Okay, this is Bruce at BookMap and we're going to go through the BookMap platform details here in this webinar. Okay, risk disclaimer, trading, equities and futures involves substantial risk of loss and is not suitable for all investors, past performance is not indicative of future results. For more information on BookMap, go to bookmap.com and there's a 14-day free trial. This will not only allow you access to BookMap, but it also gives you access to a lot of our content. Okay, so for example, we have the advanced order flow webinars in about a half hour, okay, at 11 a.m. Eastern time and there's an educational course as well and some other resources. So those will be available for current customers and you can always reach out to us at support at bookmap.com. All right, so let me show you where you can find BookMap, okay, so bookmap.com, click on explore here and there's some intro videos if you're new here. Maybe watch these, they're very short and then there's just information on what BookMap is, the platform, the benefits, et cetera. You can see our partners here and then there's BookMap for equities here as well and if you guys have questions about that, let me know. I can show you several equities that I have already here in BookMap and show you what's going on there. We use the NASDAQ TotalView, which is an excellent data feed, okay, connectivity. So we are a platform, we are not a data provider. You will need to connect BookMap to your data provider or broker and these are the methods for connecting, all right. A little bit further down, the pricing page here, okay, so we have the basic, advanced and quant, okay, so in general, there's just one version of BookMap, the BookMap basic. It's 49 per month, it's billed quarterly and you get that 14-day trial period, okay. Now for add-on features, that would be the advanced version or the advanced offering and one of them is the ability to trade right from the chart, okay. And then there are others as well. These are proprietary indicators that we developed that show something unique in the order flow that is available in the advanced offering here. And then for those of you who are quant connecting to your own data, displaying your own proprietary indicators and your order queue estimation or API, you're going to need the quant features so you can reach out to us here by just clicking on learn more, okay. All right, you can follow us here on Twitter and you can also subscribe to our YouTube page. So let me show you this page here. So if you're new, where to begin consuming some of the content, I would recommend first, we'll watch this little intro video here, and then some of the features and components. Maybe you just start with the BookMap 6.0 overview or you can click here on the features and components playlist and you can look at all of the different features that are here in BookMap, all right. So you get an understanding of what BookMap is as a platform, okay. Order flow video snippets. This would be the next step. Once you understand how to use the platform, what does it show you and how to utilize it within your trading. These are the videos to watch here. They're very concise, they're very short. Let's go through order flow phenomena that is very easily and readily uncovered in BookMap, okay. So for example, absorption, exhaustion, flipping of the order book, these types of things, you know, I would encourage you to watch some of these videos and this is the kind of content that we go through in the advanced webinars, okay. But we go through them in detail and we see them day in and day out, all right. There's also a pro trader webinar series that we had, if you want to watch some of these webinars how pro traders are using BookMap and you want some insight to some of those advanced order flow webinars, you can watch them here, okay. All right, let's jump in and let's look at BookMap. Let's see what's moving here today. You know, looking at the NAS, we've been looking at the NASAC last few days. You can see oil's coming up to an area up here of interest and gold, that's the 6E, okay. Gold as well. I mean, gold is trending on the upside. Let's see, maybe we'll go with oil and take a look here today at oil, all right. Crude and let's zoom out of here a little bit in the NASDAQ and just to make sure here. I mean, we can see the 930 open, a pretty sharp move to the downside here, or initial move up and then move to the downside. How does that fit in the bigger picture here? Okay, nice, nice little run below this area here and what's that crude look like? Yeah, all right, well, we'll stick with crude then. All right, well, so for those of you who are new here to BookMap, and there are quite a few new traders in here, so we're going to go through what BookMap is and what it's showing you because I imagine you're looking at this and thinking like this looks like something very foreign that you've never seen before, okay. I'm going to show you that it's actually really simple data and this is not an indicator. It's not some derivative of time, price, or volume. Now, we do have an indicator sub-panel down here, but I'm going to close that up and we're just going to go through the basics here. Understand what BookMap is showing you and in general I'm going to show you that this here is a very clear and objective view of what's going on in the marketplace, all right. And I'm going to have to bring up some of these settings here for the heat map, all right. So, and so, as I get into that, basically what we're showing you here, we're showing you the historical best bid and offer, where the volume traded, the volume dots here, and then we're also showing you the historical view of the dome, okay. This is the current dome over here, as you can see in the COB column right here, okay. But we take this data and we project it on the chart historically, so you can see where people are bidding and offering historically and it gives a lot of insight, okay. That's it. That's all we're showing, just these three things, okay. So very, very objective and very, very simple, even though this looks very complex, it's really not. So let's get into exactly what we're showing here, okay, and let me describe this. And I'm going to turn off all of these layers of data, okay. And here we're looking at a five-minute candlestick chart. Now we all are accustomed to looking at a candlestick chart, okay. So you can see here at nine o'clock, this is when the crude opened, and you can see the nice move to the upside here in the cash session, and so far we've been holding up here. So we can read the open, high, low, close of each candle and start to gain an understanding of buyers and sellers and where volume may have traded, but we don't know, right. And that's a problem because we can see here that all we have in the candlestick is open, high, low, close of this five-minute period, okay. And we're just kind of reaching here to understand, well, what happened in this area? What kind of volume traded here? Was it aggressive buyers? Where did they trade? And how much did they trade? You know, we have a volume sub-chart down here, okay, and this is good, that tells us a little bit more. We know that there is a volume spike here, but that's it. We can't answer those other questions, and that's an issue. We're trying to make as best as we can insightful financial trading decisions here, and this is very limited data, okay. We're going to, I'm going to show you here that we're going to look at a lot more transparency and understand exactly what's going on in some of these