範疇的急症(如：中風)後 前庭復健是可以改善暈眩(dizziness)或眩暈(vertigo) 這集先來聊聊如何在急性期作鑑別診斷吧！ Timecode: 01:00 Roger分享日本抹茶小知識 06:45 急性眩暈有可能是中風 09:30 確定不是中風後，要怎麼鑑別診斷 12:00 當病人主訴頭暈，接下來要怎麼問診 14:30 藥學相關知識對物理治療師重不重要 20:00 TiTrATE 急性眩暈初步評估工具：(1)發作時機Timing與(2)誘發因子Trigger 23:30 TiTrATE (3)坐姿下的檢查 32:30 TiTrATE (4)站姿下的檢查 32:56 完全沒有central sign才會開始考慮做周邊問題的的檢查(如BPPV的檢查） 34:15 Vestibular screening tool (VST)簡單的四個問診問題判斷是否為前庭功能(周邊)出現問題 40:00 簡介BPPV，暈眩dizziness和眩暈vertigo 的差別 44:40 看起來像central有可能是神經炎或小腦中風，下一集會介紹HINTS來區分 46:40 Stanley 急診室經驗分享 歡迎到Facebook, Instagram追蹤或來信來訊跟我們提出疑問～ Email: 2propt@gmail.com 也可以在此收聽： Apple podcast: https://tinyurl.com/y97q7tms Spotify: https://tinyurl.com/ydavzqxu Google podcast: https://tinyurl.com/yd86pbcl YouTube channel: https://tinyurl.com/y82ewo5b Music by Elizabeth's Groove by Amarià @amariamusique Creative Commons — Attribution 3.0 Unported — CC BY 3.0 Free Download / Stream: bit.ly/elizabeths-groove Music promoted by Audio Library youtu.be/-MO-mrBlo5s Reference: Saber Tehrani AS, Kattah JC, Kerber KA, et al. Diagnosing Stroke in Acute Dizziness and Vertigo: Pitfalls and Pearls. Stroke. 2018;49(3):788-795.

CPAP (Continuous Positive Airway Pressure) is a valuable tool for a wide variety of patients with acute shortness of breath. There are very few reasons why any acutely dyspneic patient should not have at least a trial of CPAP. In some situations, such as acute pulmonary edema, the beneficial effects of CPAP become apparent within seconds to minutes. Read the full article on EMS Airway.

