Okay, for those of you that I have not met, I'm Bob Hoffman, I'm the old guy in pediatric ophthalmology and the purpose of this visit today is to talk about some of the logistics of your interaction with things over primary, with the pediatric ophthalmology service, so you have a better idea of what's going on and what to do and hopefully what not to do and also when you're being asked to do something that you just plain don't have to do and so we're gonna kind of go through a little bit about you know who's on the service in terms of attendings because we're adding somebody where our staff are located and where we are seeing patients because you may get a call about a patient that was seen at Riverton or up in Layton and you need to know that yes indeed we do have people seeing patients there. In terms of the docs myself Dave Dries, Mimi or Marielle Young, Lea Owen, Lea was here in your shoes not long ago. She's an MD-PhD researcher, half time, clinician half time, came back from doing the fellowship Charleston and joined us. Griffin Jardine was a medical student here, some of you may know him. Griffin was a resident in Oregon, a fellow in Indiana and is starting in about two weeks so please take it easy on him. I don't want him to run out the door screaming. The other person that you may recognize shortly is Julie Harmon. Julie was our head tech at at primary and Julie went off to Los Angeles, trained as an orthoptist and is joining us in a couple of weeks and we're very thrilled to have her. That is going to ramp up our resident teaching and staff teaching in terms of motility issues. She'll be in clinics doing complicated adult motility measurements. I think it'll be a big plus and you know it is entirely clear where she's going to be but I did set things up. We designed the new clinic at primary so that if we divide the clinic in half, have two docs seeing patients, there's one long lane for orthoptic type motility measurements because orthoptists tend to get pretty wound up about having long lanes and I put that there purposefully so that they could have that lane. They can see patients and hopefully it'll all work. One of the kind of ongoing duties that in my practice career has changed. When I was a resident, when I was a medical student here, the junior resident of the two residents per year, usually second year, had the duty to do retinoperative charity screening. They were never seen by an attending. Attendings were not involved. Why? Well if they found bad ROP, you sign them up for the blind school. There was not much to do and so it was passed on from resident to resident and that has changed enormously over the years and now it is very involved. We take photographs of every child we examine with the ret cam. Either Siri or Mel go around Mel's learning how to do it and Siri Fry has been our mainstay in terms of photography in the NICU but we do regular scheduled screening exams midweek and depending on the attending schedules, Tuesday, Wednesday at primary, end at the U. We used to do them at IMC. When Scott Larson left, I lost the manpower to continue that. That may change in the near future. Those ROP exams are something that as a second year on our service you will participate in. You know the idea and those of you that have been there and the idea is that I look at both eyes when you're there with me on every kid, you look at one eye and while I'm taking care of the paperwork, you're finishing up, you're looking and the idea is to get you used to examining kids in the NICU, how to do it safely, how to use the nurse effectively, how to use the OT's to schmooze the kids. You know it's gotten fairly elaborate. I think it's a good thing. That is also a good thing and one of my purposes in mentioning this is you may get called when you're on call to do a consult in the NICU and one of the questions perfectly reasonable to ask is is this urgent if it's on Monday that it be done today or if it's on Friday or could it wait until the next time that one of the attendings is going to be doing ROP exams midweek and if it's something that could wait have them put it on the schedule, have them listed as a regular consult and then we'll see it together. It gets staffed right then and and and you know that's a perfectly reasonable way to do that and it'll decrease your workload terms during stuff during the week and and I have absolutely no problem with that if they say that you know it's it's urgent this time of year you know new house staff you have to still think is it really urgent or we just doing it because we want to impress the senior resident that we managed to get ophthalmology to show up within half an hour of the time we called them be that as it may if they say it's urgent I would probably go see them and if you get called and you will by somebody in the NICU saying Dr. Dries saw baby Smith last week and we think the baby is going to go home we need to know if they can go home on oxygen 100% of the time that call has to be forwarded to an attending. Okay there are huge medical legal implications associated with the response to that question so please do not take it upon yourselves to try to wing it and answer it and save us from being bothered it is always okay to call if you cannot find somebody else my cell number and and home number are on this and Elaine has this should be on the list of things you have lectures you're welcome to call me because we need to weigh into that because if we send a kid home and they show up with a total retinal detachment I mean that may happen but we want to know that we didn't contribute to it in some way and I do not want to put the burden of that decision on you folks that's something that that's why they pay me the big bucks right not but it's okay now what about the call you get from Jordan Valley Hospital or Lakeview Hospital and they say we have a baby that has to be seen we want you to come see them or we want you to give us advice about this kid the advice questions they get sent to an attending if we're given advice to somebody in an outside hospital that probably should come from an attending level it could be answered the next day after hours it could certainly go to the attending on anterior segment call after hours coverage for peeds in general particularly for trauma and things of that sort is shared with the anterior segment call person so that is the attending responsible after hours the reason it's set up that way we rotate in that I mean I don't anymore because I'm old but the rest of the crew does turns out I managed to get our department to go along with this idea that if you when you turn 60 you don't have to take call anymore it's a great thing and if you know you'll get there someday it's my enthusiasm for taking care of open globes and 80 year olds three in the morning left a long time ago but rather than taking when it was just me and being on call every night rotate call with the anterior segment folks that is how that coverage goes there are some things where they will not be comfortable and they'll ask you to call us and that would you know that certain circumstances and you know but there's nothing magic about closing a corneal laceration in a three-year-old or looking fishing fireworks debris out of a child's eye and trying to decide if it's an open globe that doesn't require a pediatric ophthalmologist it requires somebody with experience and anterior segment skills may need to involve a retina person as well and you need to use your judgment on that for