areas and make much more informed trading decisions, okay. So that's the candlestick. Let's just turn on best bid and offer, okay, historical best bid and offer, and that's it. That's all we're looking at here is the candlesticks and historical best bid and offer. Now just that one layer of data is already showing me quite a bit, all right. I can understand microstructural areas within these candlesticks, so, you know, the price movement and the structure and the break of the structure, okay. Like this move here to the upside, you know, we see the big candle here, okay, and the quick move to the upside, but that move actually started here, okay, in the microstructure. So you have that insight here. In fact, it started here on the breakout. It came up and it came back and retested where it broke from here, and the buyers came in and just, you know, they lifted the offer pretty quickly, okay. So this is the kind of structure that gives us this insight, and we're going to show you though, or I'm going to show you here where these trades actually took place and the commitment of the traders, okay. So let's turn on the volume now, okay.  Now it looks a lot better, okay. So now I have the historical best bid and offer, okay, and I have the volume dots, okay. So let's zoom into this little area right here, and I'm just going to click on this move tool, the hand, I'm going to hover over this area, and then I'm going to zoom in really quickly with my center mouse wheel, okay. So here's where that move took place, okay. This is really the insight right here, and we can see the aggressive bind lifting the offer up into a new structural area, okay. So now before I get into that and the retest back here and the kind of exhaustion in this area here, I want to first cover what the volume is here in Bookmap and what you're looking at. So we're going to zoom into this area here very quickly, and you can see the red line here and the green line. This is your historical best offer, and this is your historical best bid, the green line, okay. Now the dots that took place here, okay. These are the aggressive market buy and sell orders, and why do we consider them aggressive? Aggressor classification of volume is because they crossed the spread they wanted into the market and they took liquidity off of the best offer. They hit the market buy button and a dot paints here on the best offer, okay. So these are individual trades, okay. And you can, I can already see here, look at how the spacing and the, and this is, we're looking at, you know, 30 seconds of data between each vertical dotted line here, but you can already see some algorithmic activity here, just by the, one algo is taking a couple of trades, another couple of trades, and then another couple of trades, et cetera, okay. So yeah, it's, it's just by reading the spacing here, you can start to understand some of the algorithmic activity in the trading. And let's continue to zoom in here, all right. So I'll hover on this dot here and continue to zoom in, all right. So we're going to see that this dot here is actually several little trades that took place, okay. We're now down at the microsecond level, so millions of seconds, all right. We can continue to zoom in and we can look down at the nanosecond level here, okay. Now we're looking, you can see in the timeline here, we're looking at billions of seconds. I know exactly what traded here, when it took place and for how much. You can use this tool here, the data tip tool, hover over here. This was one individual trade for 14 contracts, okay. I have the date, the time, what was on the ask, okay. So the liquidity here was 101 contracts that's showing up here in the dome as well, okay. And I also know the volume and the price level. So at 50, 52, 101 was on the ask and this was for a volume of 14, okay. Now if you're trading now algorithmically or with automated strategies, you know maybe this can be really insightful and understanding to see where you got filled. But most of us are not trading off of these time frames. So what's the point? What's the reason? All right. I just want to show you that because we came from this environment and this visualization tool was actually developed to show where our automated strategies, the algos we were developing, where they were getting filled and how. And then book map developed into a software platform from that, okay. Now as I zoom back out, notice how all of these individual trades here, okay, aggressive market buys, I'm going to compress this timeline down here as I zoom out and it becomes a bigger dot, okay. So I have the overall shape of this volume aggregated visually for me, okay. Just visually and graphically. All the data is still here. We can zoom right back in and we can pull apart every single trade activity here, okay. It's all recorded in book map, okay. We have a very powerful complex event processor that can handle millions of data points, all right. So anyway, that's what you're looking at with the volume. And then that's the aggressive buying and then here's the aggressive selling. Now note some of these other pie chart displays of the volume, okay. This is the overall delta of the volume at these areas. Again we can use the data tip tool hover over and I can see that this was for a volume of 240, okay. Why is it a pie display is because there's so much activity here that we've compressed the timeline with both buys and sells and we're giving you the overall shape of that volume, all right. So you can see exactly what traded. You have the understanding that there's more buying up here than there is selling, okay. All right. So that's the volume and the, yeah, I mean look at how this candlestick here basically gives you some misinformation. We see the move to the upside here and then you get a wick on this candle. I mean, but this is exactly what we look at in the advanced webinars. You see the aggressive buying, lifting the offer, sweeping the book higher into these areas up here, outside of this micro range, okay, and it comes back and you see very little selling here. There are some, but it's not that extensive and then you see that the buyers start to come back in here and then here they sweep the book, okay, and we see the move to the upside, all right. So that's what we're looking at in terms of volume. Now that's an important part of order flow and, you know, your footprint charts, volume profile guys, looking at, you know, all sorts of traded volume, it's important. What is good with book map in its visual display here is that micro structure, okay.  