In this episode, Lesley and Brad delve into the vital role of communication in reducing tension and stress at work, inspired by their conversation with Ryan-Mae McAvoy. Learn why open and honest dialogue, particularly with human resources (HR), can pave the way for smoother collaborations, problem-solving, and a positive work environment.If you have any questions about this episode or want to get some of the resources we mentioned, head over to LesleyLogan.co/podcast. If you have any comments or questions about the Be It pod shoot us a message at beit@lesleylogan.co . And as always, if you're enjoying the show please share it with someone who you think would enjoy it as well. It is your continued support that will help us continue to help others. Thank you so much! Never miss another show by subscribing at LesleyLogan.co/subscribe.In this episode you will learn about:The transformative impact of speaking up and driving change.Debunking the misconception that HR only prioritizes the company's interests.Navigating the challenges of handling difficult HR scenarios. Embracing one's multifaceted nature and celebrating individuality.Cultivating authenticity and embracing imperfections for personal and professional growth. Episode References/Links:Online Pilates WorkshopMullet Tour: Leeds UKWest Coast Tour opc.me/tourContrology Pilates ConferenceCambodia Workshop http://lesleylogan.com/retreatHot Sauna SpaceEpisode 5 Amy Ledin  If you enjoyed this episode, make sure and give us a five star rating and leave us a review on iTunes, Podcast Addict, Podchaser or Castbox.Get your 15% discount for Toe Sox – use coupon code LESLEY15Be It Till You See It Podcast SurveyBe in the know with all the workshops at OPCBe a part of Lesley's Pilates MentorshipResourcesWatch the Be It Till You See It podcast on YouTube!Lesley Logan websiteBe It Till You See It PodcastOnline Pilates Classes by Lesley LoganOnline Pilates Classes by Lesley Logan on YouTubeProfitable PilatesSocial MediaInstagramFacebookLinkedInEpisode Transcript:Lesley Logan 0:00  What a dream to work at a company where HR is actually like, valued. Like, it's almost like the Venn diagram of the company's needs, and the employees needs. And the human HR is like in the middle going, hey, how do we make sure everyone gets happy? So the job gets done?Welcome to the Be It Till You See It podcast where we talk about taking messy action, knowing that perfect is boring. I'm Lesley Logan, Pilates instructor and fitness business coach. I've trained thousands of people around the world and the number one thing I see stopping people from achieving anything is self-doubt. My friends, action brings clarity and it's the antidote to fear. Each week, my guest will bring bold, executable, intrinsic and targeted steps that you can use to put yourself first and Be It Till You See It. It's a practice, not a perfect. Let's get started.Welcome back to the Be It Till You See It interview recap where my co host in life, Brad, and I are going to dig into the people centric convo I had with Ryan-May McAvoy in our last episode. If you haven't yet listen to that interview, feel free to pause this now, go back and listen that one, and then come back and join us. Who would have thought that a conversation with the head of HR could have been so fun?Brad Crowell 0:31  She's a riot. Lesley Logan 0:32  Try it. Brad Crowell 0:32  Yeah.Lesley Logan 0:33  It's like, ah, I mean, like, she came totally like, I love the person who referred her, so, like, I'm in. Many of our listeners actually work for a company. Not everyone is meant to be like someone who like, you know, works for themselves. And she feels like an entrepreneur because she, like, has so many great ideas. And she's like, how do I take these amazing ideas, and then make it work with a company, but also like, I just really loved the permission she gave to anyone listening like a will help you whether you work for yourself, or you work for someone else. I just, I went way long, and I'm okay with that. Brad Crowell 1:05  It was a good interview. Yeah.Lesley Logan 1:08  Today is June 22. If you're listening in real time, which is World Rainforest Day. I just want to like take a little brief side journey in the scenic route. It's also like National Kissing Day. And last week was like sneak a kiss day and I'm not sure who's making the days but like, apparently June is all about kissing. It's also pride month. So like we didn't actually announce at the end the month but I just wanna say Pride Month is going on. And I saw this amazing meme that says "Pride Month. I hope all the people who are homophobic have a super uncomfortable month." And I'm like, Yes, I hope you have a super uncomfortable one. Happy Pride Month. But also world rainforest day is as important as pride month because you guys the rainforests are why we get to breathe air. It's true. Whether or not you live near rainforest, you rely on the rainforest. So please do your share, to rock your life so that the rain forest can rock yours. So...Brad Crowell 1:59  Yeah, I think I was just looking at the statistics. The you know, with deforestation happening down in Brazil, it's really changing the dynamic of air quality around the world. Yeah, it's kind of insane. And I don't know why that's not seen as as like an important priority.Lesley Logan 2:26  Maybe outside the US people are talking about a lot. But like, I just know that what I've heard from the stuff that we like you and I have dove deep into, it's like, people are trying to get, you know, Brazil's government to like take care of its rainforest. And I don't know what the new person is doing. So I don't want to knock that person but the person before was a bit of a dick. And some shady fires were happening that. Oh, well, now we get to farm here. So at any rate, like Brazil, I love you. I love visiting you. I think it's amazing. You're also not the only rainforests. So I don'tBrad Crowell 2:59  They're just the largest. And I wonder, since it's obviously like, an international resource. Like and their argument is like, you know, we need to do industrial stuff. I wonder if like we could buy their non-destruction of the rainforests?Lesley Logan 3:18  I don't know. That's an interesting question. We're not that podcast, though. So I'm gonna say like, y'all...Brad Crowell 3:26  This has been something that's been on my mind since I was in fourth grade.Lesley Logan 3:29  Brad has had this on his mind for a long time. So here is the thing, this is where you have to like pick and choose your thing that you're gonna dive into. And so you know, there's a million problems, at least on this planet, pick the problem that you're most dedicated to donate your money to that and, and you know, and then make people aware of this amazing day. And maybe they'll donate to this too. Anyways, wellbeing for state take care of the rainforest near you. And so also we are about to do a really fun, virtual OPC event with our OPC teachers with myself with some contributors. If you are into Pilates, you love to nerd out about Pilates, you want to do it online, then July is your best chance to do that with us. And so you want to go to opc.me/event. Speaking of July, we will actually be in the UK with an amazing business workshop and Pilates workshop. And at this point, probably will have opened up the doors for the few single ticket ala carte workshops you can buy. So you'll want to go to opc.me/uk to check out those options. Brad is going to join me, he's teaching the business workshops with me. Brad Crowell 4:42  I'm excited about that, it's going to be a lot of fun!Lesley Logan 4:44  So excited. They're gonna love your accent. August, this summer tour, our West Coast tour, Hello, West Coast best coast. We're coming up your alley and we are going all the way to the top. So make sure you go to opc.me/tour to get all the information. And hello Poland. Hi, Poland, hello Europe. Basically, if you don't want to join me in the UK, then you need to join me in Poland. And by the way, the workshops are totally different. So you, you could do both. And it's going to be a lot of fun. It's my first time in Poland in over four years and we have the Contrology Conference, go to contrologypilatesconference.com to get your spot, there are limited spots available. And then October we will be in Cambodia. And it's lesleylogan.com/retreat for the retreat info because I'm really, I'm just so stoked. I'm so excited. I cannot wait to get back there. I gotta be honest, I love shay shui, but I was like, should we get flown to Cambodia instead? You know, like, I get to see the rest of the world too. But like, I miss going there several times a year, so I cannot wait to be there on this retreat, and then I get to hang out longer. So I'm super excited about that. Anyways. Yeah, before we dive into Ryan, we have an audience question to respond to.Brad Crowell 5:54  We do. This is from Megan (...). And she said, Hi, a while ago, I remember the link for the red light LL uses being in the show notes, but I couldn't find which episode that was in. It's the most beautiful red light I've ever seen. And if I'm going to relax and stare at a light, I feel like it should look beautiful. I was thinking of adding it to my wish list. Do you know the name of that company?Lesley Logan 6:16  I love this you guys, you can ask us any question you want. And this question is not even a long answer some super like, love. Ah, you should look beautiful in your red light and your light to everything you own can look beautiful, you do not have to have ugly red lights. So I do love this red light and you can go to beitpod.com/saunaspace. So sauna like a hot sauna space. And that will take you to the red light company that I got my red light from and I use it pretty much everyday we're in this house. Yep, she does. And when Brad is like, I don't know, like, you should sit in front of the red light.Brad Crowell 6:56  It's very calming. It also like helps with skin rejuvenation. They use it a lot for recovery for injuries and stuff for like, you know, skin injuries and stuff.Lesley Logan 7:05  It's why we don't look like we're 40 When we are.Brad Crowell 7:07  Yeah, so it's great for your face.Lesley Logan 7:10  I mean, there's a bunch of other awesome stuff with it. I just I love how I feel when I'm done.Brad Crowell 7:15  Yeah. And also like helps with your mind. You know, there's a lot of interesting stuff.Lesley Logan 7:20  Yeah, sometimes I play video games in front of it. And I don't even meditate. I just sit there and I'm like, this is what I want to do right now. But I'll be honest, like it has saved me from days where I feel like I just want to, which is actually gonna go into like this whole conversation we're about to have about Ryan, like, I just want to quit myself. Oh, can't do that. Well, I'll better turn this light on. And like 20 minutes later, I'm like, you know, it'd be really amazing. Let's do these five things. It's like, oh, it's like, whoa, we just switched, we literally flipped a switch. SoBrad Crowell 7:48  Yeah, it's super calming. So if you're working in a stressful space, or you have a lot of stress in your world, getting a red light, you know, can actually be really beneficial for you and also like your mindset. So we are big fans of the one that we have called from sauna space. So go to beitpod.com/saunaspace.Lesley Logan 8:09  Yeah. And also Amy Ledin, who is Episode Five, Episode Seven, Episode Five, she actually has one of their setups as well. She is recovering. Like she's always in recovery of the cancer that she's had. Because it's come back a couple of times and so she every single day stands in front of her whole red light setup from them so there's a couple of different options you have.Brad Crowell 8:31   Episode Five. I'm impressed.Lesley Logan 8:39  Every time we do this, guys, you have to, I wish you could see it, like, if you're watching me on YouTube you can but like I literally say a number and then Brad Google's to see if I was right and then he's always like, I'm if I'm ever wrong. I'm like, either an inverted number off or one off. I'm like so close. It's never, like, wow, (...) 100 episodes off. Anyways, Megan, put it on your wish list. Get this for yourself. It is awesome. And you will use it at this point. It cost me no money because I've always, I've used it every day. So anyways, you can send in your questions to the Be It Pod. I actually don't know where the email is. So just you know, DMS on Instagram or they'll put it in the show notes, I'm sure.Brad Crowell 9:20  Yeah, just sign up for the weekly newsletter and there's a link in there. Yeah. Okay, now let's talk about Ryan-Mae McAvoy. Lesley Logan 9:42  What a name! Brad Crowell 9:43  It's great name. I always get confused if it's MacAvoy or McAvoy because there's not an AC or this still pronounced exactly the same.Lesley Logan 9:55  It's a great question for her. You should ask it when I interviewed her.Brad Crowell 10:00  Can you confirm it's Ryan-Mae. Yeah, it's Ryan-Mae. Yeah, I know, but you never mentioned her last name during the interview, it's like, Okay, that's all right. With a diverse HR background, she offers a fresh perspective on human resources but recognizing the untapped potential in corporate environments, she is dedicated to driving positive change from the inside out striving to cultivate a workplace where employees are valued, supported and inspired to reach their full potential. So first thing before we even jump into our ideas on like, what we liked about the conversation, I just thought it was great to define HR. And this was the first time that I usedLesley Logan 10:45  I used to go Oh, my God, HR is coming, HR is calling, fuck my life.Brad Crowell 10:49  Right? Yeah, it's like, it's, I be in fucking SVU. Like, you know, the internal, you know, like, they're coming to get you. Internal Affairs. No, HR, the way she defines HR is that it's human operations. So anything that has to do with the humans in the company, and the operating like, operations around them. So, you know, she's talking about, obviously, like, the insurance side of things, and all the paperwork and all that kind of stuff, but also like, the mental well being. And she gave a couple of examples that I'm drawing a blank out at the moment, but I thought it was like, Oh, that's a different way to think about, you know, there should be somebody in the company, who is looking after the well being of the people in the company.Lesley Logan 11:40  I, because the the first corporation that I was at didn't have HR, like the CFO was kind of like, also acted as HR. And so we didn't really have an HR, like, if I wanted to complain about my boss, it was to my boss, so super fun. Doesn't work. And then, and then, when I worked for a high end fitness company, there was HR, but like, man, it was like, you talk to them, like, I have to write this person up. That's not good enough, right? (...) You haven't read them up every time like, and like, but since I've left, I've since heard that they have like, they have opportunities for life coaching, they've added in some amazing resources, it's very much more human centric. So when Ryan describe this, like I, oh, my God, what a dream to work at a company where HR is actually like, valued. Like, it's almost like the Venn diagram of the company's needs, and the employees needs. And the human HR is like in the middle going, hey, how do we make sure everyone gets happy? So the job gets done? And I just thought, I just really enjoyed her, like, how fun is she? I don't even want to work for a SaaS company. And I actually don't even know what they do. But I want I would like her to be my HR person.Brad Crowell 12:56  Yeah, well, after listening to her talk about how, like her approached HR, and how it's incorporated in their company, it actually reminded me a lot of our friend Eddie, because he actually, in his role, like he works for a security company. So it's a lot of, you know, men in, like, private security, where they're taken care of super high profile people. It's like, militant, you know, where the, it's effectively like police, but like, private, like privatized, and, you know, so all of the expectations that you might have around that idea, and his role in the company is to make sure that the people are able to function as human beings, you know, and so he goes around, and he, you know, can, he has the authority to give someone a week off if they need it, like, whatever it might be, or, you know, take someone out to lunch or whatever, and dig in and have these conversations, but I never actually, I always thought like, wow, what an epic role to play in a company, but I never thought about it as HR. And so actually, I think it might be aligned with HR.Lesley Logan 14:11  Yeah, well, I'm gonna dive into what I love. She talked about your relationship with yourself being it's the most permanent relationship to have. And so going back to the red light, it's like, sometimes I just wanna get the fuck away from myself. I'm like, I'm annoyed. I'm annoying myself. I am, but I can't leave me as far as this lifetime is a concern. So she said, it's really powerful, they'll walk away and like, and she talked about, like, so being the most permanent means that you're not like, you're not stuck. You're not concrete. You're not stuck as who you are, but you don't get to leave you so. So you really do need to take time to get to know yourself and she is really focused on self-improvement, like making sure that every year she focuses on like, acknowledging what's going on and learning about how her wasn't her best self, what were her mistakes and then building up the good stuff and like acknowledging what the good stuff is like, the other day I was teaching my eLevate group and someone goes, I don't want to say like, I know that sounds really weird, but I want to say I'm so proud of myself. And I'm like, it should not be weird to say, I'm so fucking proud of myself. Like, it should be like, seen as like a Hurrah. Like, that's amazing, right? So I just love that she actually brought up like, getting to know yourself and being like, in this, really being amazing with the relationship with yourself as being awesome. And being it should be a priority. And you know, when you work for someone, or you maybe work for yourself, like sometimes you and I both at separate times, like I'm gonna get the hell out of here. Like I, I am not serving anybody in this moment. Like I need to go away. And it should not be like a strike on your amazingness at the job that you're at, it should be seen as like, okay, way to acknowledge that you aren't titrating right now you are not showing up in this amazing thing. And like, you need to go take yourself away. So you can like love, like, figure out what you need right now, what you need to like, take care of yourself right now. Titrate. This is what Brad's looking at right now. So titrate is like, do I need a walk right now? Do I need to take on more responsibility right now? Do I need to take on less responsibility right now? Here's how I'm going to use it in a sentence, because that's what everyone's gonna want to have. So I have these ag one, vitamin D drops. And I can put in a drop, or I can titrate and put in more drop, I can give myself more drops? Should I feel like I need them? It's called titrating. It's like, it's like aBrad Crowell 16:40  it's a science word for sure because there's not a single definition that talks about it in the way you are. Although there's a parallel.Lesley Logan 16:48  Yeah, no, I learned it at my breath work. And I also learned it from AG1 when they're like titrate, between one and five drops. So like it is a word people use, it's like a measurement. Brad Crowell 16:55  It says to ascertain the amount of a constituent in a solution by measuring the volume of a known concentration of reagent required to complete a reaction with it.Lesley Logan 17:12  AKA, acknowledge if you need more or less time in the space that you're in, and go get yourself what you need (...)Brad Crowell 17:20  Yeah, so it looks like the sample is titrated at a pH near 10. With EDTA solution. (...) Oh, it is it is totally because the sample is titrated. You know, so it's hydrated, meaning it's, it's diluted, or it's you know, there's something that's being added into the thing. Yeah. So in this instance, you know, you were talking aboutLesley Logan 17:43  giving yourself more or less of other things, so you can become the best version of yourself.Brad Crowell 17:48  you know, you're inserting something into the middle of the thing. Like taking a breather.Lesley Logan 17:53  The best the best word I could have used. I love that. In this example is great. Thank you. Yeah. What did you love?Brad Crowell 18:02  Okay, so she said to speak your truth. vocalize what you're not comfortable with. And I think that it's, especially in the corporate environment, it's easy to get, you know, like the, the tomatoes thrown to the person who stands up above the crowd, or the things everyone's to be Daisy, all that stuff. You know, and I mean, I worked in a very volatile environment where you just kept your fucking mouth shut.Lesley Logan 18:29  Your environment stressed me out, and I wasn't in there. Brad Crowell 18:31  Yeah. Because if you, you know, and unless it was like, you know, that it was very infrequent that someone would ever push back because it was not really welcomed. And it just created stress. And that stress was never fun. So, but she said, you need to, it's important to, you know? She said, we need to speak up inside corporate walls to create change because there are misconceptions about HR, that they only care about the company. And she said, it's not true, because she's also an employee of the same company. So like, how can the employee of the company be only for the company and not for the employees who wouldn't be for herself? Right? So that's like the weirdness.Lesley Logan 19:23  I think that's like such a great like comeback to people who are like have a neg on HR, it's like, okay, but then I would literally be doing a disservice to my own self.Brad Crowell 19:33  Right. So obviously, you know, there's an ulterior motive because if she makes rules that don't make sense, then they're not gonna make sense for her either. So anyway, she said there's a human element what they do, and they deal with difficult situations, such as layoffs, terminations, performance issues, etc. But people don't get to those points without there being like, things along the way that will take them to the point of a layoff, termination or performance issue. And she said she can't solve problems that she doesn't know about. And so it's so important as a person who's working in an organization that has HR to go and speak to HR and say the things that need to be said, you know, and it's not a bitch best, but like, it's a, you know, again, just like we were talking about a week ago, with, you know, relationships, it's communication that's going to allow the easing of tension, the easing of stress. And what's really lovely about having someone who's in HR is that, you know, that you can schedule a meeting with them, and you can sit down and have a conversation about something that is bothering you.Lesley Logan 20:42  Oh, my goodness, you know, what the last company I worked for, outside of a courtroom, because I got subpoenaed. I was not working for them anymore. But I got subpoenaed, I had to go in. And I was sitting out there waiting to be my witness self. Trust me, I tried to get out of it. And the person who sat down next to me was the head of HR for the West Coast. And I was like, your job, just, I've just, like, felt like it fucking sucks. He's like, Well, this is not the highest point of my job (...) I was just like, can you just lose my number, like, just please do not call me in for this ever again. But I saw him as a human, I think for the first time ever. And I remember thinking, gosh, I wonder how my job would have been different if I had seen him as a human being? (...) I think I probably wouldn't use them in a different way. I think I probably would have stuck up a navigator for myself in a different way. And like, that's not his fault. Like, I had this like negative look on HR. And maybe like, it's part like, maybe we'll both take responsibility, like, he could have explained how he could have saved like, saved my ass some time. So that would have beeen nice. But I also like, when it comes to laying people off, just so you all know who are employees. It fucking sucks for the employer too. It costs so much money to hire train someone. It is way, way cheaper to have an employee who's with you for a really long time.Brad Crowell 22:15  And well, I mean, aside from that, and yes, of course, the financial side of it. The reality is that when you build relationships with team, so, you know, like, the dynamic of the whole team is gonna change. And, you know, especially if you like the person that you have to let go, like, that sucks.Lesley Logan 22:33  Yeah, like sometimes you're letting someone go, not because they're an idiot, or a bad human being, it's like, this is not the right role for you. Brad Crowell 22:41  Or, I mean, it could be like, we know, we tried this initiative, and we're not gonna do it anymore. Lesley Logan 22:49  Do you, like, our friend Michael, we were like getting on a podcast with him. And he's like, Oh, hold on. I just had to fire someone. Let me take a moment. And we were like, Oh, no problem. I've been there before. And he's like, my whole goal is that I like people know that they're getting fired like they should. It should not be a surprise, you know, and like. So typically, if your HR, your company or your boss has been doing their job, they've been getting feedback along the way. It's not a surprise. It should not be a surprise, but it's so sorry. This isn't working out. No, it still sucks. It still stings. It's so awful. But but you know, I just Ryan, love you. I wish I could have you on my HR team. I wish I could have an HR team. I think she offered her services and elecard. We'll get there. We'll get up, we'll get Ryan someday because she is not Ryan dreams like you are the standard. You are the I Want To Know Your Strength Finders and all the things you can write a description for the person that I'm hiring. Anyways, yeah, I loved it. It's so good. Let's do the Be It Action Items.Brad Crowell 23:54  Yeah, we'll be right backAll right. Now let's talk about those Be It action items. What bold, executable, intrinsic or targeted action items can we take away from your convo with Ryan-Mae McAvoy. Do not label yourself as just one thing. She was talking about being a multifaceted human being. We're not robots, we aren't only doing the thing that we do at work all day long. No matter what your employer may want. You know, she said serve the version of you at the moment that serves you best. So, for example, she said, yeah, during the day at my job, I'm Ryan-Mae, the HR person, but I'm also you know, a wife. I'm also a cat lady. And I love Netflix with some mac and cheese.Lesley Logan 25:02  We have gluten free dairy free mac and cheese.Brad Crowell 25:04  Like it's amazing.She said it's the seed of the garden to being more than just your job.Lesley Logan 25:15  Yeah, I think that's beautiful. Like, some people like they just like work themselves. 24/7 because they think that that's going to make them better at the job. But really, it's like your multifaceted self that makes you bet the best at the job.Brad Crowell 25:29  Yeah, it's it's very weird. I'm, I like fall straight into this trap. You know, for me, it's like, if I could work on the thing, 24/7 that I think that it's going to be, you know, I'm gonna move the ball forward or something like that. Lesley Logan 25:42  I love that I caught you watch a superhero movie on your lunch break today. I think that's great. I think it like you need those pauses, you need to have any interest because it allows you to draw inspiration in different ways. And also like, you're not a fucking robot. You're a human being.Brad Crowell 26:00  It was also the weekend and we were working all weekend. But I did. I know I'm out this week. And that's why I was doing it.Lesley Logan 26:06  Yes, a little asterisks, hold on one second, one little moment. We do not work all weekend every weekend. Particular work weekend was a planned work weekend because of vacations prior to and after. Yeah. So there we go. Okay. Go back to your point.Brad Crowell 26:23  I don't think they're judging us. It's okay.Lesley Logan 26:25  No, I just think it's important for people to actually understand that, like you, it's part of you. We plan these things in so you (...)Brad Crowell 26:33  We work because we work for ourselves. You know, we and we want you know, y'all know, we went to Korea, we tagged on the because we were already over there was like, well, let's go take four days and actually take a break.Lesley Logan 26:46  And it ended up being six days.Brad Crowell 26:48  Well, right (...) The island of Jeju was was we were there for four days. Yeah. So the point is, we actually weren't working then, which would have been during the week. And so yeah, this week, and we're home. So like, Alright, let's do this.Lesley Logan 27:03  Let's get some stuff done. So break and go camping. Yeah. So I do love that Be It action item. I thought that was really great.Brad Crowell 27:11  So, I mean on that, what was your biggest takeaway?Lesley Logan 27:13  So she said, acknowledge and honor, even the bad parts, and I actually like, like, bad and air quotes, because she's like, acknowledged what these are, and learn what these parts are about ourselves that we're not gonna love. And then the more you deny the layers of yourself, that's what she said, the more you deny the layers of yourself, you become less authentic, in each version, and you can also become easily consumed. So she let her job consume her because, like she wanted to be liked. And so where there's a lot of work to be done, like, there's easy reasons for this. And it's like, you know, there are parts of ourselves that we're not the most excited to share that we're like, oh, God, people are gonna see this. But like, if you deny that part of yourself, or you hide it, or you like, whatever it is, it is easy to become more and more or less authentic.Brad Crowell 28:01  I mean, even in the day to day, it's not necessarily something you're like permanently denying. If you're having a shit day, it's okay to know that you're having a shit day.Lesley Logan 28:11  And also, like, I acknowledge at this point, like, I am not like, I don't like, I did not like who I was in one of the most recent finance means, I'm like, I don't want to be here. I don't like who I am. I want to go take a walk and I can't leave this meeting. I'm not enjoying it. Is this meeting over? Okay, it's done. Okay, thank you. Let's all try to figure out, I gotta figure out how to like myself in this meeting. I love for us and making sure that this meeting can be more fun. So anyways, be who you need to be in that moment and accept that sometimes it's not the best version of yourself. You know, that's a good quotable. I hope our team put it on a card so we can share that shit because it is okay to not be 100% amazingly awesome all the time. You can titrate and be the best version of yourself that you can be in that moment.Brad Crowell 29:20  You can titrateLesley Logan 29:25  Ryan-Mae thanks for being the bestest. So excited. You guys. We actually have another HR person coming up in the lineup, and it's a whole different topic. And I got to connect the two of them and I'm like, sick. I'm like, okay, but hold on. Did you chat what's going on? Like, I'm really excited about it. Because it's a whole it's a whole new topics all about grief, which I'm super stoked about. So thank you, Ryan for setting the stage for what HR could look like in this world. Thank you for being amazing. Keep us posted on everything you're doing. Everyone else, How are you when you use these tips in your life? We want to know. Tag the Be It pod, tag Ryan-Mae, she's like huge on LinkedIn. So, you know, head over there. Until next time, Be It Till You See It. That's all I got for this episode of the Be It Till You See It Podcast. One thing that would help both myself and future listeners is for you to rate the show and leave a review and follow or subscribe for free wherever you listen to your podcast. Also, make sure to introduce yourself over at the Be It Pod on Instagram.   I would love to know more about you. Share this episode with whoever you think needs to hear it. Help us and others Be It Till You See It. Have an awesome day. Be It Till You See It is a production of The Bloom Podcast Network.  Brad Crowell 29:59  It's written, filmed, and recorded by your host, Leslie Logan and me, Brad CrowellLesley Logan 29:59  It is produced, edited by the Epic team at Disenyo.  Brad Crowell 29:59  Theme music is by Ali at Apex Production Music, and our branding by designer and artist Gianfranco Cioffi.  Lesley Logan 29:59  Special thanks to Melissa Solomon for creating our visuals and Ximena Velazquez for our transcriptions.  Brad Crowell 29:59  Also to Angelina Herico for adding all the content to our website. And finally to Meridith Crowell for keeping us all on point and on time.Transcribed by https://otter.aiSupport this podcast at — https://redcircle.com/be-it-till-you-see-it/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Visit: https://nursing.com/140meds to request your free copy of "140 Must Know Meds" Generic Name dopamine Trade Name Inotropin What is the indication for Dopamine? used to improve blood pressure, cardiac output, and urine output Action Smaller doses result in renal vasodilation Doses 2-10mcg/kg/min result in cardiac stimulation by acting on beta1 receptors Doses >10mcg/kg/min stimulate alpha receptors leading to vasoconstriction (↑SVR) What is the therapeutic class for Dopamine? inotropic, vasopressor Pharmacologic Class adrenergic Nursing Considerations for Dopamine (Inotropin) • Monitor hemodynamics closely: BP, HR, EKG, CVP, and PAOP if available • Obtain parameters for hemodynamic values • Titrate to obtain appropriate BP (more potent vasoconstrictors may be required) • Irritation may occur at IV site • Beta blockers may counteract therapeutic effects Dopamine Audio Lecture