the junior residents sometimes it's hard to know what you don't know so I would use your connection to the more senior residents liberally because they may know in an instant what it is you need to look at or what needs to happen and it's worth a call you know for the fellows how many fellows do we have any fellows here that accidentally showed up this morning no good okay hopefully they're off doing something else getting coffee or whatever but with the fellows it's a new experience isn't attending our fellows rotate call is anterior segment attendings the the anterior segment fellows you know cornea glaucoma and you know be aware that this is their first experience some of them it's their first-ever experience isn't attending and so you need to kind of help get them through it and if you think they need to get help you might want to prod them in that direction it's a good thing to do as a resident but if you get calls you know you do not need to go to Intermont Medical Center or to Utah Valley Hospital or something if somebody calls and and yes in the past we have had residents do that because they thought it was part of what they needed to do and if there's any question about something like that call me and if somebody's really blizzard about it get an attending on the phone with them it's much better to have them mad at me than mad at you they can hurt you they can't hurt me and and I'm not too worried about what they might say or do now vacations and meetings there it with one exception is always one of the Peds attendings in town and that'll probably change they'll probably always be one here but a post national pediatric ophthalmology meeting which typically happens sometime in the spring March April depending on the location we have you know all gone and the idea with that is we arrange our OP exams and that so we kind of do them before somebody leaves town and try to juggle things that typically leave town on a Wednesday after doing our OP exams we're back by Sunday night but I've instructed every member of our division to have their cell phone with other than if somebody has a question about something you call the resident who is on our service at that point tends to get dumped on a bit in terms of dealing with some extra calls and duties on the other hand you get to run the Peds service which is kind of fun I mean 30 years ago I used to leave town for two weeks leave the second your resident on the service in charge and never hear from anybody for two weeks and they took care of everything so things have changed a bit and I'm not it's probably not okay to do that anymore in it you know again if you feel like you're being dumped on you can't take care of something always reasonable call somebody more senior and I also try to leave some attending coverage where somebody knows that you may be calling them about a consult because a lot of the other attendings have had a fair amount of experience dealing with kids and they're happy to help you as far as your vacations it's always okay to take vacations you know I mean on our service you need to kind of juggle out against what you're going to lose in terms of not being here but you know it's it's all good we will find a way I think it is good to have somebody to cover consults and be available for stuff if at all possible and we've kind of gotten used to that coverage and it's a little hard you guys do an enormous job taking care of consults and I sincerely appreciate it the outside clinics are just that they're clinics they're not inpatient facilities there are some Peds beds now at Riverton so I can't say that entirely but basically what we do is we have university clinics in Orem at Riverton in Layton that are on Epic you can pull up any note if you have access to Epic from there from somebody if you're trying to figure out what it was that Dr. Treese did with a patient in Layton or what Dr. Owen did which he saw a patient at Riverton Riverton if you haven't been out there and we want to try to get folks out there with a change in number of residents and consult coverage it is a wonderful clinic there is a large population of children in the southwest part of the Valley and they are busy in that clinic it's a it's a it's a good place they also have an OR that is staffed by pediatric anesthesiologists the same group that covers primary and so it also is a place where we hope to expand our surgical experience the needy little follow-up clinic if you get called about something with that our involvement in that is ending the 23rd of August due to a variety of reasons it is making more sense to just roll those patients into our clinics and so that's what's going to happen there so that while residents have gone there I think it's been a good way to because we only have one exam room it doesn't really lend itself to turning you lose saying here you go use this room and see patients we see them together but you also get to see how I finesse some of these kids who have had many too many health care interventions and scream the moment they come in the room and how we try to get useful information without sedating them without putting them to sleep playing games with them and to that extent it is a good opportunity to examine patients together we'll often have a neon etology fellow or a peds resident hanging up with us at the same time so it gets to be a little short on oxygen in the room and it's not very productive we can see the patients more effectively in our clinic so I'm not entirely sad that it's ending American fork I know everybody who's been on the peds service has experienced American fork the American fork training school does not have children by and large it used to have children and it had children with severe developmental disabilities when I was in medical school here it was a wonderful place to go as part of your neurology rotation to see firsthand a lot of syndromes you want to see lesh nyan syndrome you want to see various things in action and what it does to people it was great what it became was a storehouse for unplaceable adults as people were moved out into community health centers out of mental health institutions and for a variety of reasons it sort of got dropped on me I think someone used the word school liberally implying children and it wasn't true and so what I did initially with that was to move that to the residents and have the residents go and it turns out they paid me for going out there so I just had them pass the pay on to the residents it was a good deal unfortunately gme found out and I gotten some trouble and it turns out the department wanted to take the money and still have you go to the fork but not pay you at all and that wasn't acceptable so the compromise is that you get credit that you can go spend at the bookstore and it's it's a it's still a pretty good deal you're essentially getting paid but you have to spend it at the bookstore so that the department isn't taking the money and having you do the work you are getting taken care of and I think there's value in going there and examining patients who at times don't understand what you're trying to do some of them can really hurt you if nothing else they can cause you to slip and fall in a puddle of urine but there are patients there who can bite they can bite hard when I was a medical student a student had his thumb removed by one of the patients there so if someone grabs your thumb with both hands and takes a very close look at it start asking for help because the next place is going is