Good afternoon, why don't we go out and get started because we have a fantastic talk today by Dr. Ann Mosenthal. Thank you all for coming, those who came on time, and I'm sure there will be some stragglers who have clinical responsibilities or other duties that brings them in. So this is the seventh in our year-long series, marching up to March 1st, 2018 when the Adult Trauma Center at the University of Chicago Medicine opened. It's a series that focuses on ethical issues in violence, trauma, and trauma surgery, and the prior six discussants, lead, lecturers, participants at the podium, but all of you have been nothing but extraordinary. I humbly include myself among those people, that's a joke, but actually more foundationally I think we have an incredible opportunity today to tackle an area that is often ignored but inevitable. No one gets out of life alive, life is 100% mortal, but we often are challenged by how we address the end of life, and Dr. Mosenthal has been a revolutionary leader in this space in very brief, in terms of background, Dr. Mosenthal currently serves as a Benjamin Rush, Jr., endowed chair and professor of the Department of Surgery at Rutgers, New Jersey Medical School, and for those who pay attention to seismic changes, there's a lot of seismic changes going on in New Jersey in terms of how academic affiliations and community partnerships are evolving with many players consolidating in a times-fragmented healthcare system, but by way of initial background, Dr. Mosenthal received a medical degree at Dartmouth Medical School before completing her surgical training in University of Massachusetts in Worcester, when I was in Massachusetts, we call that Worcester, I didn't know any better, but it's actually Worcester, and she then went on to do a critical, surgical critical care fellowship at Master's General Hospital before moving south to New Jersey, where she's actually risen through the ranks from assistant professor to now chair of that department, and one of the many claims to fame of Dr. Mosenthal is that she became a chair who happened to be female, that's the way I like to define it, before Me Too campaigns or before the incredible Look Like Me Surgeon campaigns around what the face of excellence in surgery exemplifies, so thank you Dr. Mosenthal for your stellar leadership in that space, but moreover she has helped to create a new field. She is boarded in both, or actually triple boarded in surgery, surgical critical care, and palliative care, and has helped among many, including at the Pringle Mill in the room, advance the space related to linking surgery, palliative care, and critical care. She has had multiple important roles and is the founding director of the first division of palliative care in surgery in the nation, has served on multiple advisory roles, including chairing the American College of Surgeons Committee on Surgical Palliative Care, and a member of the advisory board of the Center to Advance Palliative Care. And among many other things, one of the things that I think is most notable is her interdisciplinary collaborative work, most notably the Project on Death in America program, which touches so many different aspects of healthcare in America at a time when there's such a focus on adding value, and that includes value at the end of life. She has been awarded multiple awards over the years, most notably I will add the inspirational physician by the American Medical Association Woman Physician Section, and this is not an obituary even those that end the life discussion and talk, so I'm sure your parents would be proud as would your children as well as your spouse, but her talk without further ado is entitled Palliative Care and Trauma, Violence, and Ethics of Care. Please join us in a warm welcome. Well, thank you. That was the most wonderful introduction that I've ever had. I really appreciate it. It is really an honor to be here. I have heard much about the McLean Center for Ethics, and I have been very excited to hear that there's going to be a new trauma center here, and so it's really a convergence of all the things that are really important to me, so I'm very pleased to be here, and my parents would be proud. However, my mother would really object to that photograph of me. I don't know where you got it, but it's terrible. Really? I think that it was a candidate at the ACS recently, and I have to figure out who took it. Anyway, so other than that, it's all over. So I am going to talk about palliative care and trauma, a little bit about violence, and a fair amount about ethics. I am not an ethicist. I am, however, a palliative medicine physician, and my one disclosure is that I am on the board to write the exam questions, so Pringle, you will not get any of the answers from me. And otherwise, I have funding from PCORI with Gretchen Schwerze, who you probably know. So this is where I come from, Newark, New Jersey. I am a trauma surgeon, as you know, and this is our trauma center. Newark, New Jersey has a reputation probably amongst all of yourselves as being a gritty northern city. We think about the Sopranos. We think about violence and all the problems that go with it, but actually on the bottom right is Branch Book Park during Sherry Blossom season. It's quite beautiful, and we have a beautiful skyline on occasion. This is the other side of Newark. We indeed have a serious gang problem. Those are the red breed gorillas. We have a lot of violence intervention issues, and people that go out and try to work with the gangs, and we have a lot of urban blight and all the issues that go with that. Our trauma center serves about, we have about 3,000 activations a year, 1.8 million people in northern New Jersey, so it is not just Newark. It's also the surrounding suburbs, the highways, the port, the Newark airport. This is the real side of Newark, which is a community just like the one that you all live in. There are people having urban gardens, taking their children to school, and going to work, and that is frankly most of what our trauma is about. We have the highest rate of pedestrian fatalities in the nation. That is our biggest problem, and everyone thinks our problem is violence. That is a problem, but we really have a much bigger problem related to motor vehicles. People walk to school, walk to work, and elderly are always getting hit by cars. I don't know why people can't cross the street without getting hit by a car. So that's where I come from, and that is how I got into palliative care, strangely enough. So how do we die? There's a lot of myths in the nation about how we die, and I think most of us imagine that we're going to get old and go nicely into the sunset and fade away like this woman in the picture. Many elderly people think about the end of life and hope that it's going to be pain-free and peaceful. There's been a lot of stuff in the lay press and a lot of public demand that we do a better job because we're not doing a very good job. And some of you may have read some of these books or seen some of these papers, and I'm sure you're all familiar with the fact that in healthcare that we provide, we are not doing a good job at the end of life care, and people are getting way more care than they actually wanted without even knowing it. I think one of the big changes in this space is Atul Gawande. I hope you've all read being mortal. It's really profound and very simple. The truth is that how we die in America, a lot of people die, at least in the Medicare age group, after having surgery. And Gretchen Schwarz, who was a McLean fellow, wrote this nice editorial about that fact that a significant number of elderly people are dying after they have surgery. This was featured in the New York Times, this study that in the final year of life, nearly one recipient in three had surgery in the last year of life, and one in five had surgery in the last month. And one can ask the question, was that really a benefit, painful, burdensome? And we don't know if they needed that surgery. They didn't need that surgery. One of the things that suggests that maybe we're doing too much or too little in some spaces is that there's a huge variability across the country. So in some regions, like the one I work in, there's a huge rate of surgery at the end of life, whereas places like Hawaii, there's much less. And the Midwest, there's much less. So we don't know the answer, but it is pause for thought. So how do we die from trauma? Turns out trauma, which we think of as a sudden, acute illness that happens, and then you die, is really not the case. And for sure, the, is this a pointer? Yes. For sure, the biggest death from trauma is in the first minutes. Those people don't present to the hospital or to care. The next group is in the first hours. We refer to the golden hour in trauma. And that is these two together are the biggest.  And then if we get out here, it turns out that there's a significant mortality years, weeks, months and years later, that is in excess of the general population. So trauma is in effect a chronic disease. And we certainly see this in Newark, where we see patients come again and again with another trauma. So this is a little bit different. And it's really a public health problem that we pay very little attention to. So it turns out that trauma is now the leading cause, the fifth leading cause of death in the elderly. This is the fastest growing group of trauma patients in the nation, partly because our demographic has shifted. And partly because trauma is now sort of the final common pathway of frail people who fall and have extensive serious illness and comorbidities, who we now can keep alive and functioning for a very long time. And they often exit the world after a trauma, not going peacefully in their bed. But what about young people? So you may be familiar with the statistic I find it shocking. Young men die from trauma. Black men until the age of 35, as you can see here, died from trauma. And then it's homicide, homicide, homicide until age 35. And it's heart disease at 35. That's a problem. White men, it's trauma, but it's not homicide. The second leading cause for white men is self-inflicted. So we have a serious problem. I mean, and young people are dying. For women, it's a little bit different. There's less homicide. But the leading cause of maternal mortality in the United States is actually homicide, which is a statistic that I just found out. And it's really shocking. That is not true in the rest of the Western world. No matter who you are and where you live, to lose a loved one from trauma, especially if its violence is a terrible, terrible event that is that one can never recover from. And this is the reason that I got into palliative care. So so many times I have as a trauma surgeon had to go out and speak to a mother or a father about their child who just died in the emergency room or in the operating room table. And I was woefully ill-prepared to do so when I came out of my training. And thinking about that propelled me to eventually do the grant that I did on the Project in Death in America to develop palliative care training and programs in trauma. One patient in particular is really the person who I think is responsible for getting me here today. And this is him. I won't tell you his real name. His name was, I will call him Johnny, for the purposes of this presentation. And I will tell you his story because in many ways it's my story. So in 1998 I was on trauma call the day before Halloween. And this young man came in. He had been shot three times with a shotgun. Once in the chest, once in the abdomen and once in the pelvis. He was about 22. Turns out that the reason he was shot is that he was robbing a bodega. And somehow the owner of the bodega got the shotgun away from him and shot him instead. He was not, as I learned to find out, a particularly upstanding citizen of the world and had a warrant out for his arrest, I think for murder. And upon his admission to the hospital he was under arrest. However, he was mortally wounded. I took him to the operating room and discovered that he had a huge amount of blood loss. And the one shotgun blast had gone directly through his pancreas in the head of the pancreas. So he almost died about 14 times that one night. I think he actually arrested on the table and we got him back. I was able to get him off the table to my surprise after a lot of blood and a lot of effort. And he went to the intensive care unit. Turns out he had a spinal cord injury at the thoracic level. He was paraplegic. He also had pelvic bleeding from some major organs. The next morning I was quite pleased with myself that I had saved this man. And I was quite pleased that I had saved a man who had a major pancreatic injury because we don't have those very often and usually people die. So I was quite pleased with myself when we presented at morning report only to have my colleague say, oh, you should have let him go because he's never going to survive.  