Good morning, God, it's been a long morning already. Good morning, everybody. Welcome to OER 22, and our session this morning is the, yeah, just checking I've got the right time, is the 10.40 in the UK time. No, it's not, this is 10.40 session, you hero and near future learning design adventure. And I'm very pleased to welcome all of our speakers this morning, Amon, Steve, Projactor, Tom, Claire, and Fiona. So thank you all so much for coming this morning. We're really looking forward to your presentation. So I will hand over to you guys. Hi, everybody, you're very welcome. OER 22 delegates to this presentation, a hi from the team here, part of the team. One is down in action, Fiona, and go away, she's listening in in spirit. And you're very welcome, you are particularly welcome because it's your adventure. You were the hero of our story today. We're gonna give you a brief flavor of an open game we have been developing. It's, there's finite games in life, there's zero-sum games where there's winners and losers. This is not one of those, this is an infinite game. It's unbounded, it has no end. We don't even know what we're doing or where it's gonna end. We're developing this game on lunchtime breaks in airport lounges, in phone calls at night. It's a very secretive and strange activity, but it's about learning design and the choices you make in your life and in your work and how you can use these in open or closed ways. But you are the hero of this adventure. And even though we don't know how it's gonna end or where it's going, we do know how it starts because it starts, waiting for Steve to share the screen for us there. That's okay, Steve, thank you. It starts with an ending because the interview ends. And at this point, you say, so let's see, let us see. Oh, Steve's on mute. Okay, and it's ending. And thank you indeed for all of that and for taking the time to come and interview with us today. We'll be in touch with you very shortly with the outcome. And oh, unless you have any questions for us, of course, because in learning design, as in life, you always have a choice. Do you say, no, none, that was all great. Thanks again, looking forward to hearing from you. Can you tell me about the toilet break policy again? C, what's the max salary after five years? Or D, what are my opportunities for advancement? So please tell us, is it A, B, or C? And I think I'm hearing a B here. So let's hit branch B and see where we end up. You're asking your interviewer and they tell you. So let's see what they say. That'll all be explained in the contract. The main thing is that everything we do is evidence informed. You say, ah, okay, thanks. I look forward to hearing from you. And then we go. So we're now in act two and two weeks later, the time is 10 30, the date is February 5th, 2024. You have just been hired as a learning designer and are working in the strangely named learning design deck, a department in the University of the near future. Now dedicated to post-digital learning. Now take a breath and A, meet one of your new colleagues in the animal A division or B, meet colleagues in the beginner's mind division. So please let us know if you would like A or B and maybe I'll just ask some of my co-designers here, which you would like to see A, can I get an A or a B please? A you maybe? A. Okay, I'm hearing A. So let's meet one of your new colleagues in the animal A division. Oh hi, how are you? How are you getting on so far? Good, good, good. I'm actually really sorry, I've actually forgotten your name. Lovely, of course. Well, welcome aboard the deck. As I say, you've chosen to work in the right division. Here in the animal A division, we have some really cool stuff going on. We are devoted to the new science of interspecies learning. I mean, we're all animals, right? Human mammals are not so special. So now, do you want to hear more about the animal A division or continue on? You, the pundering music, and we continue on. Hey, please, all right. So, go far so good. You meet with a new manager. She tells you about a new project in the early stages of planning. One that would support the Irish history curriculum and she wants you to handle it. The two of you have a great discussion for your ideas, Floyd-like sparks. You can see a lot of different versions of this project with different audiences and impacts. You can either keep the scope small and walk on supporting the curriculum or if you make a convincing case, you could expand the team and scope up the project to something more public-facing with a lot of video and multimedia content, but also with a lot of moving pieces, deadlines and pressure, as we all know. Which way do you want to take the project? A, keep it lean. You can always build on the success of a small force iteration or B, go big. You want to reach a wide audience and make a big impact and you're up for the challenge of managing all of those moving pieces. A very relatable conundrum, I'm sure. I think I'm gonna go for A, I would like to keep it lean. Oh no, Aimeen, we all know you're a B kind of person, but... We've got a A in the chat so far. So... Will we? Great outcome. Keeping the scope smaller and more manageable allowed you to go deep on making an unedited document archive that proved to be of great value in supporting student research in Irish history department. Several of the faculty have taken note and asked if you could meet to discuss helping them create resources for other projects.  Oh hi, did you hear about the new course in development? We're working on an online course. There's a lot of secrecy about who the students are, who will take this course. We must sign an NDA and management will only speak in analogies. They tell you the target audience can have a distant planet from which alien life forms are often to take a level seven special purpose of life to learn more about the slow death of a planet from climate change. However, the course notes are contained in old tablets and need to be transcoded digitally. Most of the tablets are made from clay. Head of department wants to scan the tablet, but the lead learning designer feels that the format isn't conducive to the reuse of this. We advocate for adopting the content into smaller bite-sized chunks. This would damage the impurity of the world by the use of head of department. We hope to get up there and reach the end. That sounds like a yes. There are no other choices here. So, so far so good, but now we're in act three. Act three, endings for beginnings. It's been a wild ride and we can't determine what will happen to us, but we can decide how we will react. What overall approach do you choose? A, Ed Tech will save us. B, you quit. C, you embrace failure. Or D, keep trucking. That's how many of us try and do. So, which do you choose? A, B, or C? Let us know which one of these... I think we need more suspenseful music. I feel a lot of suspense with this one actually. I was trying to build up both hands here. I'm really hoping Ed Tech will save us. I'm really, that's kind of one of my hopes, but I think we might be in the wrong conference because a lot of skeptics around, you know, a lot of skeptics over the last couple of days. I'll believe it. Quitters. C, and... Oh, two C so far. At least quit yet. Shall we? Shall we embrace failure? Wouldn't be the first time. So, let's see. What is failure? Let's see. It's inseparable from growth. You transcend beyond the logic, structures, and subjectivities of the university and are elevated to a higher plane of consciousness. You retreat from the material world and move to inhabit the realm of ideas. What is a good life? And does any of this matter outside of the university walls? Hmm, good points for pondering. And we've reached the end of one of many branches. Thank you very much for that, Steve, Tom, Lily, Claire, and in absentia Fiona. And I'd like to maybe just open it up to the floor as well. And we'd like to take a bit of time now to tell you a bit about our process, how we created this game, what it was, but also to get your feedback. We'd like to hear from you first and just ask you for any comments and things you have. If there's any of these, we developed quite a large scenario of all these different types of things that could happen in a learning design workplace. It was challenging and tricky to develop this in a distributed way and to get all the narratives to fit together and so on, but it was a lot of fun and it was interesting. So thank you so much for your time today and helping us try it out. And we'd like to hear from you. And I suppose one of the motivations or the aims behind this was trying to think about careers in a fun way and what it looks like in a workplace and some of the issues that can come up for people working in third spaces, kind of ill-defined area of learning design, particularly as because learning designers have really been a lot of the language in the popular discourse and the literature has talked about learning designers as first responders and many of these things. It's also a case it can be quite a gender profession so there's a lot of women in it and it's often characterized as a caring profession, it's a service profession and there's been a lot of burnout in the area of learning design. There's a lot of issues around precarity of contracts. There's a lot of issues around career progression and development. And so these are some of the ideas we were using to use this game to explore. And we just like to, I just using that as an opener to start the conversation and I see a question from Janice from YouTube. Thank you Janice. What platform did you use to create this? So I'm gonna maybe ask Steve to answer this one. Great. I actually, I thought, I think Kerry you'll see that I requested a screen share there again. I'm just gonna show those. I saw that there, we saw that there was another session this morning I believe on twine as an open source platform for offering multi-threaded nonlinear narratives and basically right here at a very high level without zooming in too much. You can see kind of all of, you should be able to kind of get an idea of all of the different pathways and ways that these kind of scenarios, these mock scenarios, some of them very, very speculative but some taken much more materially from our own lived experience in a number of different contexts in learning design, instructional design. You know, we can, we tried to kind of take a few different approaches to kind of depicting realistic conundrums and choices that we've all had to make and might have to make in the profession. And then just seeing how many different ways we could weave that into different scenarios. Some more science fiction and some a little more kind of mundane and all too relatable. And we basically created a three act structure there. And yeah, it was a lot of fun but as Amon was saying, twine is a wonderful environment for kind of creating and illustrating these different branches but it was very, very challenging doing an asynchronous collaborative authoring process since it's such a centralized type of platform where really works best when one person is kind of doing all the moves as opposed to something more collaborative like a Google Docs for instance. So that was a really interesting and fun design challenge for all of us. And especially outside of COVID, I think this was the kind of activity that would have been great if we did like an all day workshop. We're all kind of doing a design thinking, putting post-it notes on a board, et cetera. But we did