Do you love the Lord's presence in your life? On today's move, your mountain. We're gonna see how we can welcome his presence into your situation and day. We're gonna have worship, a time in the word, holy communion, and then we're gonna pray at the altar over your prayer requests so you don't want to miss the program today. What in G? All our sins and griefs to beg to God in prayer. That was Pastor Myra Bell leading us in worship. I'm Pastor Gary. We have a great... And that is the best meal that you can have.  The word of God is sustaining. Jesus said, no man lives on bread alone, but on every word that proceeds from my Father's mouth. That's so good. And we also want to remind you that we have prayer partners available. The number is there on your screen,<PHONE_NUMBER>. If you need prayer for anything we're gonna discuss or anything on your heart, please go to the phone and let that prayer partner agree with you. At the conclusion of our time, we're gonna end at the altar today. Then we're also gonna take Holy Communion. What a special time that is. It is, and so if you haven't got your communion elements yet, a cracker, bread, juice, get that and take it with us. It is a special time. I can't tell you how many times I talk to people out in public, Pastor Jonathan, and they say, I just love. I get my communion elements together and I take communion with you all. And that's a special time for you and it's a special time for us. So please, join us as we take communion and remember Jesus, this is that season of the year that we're coming to that point of Resurrection Sunday, the crucifixion, all that. And so we're really, we remember what Jesus did for us. It's a special time. Yes it is. Well, we're gonna get into Psalm 24, one of my favorite, favorite Psalms. I love this in verse seven.  Why does he call us that? Because number one, you and I down here on earth can give access to the Lord's presence on the earth, through our worship, through our praise, through our attitude here on earth, we are a gatekeeper, a doorkeeper that welcomes and invites his presence. Amen and I love this text because the head of a gate was in the walls of the city and the walls were the city's main defense system and the head of the gate was like that lintel, that piece of stone that bridged the entire opening of the gateway and what they would do is that when someone, a king with great prestige and honor would come, they would literally lift that lintel up, essentially destroying the gate, breaking down the city's primary defense system, not just to show honor, saying hey, we're gonna make room for you to come here but saying as long as you're here in this city, we don't need a wall to protect us because you are here and so I love the opportunity and usually it's in worship, I lift up my head and I just wanna become broken before the Lord and say whatever there is, God, use me because I want God's presence in my life and in my surroundings. Yeah, I love that and like you said, worship is those times where you can really allow the Lord to just come in and move and saturate your life. Another thing about the gate, that was the part of the city where judgments were made, where things were, court cases were heard out and if you think about that, that's the place where we need to let the Lord in our lives, he needs to come in and be able to be the judge of our life, the one who helps us to make those decisions so his presence not only gives us those good feelings but his presence helps us to make judgments, he helps us to know the right way to do things, the wrong way to do things or what we shouldn't be doing, I should say, what we shouldn't be doing and he allows his Holy Spirit to give us that direction in our life so it's so important to invite the presence of God in our lives and like you said, Pastor Gary, to give it to those around us as well, we are the light of this world so when we allow the King of glory to come in our lives and shine out, it can impact the world around us. Yeah, his presence, allowing him to move, it may be that you don't know how to say, okay, what am I supposed to do next? But when you just open your heart and allow him whatever he wants to do, just tune your ear, I often say, put your ear to God's mouth to be able to hear what he would say to us, allow him access, don't be afraid, don't be afraid to allow him, it may be that this is the first time that you just stand in his presence or sit in his presence, but he will show himself strong to you because you belong to him.  You know, big doors open on small hinges. It doesn't take much for the presence of the Lord just to be welcomed through your worship. I love to say it all the time, a singing Christian is a victorious Christian. Make a joyful noise unto the Lord because when you praise him, you put out that welcome mat. And I love that. The king of glory comes in. Amen, he does. You know, I can remember times in my life where I would be by myself just worshiping God. I said one simple line, Jesus, you are mine. And when you start to think about that fact that Jesus is ours, he is our father, he is our friend, he is our healer, he is everything we need, that praise begins to swell up inside of us.  And it'll start changing situations for you. It'll change the atmosphere, not only of your life, but it has the potential to change the atmosphere in your home and in your surroundings. Just that little bit of praise that you give, it opens the doorway for the Holy Spirit begin to move. Yes, it does. And then he says in verse eight, who is this king of glory? Oh, I'm glad you asked. He's the Lord. He's strong and mighty. The Lord, he is mighty in battle. So guess what? When he comes, number two, he's gonna fight your battles on your behalf. And that's why you don't need the gate and the wall anymore because you have a warrior king, the Lord Jesus Christ himself, that Revelation 19 tells us that when he reappears to come and set everything right, he doesn't appear as will soon be celebrating on Palm Sunday, humble, meek, gentle on a donkey, but he comes with a robe drenched in blood and a sword proceeding on his mouth, riding victoriously on a war horse to wage war and to defeat his enemies. And you have that possibility right now. You know, I truly believe, Pastor Gary, you were talking about how people going through different things right now. I believe that this is your finest moment and here's the reason why. It's easier to break the gate when you already feel broken down. It's easier to remove the lintel. It's easier to lift your head. And I know some of you are saying, I don't know what you're talking about. I can't get my chin off my chest. Well, that's the enemy because he knows that if you lift up your eyes to where your help comes from, that you will stay where you are, but I wanna encourage you right now. I don't know what you're going through. I don't know what has broken down the walls of your life, but there is a mighty king ready to fight and do battle on your behalf. And I just wanna encourage you right now, whatever strength that you can muster. Pastor Myra, just have them to lift up their heads and just look to their father, lift up their heads and say, daddy, pick me up. Yeah, yeah, he will fight on our behalf. Sometimes it's tempting to fight in our flesh, but the word says the weapons of our warfare, they're not natural ones, but they're mighty through God. He will fight for you. We have to get out of the way though and allow him to fight for us. It's important that we allow him. Some of you were fighters before you came to Christ. Some of you were not. I was not a fighter, but God had to teach me how to fight. When I say fight, me fight, it's allowing God to do the work, being willing for him to do the work. And when we do, we always, that's a guarantee, we always get the victory. And I like victories. And you know, where revival is breaking out in college campuses, in churches, around our nation and around the world, worship is the key ingredient. It's when people are entering into worship that the king of glory, the kavad, the weightiness of his presence is descending. That's why we love to make worship such a key ingredient of this move your mountain program because we know that his presence is what we need. It's his presence that's gonna come and fight your battles. You know, I see so many people that come to church and during worship their hands are folded like this, or some people think that the worship service is the half an hour waiting for everybody to get there. No, no, no, no, that's the time when we come.  And when we do, the king of glory will come and he will come mighty in battle to fight for you. I think of Moses when the Amalekites attacked and he said Joshua out and God said to Moses, go up on the hill with Aaron and with her and as long as Moses lifted his hands, they won the battle down on the battlefield against the Amalekites. Every time Moses got tired and lowered his hands, the Amalekites would win.  Amen, you know, I think that if you adjust this week when you go to church, even before that, but especially when you're on your way to church on Sunday morning, if you would just start praising God, setting that atmosphere, you might say, well, our church is so boring to go to on Sunday morning. Our worship team just doesn't have the stuff together. Well, it starts with you. It doesn't start with the worship team. Just like Pastor Gary said, it's not just a waiting time for people to get to the church. You should be ready for battle when you go into church. I remember the Israelites, they sent Judah first out to battle, they sent the praisers, those that were preparing the way with praise and worship. And then what happened? God showed up and he fought the battle for them and he won the battle for them in your churches, in your homes, praise the Lord, praise God. Set your heart to praise. Forget about those things. There's a song that says, forget about myself. I concentrate on him and I worship him. We need to forget about ourselves. Forget about those things that are going on and start focusing on the Lord, focusing on the victor, the one who has won every single battle, the one who will not fail you. He never has and he never will. And when you go into church and you go in already praising before the music even starts, you are gonna see, there is going to be a difference in that service on a Sunday morning.  This is saying, we don't want you here, King of Glory. I don't want you in here. And I think that there's something really significant. It's funny, I was literally just the other day. Actually it was this morning driving here. I was wondering, I was like, I'm gonna look up. What's the significance of Moses lifting his hands? It's just insane. And as Pastor Gary was sharing that, I felt like I heard the Holy Spirit say, Moses was a gate. The victory that already existed for the people of God in heaven was released into the earth through Moses being willing to open himself up. It wasn't the savvy warfare and strategies and schemes of Joshua and the other Israelite warriors. They were all just delivered from slavery. It was literally the gate of heaven being opened and poured out through Moses to come and to bring victory for people who didn't even have their own weapons until God drowned the armies of Egypt in the sea. And so I don't know what battle you're facing. I don't know what's going on, but I dare you.  If you could just lift your head and become that gateway, that portal to heaven to let the mighty King of Glory not just come into your situation but to bring victory through your situation. Oh my goodness. You don't have to try to figure it out. You don't have to call all of these other people.  