So I operated on him about 40 more times. He almost died another 40 times. He had an open abdomen. He had malnutrition. He had every complication. He almost bled out of his femal artery which exploded following various procedures to try to revascularize his iliacs. He could not eat because his stomach was completely stapled off. But I got him through it. I got to know his family. He had 12 brothers and sisters. His family matriarch was his older sister who really ran things and every time he almost died I would go to her and say, I think this is it. I think I'm not going to be able to pull him through. And she would always say, just try. And I knew that he was going to live a life of misery if I could pull him through. But she would say he would want to live. So I did. And we pulled him through. He was in the hospital for nine months and eventually I sent him home. Fortunately, the criminal justice system decided that he would probably be too expensive to keep in incarcerated because he was on TPN. So he went home on home TPN and his girlfriend took care of him. He developed huge dacubid eye and essentially his lower extremities became gangrenous and he had to have amputations. And he was in and out of the hospital with sepsis and a lot of problems. After about a year and a half and actually it was about a month after I got this grant and the project on death in America, he got readmitted and was very near the end of life. And I finally sent him home on hospice with his sister, all of his children. He had four children and he died at home a year and a half after his injuries. And I began to think, what was I doing? Was that a great surgical success? Or was that an abysmal failure? Did I just waste all these resources on this guy who was never going to do well? Or was it a great case? And I really don't know. For him, was it worth it? He had such a will to live and he survived. He got a year and a half that he otherwise would not have had. But I saw the suffering. He came to my office every week for wound care and he would sometimes bring his little son who would see this man. He was a very vital man in the beginning, totally diminished with his huge wounds and amputations. And I thought, wow, this is a terrible burden on his family. But he was always positive. And just before he died, they actually went on a trip to Florida. So I don't know. And I thought, is this trauma surgery or is this palliative care? And it began to get me thinking that maybe these really might be the same. So this is how I began to think about how trauma and palliative care really should come together. So because we're talking about ethics, I ask the same question. And I ask of you. From an ethical perspective, what was this? Was this futility? Did I observe his autonomy? I think I did. But I'm not sure. Did I help him? Or did I do more harm? And from a justice standpoint in terms of society, did I waste a lot of resources on a man who most of the world did not appreciate? When I think about it from an ethic of care standpoint, I developed a relationship with this man over 18 months. He was my companion every day. I knew I knew him inside and out. And Eva was very difficult to work with and take care of. But in the end, we had a very close relationship and he trusted me. And I really took care of him. From a violence standpoint, why did this happen? The structural violence issues of what world did he come out of? Why was he robbing a bodega? Was he a victim or was he a perpetrator? And does it really matter? These are all the questions that I think his case brings. And I'm hopefully going to explore with you a little bit more. So what I hope to do is define what palliative care and trauma is from a clinical standpoint and also an ethical standpoint. Talk a little bit about the epidemiology and the palliative care disparities that we see as well as trauma disparities. And why is this hard? And it's really hard. And we talked about it today in various meetings with the fellows. I was really amazed to hear the diversity of thoughts and opinion and how hard this really, really is. And then talk a little bit about the challenges and some framework that how we can move forward. So what is palliative care? Palliative care means patient and family-centered care that optimizes quality of life. It actually, in this current definition, which is from the National Palliative Care Consortium, has nothing to do with prognosis. It doesn't say anything about dying. And it's really a kind of care that can be offered throughout the continuum of illness regardless of prognosis. It involves addressing the whole patient, physical, intellectual, spiritual, emotional, social, and to facilitate autonomy. There's a lot of definitions. These are some of the other ones. Live as well as possible for as long as possible. Live well until the end. I think that's what Atul Gawande says in his very profound book. It's not about having a good death. It's about living well until the end. It's also the best possible care at the worst time of one's life. Cecily Saunders, who is really probably the, certainly the founder of the hospice movement in the United Kingdom, she died about 10 years ago. She defined palliative care as the relief of total pain, physical, emotional, social, and spiritual. She was an amazing woman, actually a nurse before she became a physician. So when I was thinking about this in ethical framework, I started looking at what the ethic of care is. And it was interesting to me that palliative care in many ways kind of defines the ethic of care. Erica Sal, who was an internist and a physician who wrote a very seminal article in New England Journal about suffering, which, if you haven't read it, you should. But this is one that I think is so relevant to palliative care and to trauma care. Recovery from suffering often involves help, as though people who have lost parts of themselves can be sustained by the personhood of others until their own recovers. As physicians and healthcare providers, that's what we do. We lend strength. We were talking today, and I see Ann in the back of the room, was really opening our eyes about her work as a physical therapist with patients that we've sent out from the hospital. And she lends strength to help people recover. And I think that's so important part of what we do. So palliative care ethics, and this is Dr. Saunders again, talks about the relationship as being really important. And it's the individual in the context of the setting and the world that we find ourselves. So it's not just about the individual and the autonomy. It's about the relationship. And I won't read this quote. But the end of it is, their autonomy must be seen in the context of society as a whole. So I think there's a shift to it's not just the individual patient, it's their family, it's the healthcare providers, it's society. And that's what palliative care brings. She also talks about truth telling. And that truth telling again needs to be in the context of a relationship, not just information. And she refers to this pretty famous quote from John Dunn, that no man is an island. So the ethic of palliative care is a little different than what we think about in trauma care, which is very aggressive. And we save people and we cure them and we patch them up and we do amazing things with technology. And it's all about the individual person. And we have a sense of duty that at all costs we must save lives. And that as a trauma surgeon is how I was trained and what I believe. But we also have a duty to observe a patient's preferences and what do they really want in the context of their illness. The ethic of care, on the other hand, is that dying is really an important event, but it's also a natural one. As someone said, we're all going out of this life at the end of it, no matter what. And perhaps we need to shift our framework of what we're really doing here. People are in relationships in all of society. And to be socially isolated is one of the worst things that can happen to a person. And we need to care about the relationship, not just a contractual agreement. This is a wonderful book by Joseph Finns, who is a palliative medicine and an ethicist. He was for a long time at Cornell. And he talks about palliative care as an ethic of care in the context of a cultural milieu in society as well. And that the way to get there is through the patient-physician relationship and through excellent communication. And this to me is the aha, which is it's all good to be philosophical about it, but how do we make this happen? And the way we make it happen is by talking to our patients and having a dialogue. So palliative care on a practical level and an operational level is really care that's provided alongside disease modifying treatment. And there's now plenty of studies, certainly in cancer, that if you have palliative care alongside your curative therapy, you will live longer and have a better quality of life. So this is really the framework that I think we need to shift in trauma care, that we are doing palliative care and trauma care and resuscitation and curative therapy all together. And it's not an either or. It's both. So why palliative care and trauma? Because it's good for the patient and maybe it's what patients want. It's certainly good for the family and huge burdens on families to take care of survivors of trauma as well as to make decisions for those who die. The clinician imperative, we have moral distress and taking care of our patients and I heard a lot of that today in our conference. Quality, it's high quality care. It's patient centered. It's high value. And there's also an ethical imperative. We have an ethical imperative to observe the patient autonomy and to provide them the care that will benefit them and not harm them. And sometimes that's palliative care. So what do patients with serious illness want? There are a lot of studies now, mostly looking at elderly patients with serious or chronic illness such as cancer, dementia, vascular disease. They're really none in trauma. And they want what we want, which is pain and symptom control, relief of suffering. We don't want to pull on the dying process, have a sense of control, and most people don't want to burden their family. And we want to be able to strengthen our relationships. There's that relationship thing again. So lots of polls and most Americans, if given the choice in a philosophical discussion in the survey, would choose quality over quantity. That's not true for everybody. And we don't know who they are or who we are until we really think about it and we ask. What do family caregivers want? They want their loved ones wishes to be honored. They want to be included in the decisional process, but they don't want to be burdened. And they want help. They want help in all the practical things that go on with dying and the end of life and being seriously ill. And most of what they want has nothing to do with medical care. It's support and help in a practical way. What do we want? We want to give great care that's going to benefit somebody and we don't want to do harm. And we have significant moral distress if we do and we don't want to prolong suffering. I think none of us want to do that. The challenge is to tell which is which. And we don't want to do futile care. Society wants to avoid cost. And we say we want to avoid prolonging of dying, but we don't seem to be able to quite get there in a political sense. All of this is in conflict and it results in ethical conflicts and moral distress for us and families and people. So we really want equal access for all and we are certainly not there. We want everyone to have access to palliative care and hospice at the end of life and that includes trauma patients. And if you live in an environment and a context where that is likely to happen, then you need the same access. And we want to be sure that it's fair and just. But we have disparities. So we certainly have disparities in many, many ways in healthcare, but we do have disparities in palliative care and we're just beginning to understand that. So now as of, I think this was in 2015, 63% of hospitals have palliative care service. I know you have one here. 85% of large academic medical centers have one, but only 50% of safety net hospitals have palliative care. So that's only half. So that's a whole group right there. And it is clear that where you get your care, the culture of that hospital, we talked about this today, is really probably the major determinant of whether or not you get palliative care. There's a lot of studies on regional variation, but it's probably specific institutions that matter. So what about minorities? So there's a lot of work on this. There's less utilization of palliative care. There's certainly less utilization of hospice. There's also less access for the reasons that I just said. There's less access to opioids and pain management. There are clearly disparities in how we approach pain management based on race and ethnicity that we are just coming to understand and we need to do something about. There's poorer quality physician communication with their patients.   