Welcome to another insightful episode of The Nurse Dose Podcast! In this episode, we dive deep into the fascinating world of titrating pressors. Join us as we explore the critical role of nurses in managing patients requiring vasopressor support and unravel the intricacies involved in adjusting these medications to optimize patient outcomes. Critical Care Cheat sheets are available at: ⁠https://www.etsy.com/shop/NurseDose⁠ This podcast is intended for informational and educational purposes only. It is not intended to provide medical advice or to substitute for the advice provided by your own physician or other medical professionals. The information contained herein is not intended to diagnose, treat, cure, or prevent any disease. If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional. The opinions expressed in this podcast are those of the host and guests and do not necessarily reflect the views of any medical institution, organization, or employer. By listening to this podcast, you agree to hold harmless the host, guests, and any associated parties from any and all liability or damages arising from your use of the information provided.

Whether you're trying to gain, lose, or maintain weight, strategic management of hunger and appetite can come in handy. In today's episode, Eric Trexler discusses a variety of practical strategies for managing hunger and appetite to support a more successful and enjoyable dieting experience. SUPPORT THE PODCASTJoin the Research Spotlight newsletter: Get a two-minute breakdown of one recent study every Wednesday. Our newsletter is the easiest way to stay up to date with the latest exercise and nutrition science.MacroFactorIf you want to learn more about our MacroFactor diet app, check it out  here.To join in on the MacroFactor conversation, check out our Facebook group and subreddit.CoachingGet personalized training and nutrition plans from our expert coaches: Learn more hereMASS Research Review Subscribe to the MASS Research Review to get concise and applicable breakdowns of the latest strength, physique, and nutrition research – delivered monthly.SponsorsBulkSupplements: Next time you stock up on supplements,  be sure to use the promo code “SBSPOD” (all caps) to get 5% off your entire order at BulkSupplements.com.Sports Nutrition Association: Learn more or become a member of SNA. The Sports Nutrition Association is dedicated to ensuring the sustainable prosperity of the Sports Nutrition Profession, and they offer a unique pathway to robust insurance coverage for your sports nutrition business. TIME STAMPSIntro/Announcements (0:00)Practical strategies for managing hunger (4:23)Adopt an acceptance-based approach (4:53)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4238039/Eat slow and savor (speed, focus while eating) (16:18)https://www.sciencedirect.com/science/article/abs/pii/S0950329318300582https://pubmed.ncbi.nlm.nih.gov/30591684/https://pubmed.ncbi.nlm.nih.gov/20351697/Titrate your amount of non-lifting exercise (21:42)https://pubmed.ncbi.nlm.nih.gov/29289613/https://pubmed.ncbi.nlm.nih.gov/30131457/https://pubmed.ncbi.nlm.nih.gov/24355667/Reduce meal-level energy density, and make the easy swaps first (35:57)https://www.strongerbyscience.com/research-spotlight-energy-density/Opt for harder food textures (49:55)https://www.strongerbyscience.com/research-spotlight-hard-food/Minimize foods that are hyperpalatable (53:01)End the meal strategically (green tea, capsaicin) (1:02:14)https://pubmed.ncbi.nlm.nih.gov/19345452/Eat enough fiber and protein (1:07:29)https://pubmed.ncbi.nlm.nih.gov/21115081/https://pubmed.ncbi.nlm.nih.gov/32768415/Summary of strategies (1:15:31)Strategies for bulking / weight gain (1:16:36)https://www.strongerbyscience.com/bulking/Conclusions and practical applications (1:25:28) 

This week we welcome Nathaniel Hodder-Shipp, a drug and alcohol counselor, breathwork practitioner, and founder of the American Breath Work Association and Breathwork For Recovery, an 800-hour breathwork clinician that provides more intense training for teachers and practitioners. We sit down and talk about Nathaniel's journey of becoming involved with breathwork, his decision to help create Breathwork For Recovery, and the necessity of developing equity, ethics, and regulation in the field of breathwork. I also share my story about attempting to learn breathwork and that it was a traumatizing experience. Nathaniel offers a compassionate take on what I went through, which may have also happened to some of you. We end the episode with two breathing practice options you can choose to do to reset and reframe yourself anywhere, and at any time. This episode is a must for anyone looking into breathwork who wants to know about it from a real expert.

Download the cheat: https://bit.ly/50-meds  View the lesson: https://bit.ly/DopamineInotropinNursingConsiderations    Generic Name dopamine Trade Name Inotropin What is the indication for Dopamine? used to improve blood pressure, cardiac output, and urine output Action Smaller doses result in renal vasodilation Doses 2-10mcg/kg/min result in cardiac stimulation by acting on beta1 receptors Doses >10mcg/kg/min stimulate alpha receptors leading to vasoconstriction (↑SVR) What is the therapeutic class for Dopamine? inotropic, vasopressor Pharmacologic Class adrenergic Nursing Considerations for Dopamine (Inotropin) • Monitor hemodynamics closely: BP, HR, EKG, CVP, and PAOP if available • Obtain parameters for hemodynamic values • Titrate to obtain appropriate BP (more potent vasoconstrictors may be required) • Irritation may occur at IV site • Beta blockers may counteract therapeutic effects

***Possible Trigger Warning***Learning about disorganized attachment might feel overwhelming and bring up uncomfortable feelings.  Listen in a place and at a time you can take breaks and seek regulation.  Titrate yourself!  Maybe read the article on the blog instead of listening to the podcast.  www.RobynGobbel.com/disorganizedattachment***********Another episode in the June series on attachment!Today is all about disorganized attachment.  If you haven't caught the previous four episodes in this series on attachment, be sure to check them out.In this episode, we look at What happens when a baby's attachment system has them fleeing toward their caregiver when they are afraid, but the caregiver is who is causing the frightWhy disorganized is disorganized- it's the only attachment 'style' that isn't organizedThe kinds of experiences an infant can experience as disorganizingThere's a lot in this one episode and the whole six-part series!  I made the series into a beautiful eBook so you don't have to take notes and you can review it as often as you want.  To download the F R E E ebook, click here: https://robyngobbel.com/ebookHit subscribe to Parenting after Trauma in your podcast player so you don't miss anything in this monthly focus on attachment!  Tomorrow we'll explore How Attachment Changes!  Over on my website you can find:Masterclass on What Behavior Really Is (FREE)eBook on The Brilliance of Attachment (FREE)In depth parent course: Parenting after Trauma: Minding the Heart and BrainOngoing support, connection, and co-regulation for struggling parents: The ClubIt's April 26th and the webinar How Do I Stay Calm?! is happening tonight at 8pm eastern.For all parents and caregivers who are having a hard time not flipping your lid- when your kid is flipping theirs!Can't attend live? No problem! Everyone who registers will receive the recording.Register here: https://robyngobbel.com/staycalm

Faça sua pré-inscrição no CURSO TdC de Pronto-atendimento e receba BÔNUS exclusivos: https://cursotdc.com.br/ Iago apresenta um caso de tontura para o Pedro e Kaue, com um foco na investigação da tontura e no exame físico direcionado (HINTS). Vídeo do HINTS comentado por Kaue e Pedro: https://youtu.be/keqwC-36HmM Referências: 1. Newman-Toker DE, Edlow JA. TiTrATE: a novel approach to diagnosing acute dizziness and vertigo. Neurol Clin 2015;33(3):577-599. doi:10.1016/j.ncl.2015.04.011 2. Edlow JA, Gurley KL, Newman-Toker DE. A new diagnostic approach to the adult patient with acute dizziness. J EmergMed 2018;54(4):469-483. doi:10.1016/j.jemermed.2017.12.024 3. Bisdorff AR, Staab JP, Newman-Toker DE. Overview of the international classification of vestibular disorders. Neurol Clin 2015;33:541-550. doi:10.1016/j.ncl.2015.04.010 4. Kerber KA. Episodic positional dizziness. Continuum (Minneap Minn) 2021; 27(2, Neuro-otology):348-368. 5. Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clin Proc 2007;82(11):1329-1340. doi:10.4065/82.11.1329 6. Steenerson KK. Acute vestibular syndrome. Continuum (Minneap Minn) 2021; 27(2, Neuro-otology):402-419. 7. Wasay M, Dubey N, Bakshi R. Dizziness and yield of emergency head CT scan: is it cost effective? Emerg Med J 2005;22(4):312. doi:10.1136/ emj.2003.012765 8. Huang CY, Yu YL. Small cerebellar strokes may mimic labyrinthine lesions. J Neurol Neurosurg Psychiatry. 1985; 48(3):263–5. 9. Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, Hill MD, Patronas N, Latour L, Warach S. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007; 369(9558):293–8. 10. Oppenheim C, Stanescu R, Dormont D, Crozier S, Marro B, Samson Y, Rancurel G, Marsault C. False-negative diffusion-weighted MR findings in acute ischemic stroke. AJNR Am J Neuroradiol. 2000; 21(8):1434–40.