right in his mouth but I you know it's useful because you will see some of my developmentally impaired patients if you're in practice in the area here when they grow up to be adults and I think knowing how to reasonably and compassionately deliver care to those folks to help them interact with the world around them is a good thing there are also surgical cases that come out of there they're basically the result of trauma you got traumatic retinal detachments cataracts glaucoma due to repeated injuries self-injuries usually and those if it's something that you're capable of doing find that attending schedule it get it done and more part to you if there are issues out there call me but I have truth been known not been to that clinic in many years my name is on there because I was initially conned into going there um but at this point I think you know if you decide that something's changing and it's not a useful experience I need to know but otherwise what ideally you find time and it'll be passed on resident to resident to go out there when you're not doing something that is more useful on our service I would particularly urge you not to cancel our time usually there's some down at downtime administrative time in my schedule you know a half day or two a month where you can find time to go out there and just bargain with them and and and set it up now this thing doesn't does it yeah no it does do that how about that that's cool so in terms of service coverage we touched on the consults you know knowing where a well-baby nursery is nick you at the U in terms of peds are are essential and making sure your little badge gets you in there the er at primary is a place that you'll come to know well in our clinic you will find instruments there are lid speculums scleral depressors there are drops there are indirects on the wall in every exam room if you take one that's fine please bring it back put it back in the charger when you're done and those lid speculums and scleral depressors do not come back to the moran or they don't go to the retina clinic please put them in our clinic there's a little basin on the back counter by the autoplay where they clean that stuff up they're very expensive we do have to pay for them it's my expectation that they have them available you know for you and if you don't know where they are grab one of your senior residents or come by clinic when one of us is a clinic our text can show you around your key card for primary should get you into our clinic that's the expectation if it doesn't stop at the security desk if they tell you you need some special dispensation for me to do it get whatever form they want i'll sign it because you all that stuff now is key card access and after hours it is my expectation that you be able to get into our clinic to get what you need and i trust you to get in there and you know and then make sure that whatever it is gets back to to where it needs to be there are tonneau pens there tonneau pens are particularly expensive i think that there is one in the resident call box anyways or not so you shouldn't need one but if you find you do you know it's find the other place you can get one if you're really stuck at primary the or we have indirect tonneau pens and various things they usually live in our room and roommate in the closet or they're hanging on the wall and if you're really stuck you can get that there that's also where the ret cam lives so if you're trying to get the ret cam because i'm coming in to take pictures at night of some child with you who's you know had abusive head trauma and as retinal hemorrhage is if you call the or they'll have it at the front desk for you you just wrap it all up take it to where we're going to use it you take it back they want a stamper thing from the kid so that they can bill for the use and i think that that you know is again another useful place to know er or in our clinic and if you really feel lost around the children's hospital get one of your senior residents or i'm happy to give you a tour because knowing where the inpatient units are the nicu icu and that i think is is is also very helpful you also don't know where the resident lounge is they have much better food for the residents at primary than they do for the attendings so of the two lounges i would definitely find a way to get into the peds resident lounge they eat like kings for lunch every day that's how they get them to go to their lectures they don't stay after hours like you guys do or come in early that's what pediatricians do they don't come in early but they do have a good lounge and if you can get one of your peds resident colleagues to help you figure out how to break in there i'd go for it post-ops you know i i can tell you for a fact that if you have an issue with one of my post-ops i want to hear from you it is always okay to call you know if there's a question do you think one of my post-op cataracts has endophthalmitis you're not bothering me by calling you know i'm grateful to hear about it if there are questions the things that commonly come up in years past we put a lot of crofford tubes in lacrimal systems they get pulled out that's why i don't put them in many patients anymore but if you do get called and you have a big loop of tubing sticking out the best thing to do is to have the parent tape it to the bridge of the nose and call us in the morning having tried this many times crofford tubes cannot ever be put back in you can stuff the whole thing in the lacrimal sac you could make the parents feel really good but generally before they even get to their car in the parking lot the whole thing's going to be sticking out again and they're going to be driving in nuts so the problem is that not knowing exactly what's on the lower end and the nose there could be hardware attached to it there could be a you know a brazilian knots you know down there to quote george bush lots of knots in the nose i put them in i sew them temporarily to the to the lateral nasal wall so there may be suture attached to it they generally can't get a big loop out unless they've managed to rip the suture out of the tissue but you might try rotating the tubing out i generally talk to whoever put it in first to figure out what they did on the other end and and it may require a trip to the or now if you're going to go to the or you're going to do a sedated exam it is generally available first of all in the or you have to have an attending there's really no exception to that you'll at least need to speak to the attending if they're going to have you run in and they're going to meet you because an attending's name needs to be on it if you're going to go to the or and if you decide to go on your own i mean other than some oh my gosh emergency and i really can't think of any with eyes that you know other than maybe doing an emergent you know lateral canthotomy and upper lower crease cantholysis if one of the ent surgeons has put way too much air into an orbit via the sinuses and you got a central rotten artery occlusion and i have gotten that phone call to our or as a primary on a number of occasions i mean feel free to do if you know what to do to do it and that is a very useful procedure if you don't know how to do it to learn how to do it because it can be vision saving in terms of reestablishing circulation to the posterior segment otherwise you need an attending with sedated exams useful to run through the exercise being that the kid's going to be sedated they have everybody you think might need