Oh ye gates and the King of Glory will come in. Am I talking to any gates today? Am I talking to any doors today? I know there's some of you. The enemy has stolen your song. You've been quiet. You've been silenced. You've been depressed. But you're hearing this message today and it's time for you to arise. There's a passage of scripture that says lift up your hands that hang down. Pastor Maher, there's some folks whose hands have been hanging down. Yeah, yeah. And he said, strengthen your feeble knees. We have to do that Lord. I think about, Jesus told the woman at the well, they that worship him must worship him in spirit, out of our own spirits and in truth. As we lift up God, as we allow him to work, he will give you that victory. Now we do have to resist the enemies, steadfast in the faith, in the faith. What we believe, the Word of God, believing God for it, God will fight for you. Amen. So if you're going through a battle right now, why don't you call<PHONE_NUMBER>? Hey, maybe you want to just say that prayer, partner. I don't want you just to pray with me. I want you to praise with me. That's good. Come on, just lift up your hands today.  That you're going to get on offense. You're going to stop playing defense. Be a praiser. God's put a song in your heart and in your spirit and let it out. Shout it out today.  Who is this King of glory? He's the Lord of hosts. He is the King of glory, Sila. Say, wait a minute, he just said that. Yeah, he did. In the New Testament, what he says, verily, verily, what he's really saying is, whatever's next, you better get this. Underscore this. Get your yellow lighter out and just, come on, make sure you don't forget this. God's not only saying a verily, verily, a surely, surely here, he takes the whole two verses and he repeats them now a second time. And I think he's saying as clearly as he could say, understand this, this is a key principle in your life. It is, you know, and I love that Pastor Gary because we need to get that. We need to get the fact that God demands our worship. He desires our worship. He desires our praise. He desires us to not look at our circumstances, not look at the things that make us downtrodden and depressed and discouraged and look to him.  Why are you staying in that place of depression? Why are you staying with your head hung low when all you have to do is begin to praise him, begin to adore him and worship him? I know, I've been there. I have those experience. I've been down before, but I know when I get down that I have to look up because that's where my source of help comes from. He's the one who is our strength. So if you're battling with something today, if you say it's something that I can't do on my own, you're right, you can't. Only Jesus can, only God can fight that battle for you. You begin to praise, you begin to call, you might not feel like it. That's okay, praise him through that. Do it regardless of what you feel like. Your feelings are fleeting. You'll find that out as soon as you begin to praise that your feelings are fleeting. But you begin to worship the Lord.  And you are going to see things change. Your attitude is gonna change. Your feeling of being down and depressed is going to change.  I'm telling you today, you need to give it to the Lord.  Listen to what he's saying.  If you everlasting doors be open and let the King of glory, he will come in. Yeah, yeah, yeah. And we have to be determined not to be silent anymore. We have to be determined to give him glory. You may have to say it over and over again. When the enemy comes in like a flood, give God glory. That's right. When the enemy comes at you with thoughts, those things, if you allow the adversary, he will press you down with those thoughts. But we have the power in us to take those thoughts captive. When I think about a captive, I think about something that I have to go after or someone that I have to go after. Well, listen, you may have to go after those thoughts. Those thoughts that come, God will overcome those through the power of his words. So go on and quote what the word says. You may only know one scripture, but say that when the negative thoughts come, when you feel down, give God praise. It may be this one that we're talking about today. Lift up your heads, O ye gates. It may be just that verse and you just combat the enemy with it. Listen, victory is yours already. Victory today is yours. Amen. Think of blind Bartimaeus.  And the people, the disciples, and they say, shh, shh, be quiet, be quiet. They were the founding members of the cancer culture. And he said all the louder. Jesus, if the enemy is trying to shut you up, I say all the louder praise him. Amen. And you know, you might be sitting there right now and saying, well, you don't know what I'm going through. You don't know how hard it is. Can I give you a picture? Two Psalms previous to this is Psalm 22. And as we get ready for Resurrection Sunday Easter, we know that one of the seven last things that Jesus said while he was hanging on the cross was, my God, my God, why are you forsaking me? And there's been many people that have said many things about that, oh, the father turned his back on Jesus or this, that or the third. But do you know what that line is? It's the first line of Psalm 22. Even in his moment of greatest anguish, embarrassment, brokenness, sorrow, hanging on a cross, slowly suffocating to where he literally did not have the air in his lungs to hardly say a thing. And he literally could not lift his head up. Jesus still found a way to worship. So I want to encourage you right now, even if it's just a hand, you don't have to get the whole song out. Jesus, he got the first line, but that's all he needed to do because he postured himself to be the gate that he was intended to be. He knew that what he was going through served a greater purpose in God's will and God's design for his life. And I don't know what you're going through. I've been through some things. Everyone on this couch has been through some things, but we've all come out on the other end and seen how God was doing a greater work in our lives. And so I want to encourage you right now, don't fixate on the pain. Don't fixate on the crucifixion, the suffocation, the embarrassment. Fixate on God.  You ancient gate. And like Pastor Myra said, that's why this song repeats itself because you don't have to say much. You just have to say a song. And so I encourage you, I encourage you to just find that song, let it rise up out of you and watch the King of Glory come in. Well, we better put this message in power and demonstration. We better go over there and lead us into some worship. If you need prayer, remember prayer partners are available. Make sure you get your communion elements together. Why don't you join in? Pastor Rebecca is going to sing a song you probably know very well. Blessed assurance. Battles for us. You know, Mary, she called, she was battling diagnosed with carpal tunnel. She had severe pain in her hand and in her wrist, she called the prayer line, a prayer partner prayed for her. She was completely healed of carpal tunnel and all her pain is gone. God fought for her. For him to fight voice, lift up your hands in worship. And I believe the Lord worship and praise him. Amen. And you know, we're talking about gonna be taking communion and celebrating Jesus. That is something that we need to praise him about. We need to not just let it go by as just a form, something that we do whenever we gather together here on Move Your Mountain. But we need to understand that this is Christ's body and blood representing Christ's body and blood. And what he did for each and every one of us on Calvary is amazing, but it didn't stop there because he rose again on the third day, conquering death, conquering hell in the grave. And I'm thankful for that today. So if you are in the midst of a battle right now as Pastor Gary said, you begin to praise him. We're taking communion. And this is just a remembrance of what Jesus has already done. It's already finished. He's already conquered your battle. Just give it to him today. Amen. You know, and I feel like some of you are wondering why Jesus hasn't shown up yet. Can I just challenge you right now? Have your praise shown up yet? If we're the gates, and I believe that, and the presence of the King of glory isn't in our situations, have we opened the gates yet? Have we let him in yet? It's true. And I think a lot of times in our culture, we wait till God shows up and then we'll praise him. But I believe that in this hour, and we're seeing it at revivals all across the nation right now, people are opening themselves up to the King of glory and the King of glory is showing up just like he says in his word.  There's something that's drawing me. It's pulling me closer. I don't know what it is. That's the presence of God that is here in this environment and atmosphere that has been set with worship and with the Word of God. And before we go one more step, before we take the elements that symbolize Christ's broken body and shed blood for the salvation of mankind, I wanna give you an opportunity to give your life to Jesus. This is the key to opening up the gate in the first place. We're gonna get the rust off of the door right now and you say, well, how do I do that? Well, it starts with surrender. And you say, Lord, I am a sinner. I acknowledge that I have fallen short of the glory that you have ordained for my life. Romans 3.23 says, all have sinned and fallen short of the glory of God.  But right now, you say, I'm a sinner, but you don't stay there. Because Jesus didn't die to keep you as a sinner. He died to make you a saint, a son or daughter of the Most High God. And so you say, well, how do I get there? Now you invite him. And you say, King of glory, King Jesus. Will you come into my life? Will you become the king and ruler of my life? No more am I gonna do things my way? My once, my, my, my, it's what do you want, Lord? Show me the way you want to go. Lead me into battle, lead me into victory. Lead me into those eternal gates called heaven. I confess my sin, I acknowledge that I don't deserve it, but God, I also acknowledge that you have freely given it and I receive it right now. I receive your life right now. I receive the cleansing of your blood and I receive the healing by your broken body into my life right now. And I ask you to change me and make me new in your name. He says, behold, I stand at that door and I knock, but the doorknob's only on the inside. He's waiting on you. He's waiting on you right now. Just to open up to him, to allow him to have his way. You were made in his image after his likeness and he wants to be a greater part of your life. So just let him, just let him. If you have your communion elements, let's get them now and let's partake. Would you pray? Father, we just thank you God that you are all sufficient for every need that we have God in Calvary was just one of those proven grounds of that Lord Jesus, that you were able to handle the pain, the agony, the shame of Calvary God and that you did that for each and every one of us God. We just thank you Lord, you are powerful. And Father, we just praise you for your body and for the blood that was shed for each and every one of us that we can be healed, set free, delivered and have assurance that one day we are gonna see you face to face God for that total and complete victory that we all desire. God, we thank you for your sacrifice at Calvary and we remember your love for us at Calvary in Jesus' name. Take your bread, your cracker, eat of it now and be healed in the name of Jesus Christ. We just command all pain to go from your body right now. There's someone, your stomach has just been, I think you've been battling ulcers. It's caused just your whole digestive tract to be off. You've not been able to eat, you've not had an appetite. Right now the Lord's healing your stomach of those ulcers in Jesus Christ's name. Thank you Lord. And there's someone watching right now, you've been plagued by doubt. You've been plagued by doubt and fear and the Lord is saying to you today that you will have to change some of your people, places and things because they are contributing to that doubt. God is saying to you today, trust me, trust me and watch what I'll do in your life. Let him have his way. If you're struggling with fear right now, I just encourage you to lift up your hands as a sign of surrender, lift up your head to heaven right now. If you're struggling with fear, we're gonna chase fear out right now and we're gonna replace it with perfect love because 1st John 418 says fear is driven out by perfect love, perfect love casts out all fears. And so right now we want you, you are perfectly loved. You are loved by the perfect father. You are loved by the perfect son. You are loved by the perfect Holy Spirit. You are loved with a love that is perfect and you are perfected in his love right now. Fear has no place, fear must go, fear must flee because right now the love of God is washing over you. It's cleansing you, it's flooding into every fabric, every area of your being right now. Every nook and cranny of your life is being overwhelmed and overflowed with the love of God and fear has no place anymore because perfect love casts out all fear in Jesus' name. Make your cup now, take and drink and be washed and cleansed by the blood of the land. There's a healer in your house today.  