When do interventions need to be “weaned”? Stop using this word when you don't mean it! Titrate, target to effect, but only wean when there is a physiologic dependence.

***Possible Trigger Warning***Learning about disorganized attachment might feel overwhelming and bring up uncomfortable feelings.  Listen in a place and at a time you can take breaks and seek regulation.  Titrate yourself!  Maybe read the article on the blog instead of listening to the podcast.  www.RobynGobbel.com/disorganizedattachment***********Another episode in the June series on attachment!Today is all about disorganized attachment.  If you haven't caught the previous four episodes in this series on attachment, be sure to check them out.In this episode, we look at What happens when a baby's attachment system has them fleeing toward their caregiver when they are afraid, but the caregiver is who is causing the frightWhy disorganized is disorganized- it's the only attachment 'style' that isn't organizedThe kinds of experiences an infant can experience as disorganizingThere's a lot in this one episode and the whole six-part series!  I made the series into a beautiful eBook so you don't have to take notes and you can review it as often as you want.  To download the F R E E ebook, click here: https://robyngobbel.com/ebookAnd while you're on my website-  be sure to check out The Club and add yourself to the waiting list!  Doors open again at the end of June!  https://robyngobbel.com/theclubIn July, August, and September in The Club, we are going to be exploring the neurobiology of attachment, allowing us to embody attachment and bring healing to the parts of ourselves, and our children, that didn't get what they needed when they were young.Hit subscribe to Parenting after Trauma in your podcast player so you don't miss anything in this monthly focus on attachment!  Tomorrow we'll explore How Attachment Changes!  **********There are so many benefits (and no drawbacks!) to teaching kids and teens about the brain. I'll give you simple, fun ways to Teach Kids about their Awesome Brain. This 1.5 hour webinar airs live on Wed Oct 20. Everyone who registers will receive the recording so you don't have to attend live! CLICK HERE.

Happy New Year! Jeffrey and Brendan ring in the year with a new segment called AntiGra! ("Against the Grain") and we do a deep dive into maladies, our grave new world, Taytay and more.

This week, 2 Male Nurses are diving into the topic of vasopressors! Why does Epi effect the heart rate? Why does Levo increase MAP? What about Dopamine?! Listen, to better understand how YOU can titrate these BIG MEDICATIONS!

Martha Sajatovic, MD, conducts a Masterclass lecture on older-age bipolar disorder from the Psychopharmacology Update in Cincinnati. The meeting was sponsored by Global Academy for Medical Education and Current Psychiatry. Dr. Sajatovic is professor of psychiatry and of neurology at Case Western Reserve University in Cleveland. She also directs the Neurological and Behavioral Outcomes Research Center at University Hospitals Cleveland Medical Center. *  *  *  Help us make this podcast better! Please take this short listener survey: https://www.surveymonkey.com/r/podcastsurveyOct2019 *  *  *  Conceptualizing OABD Older–age bipolar disorder (OABD), defined as a person aged 60 years or older with bipolar disorder, makes up one-quarter of bipolar patients. It is a heterogeneous population that includes early- and late-onset disease. Late onset is diagnosed when a person has a manic or hypomanic episode at or after the age of 50 years. Bipolar depression in later life has long been seen as a “special population,” and the treatment has been extrapolated from larger clinical trials of younger patients. Late–onset bipolar disorder usually has attenuated manic episodes and depressive episodes are prolonged and severe. In OABD, the patients are more likely to have multiple morbidities, which makes medication management more complex. People with bipolar disorder lose 1-2 decades of life, compared with the general population. No medications are specifically approved by the Food and Drug Administration for bipolar disorder or bipolar depression in older adults. However, the treatment follows general geriatric psychiatry principles: Start low and go slow.  International guidelines on treating bipolar disorder Starting low means using half or even less of the recommended dose that a clinician would use in mixed-aged populations. Titrate slowly to allow the person time to acclimate to side effects that usually resolve. Bipolar disorder is a chronic disease, so medication adherence is paramount. Adherence can be jeopardized when a person experiences excessive side effects from the beginning of treatment. First-line treatment for bipolar depression in OABD include lurasidone (Latuda) or quetiapine (Seroquel) with low dosing and slow titration. This recommendation is supported by data from a post hoc analysis of the clinical trial data of lurasidone for bipolar depression. Lithium is also recommended and underused. The level should be lower for OABD; an appropriate target for older adults with bipolar disorder is 0.4-0.8 mEq/L, especially in people who are older and frailer. Lamotrigine (Lamictal) also is helpful and fairly well tolerated. Clinicians need to be attentive to a patient’s medical comorbidities and psychosocial support to enhance adherence and improve outcomes. This approach would entail working closely with primary care clinicians and using an integrative approach as the medical comorbidities will influence the success of bipolar treatment.  References Sajatovic M and Chen P. Geriatric bipolar disorder. Psychiatr Clin North Am. 2011 Jun 3;34(2):319-33. Eyler LT et al. Understanding aging in bipolar disorder by integrating archival clinical research datasets. Am J Geriatric Psychiatry. 2019 Oct;27(10):1122-34. Shulman Kl et al. Delphi survey about using lithium in OABD. Bipolar Disord. 2019 Mar;21(2):117-23. Forester BP. Safety and effectiveness of long-term treatment with lurasidone in older adults with bipolar depression: Post hoc analysis of a 6-month, open-label study. Am J Geriatr Psychiatry. 2018 Feb;26(2):150-9. *  *  *  For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: podcasts@mdedge.com Interact with us on Twitter: @MDedgePsych    

With the holidays coming up are you going to Titrate down on your goals and wait till the new year? DON'T DO IT ITS A TRAP! Don't wait till the new year to start your resolution. Start today and your new year will be even better. Dare to be different and start a new trend, start your resolution today, why wait. Every person is different this should be too. https://www.facebook.com/RiskeEntertainment/ https://twitter.com/jaimeriske https://www.instagram.com/riskefitness/ --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/jaime-riske/support

Welcome back to our weekend Cabral HouseCall shows! This is where we answer our community's wellness, weight loss, and anti-aging questions to help people get back on track! Check out today's questions:  Margie: Hey Dr Cabral Thank you so much for all the work you do to educate us on wellness! I have learned so much from you. My son gets nose bleeds. Without bumping husband nose or any kind of trauma his nose will start bleeding. It usually stops after some pressure in around 5 minutes or so. There are times it will bleed a few times a day.There are times that it won’t bleed for a month and then it will bleed weekly.Is there anything I can do to support his body and little nose to heal and come back to balance. Thanks in advance. Aracely: i would like more information , about a ringing problem in my ears , they give me rx for inflammation , and I would like to know more in lose weight. Bev: I purchase your collagen. I was wondering if it has ALL types of collagen included in it? I was told that a good collagen has to have all types included. I am sure it probably does but I am just making sure Thanks Bev Gemma: Dear Dr Cabral, i have 2 interlinked questions. First, i have very high methane SIBO but hydrogen was in range. My baseline was 24 (too high to even start) but after 3hrs my test showed 68 whichi believe is pretty high. I have been taking atrantil but it hasnt done much so far. The test indicated that its likely LIBO rather than SIBO. Is there a difference in treatments for these conditions? I was thinking to do the Cabral detox for the LIBO but also the CBO program but I am confused in what order to do them. Also, with christmas coming it - it will be hard to stick to a 3 month program if its rigid - does the CBO program allow for an occasional alcoholic drink and a number of christmas dinners (various events leading up to christmas which all seem to involve food)? Troy: What are your thoughts on male ejaculation in relation to vitality energy and health? I've heard that retention of semen (seed) is important, but when I restrict myself I tend to beat myself up over it when it's obviously hard to be celibate.Would love to hear your thoughts! Please include this in IHP :) Heather: Hi Dr. Cabral,Thank you so much for the work you do. I recently completed your 21-day detox and feel great! I am continuing on my journey to health and excited about where it will take me. I am writing on behalf of a friend of mine who has struggled with alcoholism and now has cirrhosis of the liver. I’m not sure how far along it is. In addition to that, she now has a lump in her throat and the doctors are not sure what it is although they have suggested it may be cancer.Is there any guidance you can provide from a functional medicine perspective regarding treating cirrhosis of the liver? Is there any way to reverse the damage that is already done. Thank you!! Rani: Hi Dr. Steven Cabral, I have a quick question for you. I have tried the intestinal cleanse after completing the CBO protocol and got some abdominal pain on day two that lead to diaherra. Of course, I stopped the protocol. Then I tried it later this summer and got the abdominal pain within a day. My husband ended up doing the protocol and had no problem. Why do you think I have a reaction? And is there an alternative method to do an intestinal cleanse, since this one doesn't work for me? I know the coffee enemia only cleanses a small part of our colon. Is this maybe my only option for now? Thank you, fellow IHP student.   Thank you for tuning into today's Cabral HouseCall and be sure to check back tomorrow where we answer more of our community’s questions!  - - - Show Notes & Resources: http://StephenCabral.com/1373 - - - Get Your Question Answered: http://StephenCabral.com/askcabral   - - - Dr. Cabral's New Book, The Rain Barrel Effect https://amzn.to/2H0W7Ge - - - Join the Community & Get Your Questions Answered: http://CabralSupportGroup.com - - -   Dr. Cabral’s Most Popular Supplements: > “The Dr. Cabral Daily Protocol” (This is what Dr. Cabral does every day!) - - - > Dr. Cabral Detox  (The fastest way to get well, lose weight, and feel great!) - - - > Daily Nutritional Support Shake  (#1 “All-in-One recommendation in my practice) - - - > Daily Fruit & Vegetables Blend  (22 organic fruit & vegetables “greens powder”) - - - > CBD Oil  (Full-spectrum, 3rd part-tested & organically grown) - - - > Candida/Bacterial Overgrowth, Leaky Gut, Parasite & Speciality Supplement Packages - - - > See All Supplements: https://equilibriumnutrition.com/collections/supplements  - - -   Dr. Cabral’s Most Popular At-Home Lab Tests: > Hair Tissue Mineral Analysis (Test for mineral imbalances & heavy metal toxicity) - - - > Organic Acids Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Thyroid + Adrenal + Hormone Test  (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Adrenal + Hormone Test (Run your adrenal & hormone levels) - - - > Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Omega-3 Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - > Stool Test (Use this test to uncover any bacterial, h. Pylori, or parasite overgrowth) - - - > Genetic Test (Use the #1 lab test to unlocking your DNA and what it means in terms of wellness, weight loss & anti-aging) - - - > Dr. Cabral’s “Big 5” Lab Tests (This package includes the 5 labs Dr. Cabral recommends all people run in his private practice) - - - > View all Functional Medicine lab tests (View all Functional Medicine lab tests you can do right at home for you and your family!)

Goals on Initiation Reverse shock and increase tissue perfusion: Improve blood flow BP (MAP >65) perfuse coronaries and brain Mental status End tidal CO2 Maybe:  urine output (if Foley present) & capillary refill time Increase venous return Avoid ischemia & other adverse events Which vasopressor do I choose? It depends. For the prehospital provider, most of these are not an option. However, having one pressor that you're familiar with that can be implemented safely and rapidly is probably more beneficial to the patient than not using a pressor at all, or worse, using it incorrectly. Currently, norepinephrine is recommended as first line in the vast majority of shock states. However,  this is only commercially available in a vial as a concentrated solution, requiring drip preparation. Most EMS Providers in our area are either more familiar with dopamine or have it as their only option per Protocol.  This is likely due to it being a commercially available pre-mixed drip.  In short term, may be fine, but is more arrhythmogenic than norepinephrine. Alternatively, "Dirty" Epi is an option: 1 mg into a 1,000 mL NS (conc 1 mcg/mL). Maximum rate of infusion will vary with catheter size, IV bag height, and squeeze on the bag; however, with a wide-open 18-gauge IV, the patient will receive about 20-30 mL/min (or 20-30 mcg/min) of epinephrine, which is similar to the recommended push-dose epi (0.1 mg or 100 mcg over 5 minutes = 20 mcg per min Run wide open in your peripheral IV or IO until the patient’s hemodynamics stabilize. Can set up the pump, follow  protocols, and perform double-checks. Adequate labeling is important to mitigate errors. Or, compel your service administrators to buy the right equipment (IV Pumps) and the right vasopressor (Norepi). Vasopressors Turn Unstressed Volume Into Stressed Volume Unstressed Volume - Vol­ume of fluid to fill the vascular bed to the point where its presence exerts force on the vessel walls Stresssed Volume - Anything greater ⇒ which will exert an increasing degree of pressure on the venous vascular bed ⇒ determines flow Vasopressor Classification - A Simpler Approach Pure vasopresors (isolated vessel squeeze) Phenylephrine Vasopressin Vasopressor with ionotrophy (both vessel & heart squeeze) Norepinephrine Epinephrine Dopamine Ionotropes with vasodilators (heart squeeze & vasodilation) Dobutamine Milrinone Maximum doses vary greatly between institutions.  It is likely that your hospital or agency has set a maximum dose for each vasopressor.  Maximum doses can be exceeded if needed to maintain hemodynamics. When to Titrate (frequency) Peripheral Administration Tips for peripheral administration: Use well functioning 18-20G IV proximal to the wrist Place BP cuff on opposite arm Regularly inspect IV site for signs of extravasation Ask patient to report discomfort around IV site Be prepared to manage extravasation Prolonged administration = Central access Extravasation Management Compatibility Sterility When properly mixing Push Dose Epinephrine, repeated entries into any one container should be limited to maintain integrity/sterility of the original container. Ways to limit puncturing the carpuject, as described by Dr. Baum in the podcast: Instead of puncturing the carpuject, it may be more more sterile to remove needleless cap from the Epi and insert it into the tip of the 10 cc syringe. Or... Purchase a Luer Lock-to-Luer Lock  connector so you don't have to expose a needle. Care Transitions Be cautious when stopping drips when delivering patient to the hospital.  This is especially important with agents like vasopressors as they have short half-lives.  Patients needing these for support may decline.  Best practice is to transition to hospital product before discontinuing. Reporting of infusion rates during hand off:  Medication infusions need to be reported in a concentration per time Examples: mg/hr or mcg/kg/min or units/hr ml/hr is NEVER appropriate due to differing concentrations of medication infusions Vasopressors may be dosed in mcg/min or mcg/kg/min beware of units IV fluids like normal saline and lactate ringers ml/hr is appropriate. Special thanks to Dr. Regan Baum for providing us with these notes and images. A few additions were made by Curbside to Bedside.