a lot of Zoom sessions and discussions and kind of collaborating through a script. Really fun, really interesting learning experience for all of us, I'd say. I see as well some great, just reading the comments. One of these things is like, it's kind of like flying a plane sometimes in these presentations. You haven't a clue what's going on. Your heart is going like a jackhammer. You've all these comments, you have co-presenters like it was chaos. So we couldn't actually, one of the questions from Yvonne here was, how did you, I think it was, were my responses timely enough, you know? And this is a big problem. We thought exactly what you thought about that about having a poll and getting people to respond to the poll. But we thought that could be kind of confusing as well and maybe take too much time. And we were trying to come up with a low friction, kind of low tech sort of way of doing that. So it was just kind of shouting out and putting into the chat. And sometimes I couldn't even see the comments. So then I was asking like, my colleagues in the presentation just to give me an option, you know? So we're kind of going back now and just reading the comments and it's great to see you're engaged. So even perhaps you may not have been, I think it's the key thing is just getting people to feel part of the story is very useful in the field. They have some kind of thing in it. And that's, I see a comment from Sarah as well about a link to play the game. Yeah, that's great. We have Fiona's is we're going to try and host it on because actually there's some loads of, there's actually some nice content in some other story paths that we never got to, you know? We had some lovely little story lines in there. And that's one of these things. So we did, and as Steve was saying, it's complex to work on these things in a distributed way. And there are recommends for things like you can use GitHub, for example, to work on these things collaboratively. But Twine is basically, for anyone not familiar, it's very, very easy to use. You don't need any kind of programming or technical ability. And it works in the client. So it just opens in the HTML window and that's all you need. So it's, but it's also very powerful and you can do programming and if you have a program where you can help with that or if you have some a little bit head for that, but also if you're somebody who knows a bit about design or making web pages, you can do that. You can include, we didn't get in the branches, but there's videos and stuff we had as well. Please multiply again. No. So any other questions? And I'm gonna... There's a good question, which is the critical path. I'll tell you, if you know that answer, I'll tell you, you're a better person than us when we did, which is it, yeah. I would say the process-wise. Well, the hook that Aiman really kind of built this around was that in learning design as in life, you always have a choice. And I think we've all seen different directions and different ways our careers could go based on the types of preferences, values, organizational kind of preferences that we've all had in different experiences and different contexts. And so I think we wanted to allow for a number of those different kind of styles. And this was kind of a proof of concept version one that I think we really could flesh out. And as an open resource, it could be, I don't know, helpful as a reflection on practice or maybe even as a taste of things to come for people early career. So this was kind of a way to get that up and running. And I don't know, I'd be interested in seeing what kind of future purposes or value people might find in such an open, multi-threaded, non-linear story. That's a reflection on learning design practice. I think it's a great question on what's the critical path? And you could read that question number of ways. What's the important path? What's critical? Or in the kind of sense in the scholar ledger about critical, taking a critical stance on something and considering it and kind of having a considered or reflective view on it, I should be like, and there's lots of threads and there's obviously no, there's many paths but there's only one way. I'm reading the Tao. I'm getting interested in reading Taoism at the moment. So, but I guess for me, there's lots of things. You look at learning design and this kind of activity or whatever we're doing in workplaces. And a lot of the path for me feels about what is the value and the quality of your work at a kind of micro level. You can like, there were some scenarios where you can take too much work on and things like that. But a lot of it as well can be kind of, which is a subtext of some of the things is how we treat other people or how we, because you can have, you can also have great values and be very well intentioned. And then just, you know, turn up to work stressed and shouting at people to do good stuff. So that's a challenge for me anyway, certainly. So I don't know if that answers that ending on or anything. So there's another particular one about twine, Steve, as to how you get that exactly. It's a download, isn't it? Yes, an open source tool. You should be able to see, let me see. I can share fire screen and twine narrative. And twine narrative. So twinary.org is the download for twine, and then it works in the browser as well. It's a very kind of low, low impact app. So only a few megs. And it does a lot for its kind of compact size. Not sure the degree to which we are announcing our version one. And it doesn't look like there's a good way for us to share in the chat, but this is the URL of our kind of version one proof of concept here, learningtale.com slash uhero.html. We could put it in Discord. Yes, we could. I was hoping that we'd have an interactive chat with those in the audience. Great, there you go. ALT just put that in there. So you can give a spin to a few of the different directions that we have here in version one. And it's such a good way of making yourself pull in different directions when there's no right answer. Like those are always the best decisions because you don't want to choose either of them. But as in life, you have to end up with one of them even though you're not 100% behind it. So really good for that kind of reflective prompt. Yeah, and I think with case studies and with different kinds of storytelling, helping the learner or the audience get to those kinds of relatable decision points is always a challenge. So I think we've tried to get a few good ones in there. A couple of thinkers, a couple of reflective questions that really make you relate to experiences where you have to make a decision about what kind of environment you want to work in, what kind of style you have for working. So yes, it'd be interesting to see everyone if you have a go at it and then post later on Twitter or Discord the decisions you made where you ended up. Yeah, please do. A broken ed tech or a very rich and successful one. I'm just thinking actually, have we got a hashtag for people to post or follow? Do we have a, do you hear them maybe? Do you hear them? Do you hear them? So hashtag you hero, please. That'd be so lovely if anybody wants to have a look at them. See how you get on. Just put a version of it in the chat to carry maybe, yeah. Okay, he's already done that, thanks. Awesome, excellent. Yeah, I think that'd be very, very interesting to do. Yeah, it could form the basis of a very, very interesting presentation at OBR23 about some sort of crowdsourced project. Well, you know, since we have the chat coming in from the audience, but I do have a question for the other participants here. What do we see as an ideal future iteration for this as an open education resource? Well, like a starting point as in designing your own teaching materials and also that reflective prompt. So I think it's got two starters for me professionally. Yeah, I think as a grad student or early career instructional designers slash learning designers and related fields, it's one thing when we learn a lot of theory in a vacuum, so to speak, in the academy. And there's really very little professional preparation in grad school around instructional design for the actual kind of pragmatics of collaboration and kind of navigating organizational challenges. So I think this is kind of like a, not exactly a case study, but as a kind of inhabited narrative. Might help prepare people for some of the challenges that they don't expect after, you know, doing their dissertation, for instance. I think as well, it's got a lot of potential for starting conversations with other people regarding the technical surveillance. So we didn't get into that thread in our iteration, but it's a really clear way of showing some of those, perhaps arbitrary things we decide at policy level and seeing it in action. No animals are harmed in the making of this game, by the way, but there's potential human harm. Now, I agree with you, Claire. I think one of the real benefits of something like this is by presenting it in such a way, it encourages to engage in conversations.  This is just a way of just getting it out there and just sort of having someone out and part in conversations. Because sometimes, you know, true word is said in jest, and you can have a bit of fun in the game, but it can raise us to, even in putting the game together, it encourages you to say stuff that you wouldn't do if you're writing a document or something formal. I thought that was good. Amen, there was one thing you said very recently that really struck me as being a salient. I think you were mentioning something about how you enter a new position with all sorts of values and priorities, and then you find yourself in a system and suddenly everything has changed and your ability to kind of navigate and do things might be hindered. I didn't want to reuse your words, but does that ring a bell for you? Yeah, there's often, John John had a great title of a paper, one turn about ed tech and kind of choices and things, and it was any color you liked, as long as it's blackboard. And it was an allusion to Henry Ford's kind of thing about the Model T and the production model of technology, you know, and you just have a big technology, you have to kind of use it.   You know, we'll have an edit button and we can go back and undo all the things we said. Not gonna happen, doesn't exist. So I think it's a great way for having questions, asking questions. I think you can use kind of creative approaches and playful kind of science fiction type approaches. Also, it's kind of protective for participants because you can talk about scenarios without, you know, you can talk about something in a workplace that you may not be able to talk about otherwise, that you could get punished for, or you could talk about a product that you could get sued for. I think pro for example, if someone is getting sued for a property product, so I better stop talking soon because I think we might be, we might be able to get sued. So thanks everyone for coming along. Yep. Thank you. Thank you very much. Just want to say a very big thank you to Claire, Projector, Amon, Steve and Tom for a fantastic presentation this morning. Really good fun, really interesting to see what you've created there in Twine. And I've not heard of Twine, so there's another thing to add to the arsenal of equipment to have a play with this afternoon. So thank you all very much. I think now we are gonna have a short break in the program.  So thank you all so much. Hope you enjoy the rest of OER 22. Bye-bye.