You're not going to see, you know, it's going to aggregate back and forth within a time period and you're not going to see these micro structural areas here, okay, because we have the best bid and offer and we can show everything in that structure. It's not the aggregation of it, all right. So anyway, the understanding, the volume is important, but what about the other side of order flow and the market? We want to know the participants, okay, where they lined up in this auction and it is an auction. Each market here is an auction. We're using a lot of the auction market theory here as well, okay. We can see here at 5070, there's 320 contracts here, quite a bit. 5075, there's 339. It's probably the same guy, you know, spread out five cents here, but that's providing a lot of that liquidity. But, you know, anyway, that's just, you know, a hypothesis there. So, but that's important data. We want to know that, all right. Now, and this current view of the limit order book here is giving us some pretty good data, okay. We can see that there's 200 contracts here, very aggressively placed here, just below the best bid, okay. So, you know, maybe a bit of a skew in the book there. And we'll see if they just got filled or not. But we're gaining some insight to the market and the intent of these participants providing liquidity. Do they really want to trade or are they just going to pull their liquidity as price comes there and decide not to trade, okay. Well, that kind of insight is rather difficult to get from the current order book because these numbers change, the liquidity changes. And once it updates, that previous data is lost, okay. So, that's the problem with the limit order book, the dome, okay. Where book map solves that problem is with the heat map, okay. And the heat map here, what we do in this window here, which is also the current order book, okay, best bid and offer right here currently. And this is the last traded volume right here. And what we do in this window here is we take those areas of high liquidity and we turn it into a heat map, right. So, you can see 50-70 here, over 300 contracts is very bright, okay. It's a little too bright here for me and we can just adjust that heat map to get a little more insight here, okay. So, 171, see it's a little darker here, it's still high liquidity, but it's darker compared to 50-70, okay. So, we have an understanding here in this current market window. When these numbers change, the heat map changes, all right. You can see them adding and pulling right here at 66, okay. Now, where this gets interesting is we take this data here and it's recorded and projected onto the chart historically, okay. So, what we're looking at here with this, look at these striations here in the liquidity, okay, right here at this 66 level. This is the adding and pulling of liquidity, right. So, price is coming up and now these guys really want to trade or not. And I would bet no, because they continue to add and pull here. As price moves away, they add it back in, as price comes back up, they pull it, okay. So, probably up here, they have, you know, we'll see if we get up here, if they have the intent to trade. But we can start to gauge now that these guys here at 66, you know, they're probably going to pull. So, we know that just by this kind of, you know, looking at this behavior here of this level in price, that the players at this level don't have a lot of intent to trade, okay. They have some, but they're also pulling a lot of it, all right. Now, we'll see if we come up here and test it and if they completely pull, all right. But we have all of this data. So, we're able to make use of their intent at this area, okay. So, we can make a distinction between what's real and what's not in terms of liquidity, all right. And that gives a lot of insight here, because now we can start to understand where the larger traders are providing liquidity and have the intent to trade, okay. So, for example, look at this trending market to the upside. We continue to trade into high liquidity at higher areas. That's very indicative of a trending market. And then on these pullbacks, actually, you do see some support here at 5040, okay. Now, we're just breaking out here, okay. And we can, let's go back and answer that question, all right. So, did these guys have the intent to trade? Actually, they did. I'm kind of surprised. 167 contracts traded right here, and they remained in the book with 227, okay, on the offer, okay. So, kind of interesting to see. So, it looks like, you know, they kept on adding and pulling, but in the end, you know, we see the transaction, okay. It's all here. We know they absorb price up at this level, okay. They are now short. The buyers took these guys on, and they actually traded through, okay. They lifted the offer through this area. They swept the book. They took all of the liquidity up into these other areas here. Look at them jump on the other side here, on the bid now, okay. And then they actually pull here, okay. Now, we're at a new trading level, okay. We're above this 65 area right here. It's actually, the breakout here actually took place around 66. But, and we're trading above it, okay. Are we going to accept or reject above this area, okay. Well, if we're going to accept, I'm looking for a little bit stronger breakout. I'm looking for more buyers to start to show up and lift the offer again. I'm seeing some selling coming in now, okay. I'm seeing some selling here as well. And up in this area here, I don't see a lot of buying, all right. So, based on this, and based on the strength of this move, there's the possibility now for this to maybe come back down and test into this area around 50, 60 or so, all right. Okay, just by understanding the order flow, the traders and their intent to trade at these levels. If they really wanted to buy and continue to support price above this 66 level, we'll see them flip in the book here and they're going to provide high liquidity up at this area here, okay. Around this 65 or 64 area, okay. And they're starting to, I mean, we can see a little bit of activity here, but it's not that extensive, okay. What about on the offer? How are they behaving? Okay, they're back in here at 70, right. Now, are they being aggressive? Are they lowering the offer? Do we see other traders front running them around this 70 level or not? And now it looks like they're just kind of staying here, okay. So, you know, if the market rotates back up, it's gonna find the liquidity here at 50, 70. And we just retested that area, okay.  These guys are staying in the book. I mean, they're adding and pulling too, but you can see last second they're kind of pulling, but they're also interested in trading up here at 70, all right. Now, let's look at some of the transactions that took place, okay. Well, that's what we were doing earlier. I'm seeing some, this is a little different picture now. The retest up here was we didn't see a lot of buyers. I'm starting to see buyers step in here up at this level though, okay. So maybe they'll trade through these guys and take them on now. Okay, it's a different picture than it was, just a minute or two ago, okay. And here they come, here come their aggressive buyers, okay. Trading through 70, okay. High liquidity now here at 72 and then 75 here up above. All right, any questions? I've got a good group in here today and newer traders, welcome. This is just the basics here. There's all sorts of things to dive into in terms of the platform itself, okay. Trading into 72, now we're looking at 75, okay. And now we're starting to see a flip of the book a bit here, you know, providing higher liquidity underneath, okay. As we continue to lift the offer up and they're trading through these guys, right. Right up in through these areas here, okay. All right, okay. Well, we noticed that behavior change here, okay. It happened here, okay. Originally it didn't look so good in this area here. And I thought it looked like we had the potential and I saw the selling here and I saw some selling in here that we had the potential to come down and maybe test 60. But that all changed right here, okay. And it looked pretty good. They were testing into these guys and then this surely gave the insight here as soon as you see them take them on here and lots of volume trading at the higher area here than previously, okay. And they continue to lift the offer, right. Anyway, that's what Bookmap is showing you and I better jump to the next webinar and we'll see you there, okay. All right, thanks guys. We'll see you tomorrow.