to look there with you so that they can look at the same time you know if you're going to need attending to look let them know you're going to sedate the kid and say do you want to be here and that's i think always a a good way to approach that so that we don't find out that the the result is well i need to see the kid too keep sedated and i'm driving in from home and i'll be there in an hour probably not a good thing and a little embarrassing in the er political issues you will at times be asked to see patients certainly at primary and i think at the u by craniofacial surgery plastic surgery ent where they are repairing orbital fractures facial fractures and they want to know if the eye is okay it is my firm expectation that we do the right thing for the patient and make sure the eye is okay it is not my expectation that we only see the patient if our ocular plastics folks are going to take care of the fractures or the lacerations there are our you know craniofacial surgeons do a an exquisite job of taking care of orbital fractures they do a great job i think you need to watch the neurosurgeons when they start coming in from the north playing around in the orbit sometimes they get in the trouble but that's something that needs to be sorted out at the attending level as far as doing that i think that in general i would urge you to you know and if they call and say we want you to come to the or to look at this kid we have in the or i would touch bases with an attending before you do so they know about it you can at least put their name on it and they make a good faith effort to try to be there with you i mean that often if it comes up on thursday i'm in the or anyway i can walk down the hall stick my head in the door while you're taking a look at the kid and it's fine but you know i need to be able to say that i actually saw the child and looked at them if you know and and the other question when do you say when they've got orbital fractures well i'm gonna i have to get my ocular plastics attending you know you have to kind of sort out who's already involved in the patient's care if there's a service that's going to take care of the fractures they want you to clear the eye always reasonable you know to ask what do you want me to do do you want me to get ocular plastics involved yes or no they'll tell you perfectly reasonable question but i would never insist you know thinking that somehow it's something that our ocular plastic surgery folks have to take care of because you know what with isolated orbital fractures certainly i think our folks can do as good or better job than anybody the other folks can too and there are some political issues involved and with the craniofacial surgeons they're often dealing with multiple you know fractures and complicated facial trauma they're often going to the or earlier because of the other fractures they may be doing something combined with neurosurgery with dural terrors or something of that sort and so it gets to be complicated if it seems to be more complicated then you can sort out i'm happy to talk to you about it now what do we do with abusive head trauma non-extital trauma you'll be called numerous times on call to see children where somebody thinks they've been shaken they're not sure what happened and they want you to look at them there is a program that julia put together looking you know as far as trying to get photos and all these kids trying to get them seen quickly and we're currently working out neurosurgery's role as the major impediment to pupillary dilation and how important it is to wait as long as they wait on some of these kids because we need to get a good exam we need to gather evidence if somebody's actually done something to a child and um you know when i was in your shoes the idea that if a kid had retinal hemorrhages they were shaken and that is just plain not true there are certain patterns distribution of hemorrhages in conjunction with the story of what happened with the child that may make it fairly clear that that's what happened but the findings have to be interpreted based on the patient's history and other findings and so we're mainly an information gathering service in that arena and it's important that we not make claims that are not true based on undilated exams so i would urge you you can say based on an undilated exam that there are hemorrhages or there are not hemorrhages but as far as the nature location distribution of hemorrhages whether they are multi-layered superficial around the optic nerve throughout the entire retina whether they're circumventative folds those are things that come from a dilated exam only and be careful about that and as far as saying that you think that something is due to abusive head trauma it is my firm expectation that every child who's got retinal hemorrhages be at least discussed with an attending and preferably examined by an attending and the attendings involved are typically either one of the peed's attendings usually me or one of the retina fellows and they quickly learn to be very good at this or one of the retina attendings although it's harder to track the attendings down they're busy fixing retinal detachment since the life of a busy retina attending and we try to get photos on all kids there is a push to try to have them seen within 24 hours of their admission at the hospital again the stumbling block being whether they are stable enough per neurosurgery to dilate and you'll hear more about that and I'll send information out there are currently meetings kind of going on between Tony Lasky who is the child abuse specialist pediatrician in charge of safe and healthy families at primary Doug Brockmire chief of pediatric neurosurgery and myself trying to sort out just how we want to approach this you should be aware that there are ongoing studies that some people are participating in here with Brittany Coates who is a just a rocket scientist researcher a mechanical engineer at bio engineering here who is doing active research looking at the mechanical forces and trying to unravel really what is happening in abusive head trauma she's doing very elegant research if you have any interest in that area be a good thing to get involved with Julia is doing a project with Brittany and I right now looking at vessel tortuosity in our ret cam photos and hopefully that'll lead to something that we can use during the weekdays there is a system set up so if you see a child who's got hemorrhages Ciri or Glenn are available they know they may be called they'll get the ret cam they'll come take pictures for you probably useful to have an attendee come at the same time so you can get everybody to see the patient and what else do we have on here oh and as far as this basically the protocol Julia was kind enough to put together if they've got a circumvacular fold and it's a weekday we want the photographers to get an OCT as well they can use handheld OCT at bedside if the patient's dilated it turns out that documenting the structure of the retina the presence or absence of vitreous traction on the fold which is the presumed mechanism of it traction on the retina as dissimilar structures are moving to and fro with acceleration deceleration of the head and if the safe and healthy families attending wants photos and is after hours please arrange them and again I'm happy to come in retina fellows should know how to use the ret cam James Zimmerman in particular is very good with it and as far as taking the ret cam if you've never used it it is