He's arising with healing in his wings. He is your Jehovah Rafa, the Lord your healer today.  I would encourage you today. You begin to praise the Lord and give him the glory for the battle that he has already won. You have not lost that opportunity. He's still going to bring you deliverance. That's right, that's right. Hey, this is the greatest miracle of all, Joan, 25 years young. Wow, from Albrightville, Pennsylvania, gave her heart to the Lord very first time. Very first time. Welcome to the family. There's a party going on in heaven. Thank you, Joan. My daughter's talking to me about Joan of Arc today and I don't know if you're watching right now and if you know anything about Joan of Arc but Joan of Arc was known for hearing God and I'm believing now because you've opened up your gate, you've let Jesus in. You're gonna start hearing God and so you're gonna wanna make sure that you're under spiritual covering of good, godly, biblical men and women and so if you haven't found your way, you can call<PHONE_NUMBER>. We can try to help navigate you, get you in a good place where you can help to cultivate that ability to hear God in your life.  It's gonna be shocking to you but wait and see how well your life is ordered as you get your marching orders from the King himself. If you're blessed by programs like Move Your Mountain and you would like to see them continue, we have a whole lineup of programs we produce here in-house as well as our national programs. Many are on every day, some on once a week. We cannot continue to bring them to you without your prayers and your partnership. I'm gonna give you our address and ask you to prayerfully consider sowing a seed, whether it's a one-time gift or a monthly gift. If you've made a pledge during one of our fundraisers, our Vision of Hope fundraiser earlier in the year, please be faithful to fulfilling your pledge. Our address is CTVN, Cornerstone Television, One Signal Hill Drive, Wall, Pennsylvania, 15148-1499, Cornerstone Television, One Signal Hill Drive, Wall, Pennsylvania, 15148-1499, thank you, thank you for supporting this ministry, the good news of the gospel. Well, we've been talking about worship and praise this whole program, how that is what opens the gates. So please join Rebecca as she sings for us, believe for it. This mountain can be, they say these chains will never break. They don't know you like, there is power. Pastor Rebecca, there's a lot of people believing, it's altered today. Amen, because we know that God is a God of what seemingly impossible in our lives, He can do it. And I am so thankful that you have called in, that you've written in, and we're just excited to pray and believe with that. We need to take the limit off of God today. That's right, that's right. We're talking about the God who knows the end from the beginning. So trusting in Him, that He's going to work out everything we need to have done. And we pray together for God's will, His perfect will to be done in your life. Amen. Sometimes I wonder if we're not the limit for what God wants to do in our lives and through our lives. And today's teaching was just so spot on and so poignant that when we're willing to open ourselves up, even to the point of destroying our own outer defenses. And I believe that's why a lot of people don't really ever get into worship or get into prayer or get into church or into serving or whatever the case may be. And I just want to challenge you, as we get ready for Resurrection Sunday, let's open ourselves up to the power of God. Let's say I'm taking down all of my defenses. I'm going to be open for what God wants to do because it's not just this text we all have seen in our own lives. How when we let God in and He does what He wants to do, I mean, Pastor Gary and I, we were talking just a couple of days ago was the two year anniversary of me having a stroke. And on the same day, two years ago, just a couple of days ago, one of the leaders in our church, their father had a stroke. And in the same way I walked out of the hospital two days later, their dad walked out of the hospital two days later. What might God be ready and willing to do if we just open ourselves up to Him? The same spirit that raised Jesus Christ from the dead. Think about that. Lives and dwells in you, in you. So come on, let's pray, release your faith right now. Would you be good? Thank you, Papa. Father, we just thank you God and we praise you because we can trust you. We can say we're gonna stop holding back. We're gonna stop letting ourselves get the better of us, God, letting us get in our minds, but we're gonna open ourselves up to you and we're gonna let your glory and your power in our lives, God.  So as we're praying together right now for each and every one of these needs, God, I pray that you would intervene in each life. Lord, you see the need. You know where there's healing needed, God, whether it be cancer, whether it be diabetes, a heart issue, God, whether it's back issues, God.  And I pray right now that you would bring deliverance and healing in those that are needing it today, God. Lord, we pray against every addiction. We pray against those things that try to overpower and overcome our minds and our attitudes, God. And we ask that your Holy Spirit would just come in and saturate that you would break off of us those things that Satan would like to keep us bound in and, Father, that you would give freedom to your people. Lord, I pray for family relationships, God, that you would bring restoration into family's hearts and lives, Lord Jesus. And, God, I pray that as we gather into our churches on Sunday or the midweek service, whenever we gather together with one another that we would have our mind in unity in one accord to praise and worship you, to honor you with our words, to honor you with our actions, with our behaviors, God. Because you truly deserve every bit of glory that you can receive, God, that we can give every breath that we have, Lord, is yours. And so, God, we just thank you and praise you for what you are going to do in meeting each and every one of these needs. In Jesus' name, amen. Praise you. Father, we thank you for each and every one that exercised faith to call in, to write in that you would have your way in their lives. And that one who's been waiting on you to respond, we pray now that they will not give up on you, that they will hold on to your hand, hold on to your word because they are trusting. Today has said trust and praise, trust and give you glory for what you're going to do. And we pray for each one now. And we thank you for each one, their victory in you. And Father, God, I not only pray for the meeting of needs that are represented by so many requests on this table right now, Lord God, but I pray for a release of joy and a release of pleasure, Lord God, that you're not just trying to get them to wear their heads above the water, but you're trying to get them on the beach, enjoying the sun and time in your presence because your word tells us that in your presence is fullness of joy and pleasures at your right hand forevermore. And so God, as we enter your gates right now with thanksgiving and your courts with praise, we come into your presence, God, and we ask you right now to let every sinful thought just fade away. Let every addiction, let every disease, let every broken relationship wounds emotionally and spiritually, deep pain in people's souls and bodies just melt away, just evaporate, Lord God. Let the glory of your goodness eradicate every unfit thing in your people right now and let them enjoy your presence. Let them have pleasure, God, at your right hand because they are yours and you are ours. God, we thank you today for allowing us to enter your presence in Jesus' name. Amen. There's someone, your sciatica's been inflamed, creating tremendous pain down your lower back and legs. I just say, be healed in the name of Jesus. Someone else, you've been tormented. Like just feeling like there's mental illness, confusion in your mind. Be delivered in the name of Jesus Christ. Someone else, I think you've had an infection in your tooth and gums, creating tremendous pain all the way up through your ear. Be healed in the name of Jesus. Receive your miracle today.  Be lifted up, you everlasting doors and the king of glory shall come in. Who is this king of glory? He's the Lord, he's strong, he's mighty in battle. He is your king of glory. Oh, we hope you were blessed, encouraged and ministered to by today's move your mountain, have a blessed day in the Lord. When Laura called our 24 seven prayer line, she had so much fear that she didn't want to leave her house. She had lost her husband of 54 years, just six months earlier. Laura was flipping through TV stations when she came across Cornerstone Television. She felt compelled to call. One of our prayer partners talked, listened and prayed with her for 45 minutes. At the end, Laura said how much the ministry had helped relieve her fear. Praise God for how he's using CTVN. 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Welcome to Access to Trader, the number one community for those who are committed to taking control of their trading in order to achieve success, profitability, and longevity. Thank you for joining us. Here's Dan Shapiro to help you find your edge, master your process, and own your future. Hey, guys. Good evening, everybody. Welcome to another edition of TheAx is a Trader.com weekend update show, just a crazy, crazy week. I think that's the best way to describe it. We'll get to that in a second. Again, just as a reminder, I want to thank everybody who really want to take a serious step for longevity in their trading. Really, really good initial turnout for the August 24th third installment of the PS60 workshop for all you guys who are taking part. Please watch, and it's included in your third installment, but please watch the second installment all the way through. It's going to make it easier to adjust information because you'll already have a foundation of what these pivots are, what they're not, and how to use them with the all new content that is added to the workshop. It should be really, really good. August 24th, 9am Eastern time. So, all you guys who are attending, please, please, please watch the second installment, which is included in the new workshop. So, hopefully everybody is doing well. Hopefully everybody has a phenomenal weekend planned or underway. We're just living our lives.  So, let's talk about this week. You had a Fed, right? You had a Fed date, Powell 25% basis cut, all that good stuff. You had Trump 10% tariffs on the line. You had a 50% surge in the VIX, and you had one of the most aggressive sessions back half of the week that I can remember probably in the last seven years. And that's really should speak volume how aggressive it really was. Monday, Tuesday, Wednesday, at least the first part of Wednesday was business as usual, right? Complete business as usual. Everything was fine. Pivot's working very seamlessly, very good. And by the afternoon, by the time Wednesday rolled around, I was already pretty much done the day. I just don't like trading in the afternoons because the ranges always contract.  So, the setup that you could possibly get in the afternoon that could be good for 30, 40, 50, 60 cents, that same setup the next day in the first several hours can get you two, three, four dollars depending how aggressive the measure potential is. So, by Wednesday, I was kind of done. I was at a pretty decent day, and I was done and you had the comments coming out on the Fed comments. I believe it was the first caught in about 11 years. I believe that was the comment again, if I'm wrong, I'm wrong. But again, initial reaction was kind of muted. Nothing was going on.  