Hi everyone. Welcome to our webinar series here at advanced clinical training. I am going to wait no longer than three minutes just to make sure we give all of our attendees an opportunity to join. Again, if you are joining thank you so much as I said right in the beginning I'm going to wait no longer than three minutes I just want to make sure that we give all of our particular all of our attendees an opportunity to join us. I just want to make sure I'm turning the chat features on I just want to make sure that everybody can hear me well, and that you are able to respond in the chat to me so if you can respond in the chat please let me know. Awesome thanks so much. Chat is disabled. Okay, let's see. All right, so I'm working on enabling the chat here so just bear with me here. Yes, I'm working on getting the chat turned on just bear with me. All right, so we're just going to go ahead and get started and we I will figure out the chat as we go. But again I want to welcome you all to the webinar series here at advanced clinical training. I want to thank you for spending your evening here with us. We're so excited that you were here. And so, if you don't already know me my name is Lea Medwig and I am the lead course instructor here at advanced e clinical training. I have been a nurse for over 12 years and I started my career in cardiothoracic surgery and then I went on to work in a level one trauma and burn emergency department, and a very large metropolitan city. I then went on to become a complex and catastrophic nurse case manager for a large national health insurance company. I completed my master's degree and since teaching was always in my heart I love teaching and students and precepting new hires. Education was kind of a very natural, a very natural progression for me so that is how I ended up here at advanced e clinical training. Let's see. Let's see here so if you're not familiar with advanced e clinical training we are a fully online south paced allied health care certification program so we offer programs, certification programs for certified medical assisting certified patient care tech certified pharmacy clinic and you can go ahead and check out our website is advanced clinical learning.org. We are asynchronous you can complete these programs and as little as eight weeks and we're here to you know pre health students but also towards students who want to go on to medical school to go on to nursing school, who also want to go on to PA school pharmacy school and that really need those direct. Direct patient care experience so that's what we're here for and for any student for any of our attendees who aren't current students, we are offering you a discount code today for $200 off any of our enrollment into any one of our certification programs and again that. That discount code is webinar 200. All right, and one last thing we will also of course be issuing all of our attendees a one hour clinical shadowing certificates, and we will be sending that to your email the email that you use to sign up for this webinar so. As far as the webinar goes, I want to try to make this an interactive experience I realized that the chat somehow is not working and I thought I have worked out but we have a couple of polls that I am going to have you guys participate in an answer. And then we can also of course just communicate with in the question and answer. form here so I think that will be fine again we can communicate in this question and answer feature if it may be but. is, but there's no pressure here this is a learning experience for everybody. i'm so we're going to keep it as light and as professional and fun as we possibly can so. This case is case 956 and you're going to see a video of a real patient who presented to the emergency department, he was videotaped with his permission of course for educational purposes. So we all can learn together so that being said, I am going to go ahead and share my screen and we will get started i'm going to start with the video of the patient. And if for some reason that you all can't hear me or hear the video please let me know and question and answer feature all right, so are you all seeing my video awesome okay perfect. Love it okay so if you can hear it good evening how you doing let's start it over. All right good evening how you doing tonight. Doing okay thanks for taking the time to do this video and Dr more here at Yale.  Yeah, so it was where was the where's the pain hurting where was it. My body, my chest, my legs. So the chest was hurting in your legs. Was this typical of your usual sickle cell pain. Yes. Is it any worse or different. About the same. Okay, but you did have some chest pain. Yes. Have you been coughing at all. All right, so we so he comes into the emergency department this patient does he has kind of diffuse body pain he has shortness of breath he has some chest pain and some cough. And then we, and then he lets us know that he has a history of sickle cell disease so let's take a look at that. Okay, so sickle cell disease. Sickle cell disease is a group of inherited red blood cell disorders so what you can see here is on the right side you see this healthy red blood cell and it's nice and round it's kind of concave in the middle. And with patients that have sickle cell disease, this is what their red blood cells look like. So, red blood cells contain hemoglobin and that's a protein that carries oxygen to the rest of our body. So, healthy red blood cells again around and they move through the small blood vessels to carry oxygen to all parts of the body, but somebody that has sickle cell disease the hemoglobin is abnormal as we can see. And it causes the red blood cells to become hard and sticky and look like this C shaped. They call it a farm tool called a sickle so that's how it gets the sickle cell disease so when the patient that has sickle cell disease when they're red blood cells that are sickle like this, travel through the small bed blood vessels they get stuck and they can clog blood flow. And this can cause severe pain. And it can cause other serious complications such as infection acute chest syndrome and stroke. So, also, what's important about this is that the sickle cells, they die early. So, this causes a constant shortage of red blood cells. So, I'm going to. As you can see here on the left, this is a normal patient or a healthy patient that is healthy red blood cells.  