So the challenge is how can we get there? How can we bring palliative care into trauma? And there's a lot of challenges. There's challenges about the disease. There's challenges about the patient, the family, us, nurses, the system. There's surgical momentum and there's the issue of structural violence. So I'm going to talk a little bit about those. One of the challenges is we don't know who's going to die. We think that's a challenge.   And when do I know and how do I know? And the reality is that trauma of all things has a pretty well-defined prognostication scores and they're getting better and better. So injury severity score is very predictive of mortality. If you combine injury severity score with age, which I'm sorry to say is over 55 for those of you in the room that are like me, over 55, frailty is huge, huge, huge. And we're just beginning to understand that frailty is probably a more important predictor of outcome in elderly trauma patients than the injury itself. We're very good at glascoma scale and traumatic brain injury and knowing if you're going to die. And we're pretty good if you get blood transfusions and you're in shock, that's bad.  So you'd think we would have no problem, right? The problem is that functional outcomes we really don't know. So none of these things are very good for predicting what your functional outcome will be at a month, at six months, or a year. There's so much variability and a lot of things that the patient brings to the table are determinants of that. Whether you have access to rehabilitation, social determinants of health, all of these come to bear.  That's really important, particularly for a neurologic injury. So that's the challenge. Despite our certainty, we have a lot of uncertainty. So people want to know, the family wants to know in a traumatic brain injury, they just want to know when they're going to wake up. Are they ever going to wake up? That's what they want to know. Will she ever talk again? Will she ever walk again? And that's our challenge is how to manage those conversations. And then when people get angry, what do you mean they're never going to walk again? You never told me that. It's really hard to tell the truth because we don't want to take away hope. I hear that a lot when I talk to surgeons that, well, I don't want to take away hope. So what about the patient?   That is not true. Some people believe it's better to die trying. So I want that operation even if it's probably not going to help because I feel some good about I tried. People think they're going to die on the OR table if they die, which is of course not what happens. Sudden trauma, everybody's unprepared. Nobody's expecting to have a trauma. Even the elderly frail patients that I have who are 95 and have fallen three times in the last six months, they're shocked that they might have a mortal injury. Violence is a whole other spectrum of unpreparedness, traumatic for the survivors, traumatic for the family, for society, and brings a whole set of baggage psychologically to the injury and the care. And of course an amputation and a spinal cord injury are huge loss, even if you live, these are huge losses and there's a bereavement that goes with it. So we don't have an opportunity to discuss, if you have an advanced directive, that the patient has a mortal wound and usually we're discussing it with the family. So most patients in the ICU, as you all probably know, if you work in the ICU, about 80 to 90 percent of the patients who are in the ICU do not have capacity to discuss their wishes. The family has their own set of issues, acute grief reaction to the news of death, acute grief reaction to the news of spinal cord injury, traumatic brain injury. I mean these are terrible, terrible things. And families go on to have significant PTSD themselves, anxiety, grief. Just having a stay in the ICU for a family member precipitates a whole host of psychological issues and health issues for the caregiver. How the news is delivered will be remembered for the rest of their lives. That's on us, we have to do it as well as possible. So the ethical issue is, how do we tell the truth with maintaining hope? And is it our responsibility to take care of the family? I would submit that the palliative care approach is yes, the family is part of the unit of care. There's huge uncertainty, despite our certainty, we have a lot of uncertainty and we do not help families by having 17 specialists and each of us says a different thing and each of us has a body part and the nephrologist says, oh their kidneys are better today and I see you guys say, oh this is worse today. It's very confusing and the families are burdened by having to make decisions and the role of the surrogate, we really need to explain to them over and over and over that they're to help us understand what the patient would want, not what they would want. And sometimes we have to take that burden on for ourselves. They have high emotional informational needs. We all have had the experience where I told them the bad news and they don't want to hear it. We need to tell them often. And there's a nice paper I think by Len Jacobs about how many people in the United States actually believe in miracles. It's like more than half the population and I've heard that many, many a time we're waiting for a miracle. So us surgeons have a unique complicated relationship with palliative care. We have a very intimate relationship with our patients that we've operated on. I had a very intimate relationship with the man that I just described for a year and a half and I put my all into it and I did not want him to die. And I felt a sense of failure when he did. Could I have done it better? If only I had XYZ. There's also the challenge, no one should bleed to death if they're in the hospital. I mean that should just never happen. But it does happen and it's really hard to preside over that. And we are the Asian of suffering in many ways. Maybe not so much in trauma that I didn't shoot them thing but in elective surgery we are. And it's hard to grapple with that and it's hard to shift into what would the patient want and I need to do palliative care. The emergency department also has these issues. We have a real rescue imperative. We have no relationship with the patient or the family. They showed up three minutes ago. We don't know if they have a DNR, if they have a post or most. And many of us who work in the emergency room it's about getting the patient through and palliative care takes too long. So it's easier to just default to intubate, resuscitate and move along than to actually ask these questions. And it's really hard to do good communication. And the nurses and the residents have a lot of moral distress. And I think we talked a little bit about that today. And we oftentimes have conflicts within our team between physicians, nurses, whoever. And it's hard to present a unified, compassionate approach to a family if we aren't all on the same page. And lastly our culture. So surgical culture to me is totally influenced by the morbidity mortality conference. And I'll get to that a little bit in how we try to craft some solutions that would affect that. But we, I don't know about your M&M but we talk about if they died, we talk about what we could have done differently and it was our fault. And we don't talk about maybe it was a good death or maybe they had great end of life care or maybe they were on the ventilator for a month when we all knew they were going to die and nobody did anything about it. So we have some room there for improvement. And we don't talk about outcomes that patients value. I mean patients don't really value 30-day mortality. They'd like to live six months or a year or five years. And we don't talk about quality of life. We don't talk about did that get struck to me actually relieve their obstruction and they could eat again. These are things that we need to think about and where palliative care I think has a role. So we thought about all of this at my trauma center. And when I was privileged to have a grant from the project on death in America, we decided that we needed to think about where was palliative care relevant for trauma patients. There was clearly a huge gap. So we create an integrated palliative care program in our ICU. It was mostly focused on trauma. We actually did it for all of our surgical ICU patients. But the biggest group were trauma patients. And we did a three-year project and we actually showed that we could decrease the non-beneficial life support that was used for people who died. And we had no change in mortality rate. So we all had this fear that if we were aggressive about palliative care that we would actually make people die. And all that happened was the same rate of people died. But they just died earlier with less weeks on the ventilator, more time on hospice, palliative care, and being able to talk and spend time with their families. That was a huge improvement we got. So we identified initially the gaps and we found that we had huge variability in the way we communicated around end of life, dependent on who was on call, who was in the ICU. It really didn't depend on the patients at all. And that's why we did this. So we put together a communication bundle. So that's the first part, which I'll tell you a little bit more about. And we also added a peer review to our trauma section meeting where we review our mortalities every month. And we added a little peer review about the quality event of life care. Was the communication good? Were the conversations started early enough? Was there withdrawal of life support appropriately? And as I said, we showed that we at least decreased the use of non-beneficial life support and less feudal care, so to speak. So this is what we created. We did a palliative care assessment within 24 hours. And I'll show you a little bit about what that was. And we have our palliative care team. It's a little unusual. We have bereavement counselors who are our counselors. And they came and did a family support intervention within 24 hours. They talked to the family. They identified who's the healthcare proxy. They offered support. Most of these families are in crisis. And we had a family meeting within 72 hours. All the literature in the ICU says that a family meeting should happen within 72 to 96 hours. And there's a lot of good data on that. In fact, there's quite a bit of evidence. We