The next thing you know, the floodgates completely opened, really, really open, and you saw a 350 point reversal very, very aggressively. And what was the key for the rest of the week was not what happened on Wednesday. It led to Thursdays and Fridays session. And I'm telling you, the last two days of the week, I had an incredibly difficult time in gauging market risk. And we'll talk about that in a second. Many of my friends, and again, some of my friends, most of the guys that I continued to have pretty good relationships with now at this point of trading anywhere between 15 and 20 years, I think that's kind of the cycle. And the moral of the story is, what they saw, and what I saw, and what I went through, especially on Thursdays session, was a perfect example of what happens when macro news hits and market structure fails you.  I don't care what you're trading. I don't care if you're trading pivots or baseball cards or anything in between. The market structure will put you in a situation that you're not used to, that's going to make you very, very uncomfortable, and it's going to compromise your risk. And that's very, very important because when I'm trading, I know ahead of time where these supply zones are, where a measured potential move can start with stop and everything in between. If it's pivot stalls, I know I have a couple of minutes to kind of make that adjustment on the fly and you can use break even as my stop or take a loss. And when you have macro uncertainty, again, the Trump headline, right, 10%, China tariffs, all that good stuff, you know at any given moment, China's going to strike back. They're not going to just sit back and say, well, yeah, everything's all right, you know, you're fine. It's a fair deal what you're about to do. No, no, you know it's coming. You know something aggressive is coming. You combine that with the PAL comments, right? And the market obviously didn't like those comments or the action of the Fed, which I'd obviously sought 350 point decline. Okay, you started seeing slowly but surely a market breakdown in structure. Okay, why is that important? Okay, if you're a guy like me, I trade beta, Netflix, Tesla, BYMD, if I actually put it in there, right, Amazon, Facebook, Square, all that good stuff, right? All that good stuff that I trade every single day, Nvidia, Alibaba, all that good stuff. The problem is when you get market structure breakdown and you have a macro cycle of uncertainty, Fed, tariffs, all that good stuff, right? A surge in the VIX, right? 4%, almost a 4% loss weekend on the NASDAQ 100 on the comp, right? You're going to be in a position of weakness compared to a weakness of strength that I'm always used to. And if you saw the action from the Fed date on Wednesday into Thursday session, Netflix was trading at one point, I would say between 75 cents and a dollar wide, 100 share lots on both sides. Amazon at one point was trading between one and a half to three points wide, 100 share lots both sides. Now, why is that a problem? Okay, if you're trading 50 shares, 100 shares, 200 shares of Amazon, okay? It's usually no problem on a normal session, 300 shares, whatever case may be, whatever your size or accounts, it's nobody's business but your own. Okay, the problem is when you get a wide market, a thin spread, right? A thin spread wide market and you are one headline away, okay? One headline away of getting destroyed. If you go short Amazon with that type of spread and something good comes out, you are losing $7 to $10 instantly, instantly. It's not even a thought process instantly. If you are long the stock and some more news, some more negative news comes out, they will spread you down $1 or $2, $3. So it's impossible. It was absolutely impossible from Wednesday afternoon. Again, I didn't have any exposure to Wednesday afternoon to that whole sell-off, so I was okay with that. The problem going into the next day, I knew uncertainty was still there. We talked about that in the live webinar pre-market strategy. I always know what kind of session is going to be based on value. So what did Wednesday session do? Wednesday session, and this is the Wednesday session here, created a lot of technical damage in charts all over the place. Again, I don't care if you trade beta, small, whatever you traded, nothing was spared. And the problem with Wednesday's close, the NASDAQ 100, the QQQs and the elements in there, they close right in the 50% of the range. So what that means was going into the next session, you have technical damage. You have technical damage occur, not only in the indexes, but every single stock, especially in the NASDAQ 100, resembled what we were seeing on the QQQs. So they close right in the middle. So the next day, I knew, even though we had technical damage, we still kind of held this rising bullish demand. But it was a 50-50 proposition going into the next day, which obviously sent them advice to the sell side. So I was prepared to the sell side. Here was where everything that I just talked about and technical analysis and reality kicked in for me the next day. I lost money on Thursday. And I lost money on Thursday. And here is the question, and here was the question I asked people in a live webinar. I asked it on social media. And the question is, why is conviction sometimes your worst enemy? Well, here's the example, right? So we went through all this thing in the last couple of minutes, technical damage, uncertainty, macro uncertainty, Fed, all that good stuff, right? All that good stuff, 50%, 50% bounce back from the lows, 50-50, everything's in the same channel. But we knew the market was getting soft. Here's where everything that I talked about came into play. So I've been talking about this close on Netflix. And I've been saying this the whole week. I said any close below 324, it should get down to about the 312 area, right? 324, again, because if you believe in the theory of stocks trade from supply to supply and demand to demand, then if you look at the 60-minute chart, right? If you look at the 60-minute chart, and again, you see how it came down here to 312, right? So what's the problem then? You shorted the stock and went down to 312. Yeah, I shorted the stock. And I had a lot of conviction in the trade. And the one thing I say to every new trader, every single day that I wake up in the morning, I have a plan, I have an opinion, I know sentiment, and I'm waiting for my confirmation. Again, I am not smart enough, and nobody's smart enough to predict the move until confirmation starts. So everybody can save their opinions.   My opinion doesn't matter until it confirms, right? But I had so much conviction on Netflix on this trade. I knew when internals are breaking down, structure is breaking down. I knew everything was in my sweet box. And I knew if the stock would have confirmed, I knew there was a potential of a 10-12 point move, right? Everything was good. Had a lot of conviction. I also say every single morning, okay, and this is kind of one of my biggest pet peeves. When you have no expectations, right? I come in every single day no expectations. I don't know if I'm going to trade eight times. I'm going to trade two times. Well, I'm going to sit it out, right? I don't know. But I always say when you have no expectations, okay? You have no disappointments, right? You have no disappointments. And that usually slowly but surely takes away emotional commitment to any single trade. The problem was I had a commitment, okay? I had an opinion. I had a bias. And I knew, and I knew any close, right? Any close below the five-day moving average of $3.24 was going to send the stock lower. I knew it. I was talking about it for three days in a row. This was my primary look, and the stock closed at $3.23. This was my trade, right? This was my trade. I didn't care about anything else. So what happened, right? So what happened? So market structure is breaking down. It's trading very, very wide. So I get short Netflix. I talked about this whole day on Thursday. Again, it wasn't the money. It was the point that my conviction let me down. It was the point that market structure let me down. And it was the point that I broke a very, very basic rule when I trade. And that rule is once you get cash flow, use breakeven as you stop, right? Again, there's no guarantees. You're going to see a full move, full measure potential, and you move. So no matter what, I always tell this to new traders. Once you get cash flow, breakeven as you stop, hella high water.  You have to use breakeven as you stop. So I short Netflix, right? I short Netflix and it goes down very, very quickly, say a dollar and change, right? About a dollar and change. And I'm thinking to myself, this is it, right? This is it. I have zero reason to cover the stock. The market is getting weak, right? The sentiment is souring. All this uncertainty. You know China is coming out. What a response to Trump. I have everything lined up. The expectation is through the roof. The conviction is through the roof. So I don't cover a single share. And what happens after that was some sort of news came out, okay? And I didn't use breakeven as my stop. And here was the problem. The stock started spreading out. And the biggest thing for me is I always say to myself, if I can control a trade, that means that things will be all right. Win, lose, or draw on the trade. But if I have the ability to control the trade, I'm going to be okay. So I had the conviction, right? Had the sentiment, had the opinion, had the trade. Now I'm waiting for the big payday, right? I'm waiting for the big payoff for the market guys to tap me on the shoulder and say, good job, great effort. You did the right thing. And none of that happened because they spread me out. And before long, I was looking roughly a little bit less than a two dollar loss. So I went from being up a dollar and changing the trade. It didn't take any off because of my conviction. Again, this is where I kind of like conviction let me down. And then market structure because it got so depleted. That was my, that kind of made me roadkill. Now again, I wanted to be losing about $1.70 on the trade, okay?  Well, $1.70 for me, it's a big deal. Okay, it's a big deal. It's a big deal. Maybe relatively speaking, certain people, not certain people sell, but the point is I lost that money, right? And the problem was I was not in control of the trade. Once they spread me out a dollar, no liquidity was in the trade. I would just sit there literally like a deer in headlights. And this happens to me once or twice a year when you start trading in a macro cycle that you have absolutely no control. Okay, there's no control. Technical analysis does not care when you see a macro headline coming out and you're on the wrong side of the trade. It doesn't care, okay? It doesn't care because fewer participants are taking part when technical damage is occurring, when macro channels are expanding on thinner volume.  The problem was when technicals start breaking down, okay? And the structure, market structure starts depleting. That's the time I learned a very, very valuable lesson. It wasn't a month, okay? The money was, I took a solid loss. Don't get me wrong, okay? But the point is the macro structure let me down. And the one thing I always say to new traders, okay? I could show anybody how to trade a pivot, how to control a pivot. Normal days, everything is fine. The problem is when you have, when you've lost control of the trade because of all these exterior forces, you have to be an adult and stop trading. Very, very important, incredibly important because again, everything what we do is confidence, process, right? And staying in control. And at that juncture, I was completely out of control, right? Completely out of control, not emotionally. Emotionally, I'm always fine. I'm always very, very calm when I trade. But I wasn't in control. And the lesson here is any single time, folks, okay? Any single time you see more than one macro event, okay?  