Here on the right you can see a patient that has sickle cell. This is their blood vessel. You can see these blood, red blood cells that are sickle shaped and they get sticky and they, they clog together they don't move easily through the, through the blood vessel, and then they also died early. So, there's always a constant shortage of red blood cells for these patients. So, let's go back to the video. All right. So, we're going to continue with the video. Please, again, let me know if you can't hear it or see it by utilizing the question and answer feature. Paul? A little but not so much. Yeah. How about your breathing? Are you short of breath or anything like that? Yes. You are short of breath? Yes. How long has that been going on? For like two to three days. Okay. And any fevers at all? Yes. You have that fever? Yes. At home, did you measure it? Do you know how high it was? No, 102. 102? Not 100.2 but 102? 100. No, 102. 102. Okay. All right. Well, we got you here on a little oxygen. Is that helping at all? Yes. Okay. All right. We're going to do some tests and probably give you some medicines, but thank you so much for taking the time to talk to us. Okay. All right. So I am going to take this out of full screen mode because there are some items I'd like you all to see here. So let's take a look at his vital signs. He comes into the ER, vital signs. He has a temperature of 101.1. So we know that he has a fever. His heart rate is 111. We know that a normal resting heart rate for a healthy adult is between 60 and 100.  His respiratory rate, I don't really believe that it's 18. If somebody has a pulse oximetry of 81% on room air, they're probably like deep breathing, taking more respirations a minute than 18, but we'll have to take it as 18. The important thing is 81% on room air. We know that he's hypoxic and that's not normal. A normal pulse oximetry for a healthy adult is 92% to 100%. So they have met oxygen. Of course, blood pressure 127 over 76. So that's normal. And as you can see here in this graph, some of his vital signs, so they did see here in the ER, his pulse oximetry was low. So they put him on a nasal cannula for some oxygen, and that certainly was the right thing to do. So I am going to stop sharing my screen because this brings us to my first poll for everybody. All right. So what do you think? Okay, so what do you think is happening with this fusion? Go ahead and choose your answer for me. And I will wait here to see what everybody thinks is going on. All right, we have a still getting some answers here. It looks like acute chest syndrome is winning the race at this point. A few more waiting for a few more people to answer. Just going to wait just a few more seconds so we can continue to move on. All right, so I think we have everybody answer that's going to answer at this point. So I'm going to go ahead and end the poll, but it looks like acute chest syndrome has kind of won the race here. And here are the results that you all can see. So that was kind of a trick question because this patient, he could have all of those answers.  He could have had an asthma attack. He could have COVID-19. He could have pneumonia. He could have COVID-19 pneumonia. So it's a little bit of a trick question, but again, all of those answers are valid and viable. So let me see here. So based on that, so we know what his vital signs are. We know what his symptoms are. What kind of work up are we going to do for this person? So go ahead and put it in the question and answer feature for me. I apologize that our chat feature is not working, but if you utilize the question and answer feature, you can go ahead and let me just put it in there. So what kind of work up are we going to do? So go ahead and put your answers in the question and answer feature. I apologize that our chat is not working. So let me see what we have going. Well, X-ray, of course, we're definitely going to do chest X-ray. For sure, chest X-ray. Yes, tested for COVID-19. Yes, chest X-ray. Definitely EKG as well, right? He's pachycardic. So we want to see what his heart rhythm is. Definitely for sure. Yes, basic metabolic panel, blood work. Definitely CDC. Yes, complete blood counts. Yes. So you guys are all on the right track for sure. Okay. So let's see. I'm going to share my screen again. I'm going to go ahead and close down this question and answer. It looks like we're all on the right page and we're all moving in the right direction. So that's awesome.  Yes, clean medications. Yes. Yes. So all right. So let's take a look here. I'm going to share my screen again. We are going to go down to the actual outcomes. Okay, here we are. So we can see they did blood work. So we were again thinking you guys were all moving in the right direction. Your thinking was very valid and clear. And we see with this blood work his white blood cell count is 23.5. So that's elevated. An elevated white blood cell count is an indication for some type of infection. We see that his red blood cell count, his hemoglobin and his hematocrit are all very low. And I guess we would expect this in a patient with sickle cell.  They don't carry the hemoglobin protein the way they need to. So we would expect all of this. But again, you know, it's 7.3 a hemoglobin. A normal for a man is 13.2 to 16.6. So definitely, he's definitely very low. Also, I want to show you guys the chest X right this is his actual chest X right here. So this is the darker spaces or the lungs.  So he has some patchy infiltrates as in his lungs and that's usually indicative of a pneumonia, beginning of pneumonia, which is an infection in the lungs. So you guys were all thinking in the right direction. So yes, pneumonia definitely has pneumonia. No, he has some definite anemia. His hemoglobin is low. All right, so let's take a look at what the different differential diagnosis is for this patient. So of course, sickle cell crisis, sickle cell pain, we know that, and then acute chest syndrome. So this is kind of a new one acute chest syndrome. It's not very common. But they did again in the emergency room, the lab evaluation blood work and the chest X, right, which we've already talked about. So this brings me to our second poll that so I'm going to stop sharing my screen. Let's see. So what do you think causes acute chest syndrome. What is causing his acute chest syndrome in this patient. Go ahead and answer here in this cool as my attack yet pneumonia. Plural pleural fusion pulmonary embolism asthma is all thinking appropriately. So we have almost everybody is answered 80% participants have answered I'm just going to wait a few more minutes guys go ahead and answer the second full question for me what causes acute chest syndrome. All right, so it looks like everybody is going to answer has so I'm going to end our poll here. And I'm going to share the results with you. Also pneumonia went out pulmonary embolism was very close plural fusion asthma attack. So let me. And that was a little bit of a trick question because several of those things could cause acute chest syndrome but acute chest