tried to identify early the people we thought were at high risk of dying and we paid attention to pain and symptom control. We had an order set that we implemented for people who were clearly on a palliative care track and had a DNR order. And in those days, it was on paper. And we did the peer review. So on admission, we actually asked the residents and the ICU residents and the nurses to answer this question. What is the likely outcome for this patient at discharge? Do you think they're going to be dead? Are they going to be dependent? This is basically a Glasgow outcome score for those of you that are familiar with trauma. And we asked that question really just as a prompt to get people to think. Well, if we think they're going to die, then we should be doing more aggressive palliative care now, not waiting until next week. And we did the peer review, as I mentioned. So this is what happened. This is just a little bit of the data from that time. The DNR orders were placed earlier. The withdrawal of life support went up and was also earlier. There was no change in mortality rate. We also had some qualitative data where we increased the discussions on rounds at the bedside about palliative care issues, family issues, pain management quite significantly. All of this is published in the Journal of Trauma paper from 2009, I think. So how did we manage to do that? Timing was really important. And I've come to believe even more important that doing this early, early, early, and especially in trauma patients is vitally important. The palliative care team was integrated. We didn't call a consult. They came every day. They rounded with us. They met with the families and they facilitated our meetings. We had interdisciplinary family meetings. I think the key to our success was that we had all the disciplines. So it wasn't just the doctor. It was a palliative care counselor, an APN. It was the nurse, hopefully. Sometimes we couldn't succeed on that. And it was truly a communication that was involved everybody. It really supports the family. They feel more comfortable. They ask better questions. And it helped with transition of care and other settings. So this is what was hard. And this is how we addressed it. I think the key is communication as early as possible to establish a trusting relationship and support the family. And then when three days later you think you're talking about a do not resuscitate, you have a relationship with somebody. And it's important to acknowledge the uncertainty of the outcomes right up front. This is what the best scenario would be.  I'm worried they may never wake up. You have to articulate these worries even if you're not certain about them. And our palliative care team did things like ask questions that the family doesn't know to ask. Like what does better look like? Or doctor, what are you saying? What are you recommending? Sometimes patients ask but they don't always. And I sometimes have asked or they ask to the family if your husband was here, what would he say he wanted? It's not about what the family wants. Families have a hard time with that. So there's a couple of studies, recent literature, about how we're doing on palliative care and trauma. And we're not doing so great as a nation. Most trauma centers, less than 35% of the deaths have palliative care services on board before they die. And there's even fewer patients who survive who have any kind of palliative care. So we're not doing so great. This is one paper by Emily Rivett who is a colorectal surgeon and a palliative care person. And this is from Vanderbilt, the top one. We did some follow-up studies at our place and we looked at how are we doing. We actually looked at the palliative performance scale, which I won't get into here, as a possible trigger. And we found it was correlated with mortality in elderly patients. So we did pretty well. You can see that the people who died, 90% of them had a palliative care consult or family meeting or some kind of goals of care discussion. But the people who were discharged in a functionally dependent state to a nursing home, et cetera, we didn't do so well. And all those people got feeding tubes and tracts and we just did them. So for us in our hospital, this is our area of improvement. In most trauma centers, this is still an issue. So I'm pleased to say that the American College of Surgeons and the Trauma Quality Improvement Program has embraced this and we spent the last year developing best practice guidelines for palliative care and trauma. Those were just released and I think they're posted on their website about two weeks ago. And the hope is that this is now a tool that you can use as you build your trauma center, that we can really move the needle on some of these gaps. The key messages are that, again, palliative care is delivered with trauma care in parallel. It's not in either or. The patient and the family are the unit of care. The family of trauma patients have huge needs and, optimally, it requires an interdisciplinary team. And that we all, as trauma surgeons, trauma nurses, advanced practice providers, the whole gamut, we all need to have basic skills in how to communicate and how to do this. To me, I think this is kind of an easy thing for trauma centers because trauma centers are based on having all the disciplines come to bear for the best care possible. And so I don't think this is really a reach. And as you're thinking about creating your trauma center, I urge you to keep this in mind. This is, again, the same picture of the concept that palliative care and focusing on patient-centered and family-centered needs is a continuum throughout the injury, the recovery, and hopefully years to come. So I think, so I'm just going to go over a piece of what's in there because this is essentially based, somewhat based on our work in what do you do, how do you move a patient through a palliative care program that's easy, simple, and can be integrated into care. So we propose this guideline. This is really, I think, best used for ICU patients, but it can be applied, for example, to all trauma patients if you think appropriate. So all trauma patients, when they get admitted, are by definition seriously ill. Everybody should have a healthcare proxy identified on a mission. And probably everybody, I mean, maybe you could argue that young people who have an isolated fracture don't need a question about an advanced directive, but why not? Everybody needs their pain assessed and treated. And every family, whether it's a minor trauma or a major one, needs some kind of support and informational support about what's next and what's happening in all of this. And so based on that, those are very basic things that should be happening. And then we do a screen for palliative care, which includes the prognostication, the surprise question. Is anybody familiar with the surprise question? Those of you that do palliative care probably are. Surprise question is, would you be surprised if this patient died within a year? Because if you aren't surprised, that means they're really hospice eligible virtually. And therefore you need to think, oh, they need palliative care. And then there's frailty assessments, which is only relevant for elderly over the age of 65. So what's the screen? The screen is really to identify the group of patients who would benefit from an early goals of care discussion. And it really should be based on your prognostication assessment, which should include the injuries, any preexisting conditions, age, frailty, and you kind of have to think in your mind, is this person likely to die in this hospitalization? And would I be surprised if they died in a year? And you can really sort this out. I think the next level is, is there a profound disability expected? Is it a neurologic injury or an amputation? And based on that screen, you can stratify patients into three categories. The first category is a negative screen, and those patients don't need palliative care.  And the second category are those that you really expect to die, you know, who are going on to brain death, who have some severe disability and anticipated. These are some examples, which we don't have to go through. So what happens to those patients? So within 72 hours, there should be a conversation about do they have an advanced directive? There should be a family meeting to discuss what the prognosis is, what the goals are, things you might have a change in goals, and a discussion of code status. This is when it's time to think about time-limited trials, getting an official palliative care consult, if that's the way your system works. Some of this can be done by trauma providers themselves. And then there's those who are imminently dying, and they need an end-of-life care protocol, comfort measures, very focused conversations, DNR, and there the shift is pain and symptom relief is the priority. And one can contemplate hospice, organ donation, all of these are part of the discussions that would ensue. This is the whole thing put together. Everybody needs pain and symptom relief. Everybody needs, every family needs bereavement or support for themselves. What about the patient who dies in the ER? And I'll just go briefly through this. So dying in the ER from sudden trauma is not something we think about palliative care, but this is what got me into it, and it's really important. We need to know how to communicate bad news. We need to know about grief, how to manage grief in the moment. We need to understand, is it important for families to witness a resuscitation? Is it important for them to see the body? The answer mostly is yes, and we need to know how to deal with that because it all happens in five minutes. So I refer you to a fast fact, number 305, also in the Journal of Palliative Medicine, that we wrote that really outlines all the steps of how to prepare yourself for the conversation, the physical space, and how to deliver the bad news. And essentially the gist is that it's short.   And it, most families, it's very important for their prolonged grief and recovery to see the body. There's some controversy for many of us about if there's a lot of mutilation, is that okay? In general, you try to cover, and that's a whole other discussion. So the bottom line is mostly yes, particularly if it's a child. So getting back to my patient, after hearing all that, I guess I ask you, was his care, was it ethical? Did I, did we do, as his team, you're nodding, thank heavens? Did we do the right thing for him? Did I do the right thing for his family? I went to his funeral, and he actually had two parents who visited him once. And I, it was helpful to me to see all of these people who were grieving his loss. The, so I think it was good for, it was ethical for me. What about society? Did we, did we make an impact? I don't know. I'd like to think that he's one of the reasons I'm standing here today. So in an ethics of care framework, it was a lot about the relationship. It was a lot about him in the context of society and his world, in my world. It was also his autonomy. So he was very clear all the way along that he wanted every operation. He wanted every resuscitation. And even though I thought he had the worst quality of life possible, he did not think so. And he was a very proud man. And he did die surrounded by his family. So what about the cost? And in some, you know, I remember my colleague saying this is futile in the very beginning. I would say it's not. And we all have a relative interpretation of futility. I don't think this was non-beneficial care. He got a year and a half of life that was valuable to him. The class of society was huge. He was on home TPN for a year. And he was on Medicaid. So he was, you know, on the, on the dole, so to speak. What about the violence? This is huge. And this is an unaddressed problem that we need to address. He, we have huge disparities. I mean, this man could not go to rehabilitation in part because he was under arrest. In part because he didn't have benefits. And he stayed in the hospital for nine months because of that. And I think it significantly affected his recovery. He did not have, he did not learn how most spinal cord patients how to, you know, take care of himself. He didn't have access to all the bells and whistles in terms of wheelchairs, care, you know, turning. He had his fairly impoverished girlfriend taking care of him. That's not okay. And whether he, whether you think of him as a perpetrator of bad things or whether he was a victim, I think he was both. And I don't think that matters. But I think we have to think about all of those issues as we think about what's the right care for people. So I come back to, was this good palliative care? I think it was in many ways, although I wish it could have been better. Was it good trauma care? He survived. I got him out of the hospital. But it was a burden on his family. And it was a lot of care and work. So I just wanted to finish the story because I think it exemplifies all of these issues. He died, as I said, and I went to his funeral. He had 12 brothers and sisters, all of whom had many children. And in the ensuing few years, I took care of his nephew who was shot. I took care of the same nephew who was in a car accident. I took care of a different nephew. And one of his brothers was also admitted to the trauma service. I knew all of his family. And the really terrible thing was a few months ago, I was on trauma call again. And a young man came in in a motorcycle crash. And for reasons that I still don't understand, he arrested right in front of me and died. He was about 40. I went out to talk to his family.  