You could be the smartest trader in the world, the most sophisticated technology you're using. You could have this incredible algo on your side.  And the problem with that is it spilled over into Friday's session from the macro wise. Again, it made back some money on Friday. So it wasn't, it wasn't horrible. And I also made back some money that day. Trading BYND gave us a really good $1.52 move in 30, 40 seconds after that initial pivot. So the point wasn't the money. The point was that I was participating even though all these forces, right? All these forces are right sticking in front of me. And the key to becoming a better trader.  And we always say this, we are the only ones that could shoot ourselves in the foot. We're the only ones. The market's going to market. This doesn't care if it's wide, if it's spreading, if there's a macro event going on, it doesn't care that you want to trade. It really does. The market's job is to take your money, okay? Because again, the way market structure is presented to you, people are not designed to trade every day. That's why people are called, you know, that's why it's called investments. It's not called trading, right? Trading is 25, 30 years old, okay? There was no trading 30 years ago. The last public going to wake up in the morning and say, well, I don't have a job. I'm going to create my own job. So this is all new, right? This is all new. We're all learning as we go along. But the one thing I always tell traders, before we try to make you a better trader, we want to make you a smarter trader, right? We want to be smarter traders.  I probably shouldn't have participated. It's an isolated incident, right? Maybe you'll last one, two, maybe three days. But again, market structure will return, premium hands will come, and the most important thing is I will be solvent.   It's a very, very hard game to play. So, you know, this is one of those weeks that Monday, Tuesday, and Wednesday were fine. Nothing wrong with it. Thursday, I was just wrong, okay? I was wrong, I was too aggressive when I should not have been in the market. And guess what happened, right? Guess what happened two hours later, right? You had a market going from up 350 points. And by the way, I can't tell you how many of my friends came in short from Wednesday into Thursday, right? The Dow Jones made back all their Thursday losses in the first hour, which basically had everybody covering at the top, okay? Everybody covering at the top. And I can't tell you how many guys I know bought that first dip. And what happened? The Dow went from up 350, right? The Dow 280 in the next hour. So, the bulls got killed, the bears got killed, the bearish bulls got killed, the bearish bears got killed. Everybody got fisted. And the moral of the story is, again, we learn from our experiences. That's why folks, again, for all you traders who believe that you could work 15 minutes a day and don't care about screen time, because, again, it doesn't affect you. Eventually, it's gonna affect you. And the last thing you wanna do is keep on repeating the same mistakes over and over and over and over again. So, the lesson here, guys, again, we're not smart, we're reactionary creatures that are trying to stay in control. When you have this aggressive market interval, and again, this will probably go away by Monday, maybe Tuesday at the latest. Again, people digest information very, very quickly. Even the most aggressive distribution cycles that have channels kinda contract, they go away after three, four days. So, I'm assuming everything will go back to normal Monday, maybe Tuesday at the latest, okay? But, in the meantime, guys, and this, again, speaks to myself, gotta be smarter, okay? Gotta be smarter, gotta be more responsible, have to be more mature, and sometimes, again, there's a big difference between sitting on your hands and sitting on your hands, because, again, you cannot fight the good fight. Again, you cannot bring a butter knife to a gunfight. It's just, you're going to lose every single time. Again, it wasn't the fact of the money on Thursday. It was more of the idea is that I could have controlled it, I could have said no, but again, quote, unquote, fear of missing out, right? Fear of missing out. Again, we're human beings, we're gonna make mistakes, and to watch Netflix go from literally, and by the way, if I didn't cover it, right, if I didn't cover it, I watched the stock go up six. I literally watched the stock go up six. Only to watch it go down about $7 from where I initially shorted it, like the complete gut-punching experience, and if you would see me, I was literally punching the air. I was very, very calm on the microphone, very, very calm on the live webinar. I was punching the air. Again, I was just so much more disgusted that all this was going on that I just couldn't control. So hopefully, that will be a good lesson for everybody going forward. Again, when you see something that you can't control, please stay out. Other than that, again, Friday's session was fine. You know, I was just scalping away Friday. Scalped, again, Tesla. You know what else I was scalping? Tesla.  But I was just scalping away. I was scalping away. It was fine. You know, I made back some money, but the moral of the story is it really took some life out of me, man. It really did. It really took some life out of me. By the time Friday after the close came, I was, dude, I was a vegetable. My eyes were tearing. I had a migraine. The only thing that saved me was this magical bird with a full disclosure. I'll start by dying on Monday. So let's talk about Friday's session. Again, Netflix broke down pretty, pretty aggressively. Broke down pretty aggressively. Again, again, it wasn't the easiest move. It wasn't the thinnest. It wasn't the, you know, the most, it just so many hiccups because of the spread. But again, 316 build went down to this 31180 area. Again, again, and you can see the reversal very, very aggressively. You had Pinterest and there was two trades on Pinterest. We had in the live webinar, the first one to the upside, 3340, 3330, 3340 to the upside. Again, this is a pretty basic opening range play. Here is the, you know, here is the whole cycle right here. Initially it went up about, you know, 50, 60 cents or so before it came in before it kind of ultimately went up. But this is the sneaky pivot that I think a lot of people did take in the live webinar. I even tweeted this out. There was actually a value play and there were the 32 puts that were trading, they were trading around, I think a nickel, okay? I think a nickel when the stock was like 33 and a half. And I said, hey, if this thing starts building below 3290, you could get a move in those puts. I know some of you guys did buy them and the stock went down to the 3240s before rebounding. But puts went from a nickel to like 20 cents. Pretty, pretty incredible. Okay, so at least I get the idea why so many people love the options markets. There was a two-way trade there as well. Tandem went pretty nuts here at the open. 6750, we talked about, here's a 6750, went to 70 before a pretty aggressive reversal. FTNT, we talked about 8850 needs to build. FTNT, right, 8850, here's the two candles, 8850 needs to build, went to as high as 93. Pretty, pretty aggressive move here. OLED never got up there. And so I'm on a market structure, right? Just to give you an idea of market structure. We saw OLED go red in the day or it was about to go red in the day. And I turn around and say, hey guys, watch that 208 breakdown before I could turn my head. Literally, I mean, this is within 30 seconds before I could just to give you an idea of how market structure broke down, how thin things were. It went from 208 to 203. And then ultimately it went to like the 190s. I would say all this occurred probably in about two minutes. Insane, obviously I had no piece of the trade, but just to show you how aggressive market structure will play out if you're not in control of your trading. BYND, we're waiting for that 182 break that never came. Actually it came, excuse me, it did come, I'm sorry, the sneaky pillar I think I tweeted out was 179. I don't think I put this on the stock to its feet, but it was 179. It actually went up a couple of points. Boeing 338 needs to build for some cash flow. Here's a 338 on Boeing. Actually went to 340 and change. Roku never got up there. Tesla's a decent trade. I caught like, and again, just wasn't big moves. I wasn't trading a lot of size, but you know, give about an 80, 85 cent move. And then I covered most of it. I just wanted to take some cash flow. And then the rest I got stopped. That was small loss, but it was a pretty decent trade. Oh yeah, here's the sneaky pivot I talked about. BYND, 79.50, if the bills can give cash flow. And here's the pivot. Again, here's the sneaky pivots we talked about. So here's the 79.50 right here, right? Here's the 79.50 right here. And nice move. I mean, it actually went to almost 81. So again, good trading vehicle. I do believe there is going to be, I mean, now we have very, very definitive channels here. You can see it from the downside to the upside. Look, I've watched 100 people talk about how expensive BYND is. They're right. Of course they're right. Right? Of course they're right. I mean, I saw all the numbers. The valuation is through the roof. It's worth 60 times more than like pilgrim's price. Look, everybody knows the stocks are going down, right? There's no secret. Nobody's, you know, 60 times sales, everything, right? Multiple, look, everybody knows. Everybody knows it's going to go down. Everybody knows it. You can save your opinion. It's not a stock scam. It's not, look, momentum is the most aggressive enemy of people who don't believe things should play out. Okay? Momentum has been around for ages. When Amazon was trading at 3,000 PE, how can you buy Amazon at 3,000 PE? This was 1,800 points ago. Okay? So companies, there's not a scam. There's nothing to scam. Look, analyst, man, is this the best? There's so many videos this week. I was like, wow, people are really, really taking this to heart. And trade the momentum. There's credits to the upside, trade to the upside. Look, there's a definitive channel here. Okay? If you look at the 60-minute view, you can see it. There's a definitive channel to the upside, definitive channel to the downside. If you look at the daily chart, yes. Can this stock ultimately get to about 140, which is the next measure potential? Absolutely. Okay? If it loses the bottom channel this week, absolutely, guys, 100%. 100%. But until then, okay, save your energy. So many of you guys are so emotional, okay? And this is why I compare this to Tesla 2.0. You want to be right so bad that it's affecting your life, man. Calm down. It's just not that serious. It's just a piece of paper, man. You're either going to be right or you're going to be wrong. You're going to be long or you're going to be short. Okay? It's not that serious. It's just trading. You're about to put yourself in a stray jacket if you're overly so sensitive about the stock. It's just a stock like anything else. Just like Tesla, just like Amazon, just like, what was it? Ice-tea company that went crazy. Just like TLRY. Who cares? Calm down. Trade the stock. Everybody knows it's expensive. Everybody knows the stock will be under 100. Whether it's going to happen tomorrow or the next day or the next month, we don't know. Instead of worrying about that, trade the channels. Take the long side. Take the short side. Once it gives you that green light, and believe me, trust me when I tell you, I'm waiting for that green light to come this week. You will be a 20-star short to the back side. Until then, trade the channels.  Again, don't kick your dog. You know, love your dog.  No reason to get so emotional. Okay, guys? So, going into this week, again, you have to be so biased until the market gives you a reason not to be. A line in the sand on the QQQs this week will be the 50-day moving average. Again, there's no room for interpretation of this channel. Any clothes below 186 on the Qs will go down to here against the whole theory of supply supply and demand and demand. Again, so this is me, the big number of this 186 clothes on the Qs, and that will really pull down sentiment, because, again, it's the laws of physics. Whatever goes up, must go down, even the most aggressive linear market. So, again, guys, August 24th, if you're struggling with your process or don't have a process, I'm telling you, if all you guys have been following me on social media for years, I put these things in real time. Like I said on Friday, 298, 2990s, there's a pivot. You don't want to be long on that. You know, if you want to be long, when that thing confirms, it goes down 50 cents in a matter of a couple of minutes. Again, nobody's looking to, you know, to be right, to be wrong. We're just trying to stay profitable. Guys, God bless you. For all you guys who do want to attend August 24th, the PS60 workshop 3.0, and again, there is an alternative to the normal, and I'd love to show you what that is. Guys, have a great remainder of your weekend. God bless, and we'll see you all Monday. Take care, guys. Congratulations for putting in the time to take control of your trading. You're one step closer to owning your future and achieving the success you desire. Want daily trade ideas directly from Dan? Straight off his personal watch list? Unlock our free PS60 vault, where you'll get nightly updates on pivot opportunities we're watching for the next day's session. Click the link in the description to get started today.