syndrome is not a normal thing it's not something that we see in the emergency room all the time so I'm going to go back to the PowerPoint because I want to show share some information with you. So here, what is acute chest syndrome and sickle cell disease so acute chest syndrome is a complication of sickle cell disease. And it involves chest pain, cough fever, low oxygen levels, and abnormal substances accumulating in the left so these lung infiltrates and we did see that on the chest x ray that this patient did have this patchy white infiltrates in his lungs indicative of a beginning of pneumonia. And he definitely has the chest pain he has the coffee has the fever and he has the low oxygen levels so what's what's problematic about this is that this condition can progress quickly and it is also one of the most common causes of hospitalization and death and people with sickle cell disease. All right, so I'm going to stop sharing my screen I want to go back to our video to share some information there with you. All right, so let's take a look at the diagnosis. So, yes, so we, so we were right so we were all thinking in the right direction this is like a journey we're all taking the journey together and we're getting there so he was actually diagnosed with acute chest syndrome and at sickle cell crisis.  Because I am going to put a question here for you all on the question and answer feature. So, how are. So how are we going to treat this patient huh. Knowing his vital signs knowing his lab work knowing his chest x ray and what his diagnosis is so what how are we going to treat him are we going to get him better. So go ahead and pop your answers and not a shouldn't answer feature. So, I think we need to get the fluids antibiotics of course antibiotics we definitely need that for the pneumonia that's for short ID fluids definitely. You know he's probably dehydrated that could be why he's tachycardic again. You know if you have a patient that is tachycardic they could be. They could be dehydrated so ID fluids, definitely antibiotics definitely. Now, so iron medication so I wouldn't say so much iron medication he's going to need something much more strong than that he's going to need a blood transfusion or probably a couple of blood transfusions to get that hemoglobin in his red blood cells up, but definitely supplemental oxygen for sure so we are all I like the way you think you're all. Moving in the right direction so. I'll be in a role, you know anything to help support his respiratory system, definitely. Right I like the way you guys think blood transfusion. Awesome, because I should do that out of the way of my face. All right. So I'm going to stop sharing.  Okay, so let's see here. So what is causing the chest and so we want to know what causes acute chest syndrome so bone marrow necrosis fat embolism infection. So these are the things that people that have sickle cell disease, this is some of the things that can cause their acute chest syndrome in our patient here. And most likely that this infection and so it seems like he probably had some type of viral respiratory infection that then developed into a pneumonia that then caused, you know, his acute chest syndrome. It could have been a bacterial pneumonia as well that we don't really know for sure most nine times out of 10 it's viral. But it's the one ammonia he's still going to be treated with IV antibiotics so that's what happened to our patient but here is a very interesting image so this is the death spiral of acute chest syndrome and sickle cell disease so you can see why this condition is so dangerous and for our patients that have sickle cell disease. So, you know, it could start our patient could start here, it could start here he could start here here. It looks like our patient probably started right here so he had a viral pneumonia or bacterial pneumonia. It started to cause some hypoxia. So hypoxia is low oxygen saturation in the blood. So you can see hypoxia further promotes red with the red blood cells to sickle. So, because he had the low oxygen levels, it's making his already condition worse by settling those red blood cells so he starts here then he goes up here. And so the sickling occurs in the lungs it's it's because that's what he has his sickle cell disease so that's already going to happen and it's a parent it's impairing his pulmonary micro micro vasculature. So then he moves over here. So now he has hypoxia he has this further sickling of the red blood cells and his pulmonary it might be vasculature. So his, his worsening pulmonary function so his lung function is worsening. Then he drops down here. So that because he is worsening pulmonary function, his desaturization of his systemic blood is getting worse. Makes sense right because that's happening and he goes back over here so it makes him more hypoxic. So he's in he's like almost stuck in this spiral of acute chest syndrome and sickle cell disease so it's a very serious condition that needs to be treated very quickly and aggressively. So I'm going to stop sharing I want to go back to our video and show you the actual outcomes for this patient. So yes he was treated with oxygen fluids early on a biotics blood transfusions nebulizers of uterine definitely admission to the hospital. For sure. And then let's take a look at some of the standards of care, because I want to show you all that you were thinking appropriately. They're in your medical minds. I love it that your suggests to work up of labs and imaging was awesome and correct and of course, we talked about to suggest the treatment of what he needed. Moving on to some of these key points so what we need to know is that this patient had a prior history of sickle cell disease. He also had a serious condition called asthma on top of that so this patient was already so predisposal predisposals to the acute chest syndrome being that he had sickle cell disease also has a history of asthma so he's already not breathing well. He presented with the pain that he stated was typical typical for sickle cell disease most most patients that have sickle cell have chronic pain. That's very common for them. But the issue was that he had the fever that he had the low oxygen saturation that he had his bronchorus breath sounds in his lungs. And he had those patchy infiltrates on his chest X right. So they immediately treated him with oxygen with fluids with broad spectrum antibiotics for pneumonia. Broad spectrum because at that point in the are they probably weren't very sure, you know, what bacteria was causing the pneumonia so you know that usually can take a couple of days to come back to see what you know they would probably ask the sputum culture to see what antibiotics are sensitive to whatever