And she fell into my arms. And she of course recognized me. And I had to tell her yet again that one of her family members had died from trauma. And so the story goes on. And this is the world that I live in. And I think you will soon to live in as well. Because certainly in Chicago, this is a family problem. It's an endemic problem. And it's a major public health problem. And hopefully palliative care can have some solution. So that's my... I want to start by saying I actually, I'm a cold, hard-ass trauma surgeon who had chills, as you told the story of Johnny. And how the story of Johnny is your story. It gives you pause. It should give us all pause. As well as how we're all interconnected. And you didn't expect to take care of that 40-year-old who is related to Johnny. I'm going to actually start with a selfish question before we open it up. Because I'm sure there's questions in the room. Because that was very rich talk. And I hope that we can take some of that and apply that here at the University of Chicago Medicine and Trauma Center. The primordial question for me is how do you take care of you and self-care? Because this burden is heavy. Well, that's a great question. Some of it I do by giving this talk. And a lot of it is sharing that experience with others, including my colleagues who experience the same. That's a really critical part. I mean, in terms of self-care overall, I do things for myself and exercise and all that stuff. But being able... And that I think is one of the things that has helped me from a palliative care standpoint is having colleagues who really do this day in and day out and think about death and how to do it better.   And we share that sorrow and sadness. And that really is helpful. And I think that is what got me through being a trauma surgeon, to be honest. Our question is from the room. Dr. Ken Wilson, one of our trauma faculty. Dr. Miller? Hi. Yeah. Well, I think the work you're doing is wonderful. Obviously, I'm sort of similarly aligned. From what I can tell, you're the only trauma center that has an embedded palliative service. Is that true? Are there...? Possibly. I don't think entirely. I think we were just talking about Oregon. I think there's a lot of culture of palliative care in their trauma service as well as overall. And I'm looking for David. You're right there. You can verify that or not. So I think it's shifting. I don't think by any stretch it's similar to ours. But there are more and more people who are starting to do it and embracing it. Yeah. But it's a... We've got a ways to go. I thoroughly enjoyed your talk. And I'm actually Ken Wilson that we met earlier. But one of the things that I recognize in these large urban centers is that there is structural violence all around the hospital. But somehow the hospital seems to become a sacred ground where people kind of respect that. Although they have structural violence, it seems to be spared from that. And my question is, as you mentioned, the conversation of family will remember forever. And so when you can't be the hero, you should almost have, in my opinion, have a scripted conversation as to why they died. And your slide went by very quickly. So the question is, who should be there and who should not be there when you have that conversation? Understanding that you're dealing with a situation that potentially has a very short fuse and a very big flashpoint. Are you talking about who should be there from the family or who should be there from the professional side? My team. So first of all, never do it alone. And ideally, there should be the doctor who can, and it doesn't have to be the attending. I mean, it should be the doctor who was there and can deliver the news in a compassionate way. So it could be the intern, but probably not because they're less experienced. And ideally a nurse. I mean, it would be great if you had a chaplain or a palliative care person, but usually it's two in the morning and we don't. Now, you may have that. At one point, we did have a pastor that we could call in and they would come in and do that conversation with us. But it's not good to wait. So I usually do it with a nurse. Sometimes a student comes because they want to see it. And maybe a nursing assistant, you know, somebody. So there's two or three people, but that's it. My experience, and this might be controversial, is that you do not want the police or security in the room. That is very inflammatory.  You want one person who you think is the responsible party, which is, you know, often a mother, a wife or whatever.   And you need to be, you need to position yourself so that you can get out of the room and allow people to act out whatever they're going to do. The other, in certain cultures, swooning and falling on the floor is very common and you need to just let them be on the floor and not try to yell at them that they should stand up. What I found most effective when there's a lot of screaming and, I mean, which there usually is, I mean, almost everybody is totally in shock and people get very violent is to say, I know you want to see him or her and if you calm down, we will let you come in and see your loved one. And usually sort of two by two or something like that. That usually gets people pulled themselves together. I don't know if that's helpful. Dr. Siegler, when is this videotape available? Because I want to distribute it widely. Okay, because I do think there's a lot of trauma information that's rich here that we need to get to a wider audience than the 70 or so people that are in the room. My next question is actually related to disparities. Minority groups, and I hate the word minority because actually that has a superior inferior context, which is actually incorrect. So groups that are other than groups that are often on the giving end of information in this space. One of the challenges that I've experienced over and over again, who happens to be an African-American trauma surgeon, is this issue that at the end of life, it is amazing to me how people's values, which are important and need to be valued for some communities, especially African-American ones, there's a demand for more at the end of life. What's the driver? Because in every other space with respect to health, there's often less. So at the end of life, there's desiring more. To be honest, I don't think we know the answer to that. There's a lot of theories. I can give you mine. The first, I mean, and this is true related to those people of other who are impoverished is the lack of access to healthcare historically and personally is huge. They just want to be cared for, and so that becomes the driver. I think that, and that's my experience. My other experience is that cultures that have a very strong faith background often rely on that way more than any information that physicians can provide. So my worldview of this is going to be a horrible quality of life or whatever is really not relevant because there's a strong faith and they're guided by that. And there's actually a few studies. This is regardless of ethnicity, race, whatever, that most families, the most important thing that drives their decisions around end of life is not what the physician said, but it's their cultural beliefs, their faith, and how their perception of the individual patient is like he's very strong, he's a fighter, all that kind of stuff is way more important to them and how they make decisions than anything we can tell them. And the last is that for some communities, life itself is so valuable. And it's not, and then quality might look bad to me or you, but it's so valuable that it's worth a lot. So is it on? Oh, it is on. Oh, wow, it is on. Okay. In your guidelines for palliative integration into trauma that you said were published and some of the screening questions, I was just interested in, did you choose a particular frailty screen or you said you screened for frailty, but I was wondering what the screen and why you chose that one out of the many that are available? We actually particularly didn't choose one because there's so many. And I think there's an appendix in the back that gives examples of different frailty scores. There's really no evidence that one's better than another and, you know, just as long as you do something.  That's what they do, what we do, no matter what, unless they come in waving their pulse, which I have never had anybody do that. So it's just, so that's the priority. I mean, my feeling is, and we talked about this with the fellows, is ethically withdrawing life support is the same as not starting. In other words, once you've started it, that doesn't mean you have to keep it. It's a time limited trial, whether the trial's five minutes or an hour or two days or whatever. They're the same. So I think in America we err on the side of aggressive life support until such time as we think that that's not a good idea.  You gotta go. You gotta open their chest, whatever you gotta do. Does that, I don't know if that... Dr. Mosenthal, thank you so much for that wonderful talk. My name is Charles Rhee. I'm actually one of the palliative care physicians here at University of Chicago. And I have a question with the, I would say every expanding scope of palliative care, one of the things you, you may mention of was even as our scope seems to be expanding, the availability of palliative care physicians is definitely in demand. We definitely have both the supply side as well as a provider side deficit. How, what guidance would you have in terms of how to bridge that gap between the demand and the actual supply? I guess my first response is that we all, those of us who are not palliative care physicians all the time, need to know how to do primary palliative care. And we need to be educated in it. And that's what the hope is with those guidelines is that accompanying it, we will have, you know, training programs, workshops to help people develop the basic communication skills that are relevant to your specialty. Because, because there just aren't enough. And, and I also think that on the flip side, you know, palliative care physician is not familiar with all of the issues of trauma care. Now, you could be because that could be part of your practice. So I think that's important. The second is that it's not just about doctors. There's a whole wealth of providers, nursing, pastoral care, social work, psychology, that bring a lot to the table. And you can build a team you don't need an official. Sometimes when I speak to palliative care audiences, they're not happy with that because it's all, you know, our billing paradigm is that you get a consult and you put it in a bill. But hopefully someday that will go away. But yeah. So when dealing with systemic inequalities