My name is Ann Nott, and I'm Senior Director of Loss Prevention and Risk Minigation with MMCIP. And the topic today for our presentation is religious considerations in the care of a Jehovah's Witness patient, bloodless medicine guidelines. I would like to introduce our speakers. First of all, we have Dr. Ken Tanaka. He is a professor and division head of cardiothoracic anesthesiology here at the Medical Center, Dr. Tanaka. And we have Mr. Guy Stafford and John Johnson from the Jehovah's Witness community who have been very gracious to come here and present the religious perspective, as well as several members of their community. So welcome to all of you. And thank you for letting us use this venue to provide this education. The purpose of this presentation is to fulfill a claim filed by this particular patient that we're going to review as mother. We agreed with our mediation of race consciousness and share knowledge with the medical staff and about the importance of honoring the prohibition against the use of blood products in the treatment of members of the Jehovah's Witness faith. So that said, our objectives today are to provide a brief overview of a surgical Jehovah's Witness patient, discuss components of bloodless medicine, and describe religious considerations related to bloodless medicine in the care of a Jehovah's Witness patient. So we'd like to just do a brief overview of the particular case that this particular claim arose from. This gentleman had a history of poorly controlled hypertension, congestive heart failure, chronic renal failure on renal dialysis. He presented for management of a chronic dissection of the ascending aorta, an aortic root, and had severe aortic insufficiency. As mentioned, he was of the Jehovah's Witness faith and did not accept blood products or blood derivatives, but would accept albumin, cell saver, cryo, salvage, and autologous blood, and that was documented in the record. In preparation for surgery and to respect the patient's wishes, several HNHs were monitored closely. Epigen was administered and he also received oral iron supplementation. He did the complex surgery was performed and intraoperatively the patient received autologous blood, albumin, cryo, DDAVP, factor 7, all in line with the patient's wishes. Initially the patient was hemodynamically stable at the completion of the surgery, but eventually he had increased needs for vasopressors and received plasma light, albumin, and prothrombin complex concentrates. Due to the patient's continued deterioration, though, after that there was a need for platelets. So a transfusion was given after the patient's proxy gave permission. Patient had a PEA arrest, required resuscitation, had severe right ventricular dysfunction, and was cannulated for ECMO. Following these events, the patient was treated for cardiogenic shock, anoxic brain injury, and findings compatible with embolic infarcts on the head CT. Unfortunately, the patient's condition continued to deteriorate, resulting in death, two months post-op. So the major issue that was identified in this case was failure to abide by the patient's wishes, not to receive blood or blood derivatives. So now I'd like to bring up Dr. Tanaka to talk about bloodless medicine. Thank you. Thank you, Anne. And my name is Ken Tanaka, and it's a great pleasure to be here and share my thoughts about bloodless medicine in cardiac surgery setting. So for me, bloodless medicine is a polaris. You know, that's something we always strive for. So this is not only for Jehovah's Witness patient, but all the cardiac patient, cardiac surgical patient, benefit from this effort. That's my belief. And transfusion obviously has some side effects, and we should be cognizant about that. And lastly, there are multiple transfusion alternatives available in the 21st century. So we should be always thinking about alternatives in transfusion medicine.  So obviously, WHO defines it less than 13 hemoglobin for males and 12 less than 12 for females. But obviously, a lot of our patients do come below these numbers, and they are at risk for transfusion during and after surgery. And if you look at the cardiac surgery patient, about one-third of them have anemia, and then 20% of those have iron deficiency, which can be addressed before surgery. Now when a hematocrit goes down, that increased the risk of transfusion and associated mortality and morbidity, especially wound infection, you know, after cardiac surgery. So this is something we should be always considering when we take care of the patient. But one of my junior faculty, Mike Mazefi, and I have done a database study, this is a national database study, of a 20,000 patient undergoing colon surgery. And we found that any, you know, transfusion, even one or two units of transfusion are significantly associated with wound infection. So intra-abdominal infection as well as sepsis. So even in a relatively standardized colon surgery, the risk of transfusion exists. So you can imagine when it comes to cardiac surgery, one, two, three units of red cell can do to these patients. When we think about surgical patients, we always think that the lowest hemoglobin will happen during the surgery, and after the surgery everything should go well if, you know, intra-op management is good. But that's not the case. When you look at this data, the nadir of hematocrit actually occurs in the ICU. That means that patients continue to bleed in the ICU, receive fluids, and potentially receive red cell transfusion. So we should address not only intra-op, but post-op transfusion issues. That's one of the most important points that we should learn from the case that I'm presented. So fortunately, Maryland State has a very good database in cardiac surgery, and we can look at all the institutions in Maryland who performs cardiac surgery and we can look at the data. So this is the transfusion data from these institutions. There's a significant variability in the red cell transfusion between 13% up to 60%. Now, intra-op transfusion goes from 4% to 59%, and it averages 1.7 units. Look at post-op, it goes from 13% up to 39%, and when you look at the mean number of transfusions, it's actually more than intra-op, almost three units of red cells given in post-op. So patients continue to bleed in the ICU, so we have to address that issue. Now, variability, as you can see, from an institution 1 to 10, the general trend that post-op transfusion is more than intra-op, but there are some institutions where intra-op transfusion is much more than post-op transfusion. But overall, when you have patients, those who come in with lower hematocytes get transfused, and for all the institutions, there's a good trend here that the lower hematocytes and then much higher transfusions that goes up to 90% in some institutions. So we really should address pre-op anemia for those coming to cardiac surgery. So I'll show you what we have done in our institution, and this is the data from 2011 through 2017. I joined 2014, so that's the data I'd like to focus. But if you look at the intra-blood usage, 2014 was about 36%. Now, 2017 is 25%. So there's a definite drop in there. So we have made a multidisciplinary effort to reduce intra-blood usage, so that has been shown in here. So all the product, including playlets, Red Cell, FFP, they are all down from 36% to 25%. Now, intra-op transfusion here is 17.5% in 2017. But if you look at the post-op transfusion, it's still higher than intra-op. It's almost 29%. So here you can also see the same trend that post-op transfusion is much more than intra-op transfusion. When it comes to the blood salvage, this is the most common thing that we do. Autologous Red Cell blood salvage, we often call this cell saver. Essentially, you collect the shed blood using anticoagulant, and then spin them down and then separate red cells from other debris, and then collect this in the back, so you get the concentrate of red blood cells. Now, this is acceptable for Jehovah's Witness patient, because this is considered as an extension of a patient's circulation. So this is a common procedure that we perform in every blood-less surgery cases. The issue is that you can concentrate hemoglobin by using a cell saver. But if you look at other components, playlets, fibrinogen, they all go down. So you basically spin them out. So you lose all the coagulation components and playlets by using a cell saver. So when I get one liter of a cell saver, actually, I'm not very happy because we are losing lots of playlets by spinning those blood. So that's not the best situation. Now, another technique is something called isobolumic hemodilution or acute normal bulimic hemodilution. In this technique, what we do is we take the patient's own blood, autologous blood into the bag, keep them connected to the patient for Jehovah's Witness patient. And after cardiopulmonary bypass is done, we return this blood to the patient so we can actually keep playlets, fibrinogen, and other coagulation factors in the bag and then we can return the blood after the heart-lung machine is done. So in the meta-analysis of this technique, there's about 0.8 units reduction in the red cell usage. These are not really Jehovah's Witness patients but general cardiac surgical patients and also there's a reduction in chest tube drainage after surgery. So in a large database of meta-analysis data, there is sort of a good signal that this technique works in most of the cardiac surgical patients. We actually have our own experience of using this technique and especially our patient tends to have large body size and good BMI so we could actually take a lot of autologous blood from these patients. So this is the recently published data in transfusion but we hypothesized that more than 900 cc of autologous blood will significantly reduce allogenic blood usage in cabbage and aortic valve surgery. So these are the data, this A&H is autologous group versus control, age, male percentage, about the same 90-minute bypass most of them work on aspirin but you can see that interrupt transfusion 10% versus 35% in the control and total transfusion 25% versus 45% so there is a significant impact on the transfusion by using high volume autologous technique. And the most important data I'd like to show you today is by using autologous blood you could actually reduce the blood product usage in a post-surgical period there's a significant difference in the post-surgical period so by having autologous blood you essentially reduce the post-op patients' blood loss and therefore patients are hemodynamically more stable and they do not receive any type of transfusion after surgery so it really increased the chance of blood less surgery in these patients So again, large database study by STS, American Society of Thoracic Surgery actually looked at the effects of autologous blood transfusion