I'm a fraud Hello everybody, welcome back to my channel. I'm posting a new video for the first time in months as you everybody knows We're under quarantine right now. Well, I live in America, so we're not exactly super in quarantine We're just kind of in a suggestive quarantine where they're like, well, you should stay home Italy on the other hand is full quarantine Yeah, whatever. So while I figured while I'm in quarantine, I have this whole channel that I've been neglecting So might as well pick it up again. So I actually have a lot of videos planned It's never it was never a case of me running out of video ideas It was just a case of me being lazy as some people who are watching may know I've changed up my environment a little bit I recently moved from a very small town into a town that is bigger Where's that going with that? I can't exactly give a room tour or a house tour because it's not really my house I'm living with my boyfriend's mother and family right now. I guess I could give a room tour Here's my very messy bed with pants. I have not put away yet. There's my dresser There is my boyfriend who is playing team fight tactics, right, babe?  All right. Bye. Uh, enjoy your quarantine


Good morning everyone and welcome to Grand Rounds for those of you in the room. It's a special opportunity to welcome Dr. Caroline Craven or newest hire who is in the room for those of you virtual. She is excited to be here huge smile saying hi to Judith right now. Feel free to reach out via email or in person. When you do see her next. All right, Lydia, Lydia, sour will be moderating. All right, good morning everyone and I have the pleasure today to introduce Dr. Mubarak Mohammed, who is one of our wonderful PTO two colleagues. And I asked everyone about a fun fact for themselves yesterday, and he said that he is defending the fantasy basketball champion in his league. So, with that, he is going to talk about physician wellness, unlisted occupational hazards. Thank you, Lydia, and let me know if my voice is too loud or I'm not speaking up. But certainly appreciate everyone's attention I do regret not being present for for this Grand Rounds I'm actually in Ohio. With my family for the last week of Ramadan and they're just kind of scheduling I could not make it in person but certainly happy to be here and happy that you guys are all present and watch this presentation. And the title is that physician wellness, unlisted occupational hazards. We will keep going here. I have no financial disclosures. So in some ways, struggled with the phrasing of this title, you know, being a physician is incredibly rewarding. And one of the ability to positively impact the lives of, you know, others to profession where self actualization is possible.  You don't want to be like a construction worker or a forklift offer like I am and, you know, working with my back every day. So just, you know, telling me to use my brain and making sure that I didn't have any, you know, work related hazards. The job itself is, you know, well respected in the community. You know, a lot of people are esteemed and admired for being physicians.  All in all, it's a pretty sweet job. And I think we're all lucky to get to experience this. However, like many other jobs, you know, it does have some occupational hazards and certainly not at once but little by little and through my experiences and early resident.  And this is something that's over time, kind of overlooked and oftentimes, you know, not by society itself but you know ourselves and in the profession as well. And when many of these occupational hazards we are familiar with, you know, in the war in the clinic physicians are exposed to infections pathogens. Airborne continuous contacts. It's not an insignificant cause of physician morbidity in the workplace. We know that, you know, I looked at quality pottery and all of its kind of carcinogenic effect. And then as Jordan does it tell I presented early in the year and his grand rounds, kind of pretty accidentally as far as the musculoskeletal complications and ophthalmology, the force and skill required of manipulation and standing and sitting in the or lack of ergonomic insight that do lead to, you know, injuries among surgeons and physicians. So the occupational safety and health administration describes five categories of occupational hazards. I think we're all familiar with the physical safety hazards which include anything that could happen in the workplace as an injury. They are described as quote unquote health hazards where, unlike physical safety hazards they describe risks of injury after cumulative exposure to harmful condition or substance, rather than a similar accident. And then those are pretty self-explanatory as far as like chemical biological hazards physical hazards include like excessive noise or elevated or low temperatures or radiation. We can just kind of, you know, see over and over again that can impact your health and then ergonomic hazards we are well aware of as well. Notably one thing that is missing though are the psychosocial hazards aspect of work, which can, you know, have the potential to cause psychological or physical harm. Our government, the OHSA does not list it as one of the kind of five core occupational hazards, but this is just kind of the definition from the Australian government and their co-equivalent to OHSA, which lists again psychosocial hazards as being an aspect of the health and safety of their occupation. So this was a recent article that I saw back in September actually and I think we got an email from the GME as well. Just saying that, you know, that day I think it was September 17 that it was National Physician Suicide Awareness Day. I actually didn't even know there was a, you know, Awareness Day for Physician Suicide. Certainly I think, you know, as we go through training, we all have like many experiences with certain, you know, kind of the how hard work can be and certainly hear stories of, particularly with me as I started residency just in terms of the journey aspect of your mental health and burnout and things of that nature. And certainly we all kind of are, you know, have a cursory awareness that physician suicide is a thing and it's higher in the, you know, in our population than the general population, but certainly not to the extent that, you know, there's an actual day where you are kind of observing the amount of suicide that happens in the nutrition community. Certainly there's a lot of risk factors, you know, that sleep deprivation, long hours, excess workload, certain financial hardships in terms of loans and whatnot and then legal issues from a medical legal standpoint that exacerbate these issues. But it's oftentimes something that's not really looked at, you know, in our community and this is, you know, evident for me as well which, you know, as a physician I didn't even know, you know, a day kind of looking at this was something that was, you know, on the radar as far as on the national community. So I just wanted to kind of take this time as an opportunity for myself and just, you know, had the opportunity to present a grand rounds where I could kind of look at this a little bit more and then particularly talk about physician suicide to kind of not only educate myself but then, you know, other colleagues as well. So I'll start out with, you know, Burnout is something we're all familiar with it's a more related syndrome involving emotional exhaustion, depersonalization, in a sense of reduced accomplishment. These folks surgeon now we're kind of the first to assess burnout and resident in residence and faculty and the numbers are pretty high as we kind of all probably are aware of, you know, I'm 30% of residents in almost 30% of faculty as well scored in a high range of emotional exhaustion. More than 50% of residents and about a quarter of faculty scored in a high range of depersonalization, and then about a fifth of residents and 10% of faculty scored in a range of personal accomplishment, which, you know, is pretty eyebrows raising, you know, as far as, you know, we're all highly educated in a highly accomplished folks as well. And then in terms of, you know, suicide I think we all know that, you know, female physicians are about like twice as high to commit suicide as compared to the general population and then for males, the hazard ratio is about 1.4 In a recent study, serving almost 8000 surgeons in the UK, about 6% reported suicidal ideation within the past year. And then for the for that population itself among surgeons, it was three times more common. And the most probably, I guess, eyebrow raising, you know, fact is only a quarter of them sought psychiatric help and almost the majority, you know, 60% say they were reluctant to seek help, due to concern that could compromise their careers and I think we all know that's true as well. So I think I would argue, particularly with, you know, the hazard ratios that we see, and just for the fact that we have, you know, an awareness day for this in a profession that it is an occupational hazard of those physicians. It's the only cause of mortality that's higher in physicians than non physicians as well. And this was the study that I was citing earlier as far as the suicide rates among physicians by Sherman Homner as well. So, one study that I wanted to kind of look through was looking at suicide ideation in medical school and medical students. And this recent meta analysis, believe back about five years ago, or a little bit longer. Sure that the purpose was pretty high among medical students and it kind of started there. So the prevalence was about 11% in the medical student population and then when you kind of extrapolated out to the past year or so about a quarter of medical students indicated suicidal ideation within the past year based on that study. Notably this study also and other studies have shown that you know the burden and prevalence and incidence of mental health disorders is not higher among medical students compared to the general population. I know that suicidal physicians face unique barriers to care and I think we're all aware of just kind of the pressures and my professional standpoint. Encounter, you know, barriers that not only you facing like, you know, general population as far as stigma, lack of time and a lack of access to care. So physicians, especially have an added burden concerns in regards to concerns with regard to like confidentiality fear discrimination and licensing and applications for hospital privileges to actually do their job. And then this is a study by Shenifelt and co I believe out in Brasca and up to 35% of physicians did not have a regular source of health care, again, which is associated with less use of these preventative medical services. The use of mental health unsurprising was also low, but certainly in the research I was looking at there was a little bit of a lack of information in regards to these patterns. There is a little bit