Today’s question is: How to manage the non-hematological adverse effects of clozapine? Here is a summary of this episode: For sialorrhea start with local agents like sublingual atropine drops or mouth ipratropium spray. If that fails, systemic agents like glycopyrrolate or terazosin can be used. For constipation, bulk agents can make constipation worse and should be avoided. After docusate, the next agent to add is PEG 3350 and then a stimulant and then lastly, if needed, lubiprostone. For sedation, titrate clozapine slowly, use bedtime dosing and reduce other sedating medications. A trial with modafinil or methylphenidate can be attempted, but the evidence is not strong. Tonic-clonic and myoclonic seizures can occur with clozapine. Titrate down and divide into multiple doses. Divalproex is the drug of choice in preventing clozapine-induced seizures.   Download a PDF of this interview here Become a premium member of the Psychopharmacology Institute

Rounding out the trifecta of wonderful nurse guests this month on Maybe Medical is Flight Nurse Colleen R.! We covered how she feels you need to be able to fly by the seat of your pants to perform in her role, as well as have an emergency and critical care background. We talked about work and home partnerships and how to balance it all while supporting each other. She was extremely inspirational and I can not express my gratitude enough for her taking the time to sit down with us. Thank you Colleen!   Registered Nurses* Registered nurses (RNs) provide and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members.   2017 Median Pay: $70,000 per year ($33/hour)   Educational Degree: Initially Associate's Degree or Bachelor's Degree   Number of US jobs in 2016: 2,955,200   10 Year Job Outlook: 15% growth, much faster then avg.   *Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Registered Nurses, on the Internet at https://www.bls.gov/ooh/healthcare/registered-nurses.htm (visited November 16, 2018).       Terms Covered in Episode American Nurses Association Trauma Surgery - Surgical field dealing with acute traumatic injuries such as falls, motor vehicle crashes, gunshots, blunt and penetrating injuries, etc. Pulmonology - A medical specialty that deals with diseases involving the respiratory tract. Consult - When asked to weigh in officially with your medical opinion from your specialty on a patient managed by another team. Perforated Bowel - Opening in the intestines due to trauma (knife, bullet, etc) or disease (infection, cancer, etc).  Is a surgical emergency.  Yuck. Sepsis - A potentially life-threatening condition caused by the body's response to an infection. Ventilator - To move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently. "Coding" - What we casually use to describe a cardiopulmonary arrest in which there is a sudden loss of function of the heart or loss of respiratory function that requires immediate intervention in a life or death situation. IR (Interventional Radiology) -  A subspecialty of radiology that uses minimally invasive, image-guided procedures to diagnose and treat diseases in nearly every system or organ of the body. CVA (Cerebral Vascular Assault, Stroke) – Possible permanent damage to the brain from a loss of blood flow from either rupture of a blood vessel or obstruction from a tumor, clot, plaque, etc. MI (Miocardial Infarction) - "Heart Attack" refers to a blocked coronary artery that has caused, or is moments away from causing, irreversible cardiac (heart) tissue damage. ET (Endotracheal) Tube - A tube of varied sizes that is inserted into the trachea for establishing and maintaining a patient's airway. Choose Your Own Adventure Books ER (Emergency Room, Emergency Department, Emergency Ward, Accident & Emergency Dept) - Department that must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention that arrive unplanned by walk-in, private vehicle, or ambulance. ICU (Intensive Care Unit, Critical Care Unit, or Intensive Therapy/Treatment Unit) - Part of the hospital with the sickest patients requiring the most intervention from both staff and equipment.  May consist of intubated, sedated, and ventilated patients. Bachelor's Degree - On average four to five year University Program to pursue a degree in a specific field. Sacred Heart University College of Nursing Bridge Program - A postgraduate program that is usually shorter then traditional programs that take into account previous experience. Physical Therapist - An important medical provider and part of the rehabilitation team to help assist with treatment, recovery, and overall well being of patients with chronic conditions, illnesses, or injuries. Prerequisites - Classes you may need to take before further applying to a program.  Usually a focus on science/math for the medical field. PA (Physician Assistant) - Providers who practice medicine on teams with physicians and other healthcare workers. They examine, diagnose, and treat patients autonomously and as part of a team in all various specialties of medicine. On average a Master's level degree of education. NP (Nurse Practitioner) - A nurse practitioner is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, prescribe medication and formulate treatment plans.  They may work in a solo practice independently or they may work within part of a hospital system.  They graduate from a Master's or Doctorate level medical program. ASN/ADN - Associate’s Degree in Nursing.  Usually around two years. EMT/Paramedic - Emergency medical technicians and paramedics care for the sick or injured in emergency medical settings by responding to emergency calls, performing medical services and transporting patients to medical facilities as needed. ER Techs - Staff who in all aspects of patient care under the supervision of the Practitioners and Nursing staff.  Many have a paramedic/firefighting background. Travel RN - Nurse who travels for limited contracts working in all variety of places and roles.  On average 8 to 13 week contracts. Smart Pumps Compact Nursing States NCLEX (National Council Licensure Examination) - A standardized exam that each state board of nursing uses to determine whether or not a candidate is prepared for practice. Wake Forest School of Medicine PA Program Harborview Medical Center King County Medic One "Board & Collared" - Refers to the practice of placing a patient on scene on a very hard and rigid backboard to immobilize them and place a neck collar on them to prevent any head movement in the event of a spine injury while they are transported to the hospital.  They are incredibly uncomfortable. Intubated - When an ET Tube, or similar artificial airway, is placed, either in an emergency, where there is loss of respiratory function or planned such as in surgeries. First Responder - Generally refers to the first on scene in an event.  May be police officers, firefighters, or paramedics for example. "Packaged" - Patient is ready to be transported.  IVs are in, airway is secure if one is present, patient is strapped in, paperwork is read.  Let's roll!   EZ-IO - Used to gain access for medications or fluids when unable to get a line in a blood vessel.  Using a drill a hollow bore is inserted into the broad side of a bone.  Yeah, you drill into bone. "Push Line" - An IV that gives you access for medications that need to be administered over a short amount of time.  Pain meds, sedatives, cardiac meds, etc.   Vasopressors - Class of Antihypotensive medications that are used to raise blood pressure by contracting blood vessels.   EJ - An IV placed into the external jugular of the neck.   Central Line - Larger then an traditional IV placed into veins in the neck, chest, groin, or through veins in the arms.   EMS (Emergency Medical Services) - Services that treat illnesses and injuries that requiring an urgent medical response, providing out-of-hospital treatment and transport to definitive care.  Paramedics, Police, Firefighters, etc.   Level One Trauma Center - A Level I Trauma Center is capable of providing total care for every aspect of injury – from prevention through rehabilitation and includes teaching residents and medical students in all fields.   Med/Surg/Floor Nursing - Refers to what you would think of "general hospital patients." Those with pneumonia, new cardiac issues, skin infections, etc that do not require focal subspecialty involvement (cardiac, neuro, ortho, etc) or critical care support.   Nocturnist - Hospital-based practitioner who only works overnight.   Admit - To be brought in to the hospital for specific medical care.  Entails obtaining a medical history, making a medical diagnosis, writing orders for treatment and other diagnostic procedures, diet, activity, etc.   Post-Op/Recovery Room - The period right after surgery.   GI (Gastroenterology) - The branch of medicine focused on the digestive system.   Orthopedics - Branch of surgery concerned with conditions involving the musculoskeletal system.   Neurology - The area of medicine focused on the nervous system.  This includes the nerves, brain, and spine.   Potassium - A naturally occurring mineral and electrolyte consumed in our diet.  Involved in metabolism, hormone secretion, blood pressure control, fluid and electrolyte balance, and more.  Normal standard range is around 3.5-5mEq/L. Critical Values - Any values considered to be too high or low and requires immediate medical attention to prevent further issues. "Bagging" - The act of using a manual balloon like bag that is squeezed for each breath to a patient. "Titrate a Drip" - To adjust the flow rate or dose delivered of medication in a IV or central line. Peggy Sue - Badass Patient Advocate "Shake and Bake" - Hyperthermic Intraperitoneal Chemotherapy is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery. Patient Advocacy - Doing what is best for the patient in all facets of care provided. Listening to and understanding their needs. Multi System Organ Failure - A cascading domino like effect where multiple organ systems start to shut down due to injury/illness. Krista Haugen and Survivors’s Network Post Resuscitation - The fragile period after performing CPR or similar resuscitation of a patient. M&M (Morbidity and Mortality Meeting) - Where we dissect individual challenging cases to identify what other choices could have been made for possible alternate outcomes. Off-Label - Using a medication that may not necessarily be the indication that it was originally intended for.  For example Demerol that is a pain medication is excellent for post-operative rigors (shakes).  A small dose works like magic...fun! IV Fluids - Intravenous fluids are given through an IV, central line, or IO and usually consist of normal saline or lactated ringer's solution. Levophed (norepinephrine bitartrate) - Medications used to raise blood pressure in critical patients. Used to be referred to as "Leave 'em dead" as any patient sick enough to require norepinephrine to manage their shock, then they were most likely going to die.  Very commonly used nowadays. Epinephrine - Endogenous hormone that is given to patient's to treat a number of conditions including anaphylaxis, cardiac resuscitation, and bleeding.  Inhaled epinephrine is used to help treat symptoms of croup.  Is used in the ICU and cardiac unit to help maintain a high enough blood pressure.   PRBC (Packed Red Blood Cells) – Blood that is transfused after finding the right compatible blood type for the patient.   Plasma – Fluid in blood that is responsible for carrying red blood cells, white blood cells, platelets, etc. Is often used during blood transfusion to help stop the active bleeding by adding pro-clotting factors.   Credo Cube   Transfusion Guidelines Airlift NorthWest   MONA - Morphine, Oxygen, Nitroglycerin, and Aspirin are all meds that should be administered to a patient experiencing chest pain.   Emergency Nurse Association   Balloon Pumps - Intra-Aortic Balloon Pumps use a thin flexible tube that is inserted into the aorta of the heart to pump blood artificially in a heart-like fashion.   ECMO (Extra Corporeal Membrane Oxygenation) - Treatment that uses a pump to circulate blood through an artificial lung back into the bloodstream of a very ill patient.  Provides heart-lung bypass support outside of the body.  You are damn near dead at this point   Skills Lab/”Sims” - Focused area to learn new medical techniques or further practice known skills.   Society of Critical Care Medicine PFCCS - Pediatric Fundamental Critical Care Support ACLS - Advanced Life Support PALS - Pediatric Advanced Life Support Certification NRP - Neonatal Resuscitation Program ATLS - Advanced Trauma Life Support Certification   CCRN - Critical Care Registered Nurse CEN - Board Certification of Emergency Nurses Each and every episode of Maybe Medical is for educational purposes only, not to be taken as medical advice.  The opinions of those involved are of their own and not representative of their employer.  

Dr. Uma Dhanabalan is one of the premier medical cannabis experts in the United States. She lives outside of Boston, and conducts public and private sessions with patients who come from far and away to hear her speak. In the 3rd episode of 4 of In The Weeds with Jimmy Young and Dr. Uma they talk about dosing or as Dr. Uma's explains, titration.