and poverty that strongly impact recovery outcomes outside of the hospital, how best can healthcare providers work with those challenges, especially when taking advantage of the increased communication that palliative care along with trauma care provides? Well, the person sitting to your right can tell you a lot about it. Because we just had this discussion. I don't know. It's really a huge problem. We have these silos that, you know, those of us that live in the hospital, we don't know what happens to people after they leave. And Anne, who is a physical therapist, spoke very eloquently about those challenges. It's a real problem. I mean, we don't, we have this compartmentalization of what we pay for and that completely drives the care. And the solution is to change the way we pay for it. Because people are going out of the hospital and not, and always are not getting the care that they need. And most of the care from a palliative care standpoint in the world that's needed is not medical care. It's social support. People are socially isolated. They're depressed. They need a ride to the doctor. You know, people have to, many elderly spend, you know, three days a week going to the hospital, to the clinic to get some, whatever. They need help with getting their medication. They need financial support. They need physical therapy. They need respiratory therapy. They need things that address the social determinants of health, none of which the medical center is any good at dealing with. So I don't know the answer except that we got to change it. So you know, you and I philosophically agree. We invest a fair bit in the space related to what happens in the four walls of the hospital. But patients actually don't care what happens in four walls. They actually want to be able to recover holistically and regain a function if they lost function. And to be better than when the event that occurred, that they wished didn't occur, that occurred, can they recover to the best of their ability? And that journey continues way beyond the hospital and way beyond your ability to suture their damaged femoral artery. So I mean, I think that that is just, you know, the emotional, psychological, psychodynamic part as well as how do they integrate back into their community. So actually, in partial answer to your question, we just got a grant from a foundation in New Jersey to start a trauma survivorship clinic. And most of what we're going, the grant is going to pay for is not medical care, but health coach, social worker, an advanced practice nurse to, and we're going to have a peer to peer support program that will link both caregivers and the patient to other trauma patients. So I think that kind of program, which to me is palliative care, it's pushing palliative care out to helping survivors deal with all of the holistic, I think is the right word. So I think we need more of that. But of course, insurance doesn't pay for a lot of that. You have to have an encounter to, I'm hoping that we can develop some telehealth solutions, which I think is another place where there's a lot of opportunity to connect people. You know, there's all those social media with patients like me stuff that I think could really be used in trauma as well as lots of other things. So this goes the other direction. The ethics of end of life, what particularly prompts my question were the photos of people jumping out of the world trade towers. They knew they were going to die. And so they chose part of what makes your talk and this discussion so problematic to me is the ethics of how we help people die. I'm in religious circles where unfortunately it feels to me like keep them alive as long as we can. And I'm saying, why? So I just leave that image of people deciding to jump as a signal to us that many more people than possibly we realize are aware, in contrast to Johnny, that things are really at the end and they don't want to trouble their family or live a very awful life, even for six months. So it's a question, but a prerogative of the James Watson, one of my most difficult trauma patients in Boston was a woman young, recently married, who had told her husband she never wants to live as a quadriplegic, dove into a pool, broke her neck, paralyzed from the waist down, from the neck down. Last words before being intubated was, do not keep me alive. I'm not sure what the question is. So yeah, yeah. So I think to me it's that people choose and people have the right to choose in this culture. That's what autonomy is. But sometimes if we don't provide the social support, the medical support, the things that people really need, they may choose something that they wouldn't otherwise. In other words, they would choose an end that they might not otherwise choose if their suffering was addressed, whatever that is, if their social isolation was addressed. So I just throw that out.  We need to engage and we need to ponder it and help them deliberate in that decision and that choice. I think that's the role as physicians as well as palliative care so that people are sure they're going in the right path. I mean the World Trade Center, which I lived through, yes, I mean they only had two choices and none of them were good. But hopefully mostly it's not those two choices, I guess. I don't know if that answers your question or is just a philosophical approach. Dr. Moser thought that was a riveting, provocative, thought-provoking and enlightening journey. Thank you for the vulnerability of sharing, Johnny, and your story and we will be developing many stories here at the University of Chicago, Madison, so stay tuned.


Salaam from the People's Dispatch studios here in New Delhi. I'm Siddhanthani and you're watching Daily Debrief on the show today based on India's announcement of a national green hydrogen mission. We examined the question of what exactly is green hydrogen, both from a science as well as a political economy perspective. And we look at protests in Somaliland and get a better understanding of what the ongoing dispute there is. First up, India's central government, in an announcement made with much fanfare by Prime Minister Narendra Modi, has announced a national green hydrogen mission. Typical of these announcements in the recent past has been the attachment of a suitably enticing figure, in this case 20,000 crore rupees. That's approximately 2.5 billion US dollars. But to what exactly? We don't know yet. In absolute terms, India is the third largest emitter of carbon dioxide in the world. So obviously, the aim of the mission is to reduce emissions. But what is the science behind green hydrogen? Who will develop the technology? And of course who will pay for it? To understand both the science as well as these other aspects of the political economy of hydrogen and renewable energies, of course, we're joined in studio by Praveer Pukhaisar. Praveer, before we sat down to do the show, you were having a laugh at my understanding of the world of science. So just keeping it as simple as you can for my benefit and for those of our viewers who are also in the same boat. What does this color coding of hydrogen mean? Well, let's be very clear. This blue, gray, green hydrogen has nothing to do with the color of hydrogen. It's basically to say, if hydrogen is produced by certain methods, then how damaging it is to the environment, which means that how much carbon dioxide is emitted is a consequence. So the gray hydrogen is obviously the worst because you are converting hydrogen and letting carbon dioxide get into the atmosphere. That's the quote unquote gray hydrogen. This has been around for quite some time. In fact, refineries use a lot of hydrogen and they're obviously the way they produce it is using natural gas, burn, you know, effectively using that energy to convert a part of it into hydrogen. So that process liberates that part of the natural gas, which is carbon because after all CH3 or other hydrocarbons, there is a carbon component to it. So that sort of burnt off the hydrogen part remains in some form or the other. And that's the one which is then used in the refinery process where hydrogen actually is required for certain processes. So that is one part of it. So this used to be called well hydropower factories. But now it's been talked about gray hydrogen, not because of anything else, but because the oil companies want to market something called blue hydrogen, which is not going to be damaging to the environment. And their argument is we can take this carbon dioxide, which is being produced as getting hydrogen out of natural gas. And that we will sink in a carbon capture plant. That means it will capture, separate the carbon dioxide produced. And then after separation, store it underground, what's called carbon capture storage for how long and what we don't discuss in that. But it will be that will be done. And the result will be then the hydrogen that is there can be used for various purposes. There is a derivative of that process by which you can also produce ammonia. And therefore the green blue ammonia is also being discussed. Now all of them are to say that after that we don't have to worry about the fact there is carbon dioxide, except the question that arises. If that works, why aren't we doing it for all carbon burning processes, which could be coal, oil or natural gas. And the answer is very simple, because this carbon capture mechanism which started with coal actually has failed. And the reason for that failure is high capital cost, but that's only one. The other is also it needs a lot of energy, including the separation process that is being talked of how to separate from hydrogen say the carbon dioxide. In the other case, if you burn coal from nitrogen, carbon dioxide. So all of these processes also require energy. And what we have found apart from the high capital cost is the cost of that energy is also high. In fact, do you get a net positive out of that? The answer is probably no, we might have to spend more energy then you know not burning the coal at all. So instead of then getting a net positive, we are getting still a net negative with carbon capture, because we are then producing more carbon dioxide, then we are sinking into the so called carbon storage. So these are the reasons why carbon capture methods don't look very promising as of now. So if we look at this, the blue hydrogen is just another way of continuing to burn natural gas and oil for as long as they can do. And this branding exercise is basically public relations. This is what the tobacco companies did. If you remember, this is what the oil companies have been doing. First deny, nothing. It's not dangerous. Tobacco, not dangerous. Attack science, science denial. Then okay, we are doing something. What are we doing? We are giving you filters in your cigarettes. We are making less nicotine producing cigarettes, better cigarettes, healthier cigarettes, lighter cigarettes, all of that branding. So the same branding exercise, first deny science, Exxon has known for a long period that this is global climate change, global warming, etc. So deny science, when you no longer deny it, then claim that we are taking mitigation measures and therefore the gray blue hydrogen is being talked of. The reality is there is no way to burn natural gas and coal. And at the moment, provide a safe way of doing it. That's the reality. So we'll have to face them out. The question is how and when? And the oil companies answer is as long as they can postpone the inevitable. Well, they make profits, tens, 20, 30 billions of dollars of profits are involved. If you take all the oil company, you talk hundreds of billions of dollars. So how to protect that as long as they can? They will take the human society, human humanity. And we've also seen that governments are as complicit in this entire process of rebranding and PR as the companies themselves, obviously they are closely connected. With the peg of India's now national green hydrogen mission, what sense does it make for a country that it is a large producer of carbon dioxide, even though small per capita? Is this a direction that from an energy perspective or even from an environment perspective makes any