more known about medical students. But again, they have low rates of seeking help with only about. I think a fifth of those who had screen positive for for depression using mental health services so 80% of folks that are screening for depression or not. Talk to somebody utilizing psychiatric psychological services. And then for those depressed students that way that did have SI only 42% received treatment. And again, these are the physician late the students that will all, you know, become part of the workforce. And then most recently, or most frequently outside of barriers included lack of time, confidentiality stigma costs, and then fear of documentation on the academic record. So then, you know, why do these barriers, you know, exist. You know, practicing physicians with disorders often again occur encounter over or covert discrimination in regards to the licensing privileges insurance as well and then we know that malpractice insurance is a big deal as well particularly as you're transitioning to attending Most of the state licensing boards have removed questions about diagnosis or treatment toward questions about, you know, impaired professional performance at initial licensor and rules but there are some states again that still have kind of ambiguous questions in regards to kind of mental health. And notably the American with disabilities act has been deployed in legal challenges in regards to these medical licensing boards and then there are questions in regards to mental health questions. So it is reasonable to infirm or infer rather that the physicians concerned with disclosure of mental health records is widespread. These breaches of confidentiality between physicians and not only as you know colleagues but you know as a treating physician can resolve and kind of needless disclosures to core workers. These concerns coupled with professional attitudes that discourage admission of health vulnerability are probably the driving forces behind the the lack of you know seeking health and mental health care and in the medical setting for physicians. And I would like to maybe take about a 30 second break and you know just for everyone just to maybe think about, you know, a hard time and their training or maybe attending hood and then if you can think about maybe the most respected like colleague that you can think of someone that you really admire and if they came and disclosed, you know that they were having you know these impressive thoughts or suicidal ideation. How would you react and then kind of what your thoughts would be in regards to you know helping them out. Conversely, if you had you know a colleague that was struggling. Maybe you didn't get along with and again you found out by some way that they were also having these issues, what your thoughts would be as well as kind of a mental exercise for all of us. So in regards to the risk factors. Certainly, you have kind of the general risk factors among, you know, population itself so biological psychological and social components. Overall main risk factors for suicide include mental illness and substance use disorders about 90% of individuals who end up now passing away from suicide suffer at least one of these other notable risk factors including prior attempts homelessness access to legal means lack of an adequate support system and chronic medical conditions. And then, particularly with physicians you know in addition to these general risk factors the the elevated risk among physicians is likely due to additional population specific factors among physicians so physicians are exposed to high levels of personal and professional stress. Oftentimes make life or death decisions, you know, particularly in our field you know life or I and then constantly at the risk of malpractice as well. They also have high stakes, you know conflicts, possibly with administration or colleagues and then certainly from, you know license or standpoint as well. That's something that's hanging over your folks heads as well. So, additionally, we know that medicine and kind of medical training encourages stoicism. So from, you know medical school on, we're almost taught that there's new room for error, expected, and our expectation is that we're, you know, able to perform that, you know, exacting standards, always putting the patient first and then trainees you know in this environment may believe that you know they might be faulted for vulnerability and thus avoid asking for help. It's ironic that you know even though physicians are typically better resourced in the general population. There still remains like a significant barrier seeking this help. This is a study out in Norway, just looking at the comparatives of risk and particular factors that are related to SI among residents and then attendings or specialists as they come, you know, they're in academic medicine. These are kind of the main risk factors. The perception of need to demonstrate competence was related to SI among the attendings. Subjects to harassment. Oddly enough was only found in the attendings but I'm sure, you know, if you're subject to harassment it's not getting free from mental health in the workplace and then. The sickness presentee, presenteeism was a new word I learned in this study and basically kind of shown up to work when you're not feeling well was also associated with a higher left a higher level of ideation for both groups. A lack of empowering leadership was also associated with a higher levels of SI for both groups and then lack of regular meetings to discuss just kind of the job itself and the demanding experiences at work were also associated with higher levels of SI among the attendings. This paper reported kind of similar but in terms of just kind of looking at more of the protective factors and this was by out in the UK and looking at junior doctors or residents. And the analysis that identified kind of three main themes and hope, you know, this is kind of the main sticking point of my talk but support from colleagues with regards to managing workloads and emotional support, support of leadership, including feeling valued and accepted trust, trusted and good communication, supportive learning environment. And then normalizing vulnerability and in those instances were helpful and found to be protective and then finally access to professional support, whether it be you know counseling CBT medication and having those avenues kind of highlighted were also protected as well. And then lastly this is a stadium, a high stadium horses we call it kind of a lot of my fond memories from college are here. And one of the finest memories is just hanging out with you know a lot of my friends and one of those friends was actually a medical student at a high state as well, or an undergraduate and then went out to a medical school elsewhere but he was a resident and just started his internship last year. And I think we all kind of know where the story is going but he passed away from suicide earlier in the year and anything, anytime something like that happens definitely makes you pause and reflect, not only in our daily interactions you know just with the system in general, you have kind of a multitude of feelings from kind of guilt and shame to like anger at the system as well. But certainly, just kind of remembering him and just kind of you know the wonderful life that he lived. I just wanted to just kind of give this presentation as well not only for myself and just to kind of educate myself a little bit more in regards to the rigors and pressures of medicine how that can affect us in terms of mental health. But just you know, mainly presented to you guys as well and particularly my co residents, just make sure that, you know, this is something we think about something that we turn to guard ourselves against. It's not easy, right. And we all kind of have battles that were kind of going through but I'm just remembering just to be kind to each other, patient to each other and then ultimately supportive of one another. And this kind of, you know, hard life that we kind of go through is going to be important so I just like to would like to end with this phrase here. By Ian McLaren he's a thing of the past out of Scotland but this is one of his most famous quotes from kindness. And just want to thank you guys for your attention and be happy to take any questions. Thank you for this wonderful and certainly very important presentation. I really have a question to start off with. Do you know if anybody has looked at the difference between surgical and non surgical residencies and how the numbers of suicide differ in those specialties. That's a good question Lydia I don't know. Some of the main quote the main paper I was citing. Looking at burnout was among orthopedic surgery residents and faculty. I want to say that paper showed that the rates of like burnout were higher among surgical subspecialties. I don't know if any papers directly comparing a sire suicide between surgical and non surgical specialties. Okay, great. I have another question for you. Thank you for this topic. Obviously sobering and thank you for sharing your personal experience. You know, it was really you and the other PG Y twos this year that gave me some some new insight after all these years of being an educator around the intense pressures that you feel to not look weak be weak not be relied upon by your colleagues and and we all feel it medicine but it really. It really made me re evaluate where we are in this space of wellness and. And I'll say this I'm really grateful to work at a place that kind of abides by the Maya Angelou quote which is, you know, do your best until you know better and when you know better than than, you know, act on that and. And, you know, whether it's the kind of meditation room we're creating for you guys upstairs griffin Jardine doing the best thing I think we've ever done in the program which was create some admin days for you all. We can't just be beholden to residency has to be hard and miserable because we were all hard and miserable we always have to do a little better. And so griffin just recently at a conversation we had last week he's, you know, independent of this conversation really kind of redoubling his efforts around wellness and the residency. No one's better than griffin at kind of bringing a little bit of joy into the room and. There's a reason why we have him in that place and anyway thank you I know we've got to get on to to Brandon who's going to brighten our morning with some humor here in a moment but sincerest thanks for this this topic and always a timely conversation to be had. So thank you all. Wonderful. Thank you, Mubarak and then we're going to move on to Brandon, and to have something a little bit lighter he actually didn't just gave me one fun fact but he gave me three fun facts. So I'm just going to read those are. The first is that Dr Chris bear has never bet him in ping pong. Bobby outside of medicine is sleeping. And