  Sergey M. Motov, MD, FAAEM Courtesy of Sergey M. Motov, MD Twitter @painfreeED Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally   Missed Episode 011? Low Dose Ketamine for Pain - Administration Explained! Click Here Missed Episode 018? Deep Dive on Continuous Sub-Dissociative Dose Ketamine Infusions, Ketamine in Geriatrics?, Ethics & More Click Here A Candid Conversation on having a Hydromorphone-Free ED with Sergey Motov, MD FAAEM This episode was recorded earlier in the year at the same time as the Deep Dive Continuous Sub-Dissociative Dose Ketamine discussion. Are people forgetting how powerful hydromorphone is? Some people do forget, majority have not been educated. Why are we now using so much hydromorphone? This medication was basically thrown at us. "Use it. It’s a great and safe medication alternative to morphine." Without actual explanations of equi-analgesic conversion, potency, or lipophilicity (lipid solubility) in comparison to morphine. Morphine 8mg or Hydromorphone 1mg? There’s something mental about giving a single digit dose of an opiod versus double digit. It’s much easier to prescribe 1mg, 2mg, 3mg…6mg of hydromorphone than let’s say 10mg of morphine without understanding that hydromorphone 2mg = morphine 16mg. Hydromorphone 1mg = Morphine 8mg Hydromorphone 2mg = Morphine 16mg 48% ED attendings lack pharmacological understanding or validity of why they are using one opioid over another Opioid-Naive Patients First-line medication - should NOT be hydromorphone Initial hydromorphone dose should be 0.2-0.4mg (If you must, for opioid-naive patients) Conversion: Morphine 2-4/5mg dose How to administer opioids? Titrate at Specified Intervals *Clinical Pearl Single dose of opioids will not do the trick. No matter how you dose it (weight based or fixed). Start with a lower dose. Reeval every 10-15 minutes. Ask the patient if they need more. Give another dose as needed. Repeat. No need to wait 4 hours for the next opioid dose. Morphine peak time ~20 minutes Hydromorphone peak time ~15 minutes Morphine, hydromorphone and fentanyl are pure mu receptor agonists with no analgesic ceiling. Titrate opioids up until one or two things will happen: Pain is optimized or they stop breathing Clinical Example: Patient received 3 doses of morphine: 4mg, 4mg, 4mg. Still has pain. Now what? You want to give an opioid. Which one? Some may switch to hydromorphone. But why? Hydromorphone is not any different than morphine except for potency. The most potent opioid is fentanyl. Problem is fentanyl has a shorter half life so will have to re-dose more often. Consider adding non-opioid analgesic modalities If you do switch to hydromorphone - remember to add previous morphine doses and convert equianalgesia for total dosage. i.e. Morphine 12 mg (4mg x3) + Hydromorphone 1mg (Morphine 8mg) = Morphine 20mg Opioid-Induced Hyperalgesia The longer a patient uses opioids to treat pain, the patient will most likely develop hyperalgesia and will ultimately require a higher dose to treat their pain which will eventually lead to tolerance and possibly addiction. Constantly requires a higher dose. Hydromorphone has a Higher Abuse Potential than Morphine Hydromorphone is 10x more lipophilic than morphine. Penetrates the blood brain barrier significantly faster and saturates the mu receptors faster. It translates to a euphoria,