best to have someone who knows how to use it preferably one of the attendings when we're doing things in the or show you how to use it it is an $80,000 camera system I have had at least one of your colleagues drop those lenses on the floor before they're about $10,000 a pop it's a very sinking feeling when that bounces off the floor because they generally don't do well after that if there are problems you know you're welcome to call at any point these are my various numbers I could tell you I my pager I think needs a battery it's been very quiet for about a month so I've been trying to find a double a battery but I've not been looking too hard that home number now basically gets used now for people wanting political contributions and so be persistent leave a message that you actually are a human and need to talk to me but myself is always with me wherever I am if it sounds like I am sound asleep typically I am somewhere about 12 hours away time-wise in Asia somewhere and yes it may be three in the morning one is three in the afternoon here so give me a moment to wake up and we'll talk as far as your rotations right now we have one month last quarter of the year where the first-year residents spend time on our service the goal of that is to kind of learn where things are get comfortable with examining children that is a time when our orthoptist will spend time with you tuning up your motility exam and I think that's just going to be a wonderful thing when Nikki Batra was being our orthoptist when her husband Nick was our retina fellow that was a good thing now second year that's the bulk again three months of kind of undivided attention to peds and we do have the opportunity for elective time anytime you feel you know if you want to come and spend time with one of the attendings that you have not spent time with or do something in particular all things are negotiable expectations while you're in clinic are that you focus on you know getting maximal benefit out of your time there you want to learn the p-specific parts of history and exam you want to make a note in epic i'd like you to commit when it was in paper say put your thoughts down on paper so you're committing what you think about the motility exam retinoscopy fundus exam a diagnosis and what you want to do and there's room and the resident head he can show you where we make that resident note i think that's a great way to do that put that in epic and then on every patient if you're doing retinoscopy you can compare your retinoscopy to what i got we can talk at the end of the day and at the end of clinic of every clinic we talk about questions you have about patients go through things and issues and consults and try to debrief the clinic in the day i expect that you'll develop specific skills in measuring visioning kids doing motility measurements and just dealing with kids in general how do you get a small infant you know to where you can do an answer segment exam do a fundus exam how do you safely use a lid speculum because if the child gets a hand free and they grab that lid speculum you may wind up having to talk to the oculoplastic folks to put the lid spec together that's not a good conversation and at that point you probably should find me because i'm going to have to talk to some folks on your behalf initially you focus on learning the exam skills then you work on putting that information together to come up with what you think may be going on with the patient and how that relates to what they came in complaining of and then put that together to come up with a good differential diagnosis most likely diagnosis and a plan as to what to do in terms of further testing management whether it be medical optical surgical and i want you to gain an understanding as we kind of go through things how we interact with other services with peas retina glaucoma anterior segment how we deal with interact with our support services and the various pediatric subspecialties and clinical areas at primary surgical experience you will start in your first year experience that you need loops we have headlights but having loops that work and not the cheap ones with a working distance of about 10 inches because otherwise your face will be in the wound i'll be continually contaminating myself on your head as you put your head between me and what i'm trying to look at and it won't be a good learning experience and you get a really sore back so that at some point you can borrow some from another resident if you have a lot of refractive air and you want to have your correction in there designs for vision makes probably the best loops that are reasonably priced for residents that are good Zeiss makes the best loops but they are very expensive and unless you're going to be doing something in peas or oculoplastics where you might use them regularly it's probably not worth the expenditure in the investment in terms of the you know expectation people come with a variety of surgical experiences and exposures and i've had residents that come in who have been operating regularly for years in the military or doing something that's a different thing from i did surgery when i was a third year medical student and i'm terrified of operating on eyes and and so your role on my service in particular and with Dr Patel is to acquire good surgical skills basic surgical skills and things that are going to serve you throughout your experience here before you really ramp things up with anterior segment surgery and as long as you are progressing i mean that's all that i ask and in some residents wind up doing more than others depending on how things go i mean the model that Alan Crandall set up here in our program for teaching residents we've done it for years in peas because typically we're doing a couple of muscles so the i'm doing one muscle and you're doing the other muscle or doing what you can with the other muscle is a good one you know but having residents operating your patients i can tell you when i was a resident in michigan none of the attendings would ever let a resident do any part of a cataract operation on one of their private patients ever you know it just wasn't an issue so you're a lucky group to be in a situation where people are sharing that kind of surgery with you to peed stuff it's something that we've done you know for decades just because it lends itself more to that and and so you know i walk you through repeatedly various parts of the procedure and then you put things together and you know the expectation is that you become comfortable doing horizontal for business surgery not necessary vertical surgery while you're on the service so you can get through a procedure you could do it safely if that's something that you choose to do in practice depending on where you're headed i don't realize many of you probably won't ever do another muscle surgery after you leave our service but i want that you know skill and and an ability to be there now as far as your evaluation with this new evaluation with this committee that of you you know reviews things mike teski and i are on that in the second year we are the evaluators for the second year residents in that thing when they put all that stuff together we decided to do that because you spend bulk of your time on one of our services so we collect that information and he and i sit down and hash things out in case you wondered where those evaluations come from on that committee and i think you know we try to do a reasonable job of you know looking things over in