sense to take at this point? Oh, yes. I think green hydrogen, if we want to have certain kinds of processes continue, say cars, buses. In fact, more buses and trucks than for cars. Then instead of the electric vehicle route, it makes sense to take the hydrogen route or if you want to use hydrogen, even it can be used in normal truck engine, which as you know, CNG engines, actual and internal combustion engines and therefore you can burn hydrogen in that. So the question is, when producing hydrogen, what's the difference between the color blue, green hydrogen as it is called or other thing called green and blue hydrogen. So the origin of green hydrogen is not oil, not coal. So there are natural gas. So it is really producing it through say surplus renewable energy, which means you have wind at night, but there is no, there may not be enough takers. So you have periods when renewable energy, there are no takers. So you have storage issue. So storage issue, one storage could be batteries, but they are for short-term storage. Long-term storage could be either hydrogen or what is called reversible hydro. We don't get into it today. But reversible hydro is something India can do because it has a lot of hydroelectric resources already reservoirs exist. So they pump water up. Similarly, you can also convert it to hydrogen by electrolyzing water. And if you do that, then you get oxygen and hydrogen. Of course, oxygen has limited use except for hospitals and so on industry, but hydrogen can be used directly as energy. So if you have surplus renewable energy instead of not using it at all, you can actually use it to produce quote unquote green hydrogen because this is not polluting. So you get at the end of it hydrogen and oxygen and if you get hydrogen, then burning it only produces water. So it can be done in two ways. You can directly use it in internal combustion engine, which is equivalent to burning it, or you can use it what is called a fuel cell and convert it directly to electricity and then use an electric motor like any electric vehicle and use it. It is very clear that hydrogen under compression and that's true for green ammonia as well because a similar process can be used for ammonia. They can be used because they're compressed. You can actually store a lot of it under pressure and you can use it for long distance trucks or buses. Now trucks and buses, the electric vehicles don't work because there is not enough storage in the batteries. I have already earlier in my various columns and writings I've talked about the renewable energy storage problem and this is the storage problem that you cannot, the EVs are not a route for solving this problem and 75% or 80% of the transport energy that is spent is really using diesel or commercial vehicles, even CNG in internal combustion engines. So therefore that 80% fuel that can be saved if green energy is used would then obviously avoid that much of emissions. Transport problem is not private cars, 80% of our transport problem is from trucks and buses. So public transport of course also reduces emissions anyway but more than that we have to find the solution. So either rail, electric vehicles, charging issue as we know battery is a problem and then the only long term solution therefore is to look at essentially either ammonia or green ammonia or green hydrogen for powering this sector which is really buses and trucks and long distance traffic. Of course people might argue since you should have really metros and long distance electric railways they are much better and I agree with that but you will always have some need for this. So whenever you have that to supplement then I think this green hydrogen does provide an alternative and therefore I think green hydrogen should be a part of a longer term solution to the climate change crisis. Your piece on news click today is headlined profit for the private players in this sector and hot air for the rest of us. From a policy perspective very broadly if you can just summarize the direction in which most major countries at least are taking in this regard. There is a technology part of it there is a political economy part of it technology part of it we have discussed that doesn't change the political economy part is who develops the technology who pays for it who profits when finally it is put into operation who profits from it who is getting the money from this say the twenty thousand crore two and a half billion dollars green energy program green hydrogen programs the government has taken a part of it is also the green ammonia program which essentially is for your fertilizer production which is very important for agricultural economy like India. So given that if you look at the major outline of that it is to fund private capital to put up various kinds of plants and that funding will be provided by the government how much it will it be grant will it be loaned it will be written off we don't know the details of that are not available but it's very clear there's a significant amount of support is going to be given to private capital to put up such green hydrogen facilities either for production of green hydrogen or for production and its use. So this is this is one part of it and that's why I've said that whether it's green ammonia or it is green hydrogen it's going to be subsidizing capital and even producing electrolyzers because you electrolyze water to produce hydrogen and oxygen therefore this hydrogen comes from electricity but you need electrolyzers on a large industrial scale and for that therefore the government has to they is providing the manufacturing facility subsidy. So to produce these electrolyzers but there's no the talk of developing technology for that out of the twenty thousand crores only about a minus kilo four hundred crores seems to be earmarked for this the point is in the future whoever makes electrolyzers whoever makes the fuel cells which utilizes hydrogen they are the ones which are going to hold the market as you have seen for chips it is not the chip manufacturer it is the ones who manufacture the equipment for chip manufacturer who actually command the economy. So that is where the technology issues arise otherwise you will be buying technology or you will be asking foreign capital to set up technology or the reliances of this world Tambani, Zadani, Birla's, Tata's they will set up big facilities but by technology from outside the very finalists today are set up. All right thank you very much for being for that. Our second and final story today at least 20 people have been killed in Somaliland in violence between anti-government protesters and security forces over several days this is according to multiple reports coming in from the region though it's an ongoing dispute Somaliland has been largely peaceful this current wave of violence signals some kind of turning point in the situation on the ground as a country with oil reserves and because of its geographic location in the Horn of Africa stability in Somalia is crucial not just for the country itself but the region as a whole as always of course there are direct imperialist interests that do not always benefit from a stable peaceful and united Somalia to give us a fuller picture of the situation on the ground as well as the powers at play Prashant now joins us. Prashant welcome back to daily debrief the Somaliland dispute has been on since the early 90s but not received too much media attention not too well understood around the world so for the sake of our viewers and all of us could you paint the scenario as it is at the moment? Right so of course we talk about in the context of recent protests that have been taking place in Somaliland so Somaliland is a de facto state it's internationally most many countries recognize it as part of Somalia of course now like you said this is an issue within the pre-90s before the 90s it was not really an issue it is only 1991 I believe that the declaration took place now the important thing is that there are very close ties of course between Somalia and what is called Somaliland and the protests right now that are happening also are largely based on that because there is at least in certain states a very strong sentiment of wanting to integrate further with Somalia now in Somalia itself largely there is a lot of a lot of the politics is based on clans and their networks and what we do know also is that Somaliland especially there are quite a few influential clans but it is one clan primarily which you know has been at the forefront of demanding a separate country now on the other hand over the past few decades you have also seen any especially among the youth and increasing tendency or increasing spirit of belief in further integration and this seems to be what is spurring those protests now some of the protests took place in the last week of December there was violence I believe about 20 people were killed they have been protest reported also on the 12th of January I believe now significance of this is a larger question of the sovereignty of integrity of Somalia itself now we do know that Somalia has long been a playground for various foreign powers at some point the United States actually intervened in Somalia we also know that there's been a lot of violence also Islam's violence for instance and all of this has led to a very weakened federal government in the country and which has not really been able to exert its authority there's the absence of a very strong unified army for instance and all of this has made Somalia the perception of it being some kind of a failed state and now it's this is significant when you consider Somalia's position in the globe in the Horo Africa its vital position near the Suez Canal in the Red Sea for instance and also it has oil reserves very equally very important now all of these aspects put together it the picture dynamically changes if there is a Somalia which is united integrated and under a strong federal government because it makes it a much more sovereign country right and this is what many forces I think would not specifically like because it allows them to actually dictate the interests in various smaller regions as opposed to a federal government which might have more powerful power in control so that's really I think the heart of the issue here the question of an integrated unified Somalia versus a more federated broken down structure where local leaders clan leaders for instance can then dictate the terms of what is happening now this is all the more important when we consider the fact that oil is also a factor here for instance a company called Genel which is listed in the London stock market has claimed the right to exploit some of these oil reserves in Somaliland and the federal government to Somalia has objected to this issue and you know this has raised a lot of controversy around the same time we also know that for instance Joe Byte administration with recent document referred to Somaliland itself and it was considered a divergence from its usual one Somalia policy so all of these are interesting geopolitical issues that are playing out but ultimately the larger question is regarding the integrity and sovereignty of countries in the Horn of Africa itself they also reports coming in of for example you mentioned the the US's military intervention in in Somalia there are recent reports coming in of US troops once again training in Somaliland in fact what role or what part does US imperialism play in this region and what is sort of the US agenda here right so the Horn of Africa like we said like we talked about before is a very crucial region and there are processes taking place in the Horn of Africa which are not specific are not particularly the liking of the United States administration for instance we know that Ethiopia is a key country in this process Ethiopia was under the control of the TPLF for the longest time now under Abbey Ahmad it has taken a different path TPLF then states this whole revolt it is seems to have entered at least on paper as of now so even there it was a very similar question the question of whether Ethiopia would be an independent sovereign country which would have its own interests