then the last one that may even be in context with this talk is that apparently his first word as a baby was of terminology. So with that he is going to talk about communication breakdown. Thank you Dr so for the warm welcoming partially wasn't true. Thank you everyone for coming out and thank you to the Moran for allowing us to come up here and present unique cases and talk about topics that were passionate about some a third year ophthalmology resident here. I'll be presenting a case today title communication breakdown. So kind of talking about the background of this title my inspiration is really came from one of my favorite bands like definitely one of my favorite songs by them and for those of you don't recognize this band. Maybe you'll you'll recognize some other familiar faces and myself and some of my colleagues here who were involved in this case and they were really helpful so I just wanted to give them a quick shout out. So this case starts with a 77 year old female from a transfer center call and a busy Saturday shift that I took this year and there was concerned for acute angle closure of the left eye. In regards to the information that we gathered from the transfer center phone call. She had progressive left eyebrow pain blurred vision had a congenital vomiting that started about one day ago. She did say that she had a similar episode like this in the past after scopolamine patch use, but she didn't require any glaucoma drops, no laser procedures no cataract surgery in that left eye. Initial presentation at the outside urgent care, intracular pressures reported to be very high up to 58 net left eye, and despite three rounds of max topical drops, as well as dimox, which was instructed by the local ophthalmologist or the phone. The intracular pressure is still elevated. You can see here the patient was seeing overall okay 2060. And she did complain of eye pain and the eye was reported to be read with a mid dilated pupil local ophthalmologist was unable to come in, but he referred that the patient be transferred over to the Moran eyes center for laser procedure. So we accepted the patient. A little bit of background in regards to transfer center calls here at the Moran. If the patient is an established patient, we can typically just send them over to the Moran directly and we'll see them they'll come here. We'll get a page and we'll see them in our clinic. However, if they're not established yet will go to the ED, or if they're unstable, we need any imaging or anything more urgent. So we felt comfortable just bringing her directly over to the Moran eyes and she's already established. And typically we get a page saying that the patient is here and we'll come see them. However, in this case, I did not get a page. And I kind of went about my day was very busy call shift. And eventually I kind of went looking for the patient in the typical waiting room and also sometimes they'll be out in the main area. And when I walked out to the main lobby I saw an ambulance in front of the Moran eye center. And I'm sure most of you are well aware but we don't really accept ambulance transfers. If there's if they need an ambulance they should probably go into the ED. So I walked down and turns out this was our patient. They arrived in a stretcher. They were previously stable at the outside urgent care. However, they said that the EMS they've been waiting for over two hours, and the patient has mentally decompensated and they're concerned for hypoglycemia. And they're here because they were told that the patient needs to have laser surgery they've kept her MPO and also that she's due for eye drops soon. So after talking to the EMS I take the patient up to the Moran eye center the fourth floor from the stretcher up there in a wheelchair and get her some food, get her some water. I elicit a history patient overall is a sick patient multiple different cancers unfortunately, as well as a resected schwannoma of the right side, which resulted in some facial neuropathy. I think Dr. Patel did some plastic surgery with her to protect that cornea. Dr. Mifflin did two PKs on her and she also needed cataract surgery as well, but nothing in regards to the left eye. An examination here kind of some things highlight you can see overall she sees pretty well she's 2040 so not quite as bad as what we saw outside urgent care. The pressure for me was actually very low. So instead of 58 or 40 despite, you know, topical therapy, I got a pressure of six multiple different recordings and I was very soft. Then on my gonioscopic exam you can see here that the angle was essentially closed with near 360 degree peripheral anterior sneaky eye. The left pupil was mid dilated fixed. Not reactive power no APD by reverse. It's like an exam. The AC was shallow. Importantly, it was uniformly shadow shallow. Again, the pupil findings there and then this patient had a large cataract this lens, but the nerve did look okay. So here I put an hourglass up here because I want to kind of stop and talk about how long it took me to get the patient up from the ambulance to the Moran eye center fourth floor. I listed a history and do an exam this. This took almost two hours, which is a red flag. The patient was kind of falling asleep didn't have the energy to get herself into the chair she almost fell when I was transferring her into the chair. She didn't have the energy to keep her chin in the slit lamp. And I thought, you know, maybe she's just tired or dehydrated because she hasn't had anything to eat. Or, you know, I saw patients with angle closure in the past. They're not just throwing up. But it really was of concern and things were kind of progressively getting worse. In addition to this, you know, I was also somewhat confused. You know this patient is supposed to be a patient with, you know, a red painful I was throwing up who's nauseous pressures in the 50s pressures in the 40s despite max optical drops and my exam the I was white and quiet. And angry and the pressure is actually very soft. So, when when you encounter this situation as a resident, you should, you know, do it all good residents do and that's, that's call your your chief, your chief resident for help and that's exactly what I didn't do I went straight to the glaucoma fellow. And that's Dr Chamberlain and he told me what he should have told me and that's to call my chief fellow or chief resident so that's what I did I called Dr Colin and and at this point, Dr Colin agreed. I thought it didn't really make sense there was concern for, you know, cute compensation from a mental standpoint and also if this patient didn't need a laser. At this time I think I already got six new pages by the time I finished with the history so it's also very overwhelmed so Dr Colin ended up coming in. He walked in the room took one look at the patient said she looks horrible this is one of the sick patients I've seen. So we decided to do an actual physical exam check her pulses, and we were concerned so we sent her down to the ED directly. And once the patient got to the ED, these were her initial vitals and take note that in the urgent care, she drove herself in she was human dynamically stable there's absolutely no concern. And she was supposed to self driver, self over to the Moran so you can see she's very hypotensive she's great a card to Kip Nick, who's setting in the 70s on a full air mask and she was also hypothermic. They also did EKG and showed that she was in second degree heart block baseline labs as well. You can see many electrolyte abnormalities or hemoglobin slow. She's also hyperglycemic. And then her the ED notes. She essentially said one thing to that the initial provider and that is she felt like her head and her neck were melting into the chair. And surely after saying that she passed out and fell off the exam chair became unresponsive they had to do rapid on her. They also gave her two liters of IV fluid rapid warming protocol, multiple different basal pressures as well as atropine. So very serious situation escalated very quickly. Kind of taking a step back and thinking here about this entire case and where we started and where we've we've come. We have 77 year old female overall unhealthy but presented to the urgent care with stable vitals complex past medical history issues, essentially transferred for further evaluation and possible lpi for you angle closure glaucoma of the left eye. Initially her pressures were read to be in the 50s at the outside hospital. They were instructed to do max topical drops which they did three rounds of and also one one oral diamox pill and now the pressure was six when I saw her. On my exam the I was white and quiet as the AC was uniformly shallow. I was near closed off on my gonioscopic exam I was mid mid dilated pupil with possible fake amorphous component. Then lastly she she had that subacute kind of alter mental status where she was kind of slowly decompensating we sent her to the EB. You prove the hemodynamically unstable required transfer to the McHugh and resuscitation. So kind of thinking back and what was going through my mind at this point you know I had to take a step back to my intern year and think about actually you know medicine and this patient had a stroke. Maybe probably not with her with her presentation but possibly you know this life threatening need to consider that she had a PE. She's definitely a hyper coagulable patient with multiple cancers in her history about a heart attack about some type of arrhythmia. It should be septic and we miss this HP hypovolemic shock or dehydrated or internally bleeding. These are all things that went through my mind as she kind of mentally decompensated over the hour or two I spent with her. Essentially in the ED and in the micu they did of course you know work up for all of these things including imaging of the brain chest X right EKG labs and essentially ruled all of these things out. So at this point we still you know did not know what was going on and fortunately you know I had to continue with my call shift. So fast forwarding a little bit Dr. Polsky was our consult resident she was able to see the patient the next day in the micu and patients transfers the micu for further support you know continued fluid resuscitation. Basal presses report eventually the patients electrolytes didn't normalize the mental status didn't prove that next day the ophthalmology exam was overall unchanged pressure was still low. Despite being off all drops and importantly once the patient's mental status has improved we're able to elicit more of a history from her. And we found out this is a direct quote from the patient that the EMS gave her three different drops these were the max topical drops every five minutes while in the ambulance for about three hours. So for all this residents who just took O caps, thinking about you know, not only the ocular but the systemic side effects of topical glaucoma drops. There should be no surprise that this is a case of systemic