that but you know that whole system has changed many times in my time in this department and if you have thoughts about it renee i don't know if you have thoughts about it but but shaking your head well it's you know it it uh well we had services unfortunately where there was virtually no evaluation and for years i had a written test in a fairly organized thing that we went through on surgical skills and we're going away from that to this kind of uh you know it's a fairly organized thing that looks at everything and we have to say where you are based on other residents at your level and you know and how everything is going and make some sort of narrative comment and it is a lot of work um and um they don't give us oh i think it's getting better and i think ultimately it'll be useful my concern is i want to make sure that when they do that they are focusing on things that are actually meaningful that provide an honest assessment you know unfortunately fortunately i guess the you know the bottom line is it almost all the residents that we have come through here do wonderfully very rarely we wind up with somebody who really struggles in an area they may have not made a good career choice they may have other issues going on in their lives and it's you know really a matter of trying to sort out those things and guiding people towards making the right choices in terms of what they want to do because our job in reality is to kind of help you along the way in your career and for the most part it's a pleasant journey you know it's very very rare we you know we're blessed in that we have very good residents um and and so it usually we do not have the problems that some other programs do um as far as practice surgery sessions that has fallen by the way as far as basic surgical skills and if anyone is interested in reinstituting that i am happy to get together with junior residents and go over basic suturing skills you know on iBank eyes and you know get loops and we can sit down and do things i think it is very useful to learn to handle the instruments to pass suture through sclera and to not have the first time you do that be on one of my patients in the OR at primary and in past years what we've done is we pass suture deeper and deeper until you do penetrate sclera perforated and wind up in the vitreous in an iBank eye and you know i think that's that's a useful exercise and if anyone is interested i'm happy to get involved um as far as reading goes the basic science course is kind of the core thing we will have journal club at least two to three times a year the resident on the service will select articles and i've typically tried to make that topic oriented so we'll pick a topic that somebody's interested in select some reasonable articles and and then discuss them typically do that over at my house although as we grow my house is becoming too small to hold the entire group so we may have to make some changes in that we'll see and you are welcome to use you know my bookshelf and hang out in my office and do whatever you want to do but those are on here some of the things that i would suggest as far as text there is for the abusive head trauma thing both in the library in our clinic and on my bookshelf the book that uh rob perish and lori frazier edited that i wrote all the uh i stuff for and all those pictures were taken in our uh icu mainly or the or most of them taken by me so they're not the highest quality photos but they're okay and um you know that may be a useful thing to look at to get an idea of we're talking about circummacular folds you know what is that what does it look like and how do we tell if hemorrhages are superficial or deep and and um those are things that will come with experience but some of those pictures may be useful to you and um you know as far as you're reading in general for the junior residents you know my recommendation and it worked when i was a resident is every day you should spend an hour reading about things in general with ophthalmology an hour reading about things and whatever you're rotating in and then additional time on an interesting patient or two from the day because patients will stick with you when you read about them and do we have anything else on here i don't remember okay and so if you are having you know as far as at primary help too is currently the in-house they made it themselves electronic medical record system at primary that's going to change uh they're going to go with eicentra you'll hear more about that there'll be training sessions it will be an ordeal and i apologize for having to deal with yet another emr i tried to get them to go with epic and they had other thoughts they wanted control of data they wanted customization that epic was not able to give them and if you are having issues with you know parking or um you know what not at primary if you're there late at night and and and people aren't letting you park i'm happy to get involved in that too you know if you're here late at night parking far away in the parking garage is not my idea of an acceptable situation i think if you're coming to moran late at night it's perfectly acceptable if you're here at three or four in the morning to pull right up outside the door with the elevator that goes up if you're worried call security have them meet you and escort you to where you're going you know meet a patient at the er where there are more people around we do have you know people that ride tracks up here and sleep outside our or doors occasionally on the second floor and on the fourth floor i know because my wife volunteers at crossroads and she gives a lot of those folks their tracks tickets and they use them to come up here to hang out particularly when it's cold outside and so don't get in a situation you're uncomfortable with after hours questions concerns comments from the more senior residents about things one thing i just want to bring up is if you guys don't have an access the pete's clinic um because i didn't have that that actually is good and chris is chris cumans is c-o-o-m-a-n-s she is our clinic manager um my long-term secretary amy bigley has departed uh tom and i i haven't even learned his last name yet i'm embarrassed but tom is my new secretary uh he was here for a day or two and then they sent him off for training and indoctrination i think in epic and so i'll learn his last name he seems like a nice guy he's sitting where amy was amy carpowitz is currently burnstein secretary is currently helping with my stuff so if there are issues she could be of help to you as well but if all else fails i mean i'm around it's okay to call or come by clinic and uh thanks for being here have a good day


We're here in downtown Vancouver at the Hav program. This is a partnership between the BC Restaurant and Food Services Association and the province of British Columbia. We've provided a half a million dollars in funding. It trains them to gain entry in the restaurant industry as cooks, potentially as chefs down the road. It's an area of rapid growth and one that we know can really help fulfill the goals of some of the individuals entering this program. On the downtown east side is a whole bunch of people that are more than capable of being trained once they decide their lives they want to make the change themselves. And so if you marry that with kitchen skills, you have a perfect match. And in the last five years we have trained, have us train 500 students, 75 percent of them have all of that jobs in the kitchen somewhere in the city of Vancouver. They give me nothing but support. You know, they help me find new units and you know, call them. They give me their phone numbers, 24-7 hours to do that. And you know, I've never had people like that before in my lives come up to me and tell me, okay, we're here for you. You're part of our big family here. So it doesn't stop at just training them or giving them knife skills. It's life skills. It's everything. It's teaching them how to really like themselves again. And we find that it normally takes about a week or two and then you start to see real change, real change. And by the time the eight weeks is up and they're going to their first job, they've got an attitude that they can do anything and it's just incredible to watch.