In this video interview, Christopher Shade, PhD, describes the diverse clinical applications of cannabidiol (CBD) oil. Also included is information about safety, dosage, and other issues associated with this somewhat controversial natural substance. About the Expert Christopher W. Shade, PhD, founder and CEO of Quicksilver Scientific, specializes in the biological, environmental, and analytical chemistry of mercury in all its forms and their interactions with sulfur compounds, particularly glutathione and its enzyme system. He has patented analytical systems for mercury speciation (separation of different forms of mercury), founded the only clinical lab in the world offering mercury speciation in human samples, and has designed cutting edge systems of nutraceuticals for detoxification and antioxidant protection, including advanced phospholipid delivery systems for both water- and fat-soluble compounds. Quicksilver Scientific is recognized globally for innovating on behalf of the pharmaceutical and nutraceutical industries. Dr. Shade is regularly sought out to speak as an educator on the topics of mercury, environmental toxicities, neuroinflammation, immune dysregulation, and the human detoxification system for practitioners and patients in the United States and internationally. About the Sponsor Quicksilver Scientific is a leading manufacturer of advanced nutritional systems with a focus on detoxification. We specialize in superior liposomal delivery systems and heavy metal testing to support optimal health. Our advanced liposomal supplements are highly absorbable, and support the body in the elimination of ubiquitous toxins, enabling you to achieve your genetic potential. At Quicksilver Scientific, we are passionate about health and well-being, and are committed to improving the lives of everyone we touch. To purchase Quicksilver Colorado Hemp Oil as a Practitioner, please access www.THRTech.com. Consumers, please access www.VitaExpress.com. Transcript Karolyn Gazella: Hello. I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Today we have a fascinating and somewhat controversial topic to talk about. We're going to be talking about the therapeutic effects of CBD oil from cannabis. Before we begin, I'd like to thank the sponsor of this podcast, who is Quicksilver Scientific. My guest today is Dr. Christopher Shade. Dr. Shade, it's always a pleasure. Christopher Shade, PhD: Always a pleasure. Gazella: And I have to ask you first of all, is there a reason that CBD oil would be controversial? Am I right in that? Shade: Much ado about nothing. Gazella: Maybe. Shade: You know, is there a reason for controversy? Controversy's built out of us evolving as a society in which we had instituted cannabis prohibition, and we all had this reefer madness fear around the THC side of cannabis, the psychoactive high-inducing side. But CBD is coming from industrial hemp, which is the THC is bred out of it, and you're left with another component that is big in the resins of cannabis, and it's called cannabidiol. It's chemically different than THC, and its physiological effects are vastly different, and they seem almost magical when you look at so many ... At the variety of things that they do for you, but they don't get you high. They have an effect of balancing and calming the mind, but they have so many different therapeutic benefits, and it's really just getting people out of the fear of the evil weed, into this wonderful, medicinal plant and all the uses it has. Gazella: I want to get into the mechanisms of action and all the science associated, but first, and I know that you're not a legal expert, but is it available freely? Is CBD oil available for purchase, or are there limitations because cannabis is not legal in many states? Shade: Yeah. The entrance of CBD into use in the US was made possible by the 2014 Farm Bill, which was allowing the use of industrial hemp for various uses in trade in the US. In those uses came the use of the extracts. Now, by some interpretations, well, that's still cannabis, and that's still scheduled as a drug. Certain parts of the government are saying, "Hey." Like the DEA. "Hey, that should still be scheduled. We didn't say that's okay." Whereas other parts of the government are saying, "Hey, that's all right. That comes underneath the Farm Bill." Most of the states have rolled with this being under the Farm Bill, and being an allowed substance. It's gained so much widespread use, and a lot of that use is from very impaired people that rely on it heavily for their health. Most places are reluctant to step in and go against the Farm Bill. Certain states, however, Indiana notably, recently the Attorney General said, "No. We're not doing this, except for under certain exemptions. If you have a certain type of a ..." It was probably a seizure disorder, "Then you can get a permit to use this." Missouri, I don't know the extent of their laws, but they're kind of difficult. Most people don't sell it in Missouri. Then other states are taking a tack of trying to adopt it into a state cannabis law. Making it like THC, where it's regulated by the state, just like Colorado regulates THC. It does not regulate CBD independently, but for instance, the State of Florida is trying to bring CBD into their medical marijuana world. We'll see how it rolls in Florida, but right now the places to stay out of are Indiana and Missouri. This is such a moving target that this might change in a month. Gazella: Right. Now, just to clarify, though, CBD oil or hemp oil does not have THC in it. Dr. Shade: No. In most of the extracts of industrial hemp ... Industrial hemp is defined in the Farm Bill as a plant that, on a whole plant basis, has less than 0.3% THC. When the Colorado Department of Agriculture goes and certifies a crop here for being harvested and processed, it will take representative plants and analyze them for this threshold of THC. Now, these plants usually have, oh, 7% to 9% to 10%, upwards to peak around 15% CBD as well. There's some residual THC along with the CBD. One of the concerns originally was, "Well, when we concentrate that up, will there be enough THC for people to get high?" Now, processors who are trying to stay very clean with the law will use extraction technologies and post-extraction purification technologies that minimize the THC. For instance, in our CBD oil, there's virtually indetectable THC. Whereas some oils will have a 20-to-1 CBD to THC ratio, ours is around 500-to-1. It's super clean, and that's nice because a lot of people that want to use the oil have THC testing programs that they're in, if they're firefighters, or policemen, or airline pilots. A lot of the commercial extracts have enough THC that if you're using large amounts to be really therapeutic against something like pain, you will probably have enough THC to tip the scales on some of the analytical techniques looking for THC. Gazella: Got it. Thanks for that clarification. Now, let's get into the science, which is your area of expertise. What's going on from a mechanism of action standpoint? How does CBD oil work inside the human body? Dr. Shade: Well, it works on a number of different levels, and when we were describing this, we used to chase after one thing or another. We'd say, "Oh, it's antiinflammatory." Or, "Oh, it helps GABA-glutamate balance." As we go forward, we look at it more and more in this symphony, and this symphony, I call neuro-endo-immune poise, or balance. Neuro means neurotransmitters. Endo is endocrine or hormone, and immune is obvious. It's the immune system. Neurologically is how we used it the most, for damping neuro-inflammation. When I lecture to doctors, I say, "This is the most exciting supplement for us in the last 30 years in functional and integrative medicine." Because we're treating a lot of people with [mole 00:07:45] toxicity, Lyme disease, mercury toxicity, and all these have as part of their symptomology neuro-inflammation, where you become ... Your autonomic nervous system becomes sympathetically dominant, you've got overactivity of glutamate receptors, there's activation of the immune system in the brain called the microglia, and they're sort of at war with the glutamate receptors. That's causing anxiety first, then brain fog, then a disruption with the autonomic nervous system. You're moving resources and blood in wrong ways throughout the body, and this acts to just stabilize all of that. It will block the excitation of the microglia. It will stabilize the glutamate receptor. That will result in a neuro-stabilization. Your neurotransmitter balance between glutamate and GABA gets balanced. Your autonomic nervous system balance between parasympathetic and sympathetic gets balanced. But that starts cascading down even farther into the body, and we start to look at really what homeostasis or balance of the biology is, and it's a set of reactions that all have these yin-yang poles, which you want to sit in the middle of and take forays in the yin or yang as needed to handle different perturbations, but you always want to come back to the poise of the center, and CBD is always bringing that back to the middle. In hormones, in women, the organ with the greatest amount of cannabinoid receptors? The uterus. I always pair CBD with bitters, and guess what's in the ovaries, but bitter receptors. We find such a stabilization of the female cycle by taking those things together. Then the immune system. You want inflammation when you need to kill things, but then when it gets stuck on, and it won't turn off, you get things like development of chronic inflammatory states. These can be cardiovascular complications. These can lead to cancer. These are problems, so where's the switch to bring it back? The CB-2 receptor, the cannabinoid number two receptor, and where's that located through the body but on the peripheral immune cells of the body. CBD lubricates your endo-cannabinoid system. Why would you have cannabinoid receptors if you didn't make cannabinoids. The two main cannabinoids you make are 2-Arachidonoylglycerol and anandamide, and the reason you make them is to zip together the neural system, the endocrine system, and the immune system have that neuro-endo-immune poise, and CBD helps you build more of those endo-cannabinoids and helps potentiate those CB-2 receptors. At the same time, it's up-regulating chemo-protective and antiinflammatory genes and down-regulating pro-inflammatory genes. There's really no one thing that helps you create that poise, that essential homeostasis. Nothing does it like CBD oil does, and that's why it seems like a panacea, because it helps so many things. Gazella: That was actually my next question, because when I was researching for this interview, I found such a diverse amount of conditions that it was being effective for, so because it works on these multiple pathways, that's why you're saying it works for such a variety of conditions. Do you give practitioners who say, "Wait a minute. That's a little bit too good to be true. How can it be that good for that many things?" Dr. Shade: Well, then I give them the neuro-endo-immune poise story. Gazella: Exactly. Dr. Shade: And as soon as you said neuro-endo-immune poise, they go, "Wow." Gazella: That's right. Shade: Because what are the disorders? There's some part of you in that yin-yang balance that's stuck over here, or stuck over there. Anything that helps you zip together so many fundamental processes, everything just starts to come back together again. I mean, it runs through all of our different protocols, because it's that X-factor for zipping it all up again. Gazella: Right. Now, there's got to be some conditions that bubble to the top, and that was the other thing that I was so impressed with, with the research, is the amount of research associated with CBD oil has grown dramatically. But what conditions? As you're looking through the research and you're kind of identifying the strength of the research, what conditions are bubbling to the top, to say, "Yup, that's really what it's going to work for"? Shade: Right. In our world, we deal with detoxification, and so we're dealing with people who have various problems that are associated with toxins. Autism is a really big one. That's always ... Unless they're just totally exhausted, autistics, always bringing CBD into that, because of that neurological stabilization. Then we're dealing with various mole toxicity, Lyme disease, and the neuro-inflammation that comes from that, the different metal toxins. All of our detoxification protocols, especially when they're neuro-detoxification protocols, involve the use of CBD. Then in distinct disease states, the big ones, MS, Parkinson's, any kind of tremor. Of course, everybody knows seizure disorders. Those are all crying out for some application of CBD. But then since I understood the endocrine side of it, women who are having endocrine destabilization or hormone imbalance, we're always recommending CBD along with the bitter herbs to them, and we get great ... You might not think, "Premenstrual syndrome: CBD." But it's fantastic for that. Those are the main ones that we use. Oh, any chronic inflammatory pain. That's a really big one. Cardiovascular complications. That's really big, too. We've seen some great data emerging on the use of CBD, including some doctors who have used ours to get preliminary data, on the health of the inside of the vascular system, and you'll see those cells on the inside of the vascular system all getting less stress, increased poise, and so we recommend it in those cases as well. Gazella: Now, what about mental health? You've now just listed some conditions that are related to our physical health, but what about some conditions associated with mental health? Shade: Anxiety's just hands down the biggest one, because anxiety results from over-excitation of the glutamate receptors, and boom. CBD stabilizes that immediately. It's very, very fast around that. Now, it's interesting, for much more complicated problems, like schizophrenia, here you've got one plant, two chemicals, THC, CBD. THC is like putting the fast forward button on schizophrenia. It's really bad for a schizophrenic, where CBD has fantastic data around stabilizing schizophrenics, so there it's useful as well. Even in depression. Depression, you think, "Okay, well anxiety, you're really stimulated, and that calms you down." But depression is also often cycling with anxiety, and so depressive disorders, there's been a lot of data around use of CBD too, and most of my favorite integrative psychiatrists like Kelly Brogan, they've showed very clearly that depression is a neuro-inflammatory disorder, and so you've got different reactions to antigens in your food, in your environment. You're having these constant allergic states and cytokines, these pro-inflammatory states that are contributing to depression, and CBD is working against all that, creating that balance again so it can be used in anxiety and depression. Gazella: Yeah. It's fascinating. Shade: Yeah. Gazella: I'd like to talk about safety, because I have to tell you that I've read some conflicting statements associated with safety. Based on your interpretation of the scientific literature, is it safe? Are there any interactions, contraindications that we need to be worried about? Shade: On its own, without you having to stick something else into your body like a heart pressure medication, CBD is inherently incredibly safe. We've found a couple of people here and there that seem to have an allergy to the plant, and they just feel unhappy on it, but the issue around CBD and safety is that it interacts with some of the cytochrome P450 system, which are metabolizing drugs. If you're taking a drug for blood pressure, CBD may either lower its breakdown, so increase its circulating levels, or increase its breakdown, and thereby decrease their circulating levels. If you're on a lot of pharmaceuticals, you usually have to do a little bit of research and see if there's some interaction between the CBD and the pharmaceutical that you're on. There's starting to be good lists online of the potential interactions. They've got to get a little bit better at where these are really relevant interactions, and where they're not relevant interactions. But this will be one of the things that we come up with in the future, is nice, clear guidelines on whether something's going to positively reinforce a drug, or work against the activity of the drug. Gazella: I mean, the case that I read was specific to antidepressants, and that's where it was very conflicting. Some reports were, "Yes, it will react," as you describe, and some were, "It will not." Shade: Because it's not antidepressants. It's, "This list of chemicals." Gazella: Exactly. Yeah. Shade: They just happen to be antidepressants to your body that get metabolized down different pathways according to their chemical nature. Your breakdown doesn't care whether it's an antidepressant or whether it's testosterone. It's got a chemical nature, and it's got to fit into the cytochrone that breaks it down. You get a list of antidepressants, they have different chemical natures, and they go into different cytochrome P450 enzymes to break down, and CBD interacts with two or three of those enzymes. If the antidepressant interacts with the same enzyme CBD does, then there could be an interaction, and if it doesn't, then there's no interaction. It's not about antidepressants. Gazella: Yes, and nothing is ever clearly black and white when we're talking about this type of chemistry. Shade: No. Gazella: I'd like to talk a little bit about the product that you specifically formulated, Colorado Hemp Oil. What makes your product unique or special compared to other CBD oil products that are on the market? Shade: Quicksilver Scientific specializes in delivery systems, ways to get the compounds into little, lipid-based carrier spheres that are so small that they passively diffuse through mucosal membranes, like your oral mucosa, the sublingual space, as you're swallowing, through the stomach, the upper GI. It's the rapid and complete absorption of these little nano-spheres which is what we do, and when we stick CBD in there, there's a very fast uptake, there's a high total uptake, and it's a very rapid uptake. One of the things that's a problem with CBD is there's only net about 10% uptake of all the CBD you swallow. That's a very expensive molecule, as you know, and so you're throwing away a lot of that and not getting a lot. The stuff you do absorb is absorbed over the whole transit time of the GI, so if we look at uptake versus time, you have a very gradual, slow movement into the blood. The blood levels, the peak blood levels never get very, very high. Now, a lot of what CBD does, it does through interacting with receptors, and gene triggers, like nuclear transcription factors, like NRF-2, which turns up all your glutathione genes. Now, the receptors and those transcription factors react to peak doses. Level versus time, here's a regular CBD oil. Here's ours. You get a very high transient peak dose. You saturate the system. You're able to work very well on the brain. You're able to hit all of those transcription factors. You're able to interact with all of those membranes, and everything happens very quickly, and you get a very strong effect. The total absorption is anywhere from four to sixfold higher than a regular pill, but even if you took four to six times as much, you don't get as much of an action, because you don't have that peak dose to really induce everything, ring the bell of those receptors. What happens when you hit receptors, you trigger a whole cascade of different proteins to be made, which is affecting the metabolism of the body. That transient peak dose really creates the effect that you're looking for. Gazella: Now, your label says that the patient needs to hold it in their mouth for 30 seconds. How important is that, and is that all a part of the enhanced absorption of the product? Shade: It is, because this is a nice space in the oral cavity. Interacting with the oral musoca is a space where your spheres that you've made have not had to interact with stomach acids or bile, so there's nothing modulating them or modifying them, changing their shape, their size. It's a nice, pure space where all the capillaries are very close to the surface, and you can get a whole bunch in. Now, that being said, for some of our products that are water-core, that are liposomes, those are a little bit more sensitive to the GI conditions, and a little bit more important that you do that oral holding. The nano-emulsion that we make, like the CBD, you have an oil core with a membrane around it. These are more resistant against change in the GI tract, and they will make it through, and you'll get the absorption anyways, but it'll be a little bit slower, and a little bit less efficient. The more you can do the oral hold, the better, but it is not a game-breaker. That's important for a lot of the people that are very taste-sensitive, or if you're working with autistic children, and they won't do that, or you're giving it to your dog or something, goes right down. Gazella: I don't know. My dog is pretty smart. Shade: Yeah. You just say, "30 seconds." Gazella: That's right. Shade: "No. Five seconds more." Gazella: It's interesting. I would like to stay on dosing. Is it complicated to dose from a practitioner's standpoint? Because you do have such a diverse offering of conditions that it can help. Is the dosing- Shade: Yeah. It's really titration dosing. You start at a low amount. One of the doctors in town here, Joe Cohen, goes with two pumps three times a day as a sort of basis dosing for an adult, and then they'll add more as they need it. If you're not getting the effects, how about three pumps three times a day? Then four pumps three times a day? Titrate up until you get the required effect. You can even start down at one a day, like if you're dealing with kids and you want to start low and slow, but just keep titrating up until you get the effect you want, and often once you induce the effect and start training the body into the healthier state, you can bring the doses back down. Just start low and work up until you get what you need. Gazella: Great. Now, before I talk about the future, because you know I like to talk about the future, I'd like to have you predict the future, is there anything else that practitioners need to know about CBD oil when it comes to using it in their clinical practice? Shade: No. Don't be afraid to use it for a wide variety of conditions. Work your dosages up until you get the effects that you want. Let people know, especially if they've never had anything like this, the feeling that they have in the first couple of days may be more intense than it will be later, but it's not ... Most of the other supplements, there's more tricks around it and things to watch out for. Not so much with this. One thing, though, you will, if you're using it alone, you will start to generate detoxification reactions through two mechanisms. One is NRF-2 up-regulation, that nuclear transcription factor that's turning up the glutathione system, and the other is the autonomic balance, bringing yourself over to a parasympathetic state, and detoxification doesn't happen in sympathetic states, because it's a luxury, and you're trying to survive when you're in sympathetic autonomic dominance. This will bring you over to parasympathetic. It'll help turn up these genes, so some people will start to have detoxification reactions. If they start getting headachey, or a little lower back stress, or rashes, give them good quality bitters, like the BitterX that we make, and maybe a little bit of GI binder, like our ultra-binder, or charcoal clay capsules, and that will help them detoxify. Gazella: Oh, good. That's good to know. Now, the future. Shade: The future. Gazella: What excites you the most when it comes to CBD oil research? Shade: Yeah. It's CBD not being just a standalone, but being an integrated ingredient in formulas, where it's doing this part of it, maybe the autonomic balancing, or the brain balancing, where the other things are doing other parts, and finding which things are synergistic together, which things are antithetical together. We'll find out how to blend it with other things, and really make it work better. Even if we're just working within the cannabis plant itself, there's the essential oils of the plant called the terpenes, very strongly affect the modulation of how CBD and THC work within the body. The science on the terpenes will be worked out, then the science on other nutriceuticals playing in with those will be worked out, and we'll start to see some really beautiful formulas come. Gazella: What about when we began, we talked about the availability. Do you see things loosening up a little bit? Shade: That part of the future. It's funny. There seems to be two forces at work within the United States around CBD. There's a liberalization movement that is not necessarily ... It's not coming out of Boulder County in California. It's coming from within the government, where they want to focus on real issues, like narcotics use, prescription pain med addiction, real drugs, heroin, cocaine, and they want to get away from talking about this. On the other side, there's other people who are just ... Some part of them are just working out what's already been started, where they're just really going to want to try to enforce this. We're starting to hear much more sophisticated language from the state departments of health about CBD, and that's towards a contractive thing. And who knows where that's really coming from? I mean, you have pharmaceutical companies getting into this now, and that may be the long, dark arm of the pharmaceutical companies. There's two things now, contraction and expansion, happening at the same time. Hopefully the light wins and we expand out, and we're able to use this in a broad scale, and do all the research that's really necessary to put this to the best use. Gazella: I would agree. I think that the therapeutic efficacy of CBD oil is really ... We're shining a light on it in the scientific literature. Even though it seems that it's preliminary, uncertain cases, it just seems like it's growing more [inaudible 00:28:22], it really should be something that we look harder at. Shade: Oh, it absolutely is, and I can always gauge it by when I'm on a plane, when little old ladies start talking to me about it, or my aunt came over from Florida, and she had a bottle of it, and it's made its way out to the masses. They need it. They want it. We hope it's here to stay. Gazella: I do too, and you know, we haven't even touched on the pain aspects, because right now we are in the midst of an opioid crisis in this country. Shade: Oh, yeah. Gazella: Is there an application for [crosstalk 00:28:57]? Shade: Oh, absolutely. Maybe little smidges of opioids along with CBD. CBD, and what we'll find is what we can blend with it nutriceutically to increase its effect at stopping pain, but it's got all the right aspects for that, and for some pains, it's magic. For other ones, it doesn't work as well. Well, maybe we'll find certain blends, but it will always, if you're taking it with opioids, it will always lower how much you need of the opioids, and that's one of the most beautiful things to come out of the legalization of medical marijuana in various states. They've seen a lowering of opioid use. Gazella: Right. It sure seems like CBD oil, hemp oil, is a valuable tool that clinicians can use in their clinical practice. Shade: Absolutely. Gazella: Great. Well, Dr. Shade, as per usual, this has been very interesting. Thank you so much for joining me today, and I would also like to thank the sponsor of this interview, who is Quicksilver Scientific. Thank you everybody for joining us. Have a great day.