toxicity from glaucoma drops. You know patients receiving for monodine Timelaw dorsolomide and tannopros every five minutes for three hours. It was no surprise you know the things that we learn about for monodine and how it penetrates a blood brain barrier and causes respiratory depression and stuff like these things were all occurring right in front of my eyes. And you know in addition to Timelaw beta block toxicities you know some basic things we learn in medical school and how that can affect the cardiovascular system lungs metabolic system electrolytes and so forth. So going back to differential. This patient ended up being diagnosed with systemic for monodine and Timelaw toxicity diagnosis of exclusion a quick follow up here so while the patient was still inpatient we brought her over to our glaucoma clinic when she was stabilized. See Dr. Zabriski he did an LPI that left eye but the AC was still shallow. And at that point he agree thought this was likely fake amorphid. So when she was sent home and stabilized we brought her back for more definitive treatment. I think this was a combined case with either Chai on Mifflin or someone else here where they did you know cataract surgery removed the cataract polyurethane, adroplasty, gonioviscid dissection and also repeated the LPI. And most recent follow up she was seeing well 2015 pressures are normal AC was nice and shallow or nice and deep not shallow and she was dropped free at that point. And I kind of just wanted to go back you know this was a very humbling case. I could have kind of dove deeper and this could have also been presented as an M&M but when we're you know introduced into medicine, you know we go into medicine wanting to help people and one of the first things we do, you know, at a white coat ceremony is repeat the hypocritic oath and first you know harm I remember saying these words and it was really a gut punch the next day sleep deprived after taking a hard call shift I read the ED note and this was the first line of the assessment from the ED attending. It was a real gut punch it says the failure to initiate interventions such as adequate history taking discussion poising control and admission on an urgent basis likely resulted in sudden clinical and significant life threatening deterioration in this case. So this was a huge huge near miss this could have been much worse. And I you know it made me really take a step back and think about all the things that you know I potentially did wrong at the communication errors all the steps along the line of this entire case and in what things could have been prevented. That's why I want to talk real quickly about our favorite kind of diagram here the Swiss cheese model. And essentially this is you know a model where it demonstrates that although we have multiple layers of defense. Each of those layers still have flaws and when the flaws in those multiple layers of defense or checkpoints don't prevent misses or near misses. When those flaws line up near misses can become misses and serious medical errors can happen. We see this all the time and we've learned about this multiple times so I thought about what were the steps in this case that you know potentially went wrong where kind of I you know improved help prevent this what kind of learn from this case. So the things that were you know, on my mind you know the transfer center call there's a lot of assumptions made there's poor communication. We did not tell them to you know continue drops until they're seen for three hours but someone did but we also didn't tell them not to. We didn't know they're gonna be coming over an ambulance there's no communication there so there's just a lot of communication errors in regards to the transfer center call the paging system. And that I think was kind of highlighted here as well. You know the patient was out front in an ambulance from multiple hours before I knew they were even here. The handoff from the EMS in myself. You know, I was not told that the patient was receiving drops for three hours but I also didn't ask. And I think I was just a little bit overwhelmed so and kind of shocked at the current situation so this communication could have been better as well. And again patient history yes the patient at all through mental sadness was hard to elicit a history but I think I had a lot of cognitive biases. You know in my mind this patient was a patient with acute angle closure they need a laser at six their patients to see. Let's you know let's let's go. So the first fourth four topics here out of the five really highlight communication and that's really the highlight of this topic and we hear about this a lot in regards physician handoff and transfer of care between between attendings and there should be no surprise that almost 80% of serious medical errors do involve miscommunication between caregivers and patients. When being transferred or handed off and there's lots of discussion on the literature about things that we can do to help prevent this and we see it in our everyday lives. You're with checklists with the EMR surgical timeouts. There's also some mnemonics that we learned in medical school nursing school, all kind of encompassing areas to talk about everything that's important in regards to handoffs. In person communication has also shown the decrease this miscommunication between caregivers and handoffs. Lastly just close the communication kind of restating what you were told and what needs to happen. And one more quick topic I wanted to touch on and that's that's kind of cognitive biases. You'll hear Dr. Marks talk about this all the time you know every bump isn't actually in Dr. Zaw give a really good grand rounds and this a while back and it's one of kind of quote here cognitive biases are systematic unconscious automatic patterns of thought that made us start thinking and potentially the errors and another words how I think about this is essentially cognitive biases are our mental shortcuts. Our brain shuts off takes the path of least resistance doesn't do you know critical thinking things that were taught to do this in turn these shortcuts can increase the risk for errors. So it's kind of real quickly going through a couple biases that we're familiar about but I think it's going to be reminded about. That's confirmation biases you'll see this a lot of history taking if a patient's coming in with you know, painful eye with a bump that's kind of an oozing and read they've had this before. You're already thinking to lazy and so you kind of only ask history and gather history about what you possibly think could be going on and neglect evidence that contradicts that anchoring bias similar to confirmation bias which is kind of how we prioritize or interpret that information that affects our initial impressions and even when data or impressions are wrong, we kind of still anchor on those history points that may support our initial diagnosis effect her a stick bias. This is where we rely on our emotions or past experiences with patients or certain types of patients that may alter our judgment decision making instead of objective data. And lastly overconfidence bias and I think all of these kind of played a role in this case but this is something you know even I felt transitioning from a page by two to a page by three is I've seen this before similar presentation. I'm confident about this and when that happens that really limits our ability to dive deep into history taking consider other forms of treatment and even diagnostic work up. So overall, take away points is you know really this miscommunication highlighting this case here and most near misses and medical errors do result from miscommunication force be aware of the cognitive biases I only touched on four but those are the main ones. And lastly, I can't talk about a glaucoma case without, you know, bringing up you know the side effects contraindications drug drug interactions definitely remember these things slow down remember to be a doctor. And lastly, I know Dr Rasko is listening somewhere so it's one of touch base in the light trial and then the new data that we have out there to kind of show that SLT is just as you know effective as drops in certain cases and it doesn't have the side effects that jobs do. Thank you everyone who was involved in this case, all the attendees took care of the space as well. Here are my references any questions. Hey, can you guys hear me I'm trying driving to redwood sorry. Okay, so, yeah, thank you so much Brandon for presenting this case, I think that, you know, when we're, you know, when you're a medicine intern and they're telling you that you are responding to a code your first they say first check your pulse. I think in our setting in our on call in clinic setting my personal motto is now check your denial. Yeah, I had a similar kind of presentation of a case. This patient came to me in my chief clinic I had never seen her before but she seemed very, very out of breath, speaking in short sentences and just kind of pale. But her family was with her and said she had been like this for a couple weeks so it wasn't really sure she was there for you know VZB keratitis I kind of continued with my exam but she progressively got more drowsy. So I also just wanted to remind everyone the rapid response line for teams to come over from the university to our clinic is 1222. And not everybody is familiar with that and it didn't also didn't always use used to be the case that a rapid response team would come, but she actually did collapse in my chair. We called rapid response and she went to the emergency department and she actually ended up having a saddle embolus pulmonary embolus without any known vascular risk factors. I think the first sign in this case is taking two hours to try to get a drowsy patient up to the clinic or just having them arrive in an ambulance. I think that you know we are seeing a lot of patients by ourselves as residents and that's definitely a safety issue but a lot of these patients even with acute angle closure as you know I send to the ED or even anybody who has any sort of medical illness. I'm sending them directly to the ED just because they can't have other needs, but again thanks for highlighting, you know, all the things that fell through and you did an amazing job kind of identifying your own and a lot of other people's, you know, reactions and biases. Thanks, Dr. I'll just chime in too so I am listening Brandon. This is a really, really nice presentation and I know we discussed this a little bit at the Journal Club with Theresa and the team and Cole and Sean. Actually, yeah, and you and Sean did a great job with this and it is something we talk about as the VA, because we do see sick patients but I just want to remind everyone to I've had very healthy individuals. One drop, you know, start on Timalol and end up going into bradycardia and we were talking about this on Monday. So even when you take histories from patients, you may not have all the information and some of these drops do uncover other systemic comorbidities that even the patients don't know. And it is gut-wrenching and I think one thing you can all do better is telling our patients to bring their drops with them when they go to see their medical doctors, you know, so often we we tend to work in a vacuum. So thank you. Thank you for sharing this case and really doing a deep dive into our. Thank you, Dr. Roscoe. Paul has a question. We can hear you Paul if you want to just. Yeah, I was going to say I remember this kid. I don't know. Was this the one where my son started a fire? I was going to mention that but I didn't know. Yeah, I think right when you called my son has started a kitchen fire so that's why I was kind of can you can you call you anyway I don't think I had the full history so I apologize for not like coming in right away. But I did want to and I think we talked about this afterward but just for the residents, you know, if someone shows up shows up in an ambulance do not take the patient into the room that is you feel bad because you feel like oh my punting this to something else or someone else or, you know, should I be able to handle this.  