like we performed and this is a 13,000 case but in the nation only about 17% of this 13,000 patient received acute normal hemorrhemic hemodilution so this technique is still underutilized in most of the institutions but the effect is quite clear in most of the patients who receive autologous blood transfusion actually large body size but the transfusion rate is quite similar to what we have of that in my institution so sign language can drop in the red cell, playlets and plasma transfusions so these are very clear signals that autologous transfusion or acute normal bolimic hemodilution is a very good technique for blood less surgery Alright, so two techniques, cell salvage, it only recovers red cells, A and H, acute normal bolimic hemodilution you can keep all the components, red cell, playlets, fibring, all the blood coagulation factors so I'd like to show you one case here, this is actual Jehovah's Witness patient this is a new case, 43-year-old with a congenital cardiac surgical history, tetralogy of fallow correction at a young age, now she needs a redo pulmonary valve replacement so numbers are great, you know, playlet is 200,000, hemoglobin is 13, she was on the but if you look at predicted risk of transfusion, she would get 80-100% chance of red cell transfusion so this is a very high risk case, so even with a standard technique, I think this case would be very difficult so what do we have to think about, so in the normal patient, we always have a red cell as an alternative or treatment for low hematocrit, profile on latex state, and in 5-inrogen deficiency, reduced thrombin generation, low playlets, we have all these agents to support but in Jehovah's Witness patient, we have very limited support, especially for the red cell mass so I looked at the literature and this case is a very interesting, very successful kidney pancreas transplant and everything went well, but after surgery, patient has splenic vein thrombosis and bleeding and other complications, so hemoglobin goes down below 6 grand per liter after, you know, second day of surgery, so what they did was hemoglobin-based oxygen carrier this is available for compassionate usage, approved by FDA for that purpose it essentially gives a hemoglobin mass, since hemoglobin is in a bag 12 to 14 grand per liter it's a 250 cc bag and half life is about one day so it looks like this, this is the bag, so what they did was when hemoglobin went down they gave three shots of two units or six units of this bag and then when the hemoglobin was recovered to about 6 to 7 range and they continued to maintain patient this way now this patient had metahemoglobinemia but that was treated with methylene blue and a hypertension was also managed, of course the hemoglobin scavenges nitric oxide so that has to be treated with anti-hypertensives and overall patient did quite well and survived this complication so in this particular patient I also contacted FDA for emergency IND investigational drug approval and we obtained that and we were able to obtain 10 bags of hemoglobin-based oxygen carrier that was sent to our investigational pharmacy and we kept them prior to surgery and we actually obtained a consent from patient proxy and then we got ready for the surgery so these are potential alternatives that are available to replace some of the components in surgery so I don't have to go into details but I just want to show you that the pro-thermin complex that actually is a very reasonable source for some of the factors, vitamin K-dependent factors and also we have fibrinogen available so instead of cryoprecipitate we could use fibrinogen concentrate to replace low fibrinogen state so here we have alternatives and then for low hematocrit we have an option to use hemoglobin-based oxygen carrier so fortunately Medical Center supports thromboelastometry at a point of care in the operating room so we have a protocol, we have technicians available 24-7 for cardiac surgery so we can quickly get the coagulation test done at the bedside so we have all these numbers here but I just want to show you depending on different numbers we do different things so when this is a fibrin-specific clot formation so when this goes down we can actually use fibrinogen now when this big one goes down this usually indicates low platelet and we actually use platelet transfusion for normal patient but for the J4-admittance patient we use alternatives and lastly we have a clotting time that will give us indication for the need for the growth of fibrinogen concentrate for normal patient plasma transfusion we also use in this patient cerebral oxygenation monitoring cerebral oximeter that will give the information about oxygen state inside the frontal lobe of the brain so we actually look at this number and we titrated hemoglobin-based oxygen carrier so for here this patient hemoglobin the oxygenation went down and when we gave hemoglobin-based oxygen carrier they actually went up and then again when we gave this agent the cerebral oximeter numbers went up so not only based on the hemoglobin value we can also use other objective parameters to guide hemoglobin-based oxygen carrier so I think this is a very important information that we could use multiple data to think about the indication for hemoglobin-based oxygen carrier or even red cell transfusion for some of the other patients so thromboelastometry was used effectively in this case and as you can see, re-warming time it was these numbers were abnormal actually indicating the coagulopathy so in this case we preemptively acted on these coagulopathy we use a prothermic complex concentrate as well as fibrinogen concentrate as you can see when you give fibrinogen this band goes up indicating fibrinogen is being replaced and also clotting time went from 95 to 68 seconds so that means that clotting has been improved by prothermic complex concentrate so by using multimodal techniques to monitor the high-risk patients I think we can really improve the outcome of these patients so I'll skip those but essentially showing how fast we can treat these patients so most of the coagulation treatment was done within 30 minutes after the completion of cardiopulmonary bypass and patients did not bleed much after surgery so my proposal as an overall structure for the blood-less surgery is something like this so we have blood-less surgery and also we need to have a pre-op a pre-op, anemia management portion and also we have to think about inpatient blood management that might span into ICU management so that will also work closely with the investigation of pharmacy with regard to hemoglobin-based oxygen carrier and of course we have a coordinator from Jehovah's Witness Society and we have a very good communication here as a center for blood-less surgery so I think Epic needs to have blood-less surgery consultation and that should list all the available components or alternative techniques so this is just a suggestion and also data collection is important but that's a separate issue so anemia clinic is probably something we should also strive for which is not currently done on a routine basis for all the cardiac surgical patients so to summarize I think blood-less surgery is feasible it's a very important way to conserve red cell, non-red cell components and I think it benefits all the patients including Jehovah's Witness patients so preparing for post-op bleeding is important I think hemoglobin-based oxygen carrier was very useful in this particular case and then we as an anesthesiology department we have multimodal way to monitor these patients from coagulation to oxygenation so we have some expertise and I think in the future we really need a care coordinator who will help us communicate effectively with the patient and also with the interdisciplinary team thank you for your attention Thank you Dr. Tanaka and now Mr. Stafford and Mr. Johnson so good afternoon so my topic today is Jehovah's Witnesses, the medical and ethical challenge and I'd like to extend a warm welcome for all who took time out of their busy schedules to be present with us this afternoon my name is Gastaford and I'm a local minister here in the Baltimore area and I also volunteer on the Baltimore Hospital Liaison Committee for Jehovah's Witnesses which I will refer to throughout this presentation as the HLC so our committee graciously appreciates the invitation extended to us by Ann Norton and Dr. Galati and I'm sure there were others involved and we appreciate that and making this presentation possible we cherish these opportunities so thank you so just want to sort of get it started you know it's not uncommon to have several of our members admitted at any given time to this facility so we very much value and appreciate the excellent care that we've received over the years through this hospital doctors in hospitals we understand that you face the challenge of improving healthcare quality patient safety keeping abreast of all the technical advances also keeping abreast of all the legal requirements and changes therein while at the same time trying to control and reduce costs so additionally we see that we're living in a time where there's an extremely cultural diverse society and it's no different here and because of age upbringing and gender values and beliefs they differ even among people the same background so we know that this puts doctors they face a challenge on trying to understand individual views they try to understand individuals backgrounds and the convictions of the patients and so this also includes understanding Jehovah's Witnesses as well now at times clinicians may find the choices of their patients somewhat hard to understand however when a person's actions clearly spring from their religious and moral convictions they merit the attention of the doctor in a general sense Spinoza's philosophical approach on life also applies to healthcare and that is understanding the religious belief of another does not require a doctor to accept or follow them the intent of this presentation is to inform healthcare providers about the values and beliefs of patients for Jehovah's Witnesses as they relate to their medical care so these are the presentations objectives so through this discussion we'll highlight our position on medical treatment the hospital liaison committee network the resources for the medical community and protocol for treating Jehovah's Witness patients now regarding this first point what is our position on medical treatment so first of all we seek quality medical care which is the very reason that we come to find facilities such as this one secondly we request the use of transfusion alternative strategies additionally we've thought this through and these decisions that Jehovah's Witnesses may make they are informed choices we do however refuse allogeneic blood transfusions so Jehovah's Witnesses contrary to maybe some beliefs out there we cherish health and we definitely cherish life and some may have felt maybe in the past that Jehovah's Witnesses were anti-medicine and nothing can be further from the truth we come to find institutions like this because we want the best medical treatment that's available and so that's why we come to these facilities such as the one just mentioned here University of Maryland and we want to receive quality medical care for ourselves and for our families to support Jehovah's Witness patients the HLCs or the hospital liaison committees we provide personal assistance because you can imagine for a person who's under matter of the rest sometimes they may need a little assistance and kind of organizing their thoughts and it should be noteworthy to mention that we don't arbitrarily put ourselves into their medical treatment they seek us out and that's how we come to be involved in this situation so what do we do for them? we support the witness patient HLC provides personal assistance such as emergencies the need for a doctor referral or to help resolve spiritual or moral questions related to their medical care now to understand Jehovah's Witnesses refusal rather blood transfusion one must understand their Bible based reason for doing so so the view is simple it's uncomplicated and it's based upon this text Acts 1520 Epstein from Blood and we view