it should pursue its own path as opposed to it being more of a client state of the western fractured state right and we know that Ethiopia Eritrea and Somalia for instance they have been attempts to sort of have more discussions between these countries so the integrity of Somalia is also very relevant in this context because what it would mean is you know a strong integrated unified Somalia would mean the possibility of a different path for countries as a as a whole in that region also important to remember that in this context Somalia does not have a one person one vote system and this is something that progressive forces have been demanding for a long time because the fact that this would mean that the influence of the clan leaders influence of local interests would be broken by a democratic process right and this is something that you know very sections of Somali Somali Somali in political establishment have strong long opposed because for this reason because it gives takes away their power right right similarly the same thing with Abbe Ahmed as well who has been trying to sort of bring a bring about a larger Ethiopian nationalistic perspective as opposed to various clan and regional perspectives which are dominant for the longest time so the I think the larger question is of the future of the Honour Africa itself are we going to see a group of countries which have of course certain common interests in certain common contexts because their location and which work closely together or are we likely to see more sectional and divided regions many of which could be under the umbrella of the United States or its allies and I think this is one very crucial battle which will go on for quite a few decades as well all right thanks very much for that update Prashant and with that also we wrap up this episode of daily debrief from myself and the entire team here at People's Dispatch thank you very much for watching as always we invite you to head to our website peoplesdispatch.org for more details on these stories and all of the other work we do also don't forget to follow us on the social media platform of your choice if you haven't done so already we'll be back on Monday with another episode of the Daily Debrief until then stay safe goodbye


Hi, everyone. Joe for Jaspy's casebreaks.com. Happy Sunday. Coming at you with 2022 Tops Chrome Black Baseball. 12 box. Pick your team. Number nine. Here's the case right here. Very big thanks to everybody right here. We sold this out straight up. So thanks for spending a bit of your Sunday with me, your NFL Wildcard Sunday. Tristan LastBotMojo, Yankees. We filled this straight up. Another case in the store as well if you want to run this back tonight. Real sharp design of this Tops Chrome Black. I'm a fan of it. Thanks everyone for getting in on it. All right. Doing all 12 boxes. You can see six on the left and six on the right. One in case card. Refractor parallel to her box. Real fun stuff. Good luck everyone. Oh yeah, there is a sponge piece right here. And a redemption to lead things off. Let's see what we got in here first. Nice. Got a Bobby Whit Jr. rookie card. I like that. Not numbered, but still nice. Royals, Kevin. I got Nicoladolo and Bryce Harper. That is numbered 77 out of 99 for the Fightin' Fills. That's for Harry and his Phillies. All right. Now let's see what this redemption's gonna be about. We got Raven's bangles on in the background. A Sunday night football. Raven's up by one. Bangles driving in the third quarter. So congratulations, someone. You are due to receive an autograph. Very simple autograph of, of Mike Trout. That's Harry with the Angels. Harry bought the Angels straight up, went fishing, caught a trout. Good start. Next box. Yeah, what a start, right? Harry was in the chat earlier. There's he now. Harry with Javier Baez, Spencer Torkelson rookie card and a Jaren Duran Duran to 199. Red Sox, Howard. Torque will go to DY and the Tigers. All right. Looks like we got a rookie autograph of Cal Raleigh. Daniel with Seattle.  Sharp, real sharp. All right, next one. Right, Jeff? It just looked like a regular old basic autograph, but no, it's Mike Trout. I'll take it. We'll take it. All right, Jaren Duran, Brandon Marsh and a Ronzie Contreras, 31 out of 50. It's Darren with the Pirates DMACC. All right, next autograph is Nolan Ryan. Don't look Rex. John got the Rangers straight up. Gets the top chrome black, Nolan Ryan. Got a Salvador Perez Hoy Park and a Bryce Harper to 199. Got a Bangles TD here. 11 plays, 83 yards, seven minutes and a nice gold auto. Derek Jeter, 27 out of 50. Tristan got the Yankees straight up. Last spot, Mojo gets the Derek Jeter autograph to 50. Wow, man, so we got a Trout, a Cal Raleigh rookie auto, a Nolan Ryan and a Derek Jeter. We're only four boxes in.  A one of one somewhere? Like one of one Julio Rodriguez rookie card or something like that? Who knows? Well, let's keep going. Got more in the store, folks, Jaspy's casebreaks.com. This is the quality, the potential that tops chrome black has. There's a Torkelson rookie card and Brandon Marsh to 199 for the Phillies. Next up, 46 out of 150. Joe Carter, Toronto, TJ. TJ with the Blue Jays. Charlie Blackman, Louise Robert and Ryan Velod. More purple parallel color match with the Rocks to 150. Jeff with the Rockies. All right, let's see what we got here. We got rookie, we got some color. We have Seth Beer, 45 out of 99. Nice little up and coming prospect here, up and coming player for Jeff and the Diamondbacks. There you go, Jeff. All right, six boxes in, six more to go. And another case in the store, Jaspy's casebreaks.com if you wanna run this back. Bryce, Cal and John Van India. Six out of 99 for the Reds. Howard with the Red Legs. We've got Raleigh Fingers. Oakland A's edition that will be for John. Derek, what's up? Do you know when you're ripping flawless? I do, Wednesday on New Release Day. Wednesday, January 18th. No worries, Derek. Probably go live a little earlier that day, so I would keep an eye on the break schedule. That night thought just dropped in the chat. Then you'll know exactly when your break is gonna happen. There's O'Neill Cruz, rookie card, rookie bets, and Jose Ramirez. 167 to 199. It'll be for Corey and Cleveland. O'Neill Cruz will go to Darren and the Pirates. Those empty boxes are not for sale. Go with some milk. The next one is Bobby Dalbet. Red Sox, that'll be for Howard. Pretty tough. Jose Ramirez, Byron Buxon Blue, and a Yordon Alvarez Purple. 005 out of 150 for the Stroze, Ed P. And the Byron Buxon for Minnesota, that'll also go to Ed. 58 out of 75. I'm sure someone on eBay is selling those. Go with some milk. You can check that, check out eBay. A lot of people sell those empty boxes for the like Flawless briefcase and stuff too. We donate them to the kids that come into our shop. And we got Piedalanto. That's for Ed and the Metz. Oh, there's the TD officially. So I guess the other pass was a little short. Who was that? Was that T. Higgins? Tyler Boyd? Chad Ocho Sinko? Xander Bogart, Seth Beer, and an Orange Yordon Alvarez. Eight out of 25. And some gold. Got Jose Cansego, 34 out of 50. You're welcome, goats milk. John, with the ace. Two more to go. I'll lose Marcus Simeon and Salvador Perez. 40 out of 50 for the Royals. This is for Kevin. And we've got an Orange Parallel and it's gonna be 19 out of 25. Jorge Posada. Nice, that's for Tristan and the Yankees. That'll pair nicely with that Jeter. Last box. Another case in the store right now. JaspeysCaseBreaks.com. This stuff is great. Saez Suzuki, Cody Ballinger, Cal Raleigh. 88 out of 99. That's for Seattle, that'll be for DeLoe. And the last encased card is gonna be a rookie. You can see the RC logo up there. Rookie Otto, 60 out of 150. Jake Burger. Burgers. And that will be for Howard and the Chicago White Sox. There you go, gang. It's a great break of 2022. Tops Chrome Black in the books. More in the store, JaspeysCaseBreaks.com. Check it out and I'll break some more of that with you next time. I'm Joe, see you later.


Hello everybody and welcome back here to the channel. I'm over at it. We're here on my dress server in the new street cars that got released We're doing some first-person tandems here. Just having a little fun in the cars So yeah, wrap a rampaholic up here in the server right now We're gonna do with some first-person adored diving on these guys here for today Wish you could follow me on all social media all the time in the description box below So I know on the release bash. I was already mostly third. So today we're gonna be running this thing in full first Just trying to catch some doors Raps got the type S lights on underneath. Oh We'll see seven love going on right now Who's definitely excited for fd this weekend? I know I am oh we got this We just kind of flowing behind him right now. What was that?  They can't tuck in in the third slot definitely Much harder position. They're just brap a little bit of a loss there. You can't catch up to the Mustang It's definitely fun to have these cars out and the server up seeing some a lot of people in the server today Just checking the logs seeing who's in there Trying to catch a Mustang. He's got that thing ripped off the door. Love the door up there Try to stay focused This time unlike when I was checking chat and everything in the live drift bash Don't leave the link for the car in car pack in the script box below if you guys miss the live drift bash And you don't have the car pack yet. It'll be down in the description box below. Oh, we go in line We kind of pulse hit the dirt there. So it's kind of really no saving that go back in behind bratt Barsha tweaked gear slightly Both got our tight pass lights going on boy kind of fell off there Kind of get lost in the smoke a little bit Let's help wrap out a little bit a weak deal So I do appreciate like I said everybody coming out to the live stream yesterday in the or the other night For the live stream had a lot of fun with it now We just doing some first-person driving because did boost that stream like I said in third-person. So trying to get that That immersion feel going on right now Realizing the front bumper of this car. I don't smack into him off to catch back up. Oh, I almost over rotated there How to cut that way shallow? Grab self in the dirt this cycle back around see who's going on Back on track Don't turn behind the Mustang again. Like I said, definitely Been having a lot of fun. Good to be doing track page here on the server You know probably at the end of the week try to tuck in this man's door. Oh I thought I was gonna fit into it We're good. Don't get bumps Had nowhere to really go Got an FDR seven up there. They're probably gonna try and cut in on Trying to get behind him. Oh He spammed out Dang it. I was gonna try and go behind him. He's trying to get all The in-car And I'm here today. It's all about pure drift in cars In the C7. Oh, we were in dirt. I felt it. I can't see Can't see where I'm going. It's looking for taillights really. Oh, I may have bumped him slightly I took back in so I hope you guys are enjoying the new car back release and all the new cars Definitely like I said had a lot of work put into these and we're definitely Throw in the sound some doors gonna try and get behind Rico or Yeah, Rico Rico Not sure how it's pronounced Try to get behind an RX-7. It's killing it in the RX-7 though. Oh, almost got taken up by Mustang though. We go throw it in behind him Getting thrown in a huge cloud of smoke that rotary bang. Oh, I think I just got mustangs Mustang doing Mustang things though a little just chill the sand I'm here Trying to throw down some first-person tans for you guys Because I definitely enjoy the immersion of being a first person or VR. So little neck effect First person Tandems for you guys here with the new cars So make sure you guys follow me and also show me the knowledge found the scripture box below I hope you guys enjoyed this episode And we guys come back for more I'm leave you guys with some replay clips So make sure you follow me on social media which found the scripture box below as always I think you guys have come back watching. I'm your rabbit. I'll see you guys on the track