I mean, if they if they drove themselves like that's one thing. You know, they got discharged from the urgent care and you set up a follow up that's fine. But even if, even if they were healthy if someone shows up in an ambulance. They need to go to the ER. We shouldn't be taking that and just for if this ever happens to residents even if they've been sitting there for two hours tell them, you know, go around the corner. I'll see the patient, but they need to go to the we just, we can't take that risk for the patients. Totally agree. Thanks. Great talk. Any other questions. And then we have one more speaker today. The last speaker is forced hammering. He is a P2I one medical, P2I one resident in the neurological service. And his fun fact is that he lived for one year in Mozambique. And he's going to talk about ocular manifestations of intracranial cavernous malformations. Okay, I appreciate the chance to be able to speak today. We always try to tie this into something neurosurgical and today I'll be speaking about ocular presentations of cavernous malformations. And it starts with a case of a 26 year old female who had no past medical history other than a recent viral illness for which she was febrile three weeks previous to her encounter with neuro ophthalmology. And she had 10 days of intermittent vertical dyplopia for which she was seeing neuro ophthalmology and it was interfering with her work. She was a data processor. Her vital signs were within normal limits and you can see her visual acuity there and her best corrected visual acuity right to the 2020 both eyes with pinhole. She had no recent travel, no smoking alcohol or other drug use. But on her exam, her extra extra ocular eye movements revealed a vertical gaze palsy, which actually improved with testing the vestibular ocular reflex. And she did have some subtle convergence movements when performing up gaze, but her lamp and fundus exams were within normal limits. And the differential diagnosis for someone with isolated vertical gaze palsy obviously brings up super nuclear etiologies such as a mass or demyelination. And we also considered less likely on the differential was mycena gravus or thyroid eye disease. And again, convergence spasm was thought to be less likely. It was not classic for this, but that was considered. So an MRI was performed, revealing this lesion here on axial T one on the left and a coronal T one imaging on the right. This is post contrast and this lesion was correlated with a finding on SWI sequencing. You can see at the very the midbrain there this lesion on SWI, which is classic for a cavernous malformation. And just to show some still images, these are two different slices on SWI imaging and revealing this cavernous malformation. And just to review some of the anatomy associated with this vertical gaze palsy and this finding on MRI, the some of the control centers for vertical gaze are located in the rostral interstitial nucleus of the medial longitudinal fasciculus and interstitial nucleus of Kahal and the posterior commissure. And looking at another section here showing the interaction between the between these centers and posterior commissure controlling the superior oblique in the in the motions of the superior and inferior rectus. Just to briefly briefly review the epidemiology of cavernous malformations, the prevalence in the overall population is 0.5%. And if a patient presents to the neurosurgery clinic with an intracranial vascular abnormality, they'll represent 5 to 15% of all vascular abnormalities that present to us. And the majority are supertentorial and they'll often present with seizures if they're in this location. But they're around 10 to 23% present in the posterior fossa. And the most common risk factors are a family history because they they run an autozoma dominant incomplete penetrance pattern with a variable expression. And 30 to 50% of these cavernous malformations are familial. The majority have CCM1 on chromosome 7Q. And they're also more common in the Hispanic population, especially the familial. And so the natural history of cavernous malformations, there's a 1 to 2% bleeding risk per year. And so patients who are very young have an overall higher cumulative risk of having a bleed. And that's when they most often present is having a sentinel event where they have a bleed and it becomes symptomatic. And the risk of rebleeding is much higher than that 1 to 2%. Some have quoted 8%. Some have quoted up to 30% higher risk of bleeding after there's one event. And the risk of bleeding may be higher in brain stem relations. However, this could be simply due to the fact that they are more likely to be symptomatic if they do bleed. And they may be trauma induced. Obviously patients with these lesions should be counseled to avoid head trauma. And they may develop in the brain or spine after radiation. 40% are associated with venous abnormalities, which when they're surgically resected should be left alone. And they most often present in the third to fifth decades. And then common presentations, they're most often asymptomatic until a bleeding event and they will cause seizures most often. But obviously in the brain stem, they often present with Diplopia, for which neuro-ophthalmology is often consulted in their senior clinic by the neuro-ophthalmology team. And so just a quick literature review. This is a neuro-ophthalmology paper, which went over nine patients who had posterior phosin, brain stem, cavernous malformations, most often presenting with double vision, secondary to INO, third, sixth, and fourth cranial nerve policies. And some of them underwent surgery. And overall, most of the Diplopia resolved in its own. And when they did not resolve at 12 months follow-up, they were offered lenses or surgery, we're pretty mentioned. And the natural history of brain stem and cavernous malformations again shows that there's around a 1 to 2% per year risk of bleeding. And having a mass that's greater in size is obviously associated with greater risk of bleeding. And again, another paper looking at 690 patients found that the prospective risk of hemorrhage was at 7%. This is patients who often presented to this group having blood. And so the risk of hemorrhage was higher and it decreased after the first year. And obviously, if they present with worse findings, a greater size on presentation or across the midline, those were associated with higher risk of bleeding. So I just want to briefly cover the important part is how can we counsel these patients when we find them to have brain stem cavernous malformation. The risk of bleeding is again 1 to 2% each year. And the bleeds are often symptomatic, but they may resolve on their own without intervention. They don't always need an intervention. But once they've had a bleeding event, the risk of reblead is higher. And so they should be followed more closely. And they likely need a neurosurgical consult because management can often go in two different directions depending on how often or how many lesions there are where the lesion is located and if they've bled. And monitoring will likely consist of MRIs either guided by the neurosurgical or the neurology team every three to six or 12 months. And several studies have shown that anti-platelet or anti-coagulation therapy has been shown to diminish bleeding risk. And this is mostly in prospective and retrospective studies that have looked at patients who were already on anti-platelets or needed anti-platelet or anti-coagulation therapies. And they had a lower risk of bleeding. And this is thought to be due to clotting in the center of the cavernous malformation causing venous stasis and the clots that form causing venous stasis and ultimately hemorrhage. And then patients should be counseled to get genetic testing in case this is one of those autosomal dominant patterns of inheritance. And then intervention for high risk lesions. They can undergo surgery, radio surgery, or just anti-seizure medication. And obviously there's a high rate of post-operative deficits if it's resected in the brainstem up to 50%. But this is center dependent. If you have a very confident surgeon who's done procedures like this before, the rate of post-operative deficits is actually much lower and can be in a safe range. And then SRS can reduce their bleeding risk. But this is after a two year latency period where the risk remains the same. And then for ophthalmology, once the lesion is treated or decided to be managed conservatively, rective lenses, conservative therapy, or extra business surgery is often offered. And here's just a recent case that we did where the patient had a brainstem cavernous malformation bleed. And we opened up the cerebellum and resect, or I guess retracted the lobes of the cerebellum and found this lesion there. This raspberry-looking lesion is the cavernous malformation. And one of the reasons why we went after this is because it was so close to the surface of the brainstem through the fourth ventricle that we could safely remove it. And it had bled at least. And this is after the resection. So this patient, the 26-year-old that presented to us with a vertical gaze palsy, represented after two months and her symptoms had resolved without intervention. And she's planning to follow with imaging and with neurosurgery in both neuroanthermology and neurosurgery clinics. And in conclusion, these lesions are rare, but they potentially have a high risk of bleeding, especially in the brainstem. And they typically are symptomatic if they do bleed. And neurosurgery consultation is obviously recommended. And then 12-month neuroanthermology follow-up is important to decide what symptoms, if any, are persistent. If there's any persistent ophthalmoplesia, what intervention should be offered.