this very seriously and we view this as a command from our God and our Creator so shown here's a variety of translations if you look at the bottom of the screen a variety of translations some use for centuries that all read the same but the question is how do we understand this today? Epstein from Blood while this chart breaks down Jehovah's Witnesses position on allergen egg blood we refuse whole blood including the naturally separated primary components of red cells white cells, platelets and plasma but potentially acceptable are what we refer to as blood fractions that are derived from a component of blood so potentially acceptable means this that each individual must decide on these matters some of these decisions have been made in advance others may be made when a procedure is discussed with a physician therefore it's extremely important and we encourage good communication between the doctor and the patient so this sometimes can be confusing to the medical field we do understand that you treated one Jehovah's Witness patient he decided this you treated another Jehovah's Witnesses a Witness he decided that one witness he accepted this the other one accepted that well the reality is beyond whole blood red cells, white cells, platelets and plasma the decision primarily and the derivative of those primary components rests with the conscience of that patient so we just wanted to point that out so one common natural question is what about the use of a patient's own blood? well we take the position that pre-operative otoglous blood collection in storage is something that's unacceptable to Jehovah's Witnesses but now what is potentially acceptable? well that means once again each we back up a little bit that we refuse the use of our pre-operative blood or pre-operative otoglous blood better known as BAD but once again potentially acceptable procedures named here such as hemodialysis cardiopulmonary bypass or the use of a heart lung machine blood salvage these are something that's up to the individual witness patient and once again you may run into one witness that will accept and another witness that won't accept but that's up to their individual conscience so again good communication between the doctor and the patient is vital yet we've noticed that here this facility they do an excellent job by engaging in discussions with the witness patients prior to procedures and of course this reduces problems so the course of treatment for witness patients may be different however with good planning we can produce excellent results so to help those who care for Jehovah's Witnesses and to legally protect themselves against unwanted blood transfusions witnesses make their informed choices by carrying the document that's illustrated on this slide and it's entitled the adorable power of attorney for healthcare now this is a state specific signed legal document which clearly states the refusal of blood and the four primary components it may also include other healthcare wishes that the patient may have such as those discussed earlier and it designates a healthcare agent in the event that the individual or the witness patient cannot speak for himself now particularly challenging our situations involving children and we certainly understand that so when faced with ethical and social issues involving children there are several points to keep in mind when witness parents refuse to give consent to transfuse their children but here's a few points we truly want to highlight and that is first and foremost we love our children we love our children as much as anyone else loves their children and we seek good prenatal care and we work extremely hard even outside of the medical realm to raise our children to educate them to protect them from unsafe and risky behaviors such as smoking and recreational drug abuse and things like these however we refuse blood transfusions not to be confused with we refuse medical care we want medical care for our children just without blood so the medical literature supports the safety and the efficacy of non-blood medical management and next slide here and parents would certainly request that they have skilled and willing physicians and we also know that when it comes to children that this is difficult for everyone so we do recognize that you may not we may not get 100% assurance that blood will not be used we simply ask this please do the very best you can to avoid it so parents they desire mutual respect and good communication with the physicians so there are times when we help witness parents to understand the legal realities faced in these situations and even if a hospital seeks legal intervention parents would like to be notified so that at the very least they can have an opportunity to express their wishes on this subject so many doctors have avoided blood transfusions before these issues occur by considering the following clinical aspects the hazards of transfusions we just talked about earlier in one of the discussions there's much published medical information on this subject even dealing with children judicious clinical management protocols and we certainly highly recommend to consult experienced physicians who may have dealt with some of our younger witness patients and then where it becomes necessary the patient may need to be transferred to another physician or even perhaps another facility and so we find that by following these strategies as possible for law for ethics and for medicine to be practiced together now because of the occasional challenges in providing healthcare for Jehovah's Witnesses a well-organization done to minimize conflict and to develop a cooperative relationship with the medical community well we've established a network a worldwide network in fact of hospital liaison committees or as we affectionately call them HLCs our national office in Wal-Kill New York they direct the work of over 140 HLCs in parts of the Caribbean each committee is made up of community-based ministers who knowledgably interact with physicians and hospital personnel, social workers and members of the judiciary and a few of our members present here with us today so how can we be a resource to you in helping with the needs of Jehovah's Witness patients well here are a few ways we can provide medical articles and other information we can arrange for a doctor-to-doctor consultation or referral we can assist in the transfer of a patient if necessary we are available 24-7 for patients and clinicians clinicians as well and we cherish the opportunity to stand before you today and make presentations to medical staff bioethics and legal personnel also you can contact any of our local members home phone, cell phone, whatever phone number they have available and if you would like to have some of our materials I'll show you a few minutes where you can find them and some of the resources we make available to you so much of it is web-based these days so websites with links to PubMed journals, clinical papers peer-reviewed resources evidence-based summaries and it's good to know that although they're contained on our website the information is from people like yourself and so we really encourage you if you haven't had an opportunity to look at our website and it certainly has many subject matters I'm just going to breeze through a few that are available management and optimization of hemostasis and additional information medicine and surgery cardiothoracic and vascular surgery and it's just a plethora of information available on the website that we feel will be valuable to you and so we encourage you to explore the site and you'll be amazed and delighted at what information is available to you printed as well as electronically so we also produce high quality medical articles that are featured on our website and in citations provided by doctors this clinical evidence detail strategies to avoid blood transfusion and we also distribute the following clinical strategies and these documents are designed to manage hemorrhage and anemia with our blood transfusion in several key settings they are as you can see noted surgery critical care obstetrics and gynecology and GI bleeding and if you had an opportunity or you will have an opportunity to view these because we left in the back today there are hundreds of medical articles referencing details within each document and many doctors and departments even here at the University of Maryland have used these references in treating Jehovah's Witness patients so the HLC can make these available to you upon request but as we mentioned today they supply this outside in the lobby and we encourage you to pick up a copy if you have not already do so upon leaving so this is the packet that we've brought with us today so it's illustrated here for medical professions and it professionals and it contains information about our HLCs and a religious and ethical document detail on our position on medical therapy and other topics we'll also insert other clinical based articles and summaries based on the doctor's specialty so finally here's a recommended protocol for treating Jehovah's Witnesses review relevant blood conservation and transfusion alternative strategies and treat the patient without using donor blood consult with other doctors experienced in managing patients without blood transfusion there are many here at this hospital that have skillfully worked and treated Witness patients and others who desire bloodless medicine contact the local HLC to locate cooperative doctors at other facilities for consultation on alternative blood transfusions alternatives to blood transfusion our national office maintains a list of doctors in many specialties who have been Witness patients for decades some of whom have published some of the medical articles that you have access to on this subject and on occasion doctors here have successfully consulted with some of these doctors as well and then lastly transfer the patient if necessary to a cooperative doctor or facility before the patient's condition deteriorates in your case many patients are actually being transferred here to your facility however there may be situations where you cannot accept the case for one reason or another we understand that and if that does happen in the case is critical time is of the essence in making this decision so we trust that this presentation has been informative we certainly hope it was and Wilder Hope as Witnesses may have presented the medical community as a medical and ethical challenge we find that many have met that challenge and so we remain confident that you will continue to offer a high standard of care which includes the use of your skills to treat patients without blood transfusion and so we encourage you to please contact us if you have any further questions or obtain it by calling the number of our national office located on our website so once again I'd like to thank you for the opportunity to stand before you and make this presentation and have the privilege of presenting this subject to you today so we're going to turn it back over to Ann and after which I believe we'll have a little question and answer session we do have time a few minutes for questions and answers for the audience Dr. Tanaka would you mind coming Mr. Stafford I'm sorry and Mr. Johnson do we have questions yes so autologous blood refers to the pre-op donation so you completely separate you separate the autologous blood from the patient and keep them say in the blood bank so interrupt essentially we can take the blood but we can still keep them connected to the patient through IV tubing so that doesn't separate from the patient now if it's non-Jehovah's Witness patient we can always separate that's an option as well so I mean the difference will be less if it's non-Jehovah's Witness patient other questions okay well thank you all for attending and I'd really like to thank Dr. Tanaka for his time today and presenting this information to Mr. Stafford and Mr. Johnson and the members of the Jehovah's Witness community that we're here today to support this I think it's very valuable I'm glad we have recorded this so that we can put it out for others that we're not here today to enjoy the presentation thank you all very much