Save 10% with my code Bobby10 on raw, organic, grass-fed and grass-finished, freeze-dried organ meats from grassland nutrition. Link in the description box. All right guys, welcome back to the channel. If you're new, my name is Bobby. Guys, before I start the video, thank you so much for your well wishes. Thank you so much for your support over the time. Thank you so much for your tips and tricks. I was extremely sick and now finally, I'm somewhat better. Probably you can still hear it. I'm not at 100%, but thank God, I am good enough to record some videos. Guys, today we're going to react to Can science prove the existence of God by rational believer? So for me coming out of the sickness, hearing this question, can science prove the existence of God seems a little bit silly to me fair? I know that it is very interesting nowadays, but this is really what it boils down to. It is a question of this day and age. In this Western society nowadays, people praise science as their God. And because of that, we have to look at everything through the lens of science. Can science prove that God exists? No, then there is no God.  It is atheist logic or rather the lack of logic. If you look into the questions of metaphysics, you cannot dodge philosophy. This is not a scientific question. When we are talking about God, we have to ask the big questions, the truth claims, and this is a philosophical endeavor and not a scientific one. But nevertheless, I do understand why we need such a video in this day and age. All right, but I have to save my voice with no further ado. Let's have a look. The famous question posed by many people nowadays is that can science prove God? And what they really mean by that is can science discover God? For understanding this, we need to distinguish the difference between proof and discovery. To prove means to establish a fact or a truth by evidence or argument. And discovering by definition is to see, to find out or to gain sight or knowledge of something which was previously unseen or unknown. In short, to discover means that something should be seen or witnessed by human's naked eyes. Whereas to prove something means to provide evidences, reasoning or rational arguments in order to establish a fact and it doesn't depend on our eyesight. However, science can always discover the signature of God in nature, which means science can always prove the existence of God through evidences. But through science, we can never discover God in this world. Now the question arises why science can prove God but cannot discover Him? The answer for this is, Almighty Creator gives some sort of evidences or clues into His creation so that human being can accept His existence and to believe in Him. However, no human being or science can ever discover God because this life is a test for us. And Allah created us and gave us limited abilities to be tested with. Yes, exactly. Limited abilities which translates into lower intelligence, which translates into lower capacity of understanding greater realities and therefore, no matter what kind of scientific tools we will use, we are still not able with our limited minds to understand God. Even if He would be right in front of us right now in our state, we wouldn't even recognize Him. Get what I mean? Suppose that you are a professional modeler who uses a strong modeling software and creates a project in which there are people with consciousness. It means that the models that you have created are having the power of intellect and you put a test for them to find you. Now if you think logically, they have only two options to find you or to prove your existence in order to accept you as their creator. The first option for them is to discover you or to see you. But of course, you don't want that because it is a test and if you show yourself to them, then the test becomes meaningless. And logically, they... I believe it was a Christian Orthodox Church father that said that if there would be ultimate 100% accurate scientific proof of God, then God wouldn't be loving because in order for God to be loved by you, He gives you free will and that love is unconditional. His love to you is unconditional and therefore you have the free choice to love God, to decide to live for God. But if there would be 100% proof of God in this world, you would have no choice but to believe in God.  And that is the beauty of it. Like this, you have the choice to believe in God or not. Otherwise, you would have to discover you because you are out of this created project. So if they can't discover you, it doesn't mean that you don't exist. But the second option is that you send them signs and evidences and you also give them the power of intellect. They can find you through those evidences and their logic. It is like you have given them some tips for this test. And if they still don't accept your existence through those evidences, then it means that they are arrogant. Okay, I don't think this video is well presented, to be honest. The example is given to have an understanding of how a creature can be limited by its creator. We understood. The created model is bound in an environment with specified laws like force, acceleration and movement with a specified time scale, which are controlled by you. Yeah, the matrix, the physical world. So the model can only discover those things which are within that bound environment. And because of his limited mind, he thinks that nothing exists beyond this specified environment. Yes, this basic simulation theory, which of course appeals to the western mind. What if this is a simulation? What if there is a creator that created a simulation? How would the simulation interact with the creator? It's a good little example, but I would say that the creator God is, of course, much vaster than anybody that could create an artificial intelligence. But take in consideration that even if you make such a project, still you can't be the ultimate creator for that. Exactly. Thank you. That's what I just meant. Because the elements which are being used in this project like the electricity, the predetermined patterns of the project, your brain, etc. were created by a superior being. Exactly. Irregular AI simulation, what not, sims reality is not comparable to this.  Don't you think that you are made in a mega computer? Actually, not a computer, but in a mega creation box? So when we are inside this creation box, we can just touch, test, see, smell or hear anything which is physically inside this creation box. So these five senses help us to discover things which have connection with physics. But there are other things like love, like feelings, like intellect, meaning your mind. These things cannot be described physically.  