strain of bacteria that is so that's why in the beginning they treat with a broad broad spectrum antibiotic. And of course transuse blood for sure, for that low hemoglobin. And again as I said that accused chest syndrome is an emergency has a very high mortality rates. If it's not treated aggressively and very quickly. You can see some of these editors notes here. And he did this patient did look, you know, ill, of course. He did seem very short of breath. And so, I wanted to see. And so as we said they need to be, you know admitted to the hospital for pain control oxygen IV fluids, and, and until he is well enough to go home. Right. So that ends our. Stop sharing here. All right, so that ends. I see questions. There are lots of questions. All right, so this ends our, my presentation so now I want to start with the questions and answers, and I apologize if you are. Again that the chat feature is not working so I'm just going to type here and use utilize the question answer feature for any questions that you have about this. Again, I just want to thank you all for joining us. I really love these webinars that we're all doing here. I think they're fun and they're very informative for sure. So any questions about this case. So I see one here coming from Valerie so if given a blood transfusion. Does transfused blood cells become sickled as well. Yes, they do. Once they are in the body so. You know, something with that trait that it is with sickle cell that even though he's getting transfused healthy red blood cells once they're in his system that trait is going to sickle some of those red blood cells as well unfortunately. Okay, so let me see any other questions. Okay. Pull this over here. Could you show the x-ray for a quick second please. Yes, definitely. Let me just answer this one other question. How do you ensure you do not misdiagnosis the patient had co morbidities. That's a really good question. I think that's something that's always on, you know, a provider's mind nurse practitioner physicians assistant adopter and they're the ones that are making the diagnosis so you have to just rely on what the patient's what their underlying health conditions are and what what your clinical experience is so. Yes, he had asthma, but based on the fact that he has a history of sickle cell disease based on the fact that he had pneumonia that was confirmed by the chest x-ray.  So let me just bring up this chest x-ray quickly. And so no, there is unfortunately no cure for sickle cell disease, unfortunately. Yes, a blood transfusion is the transfusion just to increase the oxygen. No, so the transfusion is also to increase the red blood cells that will also help with oxygen is like oxygen, getting oxygen to the different tissues in the body, but the blood transfusion is really just to help more with his red blood cell count to help with his energy levels that will help increase his energy level and it will help him get better, better overall so it's not just to increase oxygen levels. So let me just bear with me here a moment. I just want to pull off this chest x-ray because somebody wants to see it. It's an anonymous attendee. Hang on here just a moment. Try to move this out of the way. Let me go back up here. All right, so here is the chest x-ray. Let's see any other questions. Can you explain what is shown in the x-ray again? Okay, so here we have the lungs left side and the right side. And I'm sorry, this is the left and this is the right. I apologize for that. So what you can see here is the darker material like the darker spaces is healthy lung tissue. It's darker, but as you can see, starting in the darker black space, there's these small white patchy infiltrates and that is indicative of a beginning of a pneumonia. If that makes sense to you. So how different would the workup be if he was unaware that he had sickle cell disease? I mean, the workup probably wouldn't be much different. We're all, we know we're always going to do chest x-ray. Someone comes into the ER and they're like, I'm having chest pain. I have shortness of breath and they have a low oxygen level. Definitely going to do a chest x-ray. Definitely going to do blood work. So the workup wouldn't have been any different than if he had not had sickle cell disease. Is stem cell transplant also a possible cure? So there is no cure for sickle cell disease. So there again, there's no cure for sickle cell disease. A lot of these patients, you know, like I said, I have chronic pain. They're on chronic pain medications. They have to get frequent blood transfusions. And really just kind of support the treatment is really trying to just support their overall health. And so they most this, as you can see them, I didn't show you guys this, but he, this patient was on hydroxorrhea, which is a medication that patients that have sickle cell disease sometimes take. So, so there's medications involved with that as well. So how long does a person with sickle cell disease live? That's a good question. I know they definitely have a lower expectancy of life. Unfortunately, just because of all the complications that are involved with sickle cell disease, you know, you have this acute chest syndrome, you have, you know, multiple you're more susceptible to viral and bacterial infections you. I've had some patients of mine that had sickle cell disease that ended up, you know, losing a leg or losing an arm or, you know, having some amputations because of blood clotting.  And so there's, it kind of just takes a tumble. And so their, their health just continues to tumble. So, I don't know what the exact life expectancy is for patients with sickle cell disease but it's definitely lower than somebody who doesn't have it. Does the pneumonia make him more likely to be hospitalized in the future? Yes, absolutely. His sickle cell disease makes him more likely to be hospitalized in the future for sure. I don't know how does a person manage living with sickle cell disease. So, you know, it's just, again, trying to live as healthy and as clean as you possibly can. So no smoking, good nutritional support. Let me just take this off here. So we can see each other.  