Meanwhile, the Nigeria Railway Corporation NRC says it has temporarily suspended its services along the Abu-Jakaduna route due to unforeseen circumstances. The NRC made this announcement via its official Twitter page. It said further clear communication would be given in due course. We now have joining us, President General Nigeria Union of Railway Workers, Comrade Innocent Ajiji. Thanks for joining us on the news breath. Thank you very much. All right. So let's just get a clear picture. Can you bring us up to speed as we get all that happened yesterday and what is going on right now as we speak? Okay. Thank you very much for having me once more. Yesterday, the train left Abu-Jakaduna, I'm sorry, Regasa normally as usual. So around eight o'clock between Dutie and Rijana, the truck, the train was attacked by the bandits or whatever they called them and, you know, they exploded the truck and quite the portion that was exploded was quite lengthy. So that brought the train to a standstill because most of the wheels derailed. And so as a result of that, there's nothing else the driver could do by moving the train either forward or backward. So as information has it, we were told that information that immediately the train was stopped. The bandits started shooting at everyone, destroyed all the coaches and then forced the doors of the train open with their bullets, destroyed even the locomotive. So and then getting into the train, they now shot sporadically and then took some people and then some fled to the bush and then even some were injured and even there were recorded deaths in the incident. So and at about 2 a.m., our management now dispatch another train to go and rescue the already attacked train. And unfortunately on getting there, the portion of the truck that was exploded by the bandits was also, the train coming for assistance was also affected by that portion by derailing some of the wheels of the coaches and so there was no way they could be evacuated from that scene using our train that was taking them to Idu. So but we were told that the soldiers, the security men and the Red Cross Society helped in evacuating some of the passengers back to Kaduna while some that were, those that were injured were taken to the hospital. Alright, from what we hear according to the government, all trucked passengers have been evacuated. Can you tell us more concerning people who died or were kidnapped? Did you hear about any of your members involved in the incident of yesterday? God bless you. Thank you very much. Yeah. As I talk to you, we, I'm here to establish contact with the driver of the train but I was able to establish contact with the assistant driver of the train that is safe but the driver, for the driver of the train nobody knows his whereabouts and also the mechanical man in charge of electricity of the train was also nowhere to be found at this moment that we still talk. We don't know their whereabouts, whether they have taken safety to the bush or they were taken back to Kaduna or they were affected or kidnapped, were yet to be properly informed about it as all their lines are not going through. So nobody could really ascertain their whereabouts and their position now. But for those that were killed, I am not well informed yet about who and who and who was killed but I am very sure that some people were actually killed in the incident. Okay. Is there any official statement from the Nigeria Railway Corporation regarding what happened vis-a-vis the union members who were involved in that particular train ride? Any statement from them whatsoever? No, no official statement from Railway Management regarding the staff that were injured or affected by the incidents yet but there's an official statement from Railway Management saying that the train was under attack and as a result of that services are suspended until a further notice and so those are the official statements I came across but at the moment so but as I talk to you they are mobilizing to go our men are already on their way to go and start work at the accident site so which we are sure that within the few days they would be cleared. All right, in a sense just before we'll let you go now let's talk about proffering solutions but before that over time have you had any meeting or the Railway Corporation as regards security along the rail tracks because this is not the first time an incident like this has happened. I remember it happened sometime last year. What has been done since it happened last year and what is the conversation like since then? God bless you very well. You know we met, I personally made a press statement during the attack of last year that took place sometime I think on the 20th of July or August I can't have the accurate date here but I made an official statement. I made a lot of observations and of course we as a union advise the management and even the government that they should be for security on the station even on the track and even in all our stations and we also suggested that cameras be put on the train that can show the driver if those were at home. All right I would seem to have lost them, comrade them, innocent, innocent are you still there? All right innocent are you the president general of the railway workers union and he joined us to bring us up to speed as regards the Kaduna, Abuja, you know attack that happened yesterday. So innocent can you just wrap up your story as we round off from this session. Okay thank you, thank you for giving me the opportunity to be here. You see we keep making statements at each interval. It will interest you to know that I was interviewed by your television station last year during the three days warning strike we embarked upon and as a result of the strike we brought up these observations and we even made references to the fact that even the train workers are not insured but the passengers are insured but after which we were made to understand that actually the railway workers are on group life assurance and but I can stand to tell you that since that policy was introduced nobody from railway has benefited from that. Why? Because the process in getting that money by the next of kin is so cumbersome. Here is a process that if someone dies you have to go to court you have to come to railway management it has to be taken to the ministerial transport it has to be taken to gear and gear for approval before payment will be done to next of kin. So most next of kinks that have applied have not benefited why because of the cumbersome nature of the of the process so that was why we advise that every railway worker should be placed on personal life assurance so that when anything happens you can easily access the benefit of the disease between the next of kin and the insurance company but this group life assurance is what we are not in support of because the cumbersome of getting paid is too is too long so all these that are involved in this now where do we start from? All right thank you so much. You know Senator G president general Niger union of railway workers thank you so much for your time on the news brief. Please do subscribe to our youtube channel and don't forget to hit the notification button so you get notified about fresh news updates


Have you ever met a sociopath, psychopath, narcissist, or dark empath before? Well, this video could be the ultimate duel between super characters to determine who wins the title of most harmful. These personality disorders have dark traits or characteristics that make them dangerous to the people around them in varying degrees. Some personalities are more aggressive than others. Some conceal themselves better than others, but what they all have in common is their manipulative traits. While they all manipulate people to get what they want, each has their unique way and reason behind why they do it. So, let's explore each dark personality type briefly before going into which one could be the most harmful to your mental health. 1. Sociopaths Hailing from the spectrum of antisocial personality disorder, which by the way is not just preferring pizza over people and weighing in with a weak conscience coupled with a weak sense of empathy. We have the sociopath. They know they're wrong, yet find justifications instead of being good. Sociopathy is characterized by, but not limited to, clearly don't care how others feel, attachment issues, unpredictable, hot-tempered behavior. Their low empathy and weak conscience makes lying and disregarding others in pursuit of their own needs easier. When confronted with consequences of their actions, they react negatively by showing spitefulness and recklessness. Empathy is a chronic condition that can be acquired by harsh family dynamics, such as parental instability or sexual abuse. Let's look at our next contender, psychopaths. Also hailing from the spectrum of antisocial personality disorder and weighing in with zero empathy is the psychopath. Any outward justification for their actions is for performative purposes only. Psychopathy does have some different specs from its brethren, sociopathy. Where the sociopath is an erratic volcano, the psychopath is a silent black frozen abyss. The sociopath will show they don't care, but the psychopath will convince you they do when they really don't. Spotting a sociopath is easy. A psychopath makes it a point to appear as normal as possible while hiding in plain sight. The pros say that to diagnose a sociopath, look for what's showing on the outside. To diagnose a psychopath, it's much more based on what's happening on the inside and why. Psychopathic qualities like recklessness and aggressiveness are caused by a chemical imbalance in the brain, not upbringing. One of their weapons is a non-automatic emotional response to others. They can choose to understand how someone feels, if it benefits them. While they, like sociopaths, are not necessarily violent, they lack the regular restraints and protections of empathy and conscience, to prevent them from becoming violent. 3. Narcissists The narcissist is the diva with the most ego. They believe everything is about and for them, but snarking you're such a narcissist when someone acts kinda douchey doesn't mean they have the disorder. To a true narcissist, confidence, limits, and basic affection are now self superiority, self entitlement, and the expectation of praise and servitude.  Everyone else is a tool tooy or toaster to be used until they're no benefit to the narcissist, then they're discarded. According to one clinically confirmed case, narcissism is self-defense in the pursuit of four primary goals, fuel, control, character traits, and residual advantages. The fuel is whatever emotion they can evoke from you. Emotion vampires, narcissists savor every ounce. They enjoy having control over how you feel. They steal character traits, co-opting aspects of another person and passing them off as their own. Money, sex, and contacts are all residual benefits from their supply. This exploitative behavior stems from childhood trauma. It could have been formed by being smothered in protection and placed on a pedestal or by being in an unstable environment. And now, a surprising fourth, dark empaths. This term introduced in a 2021 study marks this contestant as a yet untested newcomer. In this study, it was discovered that these people tend to score high on empathy, but also high on dark triad traits, like narcissism, Machiavellianism, and psychopathy. The dark empath could be described as a black mirror version of ourselves. They have everything the other personalities lack, especially empathy. Yes, empathy. But the dark empath's empathy is cognitive only. Empathy means if you hurt, I hurt. The dark empath's cognitive empathy means they fully understand the pain they cause. They just don't feel it. Even if they've been directly hurt in the past, they intuitively get how others work and feel. So like a thief with all the blueprints and passwords, their manipulations are devastating. For them, with great power comes great wrongness. There's the bell to the round and the disorder that wins the title of most harmful to your mental health is, honestly, between the psychopath and the dark empath, it's a toss-up. Or is it? The psychopath has the zero empathy attack. They have no restraints of conscious or empathy and take advantage of others without remorse. They relax your defenses by acting outwardly normal. That's dangerous. What about the dark empath then? This could be the most dangerous personality type because the dark empath can intuit as opposed to study. What other people are feeling? This makes accurate manipulation far easier for them. If you don't believe dark empaths are a thing, the singular type of personality that is most dangerous would be the psychopath who is unshackled by conscience. However, if you believe that the dark empath is an entity unto itself, then this is the winner. Beware of their machinations as they have the ability to tune in and focus attack through empathy. Comment down below with your thoughts on which is the most harmful and why you believe it is so. Always remember too that despite these personalities being a psychological phenomenon, which may or may not be conscious choices, if you are the target, you are never under any obligation to accept abuse. Stay safe and we'll see you soon.