Or you cannot discover love or your mind through these senses. Does it mean that you don't have mind or there is no love because you cannot see, touch or smell them? Of course they exist, but you cannot discover them physically. You can prove their existence through signs and evidences and using your logic. You could technically go to a neurologist and they would show you that certain synapses, neurons are firing in your brain when you're in love, or you could go to endocrinologist and they would tell you there are certain hormones affecting you when you're in love. So there are definitely certain evidences that could be shown scientifically, but nevertheless that wouldn't ask the deep, deep question of what is love? The sign for a sad feeling is crying. Or when you analyze the outcome of something, it is an evidence for your mind or your intellect. So don't think that God is inside this creation box and you can discover him like any other thing. Because anything which is discoverable is not God at the first place. He is beyond this universe and even beyond your imagination. You cannot discover him by the laws of physics because physics discovers anything which is bounded by the laws of physics. And a law is not bounded by the laws of nature. So anything which is limited by these laws is not God. That's why you cannot discover him. But his existence is proven through evidences and logic. Everything that we must verify has to be touched and felt. Yeah. But let me tell you something. If God could be touched and felt and seen, would that be God? No, I mean. Would that be God? Wouldn't it really be a test of belief, would it? Because you would know for a fact that... It's not even just a belief because God actually says there's good reasons to believe in him. For example, look, do you believe you had a great, great, great, great, great, great, great, great grandma? No. You believe in him? Yeah, but I mean, there's obviously, I know that because I'm here now. Oh, exactly. Yeah. But that's exactly the point. Have you ever seen your great, great, great, great, great, great, great grandma? You don't have access to a DNA? I know scientifically. I would have to have one to be here. How, how, how, well, no, no. See, that's the point. Using the terminology here. Scientifically, you have no clue. You have no clue. Scientifically, your damn science say we can only verify the physical world and things that we can touch and feel. This is a non-verifiable thing. Yeah. The only way you know you got a great, great, great, great, great, great, great, great, great grandma is because you're here. You've made a logical, rational decision. Not based on the physical world, based on necessity. The complexity of this universe and the laws of nature. The only difference would be, I'm playing devil's advocate here. The only difference would be that you would have a biological necessity for a great, great, great, great, great grandmother to be here. But from the atheist perspective, you wouldn't have a biological necessity for a creator.  I agree with this man. I have to laugh myself. But nevertheless, that's what the atheists would say. They would simply base it on evolution, a biological process that came into being through a big bang. Who created the big bang? Nobody knows. This is sufficient evidence for them. Are all evidences for the existence of a wise creator who has designed them in such a precise manner? So if you don't see him, it doesn't mean that he doesn't exist. The universe actually may have a purpose and some physicists are now suggesting it does have a purpose.  I really don't understand how people can go through their life and somehow derive meaning in the perception that everything comes from no meaning. Fundamental numbers in atomic physics. These are numbers like the mass, the weight of an electron, the weight of a quark, the strength of gravity, the strength of the electromagnetic field. About 20 numbers that describe those and other parameters, features of our world, but nobody knows why it is that those numbers have the particular values that they do. Now, you could easily say, who really cares? You change the mass of the electron by a little bit more, a little bit less. Does it really matter? And the answer is it does. Of course. So it turns out that if you imagine that we had 20 dials right here, and we could fiddle with those 20 numbers at will, even a small change to the values of the known, values of those numbers, would cause the world as we know it to disappear. For example, if we go back to say one second after the Big Bang, at that point, the expansion rate and the mass density have to have been adjusted to each other just right so that the universe is just at this critical point. If the universe at that point were expanding just one part in the 15th decimal place, faster, the universe would have flown apart without galaxies ever having had a chance to form. On the other hand, if the expansion rate were just a little slower than what we think by one change, change of one in the 15th decimal place, then the universe would in fact have expanded to a maximum size and collapsed. We would never have even reached the time in the universe at which we're living. A natural question. The atheists will claim that's just luck. The question that many people ask when confronted with this is, who designed it so that they all fit together so perfectly to give rise to our world? Is it merely an accident? Is there some force of nature that's out there that requires the universe to be as it is? Or is there some conscious being behind it all that has dialed things in a manner to allow... No, let's just say we became conscious, but the creation process itself is totally unconscious and behind it is of course not a conscious creator. Atheist logic. What we can do is look for evidence that suggests that we're not here out of total random events. And to me, the arrangement, the special balancing of the fundamental constants, the fundamental forces of nature tells me that there is a being there that has put this package together, which has constructed this universe, someone outside the universe that was thinking about us and put it together for our benefit. Allah subhanahu wa ta'ala is great and majestic. He preserves himself in a majestic way that befits him. He doesn't want to reveal himself to the world except by his power and knowledge. And Allah created us in a way that we are not capable to see him in this world. But this will be the greatest reward of the people in Jannah to see their creator. We must consider that we are being tested in this world by believing in God without seeing him. Blessed are those that believe without seeing. Alright guys, and this is it for today's video. This is it for the first reaction video back since I was sick. Thank you so much for your ongoing support. I truly appreciate it. As said in the beginning, I personally don't see the question of God as a scientific one. However, I do understand that this video has value for the current mind state that we are finding ourselves in. Everything has to be examined scientifically and we have to debunk the atheists, even though atheists lack basic logic. Anyways, this is it for today's video. Guys, if you liked it, do me a favor, leave it a thumbs up. If you haven't subscribed already, guys, please do so. Share the videos if you can. If you can support the links in the description box, Patreon, etc. Thank you so much for your ongoing support. I truly appreciate it. And as always, may God bless you all. Much love and peace.