So you're really just trying to maintain your health and try to not get ill, basically. Well, you're welcome. Any other questions? So what age is sickle cell usually diagnosed? So sickle cell is usually usually diagnosed in children. So, you know, in so sense it's an inherited disease. So, if one parent is known to have or both parents are known to have it usually children, their children are then tested. So they are able to kind of get a jump and a handle on things before they start having symptoms. Yes, and sickle cell disease is hereditary for sure. Questions, let's see. Yes, so sickle cell disease is definitely something you are born with. It's hereditary. It is either, you know, you can get the gene from one parent or two parents. And so it's hereditary for sure. All right, so that looks like that's the end to our questions and answers. Again, I just want to thank you all for spending your evening here with us. I want to let you know if you, you know, are not already a current student here with advanced clinical training, we would love to have you. We are offering you a discount code for $200 off any one of our certification programs. And that discount code is webinar 2000. Let me just put it here. I'm sorry webinar 200. There it is. I'm going to just put it in there. There's your discount code. And again, it's $200 off any one of enrollment into any one of our certification programs. Let me see here. So the next webinar we're doing monthly webinars now. And I'm really excited about that I, I, we don't have the exact date set for our next webinar but it will be in November. And it will probably be one of our empty mentors or PA mentor that we also have at advanced clinical training as well presenting so we like to give everybody a little bit of variety so you can learn from all of us here and that's the best way to learn in my view so again webinar 200, go over to advanced clinical training and take a look at us and thank you so much for for joining. So like I said going to send out those one you get one hour of clinical shadowing experience certificate so that will be sent to the email that you use to sign up for this webinar within 24 hours to keep a lookout for that. Let me see there's some more questions. Yes, advanced clinical.org. So go over there and take a look at us. Take a look at our programs and, like I said there's the certified patient care tax certified medical assisting. We also have the certified pharmacy tech as well. Yes, we are recording this webinar and I will have to ask one of our directors, if there is access to this recording or not but thank you all so much for joining us, and I hope to see you all next month. All right. Goodbye everybody. Good night.


A heavy police presence has smothered central ulcers, effectively blocking a resumption of a weekly protest movement that the authorities had decided they can no longer tolerate, trying to store about 20 security force vehicles in the centre of the city, six police sitting inside one, as it stood by a cafe where people drank coffee and at tables outside, nearby police stood next to barriers closing off the side streets. One regular protester who gave only his first name Amaruche, for fear of reprisals after a wave of arrest, had initially said he planned to demonstrate as usual, but later on Friday he said he had not been able to.


I have an opportunity today to show you an example of a spinal cord that has just been removed from an autopsy case. This is a normal spinal cord. Let's review for a moment the spinal column on this model, which is a little bit twisted, but that's okay. Here is the posterior or dorsal surface with the spinous processes. So let me move this out of the way and show you the spinal cord. The main thing I want to stress to you is how small and how delicate the spinal cord is. Notice it's diameter. It's smaller than the diameter of my little finger. And if I come down here and make a cross section at the cervical region right here at the top of the cord, I can show you that this tissue is totally soft. It's as soft as a piece of gelatin. And so you can imagine if there was a subluxation. The subluxation is when the spinal column suddenly with trauma goes one way or another. And the disc or the bone can temporarily compress the green spinal cord that is within it. It just takes a moment to cause, you can imagine, a jerk on the cord and to leave a patient with paralysis. This is very, very soft tissue and very vulnerable. So let's examine the cord now. Let's look up close. I'm looking now at the posterior or dorsal surface. And I can see, and I hope you can, between the forceps are the dorsal or posterior columns with branches of the posterior spinal arteries running along the surface. And if I turn it over, I can see the anterior surface with its single spinal artery. This spinal artery is very important because it provides blood to the grey matter of the anterior horn to the cortical spinal tract as it descends in the cord and to the pain and temperature pathway. Whereas the posterior spinal artery, as you might imagine, supplies one or the other of the two dorsal columns carrying propriocepture. So damage to the anterior spinal artery are nothing more than hypoxia during a surgical intervention, let's say to replace a section of aorta, can leave this anterior spinal artery without enough oxygen or blood to supply the cord and the patient will remain without control of motor function below that level and with loss of pain and temperature traveling in the lateral regions. So now I'm going to open the dura for you. The arachnoid is adherent to the dura. So we're going to look down, as we have been, on to the pia or the peal surface. Down here, near the cauda equina, we can see the dorsal and the ventral roots. And I'll open the dural sac in just a moment. Here is a dorsal root ganglion on this side. Here is the stub of one on this side. Here is another one on this side. The dorsal and ventral roots are emerging here. Now we're looking at the cauda equina and the tip of the spinal cord. Here is the conus medularis. And here are the elongated dorsal and ventral roots. And you can see that they are running to emerge. Here would be at one spinal level, probably a lumbar. And here is another one here. If you zoom in close, you can see the roots. Here's one group of roots emerging. Up here is another group of roots emerging. And in between, you can see a thin membrane here, the denticulate ligament that anchors the cord laterally and separates anterior or ventral from posterior, which you can't see from this side of the spinal cord. It's good to point out that the cauda equina, these represent both dorsal and ventral roots. Therefore they are sensory and motor. They have emerged from the spinal cord and therefore are ensheathed in Schwann cells. These are peripheral nerves, so to speak. That is to say, if they were compressed or damaged, but not separated between proximal and distal end, they could regenerate. So damage to the cauda equina roots gives you the option or the possibility or the potential that these axons can regenerate down through the Schwann cell tubes that are left behind, whereas damage to the cord at this point with our knowledge is basically irreversible, but sometimes some of the pain and temperature fibers are spared along the edges.