Do we recognize shock early enough? How do we prioritize our interventions? How can we tell whether we’re making our patient better or worse?   World wide, shock is a leading cause of morbidity and mortality in children, mostly for failure to recognize or to treat adequately. So, what is shock? Simply put, shock is the inadequate delivery of oxygen to your tissues.  That’s it.  Our main focus is on improving our patient’s perfusion. Oxygen delivery to the tissues depends on cardiac output, hemoglobin concentration, the oxygen saturation of the hemoglobin you have, and the environmental partial pressure of oxygen. At the bedside, we can measure some of these things, directly or indirectly.  But did you notice that blood pressure is not part of the equation?  The reason for that is that blood pressure is really an indirect proxy for perfusion – it’s not necessary the ultimate goal. The equation here is a formality: DO2 = (cardiac output) x [(hemoglobin concentration) x SaO2 x 1.39] + (PaO2  x 0.003)     Shock CAN be associated with a low blood pressure, but shock is not DEFINED by a low blood pressure.     Compensated Shock: tachycardia with poor perfusion.  A child compensates for low cardiac output with tachycardia and a increase in systemic vascular resistance.     Decompensated Shock: frank hypotension, an ominous, pre-arrest phenomenon.   Shock is multifactorial, but we need to identify a primary cause to prioritize interventions.     How they "COHDe": Cardiogenic, Obstructive, Hypovolemic, and Distributive.   Cardiogenic Shock All will present with tachycardia out of proportion to exam, and sometimes with unexplained belly pain, usually due to hepatic congestion.  The typical scenario in myocarditis is a precipitous decline after what seemed like a run-of-the-mill URI. Cardiogenic shock in children can be from congenital heart disease or from acquired etiologies, such as myocarditis.  Children, like adults, present in cardiogenic shock in any four of the following combinations: warm, cold, wet, or dry. "Warm and Dry" A child with heart failure is “warm and dry” when he has heart failure signs (weight gain, mild hepatomegaly), but has enough forward flow that he has not developed pulmonary venous congestion.  A warm and dry presentation is typically early in the course, and presents with tachycardia only. "Warm and Wet" If he worsens, he becomes “warm and wet” with pulmonary congestion – you’ll hear crackles and see some respiratory distress.  Infants with a “warm and wet” cardiac presentation sometimes show sacral edema – it is their dependent region, equivalent to peripheral edema as we see in adults with right-sided failure. “Warm” patients – both warm and dry and warm and wet -- typically have had a slower onset of their symptoms, and time to compensate partially. Cool patients are much sicker. "Cold and Dry” A patient with poor cardiac output; he is doing everything he can to compensate with increased peripheral vascular resistance, which will only worsen forward flow.  Children who have a “cold and dry” cardiac presentation may have oliguria, and are often very ill appearing, with altered mental status. "Cold and Wet" The sickest of the group, this patient is so clamped down peripherally that it is now hindering forward flow, causing acute congestion, and pulmonary venous back-up.  You will see cool, mottled extremities. Cardiogenic Shock: Act Use point-of-care cardiac ultrasound: Good Squeeze? M-mode to measure fractional shortening of the myocardium or anterior mitral leaflet excursion. Pericardial Effusion? Get ready to aspirate. Ventricle Size? Collapsed, Dilated, Careful with fluids -- patients in cardiogenic shock may need small aliquots, but go quickly to a pressor to support perfusion Pressor of choice: epinephrine, continuous IV infusion: 0.1 to 1 mcg/kg/minute.  Usual adult starting range will end up being 1 to 10 mcg/min. Avoid norepinephrine, as it increases systemic vascular resistance, may affect afterload Just say no to dopamine: increased mortality when compared to epinephrine   Obstructive Shock Mostly one of two entities: pulmonary embolism or cardiac tamponade. Pulmonary embolism in children is uncommon – when children have PE, there is almost always a reason for it – it just does not happen in normal, healthy children without risk factors. Children with PE will either have a major thrombophilic comorbidity, or they are generously sized teenage girls on estrogen therapy. Tamponade -- can be infectious, rheumotologic, oncologic, or traumatic.  It’s seen easily enough on point of care ultrasound.  If there is non-traumatic tamponade physiology, get that spinal needle and get to aspirating. Obstructive Shock: Act Pulmonary embolism (PE) with overt shock: thrombolyse; otherwise controversial.  PE with symptoms: heparin. Tamponade: if any sign of shock, pericardiocentesis, preferentially ultrasound-guided.   Hypovolemic Shock The most common presentation of pediatric shock; look for decreased activity, decreased urine output, absence of tears, dry mucous membranes, sunken fontanelle.  May be due to obvious GI losses or simply poor intake. Rapid reversal of hypovolemic shock: may need multiple sequential boluses of isotonic solutions. Use 10 mL/kg in neonates and young infants, and 20 mL/kg thereafter. Hypovolemic Shock: Act Tip: in infants, use pre-filled sterile flushes to push fluids quickly.  In older children, use a 3-way stop cock in line with your fluids and a 30 mL syringe to "pull" fluids, turn the stop cock, and "push them into the patient. Titrate to signs of perfusion, such as an improvement in mental status, heart rate, capillary refill, and urine output. When concerned about balancing between osmolality, acid-base status, and volume status, volume always wins.  Our kidneys are smarter than we are, but they need to be perfused first.   Distributive Shock The most common cause of distributive shock is sepsis, followed by anaphylactic, toxicologic, adrenal, and neurogenic causes.  Septic shock is multifactorial, with hypovolemic, cardiogenic, and distributive components. Children with sepsis come in two varieties: warm shock and cold shock. Distributive Shock: Act Warm shock is due to peripheral vascular dilation, and is best treated with norepinephrine. Cold shock is due to a child’s extreme vasoconstriction in an attempt to compensate.  Cold shock is the most common presentation in pediatric septic shock, and is treated with epinephrine. Early antibiotics are crucial, and culture everything that seems appropriate.   Shock: A Practical Approach   "How FAST you FILL the PUMP and SQUEEZE" Sometimes things are not so cut-and-dried.  We'll use a practical approach to diagnose and intervene simultaneously. Look at 4 key players in shock: heart rate, volume status, contractility, and systemic vascular resistance. How FAST you FILL the PUMP and SQUEEZE First, we look at heart rate -- how FAST? Look at the heart rate – is it sinus?  Could this be a supraventricular tachycardia that does not allow for enough diastolic filling, leading to poor cardiac output?  If so, use 1 J/kg to synchronize cardiovert.  Conversely, is the heart rate too slow – even if the stroke volume is sufficient, if there is severe bradycardia, then cardiac output  -- which is in liters/min – is decreased.  Chemically pace with atropine, 0.01 mg/kg up to 0.5 mg, or use transcutaneous pacing. If the heart rate is what is causing the shock, address that first. Next, we look at volume status. How FAST you FILL the PUMP and SQUEEZE Look to FILL the tank if necessary.  Does the patient appear volume depleted?  Try a standard bolus – if this improves his status, you are on the right track. Now, we look at contractility. How FAST you FILL the PUMP and SQUEEZE Is there a problem with the PUMP?  That is, with contractility?  Is this in an infarction, an infection, a poisoning?  Look for signs of cardiac congestion on physical exam.  Put the probe on the patient’s chest, and look for effusion.  Look to see if there is mild, moderate, or severe decrease in cardiac contractility.  If this is cardiogenic shock – a problem with the pump itself -- begin pressors. And finally, we look to the peripheral vascular resistance. How FAST you FILL the PUMP and SQUEEZE Is there a problem with systemic vascular resistance – the SQUEEZE? Look for signs of changes in temperature – is the patient flushed?  Is this an infectious etiology?  Are there neurogenic or anaphylactic concerns?  After assessing the heart rate, optimizing volume status, evaluating contractility, is the cause of the shock peripheral vasodilation?  If so, treat the cause – perhaps this is a distributive problem due to anaphylaxis.  Treat with epinephrine. The diagnosis of exclusion in trauma is neurogenic shock.  Perhaps this is warm shock, both are supported with norepinephrine.  All of these affect systemic vascular resistance – and the shock won’t be reversed until you optimize the peripheral squeeze.   Summary The four take-home points in the approach to shock in children To prioritize your innterventions, remember how patients COHDe: Cardiogenic, Obstructive, Hypovolemic, and Distributive. Your patient's shock may be multifactorial, but mentally prioritize what you think is the MAIN case of the shock, and deal with that first. To treat shock, remember: How FAST You FILL The PUMP and SQUEEZE: Look at the heart rate – how FAST.  Look at the volume status – the FILL.  Assess cardiac contractility – the PUMP, and evaluate the peripheral vascular tone – the SQUEEZE. In pediatric sepsis, the most common type is cold shock – use epinephrine (adrenaline) to get that heart to increase the cardiac output. In adolescents and adults, they more often present in warm shock, use norepinephrine (noradrenaline) for its peripheral squeeze to counteract this distributive type of shock. Rapid-fire word association: Epinephrine for cardiogenic shock Intervention for obstructive shock Fluids for hypovolemic shock Norepinephrine for distributive shock References Agha BS, Sturm JJ, Simon HK, Hirsh DA. Pulmonary embolism in the pediatric emergency department. Pediatrics. 2013 Oct;132(4):663-7. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013; 41:580-637. Jaff MR et al. for the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; American Heart Association Council on Peripheral Vascular Disease; American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011; Apr 26;123(16):1788-830. Levy B et al. Comparison of norepinephrine-dobutamine to epinephrine for hemodynamics, lactate metabolism, and organ function variables in cardiogenic shock. A prospective, randomized pilot study. Crit Care Med. 2011; 39:450. Micek ST, McEvoy C, McKenzie M, Hampton N, Doherty JA, Kollef MH. Fluid balance and cardiac function in septic shock as predictors of hospital mortality. Crit Care. 2013; 17:R246. Osman D, Ridel C, Ray P, et al. Cardiac filling pressures are not appropriate to predict hemodynamic response to volume challenge. Crit Care Med. 2007; 35:64-8. Ventura AM, Shieh HH, Bousso A, Góes PF, de Cássia F O Fernandes I, de Souza DC, Paulo RL, Chagas F, Gilio AE. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med. 2015;43(11):2292-302. This post and podcast are dedicated to Natalie May, MBChB, MPHe, MCEM, FCEM for her collaborative spirit, expertise, and her super-charged support of #FOAMed.  You make a difference.  Thank you. Undifferentiated Shock Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

How do you approach the child who may be altered?   Altered mental status in children can be subtle.  Look for age-specific behaviors that range from irritability to anger to sleepiness to decreased interaction. In the altered child, anchoring bias is your biggest enemy.  Keep your mind open to the possibilities, and be ready to change it, when new information becomes available. For altered adults, use AEIOU TIPS (Alcohol-Epilepsy-Insulin-Overdose-Uremia-Trauma-Infection-Psychosis-Stroke). Try this for altered children: remember that they need their VITAMINS! V – Vascular (e.g. arteriovenous malformation, systemic vasculitis) I – Infection (e.g. meningoencephalitis, overwhelming alternate source of sepsis) T – Toxins (e.g. environmental, medications, contaminated breast milk) A – Accident/abuse (e.g. non-accidental trauma, sequelae of previous trauma) M – Metabolic (e.g. hypoglycemia, DKA, thyroid disorders) I – Intussusception (e.g. the somnolent variant of intussusception, with lethargy) N – Neoplasm (e.g. sludge phenomenon, secondary sepsis, hypoglycemia from supply-demand mismatch) S – Seizure (e.g. seizure and its variable presentation, especially subclinical status epilepticus)   Case One: Sleepy Toddler 16-month-old who chewed on his grandmother's clonidine patch Clonidine is an alpha-2 agonist with many therapeutic indications including hypertension, alcohol withdrawal, smoking cessation, perimenopausal symptoms.  In children specifically, clonidine is prescribed for attention deficit hyperactivity disorder, spasticity due to cerebral palsy and other neurologic disorders, and Tourette’s syndrome. The classic clonidine toxidrome is altered mental status, miosis, hypotension, bradycardia, and bradypnea.  Clonidine is on the infamous list of “one pill can kill”. Treatment is primarily supportive, with careful serial examinations of the airway, and strict hemodynamic monitoring. Naloxone can partially counteract the endogenous opioids that are released with clonidine's pharmacodynamics. Start with the usual naloxone dose of 0.01 mg/kg, up to the typical adult starting dose is 0.4 mg. In clonidine overdose, however, you may need to increase the naloxone dose (incomplete and variable activity) up to 0.1 mg/kg.  Titrate to hemodynamic stability and spontaneous respirations, not full reversal of all CNS effects.   Case Two: In Bed All Day A 7-year-old with fever, vomiting, body aches, sick contacts.  Altered on exam. Should you get a CT before LP? If you were going to perform CT regardless, then do it. Adult guidelines: age over 60, immunocompromised state, history of central nervous system disease, seizure within one week before presentation, abnormal level of consciousness, an inability to answer two consecutive questions correctly or to follow two consecutive commands, gaze palsy, abnormal visual fields, facial palsy, arm drift, leg drift, and abnormal language. Children: if altered, and your differential diagnosis is broad (especially if you may suspect tumor, bleed, obvious abscess). Influenza is often overlooked as a potential cause of altered mental status.  Many authors report a broad array of neurological manifestations associated with influenza, such as altered mental status, seizures, cranial nerve abnormalities, hallucinations, abnormal behavior, and persistent irritability.  All of this is due to a hypercytokinemic state, not a primary CNS infection.   Case Three: Terrible Teenager 14-year-old brought in for "not listening" and "acting crazy"; non-complaint on medications for systemic lupus erythematosus (SLE). SLE is rare in children under 5. When school-age children present with SLE, they typically have more systemic signs and symptoms.  Teenagers present like adults.  All young people have a larger disease burden with lupus, since they have many more years to develop complications. Lupus cerebritis: high-dose corticosteroids, and possibly IV immunoglobulin.  Many will need therapeutic plasma exchange (TPE), a type of plasmapheresis.   Summary In altered mental status, keep your differential diagnosis open Pursue multiple possibilities until you are able to discard them Be ready to change your mind completely with new information Make sure your altered child gets his VITAMINS (Vascular, Infectious, Toxins, Accident/Abuse, Metabolic, Intussusception, Neoplasm, Stroke)   References Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 1984; 101:692. Fujita K, Nagase H, Nakagawa T et al. Non-convulsive seizures in children with infection-related altered mental status. Pediatrics International. 2015; 57(4):659–664. Gallagher J, Luck RP, Del Vecchio M. Altered mental status – a state of confusion. Paediatr Child Health. 2010 May-Jun; 15(5): 263–265. Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001; 345(24):1727-33. Oliver WJ, Shope TC, Kuhns LR. Fatal Lumbar Puncture: Fact Versus Fiction—An Approach to a Clinical Dilemma. Pediatrics. 2003; 112(3) Schwartz J et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice—Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Sixth Special Issue. Journal of Clinical Apheresis. 2013; 28:145–284. Zorc JJ. A lethargic infant: Ingestion or deception? Pediatr Ann 2000; 29: 104–107   This post and podcast are dedicated to Teresa Chan, HBSc, BEd, MD, MS, FRCPC for her boundless passion for and support of #FOAMed, for her innovation in education, and for her dedication to making you and me better clinicians and educators.  Thank you, T-Chan. Altered Mental Status Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP