So, we stopped with writing down what you wrote the Lagrangian in the last class. So, the Lagrangian was in terms of the spin orbital. So, these are the one particle operator of the Hamiltonian. So, we take all these integral of this one particle operator for each of these spin orbitals and sum them. So, I is 1 to n. Again, note that given an energy expression, we also told you how to get a spin integrated form, but to derive Hartree form, we are first going into the spin orbital which is very general. So, the spin integration we can again do later.  So, that is your Lagrangian. So, we have n square set of equations, sorry, just for correctness, I should put tilde everywhere. We have n square set of equations chi i tilde chi j tilde is delta ij and we have the Lagrange multiplier for each of them. So, Lagrange multiplier idea is that for every condition, you put one multiplier. So, if I have only one condition like I told f of x I want to optimize subject to g of x is 0, then your Lagrange L becomes simply f of x minus lambda times g of x because there is only one condition. Here actually it is not one condition because i and j are n, total i and j are n square in number. So, for each ij, I have one lambda ij. So, that is why it is a matrix. So, this is actually a matrix. I can write it as a matrix. It is n square in number. So, I have to now differentiate or I have to make this optimum or stationary with respect to chi i tilde as well as lambda ij. But of course, the derivative with respect to lambda ij is trivial because we all know that we will get back this equation and that is the reason the Lagrange multiplier is put like this. So, when I differentiate, so automatically if I differentiate del L, del lambda, any one kL let us say, the result will simply be chi k tilde chi j tilde minus delta kL equal to 0. So, that automatically gives me the orthonormality equation. So, let us say that I differentiate. I hope all of you are comfortable in this algebra. I am differentiating because I want to make this stationary and in particular of course, I want to make it minimum because of variation principle. So, the first condition is that make the first derivative equal to 0. So, if I do the first derivative with respect to a specific index of kL, this kL is a specific index. This was ij of the dummy index. So, I am going to do for all kL however, but one at a time, one set of indices at a time. So, let us say I take lambda kL. Then if you differentiate this, this part will not contribute because there is no lambda here. This is a partial derivative. So, only this part will contribute and I hope you know how to write this because this is a dummy index ij. So, only when i becomes equal to k and j becomes equal to l, this derivative will survive. Otherwise, it is again all the others are partial derivatives and in that case your i will become k, j will become l. So, you get this. So, for all kL, I can write down this equation. So, essentially I am not getting any new information. I am just ensuring that my conditions of orthonormality are satisfied. So, really this equation is of no consequence to us because that is something that I know in my mind that they will be orthonormal. What is important is of course the next set of equation which are basically the first derivative. So, then the next ones are any particular chi i, let us say chi k equal to 0 chi k at in day for all k. So, that will be my set of equations and we will actually like to see what we get out of this. So, this is the important equation. So, chi i chi k at in day whatever chi k at in day means. Now, before we start doing this, let me write the first derivative in a somewhat different manner which is easy. So, I hope all of you know this interpretation. Let us say I have f of x and I want to calculate df dx. So, this is my job of course in this case I do not write df because it is only one variable. So, how do you write this? There are many ways of looking at first derivative. Of course, if you have given analytic function you can directly differentiate. In this case such is not the case. So, one way to look at it is a following that as you change x to x plus delta x, some infinitesimal quantity, then f of x changes. So, the change of f of x to the first order I will define what is first order. First order is essentially the order of delta to the first order is divided by delta x is equal to dy. Change in first order. Now, this is very I think this is just a question for those who are mathematically well oriented they would anyway appreciate but for those who are not I will again repeat this. So, I make a change of the variable from the variable which I am optimizing to an infinitesimal delta x. Because of this there will be a change in f of x in general f of x will change to all orders of delta not just for the first order. I am only going to take the first order change and then divide by delta x I will get divided by delta x. Actually you can quite easily see let us say f of x in x square I am doing very elementary algebra now let us say f of x equal to x square. So, you know of course dy dx that is 2x I am going to find it out. So, how do I find it? I make x to x plus delta x. So, what is the total f of x? Nu f of x. So, nu f of x plus delta x is x plus delta x whole square you all agree. So, that is the new function. However, this function has first order x square this is of course no order 2x delta x plus delta x square. So, what is the change in this function? The function was originally x square the change is 2x delta x plus delta x. Out of this this is second order. So, I will not consider this. So, my first order change is only 2x delta x. Now divide by delta x you get 2x that is something that you already know divide x. For every derivative you can always find the derivative in this manner. I hope if you have done good calculus this is what they teach you and that is the reason we write y plus delta y. So, let me also relate that the derivative formula y of x plus delta x minus y of x divided by delta x limit delta x. Now, can somebody tell me how these and these are identical? Note that when I am writing this I am not taking it first order. I am taking it all. I am saying if you take first order and divide by delta x. Yes, this part ensures that all the second order onwards terms are gone because I am going to differentiate I am going to divide by delta x. So, the first order will not go. First order all of you know how to take the limit. It will be a 0 by 0 problem but actually divide by delta x. So, what remains is 2x. Second order onwards when I divide by delta x 1 order of delta x will remain all that will become 0. So, this is why I am trying to tell you. This is one way of looking at the derivative. This is what we have taught but delta x tends to 0 limit essentially means that we do not need not consider the change of f of x plus delta x from second order onwards. Because second order onwards I divide by only one order of delta x. So, one order will at least remain and they will all become 0. So, this is a different way of putting. This is how in the calculus in this book. So, I just wanted to show that this first order that I am taking is there is no error. I am taking only first order because eventually here I am not applying this delta x tends to 0 instead. Here I am taking a delta x and just taking up the first order. So, if you apply delta x tends to 0 then of course you do not have to care. So, you take all orders yx plus delta x automatically it will actually. So, both of these are identical. That is one thing that I wanted to show you and I exactly show you giving an example let us say x square that y this is identical that f of this delta x square will eventually get cancelled because it is of course not even there in my this thing. If you take it here then it would have become delta x and that would become 0. So, either way you get the same result. So, I am going to take this particular way of calculating the derivative. Now, since my derivative is going to become 0 essentially I do not need to bother divide by delta x. I hope you understand. I can only make the memory because I am eventually going to make


Welcome back to the channel everybody. Good to have you here. Good to be with you. Come with me. Let me show you something that's going on here. Walk with me through the shadows of the trees here. Upsetting. This is Upset OSG and me as well. Just look at this.   Massive massive holes here. Massive massive holes. The bird feeder which has turned into a everything feeder. Also producing a lot of traffic down here. And look at all these little huffy prints. Actually they're not even little. Those are actually good. Those are good size. I've pretty much had it with this beeswax y'all. This this hog. I can't tell if it's Gimpy or another bigger hog or if Gimpy has just grown and got over his limp. But here lately he has just been coming into the yard and destroying it. And just when the grass is really starting to grow the old Kentucky bluegrass that's been in the yard. I mean even up here what the heck. What the heck man. He's even been right up here in the top portion of the yard. It's not like I'm putting feet. I haven't even put corn out in the yard at all lately. It's just springtime I guess. Grubs are in the ground. He knows they're here. He's coming back in the same areas. He's even messed up my little retaining walls over here. I have had it. And I don't know how many videos of this hog just coming in and now just destroying the place. So we got to do something about it y'all. So anyway that saga continues over at the Lake Life family channel. If you have not subscribed yet go do it. Please just go subscribe to the family channel. That's me, OSG, Emmy and the creatures around the treehouse. Channel just needs to get to a hundred thousand subscribers and I know there's plenty of you out here watching the videos. Perfectly capable with your fingers right now you have the power to go make that a hundred thousand subscriber channel. Our comments are disabled over there and I can't communicate with YouTube through the Lake Life channel until it reaches a hundred thousand subscribers. They just won't even acknowledge that I exist over here. Not having comments takes away a ton of the fun in the channel. It takes away the ability for you to communicate with us and us to communicate back to you without just saying things on the camera. You know it's the point of YouTube and social media which brings me to my next agenda. I've been thinking about this for about the past year and it is just finally reached the point where I am ready. The channel is ready. I hope you are ready. I want to bring in an editor on this channel so that so far it's just been me and Stephanie editing all these videos and editing process it just it takes up a lot of my time. One of the things that it holds me back from is creating more content. A lot of times I'm already thinking of the next video idea and editing holds me up from being able to go do that and I've just got a lot of other stuff going on with with Gug and Bates and in Gug Squad and the other things we have going and that I I want to dedicate my time to so my time is full guys. It is full and I need your help. I've had a couple of inquiries in the past but I'm sending out the official word today. If you are interested in getting into this outdoor space being an editor where you're putting your spin, your creativity on my footage and working together on videos, on projects for both Lake Fork Guy Channel plus working with the Lake Life Channel and maybe some other projects. Maybe you already have quite a bit of experience and just looking maybe you're looking for something to edit in the outdoor space instead of you know working on something else. I don't know. I know there's a ton of you out there and I wanted to ask you guys first before I started looking at you know but just asking around for people and going on job sites and stuff like that I really don't want to do that. I'd rather get somebody that already kind of knows the content and already has a little bit of background on everything that we do. You don't have to be an editing whiz to apply for this position. When I started learning how to edit I didn't know anything. Actually when I became a camera guy I didn't know anything about operating a camera. The point was though that I had I had creativity and I had the eye. I had fished so much I've been in the outdoors. I knew what to look for and I knew what people would probably want to see. If you have that at least let me know. My email is down below. Please don't email me if you're not serious about it though. I want to make sure to go through everyone that is serious and give them a good look. So if you've got some links to some content leave it in the email where I can go view it. If you don't and you're still serious about it just let me know some of the reasons why and we're gonna we're gonna hire somebody. We're gonna hire somebody pretty soon but I wanted to let you know first because I love you. You've been here a while. You are creative. There's tons of you that are just very talented. I know this. That's why I wanted to let you know first. Now there's a lot of things I got to do today. First of all I need to get something to eat and I haven't had Chick-fil-A today so I'm probably gonna do that first. Chick-fil-A you make my day. I swear I'm not sponsored by them. I would love to own a franchise one of these days though. The first things I need to do today I've been painting to two for weeks but it's just dangle time and it's hard. It's hard to get away from the water and I need to finish this table. This is where my tools are gonna go and then I've got another one that I'm going to be building for tackle and I'm gonna take some of these finishing nails right here and attach this top. This is for any of y'all that are curious. 16 gauge inch and a half 38 millimeters if you're overseas. I've put two by sixes on here and I've got some cedar posts on here as well but I'm just going around the edges and attaching the top. I've got it positioned where I want it. This table is is pretty easy to make. I've just wood glued it, squared it up the best I can. It's not really square wood. You'll see how far this one goes in here. Do a little tester. I want it to go all the way through. Definitely did. There we go. Rock and roll with it. So even though this table isn't the most beautiful, it's designed to be functional but something I do want to do is just take a border of some darker wood. Maybe some black walnut or something like that. Go around the edges of this table just to give it a little better look and it's not too hard to do honestly. This was probably a hundred bucks of materials from Home Depot. Gonna have a bottom piece down here. Gonna do like a smaller MDF board. It's gonna go in here and then I'll be able to set tools inside of it. Still need to get one board to run across there and one for down here to make that happen but at least we've got the top secure. I don't have a planer joiner so everything is not perfectly in line. I've got some crookedness there but that's what the little dark piece of wood that's gonna go around this border is gonna be for so I can cover up a little bit of that. But that's basically what you can do with some four by fours and two by sixes and a little MDF board from Home Depot. Not too shabby. Guggen HQ. If you haven't subscribed to the Guggen channel, this is our new space. This is where we come and create things. We just wrapped up yesterday. Another good week and really our first week here at the warehouse. We gave away one of the boats. We have a couple of boats. If you sign up for the monthly t-shirts, we give a boat away or have done that for the last two years. This way we're giving away two. Had a nice really nice Aggie family come up here actually from San Antonio and they won the boat. Went home with that and right now we've got a bunch of toys in here. We got the silver bullet in here. Rob's boats in here. We get the free range truck. John's boat is here and then we have a lot of our furniture from the old house sitting over here in the corner. So focus for the space now. Is to basically make this a content creation center and involve all the great outdoor things that we love. So what I wanted to do today was just bring up my my archery target and my bow. Shoot it around a little bit. We'll probably end up doing a a full-time archery center in here or archery corner and then just kind of clean up a little bit. You know Guggen Week is a little crazy.  Luckily I'm close. I'm probably gonna be up here a lot. So you guys can see some behind-the-scenes stuff right here on my channel and we've got some of our back stock and Guggen Bates for the store. We've got organized. Rob actually inventoryed the whole entire thing. We are getting ready to do an opening, a grand opening of this place. I think it's in June 15th but it's gonna be in June. So if you want to see inside of the store and us building this place out all those videos are coming up soon on the Guggen Squad channel.  Not really sure why. Why I had all these balls. Why they ended up over here. Heads up Carl. Catch. Not so much. I have not touched these basketballs since the last basketball game we played. We actually did a sporting challenge yesterday and I injured my knee and that's why I'm not exercising my lower body today and I really need to. Y'all I'm leaving for New Zealand very soon. Another really nice thing about the warehouses. We can keep our gear here like the silver bullet and we can keep it clean.  I guess John left his rods in my in my boat. Looks like he's got some pretty serious danglers going on there. It's very fair to say it's been a bit disorganized up here since we've been moving in and this week was crazy because it was raining and hailing and we found out about some leaks that we didn't know were there. Eventually I'd like to have both my garage and the Guggen garage organized where we can come in here and if we're running out of lures or something that's like okay Bamedito Bugs natural. We've got a whole bin right here. You know crankbaits. Oh we got this. Oh we got all of our line right here all nice and organized. We even got coffee right in here. So when you're running low on that life gets pretty rough. So we've even got that. We've got some empty B-boxes in here. This is old like fall stuff you know this is gonna just get put by the wayside. Some good stuff in here though. Just wrapped up filming a little Instagram tip for you guys about spooling your line onto a spinning rail without getting any tangles. I'm just tying a little hook on here just in case the dangle is in the near future. And while I got it in my hand if you want to check out Guggen line just pulled up with some of the monofilament on a spinning rod and check it out at shopcarls.com. I'll leave the link down below but that line is available and it's good. It's affordable and I think you guys will enjoy using it. I need to get some more of these money bags because I realize these would be perfect for my hunt in New Zealand. These size and a little bit smaller to put camera gear, clothes, foods. These are really good for hunting as well. Maybe a little dense for for my mountain hunt but I'll probably use them anyway. It feels good that we actually have an office here now come up here work. We actually got our lead producer here right now Wes. He's working on some stuff.  Guggen campus. I love it. Just opened my live well and realized there's some still some minnows in there. Can't believe it. Thought I got all these minnows out. Took the other extra minnows that were in there put them in the fish tank that's in there fed them to Gary but I need to scoop these guys out somehow. Hopefully. Wow did I get all them on the first shot? That's pretty darn amazing. Okay Gary. Let's see what you got buddy. Actually the bluegills might get them too. Oh yep bluegills trying to get them. Yep. Yep. And oh oh yeah. Look at that bluegill. Voracious. Gary sees what's going on.  I don't think so. Look at the quiver. These other ones are smart staying on the herd. Gary has identified another one. Come on Gary. Come on Gary. Oh you kidding me? You gonna let that slide? Get in there. Get in there on that minnow. Okay well he's not gonna eat. As a side note the catfish is getting huge. That thing was like a finger length when we first put it in there. Power washers up. Actual washers still not put up. I put John B's rods up. Organized. A lot of our lures and such play things feel accomplished. Lead producer Mr. West Davis leaving for the day. Did you get some beautiful content created today? Absolutely. Always getting the goods. Say goodbye everybody. Mr. West. He's the mastermind. He's the one that makes us Gugans actually look good. If that's even possible but he's the man. I've never killed a turkey. Still on the quest and I'd love to kill one with my bow as well.  So it's nice we have this space where we can practice even in bad conditions. I was actually hunting a turkey. I think we're still okay folks. I actually felt really good right there pulling that bow back and I think it's due to just working out a little bit more preparing for this hunt.  Like he is not even picking up a gun in New Zealand until he gets one with a bow. That's our hardcore he is and we're talking like an average shot you know 150-300 yards usually. I can't wait to document his his experience with that. I'm kind of taking the cheaters way out. Not really a cheaters way but traditional hunting not using the bow just because I want to get it done. I've never done anything like this before. I want to make sure I get to enjoy the experience of harvesting an animal. But bow hunting mad respect for all bow hunters. My bow my stabilizer is actually a light so if I wanted to stay up and get old hoggy I could with this guy but I'd rather not have him squealing with an arrow in him running through the neighborhood. That's why you have that rock right there. Thank goodness for OSG. Yes. Did you hear me out? I did. You're never out here. You're always inside. By the way her daughter is right here. Well I picked me up a passenger over at LFD's. She's asleep now. She was so happy to have her bottle. This little bottle? Water bottle. Yeah she was happy to have it. The simplest joys. Luckily OSG she's never outside because she's always inside with Emmy and she was right here and originally I passed my rock. This is my rock right here that's how I know where to stop the boat and I went past the rock and I hit my hit my motor right here which I like having that there. You know number one it looks like a park like a park that I go to here in Texas and other states but it also is a nice little wooden deal right there for my prop to hit instead of these rocks. We got anything good for dinner tonight honey? We sure do. What do we got? Chicken enchiladas. Chicken enchiladas. Yes. Want to talk Matt? Alright y'all we're gonna shut it down right here. Thank you for coming along. Don't forget to email me if you wanted to be an editor at these vlogs. I'm doing fishing videos like I do the more intense you know longer form fishing videos. I put out a couple of those a week. Those are my faves. I do vlogs like this just kind of showing the day-to-day and then I've also got the family vlogs over at the Lake Life family channel stuff around here. So when we get an editor it'll probably change up a little bit but that's just kind of what we got for now. Hit the notifications on this channel subscribe but hit those little ding-dongs so you don't miss a single dangle and I just want to take a second to thank y'all because we just hit 700,000 subscribers on the LFG fishing channel y'all. That is amazing. When I started this channel I had no clue, no number. When I started this channel there wasn't even a whole lot of viewership on YouTube to begin with so just to have a consistent steady growth. It hasn't been the fastest growing channel. It hasn't had you know explosive growth or anything like that but I have to thank you guys because if it wasn't for you we wouldn't have this steady consistent growth right here and I'm not gonna change my ways I'm gonna keep keep doing what I'm doing and I love you guys I just want to say thank you for tuning in so go ahead and hit those ding-dongs tune in for every single video and I do hope to see you right back here on the next one hope you're having a blessed day and I will see you next time.


Aloha welcome to health care in Hawaii. I'm your host Josh Green senator from the Big Island as you can see I'm in my scrubs today and Also a worker in the ER. I'm welcoming a good friend today to our show. I'm Mr. Ken Zerry Who is the hospice Hawaii president been that for many years nurse for 33 years was on the national board of? Hospice nurses national hospice and palliative care organization board member also founding board member at Kukua Mal I am good to see you. Thanks Josh. Thanks for having me on boys for being here So we're gonna talk about a very very important issue which is hospice care today And we've entitled our show at your recommendation the myths of hospice care, right? Why don't you unpack that for me just a little bit Josh? I think that one of the phenomenon that we run into when we talk to folks about hospice It's actually all summed up in the most common complaint Which is why didn't I know about hospice sooner when you kind of unpack that to use your word you really do come into? Understanding that there are all sorts of barriers of emotional Misunderstanding barriers about people getting access to hospice sooner Yes, what we do know is that when you can have hospice in the last two or three months of life It can be almost miraculous and what we can hopefully try to achieve with that patient and their family And the beauty of it is it's generally covered a hundred percent. That's it's really important So as a part of the larger dialogue of health care, we know we have an aging population Right, we have people with severe chronic illness. We have people with very advanced cancers that lived a long time But at some point people have an option to go into hospice care. Does everyone go into hospice care? No, no actually Nationally between 45 and 50 percent of all Medicare beneficiaries Which is our largest biggest piece of data about half of all Medicare beneficiaries have hospice care in America About about 10 or 15 of percent of those are discharged alive. They graduate. They actually get a little better And here in Hawaii, we're at about a 45 to 47 48 percent probably at this point in time of all deaths That occur in the state have hospice care. That's amazing to me So that means a person has gotten very very ill and how do they qualify for hospice? How does how does a patient even contact you? Does it always have to go through their doctor or through their nurse? How do they get to you? So the the first simple question to ask is the question we like is would you be surprised? So Josh if you were making a referral for a patient to me and you said I don't know if this gentleman who's got a chronic debilitating Set of conditions. I don't know if he's eligible for hospice I might say well Josh would you be surprised if he was alive next spring because it's the fall right now, right? That's kind of a nice six-month window. Yes And if you would think about this person you think you know He's got heart disease and he's got kidney disease and he's got some some pulmonary issues Yeah, I don't really think he's gonna make it past the new year then we need to talk about hospice care for him Okay, so simply that kind of an initial screening is the first way to start now Anybody can make a referral to hospice Hawaii for hospice care Yes, and they just call our number at nine two four nine two five five It's you know Google hospice Hawaii right and you and you make that call Are you are you just on a wahoo or are you do you have affiliates? How does that work just so people know sure hospice Hawaii is one of nine providers and nine hospices in the state We serve the island of Oahu and then we also serve Moldakai for about 20 years Oh, that's right 15 years and about two years ago at the request of the folks at Pulama Lanai We began a hospice program on Lanai So we're really proud of those folks as well. That's see that's extraordinary. Now. Let me take a half step back a patient like you said has been referred for hospice assessment and It's because that they are felt by their provider To probably be somewhere near the last six months of life because that's the qualifying sure credential it seems now How do you then proceed you have an individual that's been referred to you? I say this individual is This wonderful person. They've got say bad cancer. They're very sick It's you know, it's a worry. Why even bother? Why can't I just take care of them as their primary care physician or send them a somewhat rhetorical question, of course Yeah, or send them to the hospital Down, you know in the last few months of their life. Why use hospice? Well Josh, so you're not going to be able to keep them in your ER, right? That's the truth of it right sure, I mean unless somebody is really in the last hours of life Yes, and frankly most people don't want to be in your ER. It's not about your ER They're smart Most people don't want to be in any hospital when they reach the end of their life Hospice care as a philosophy was created 4045 years ago to say how do we care for people in their last months of life in Their own homes as an alternative to being in the hospital Yes So when you make that call or when when an ER physician on a while who makes that call Then we'll go and see that patient and we'll look and see what's going on with that individual So while we use the general term, would you be surprised we actually have some specific guidelines from Medicare that we have to follow And it's we have to demonstrate that there's a medical necessity for hospice care So we know how to look at conditions in the individual. So for instance As a health care provider, I would say How many of their activities of daily living do they need assistance in right the ability to bathe yourself the ability to Feed yourself the ability to make your own meals and if they need help in two or three of those Then are that's a sign that this person is kind of debilitated. We also look and see Have they lost weight? Do they have progressive infections? Are they going in and out of the ER a lot? Those kind of some of the criteria that we look at to say is this person going to be medically eligible for hospice care? Yes, certainly with a cancer patient. We might say well, what's the progression of their cancer? But with the cardiac patient, we might say what's the functionality of their heart? So our medical director in concert with you in collaboration with you it's gonna as their PCP, right? It's gonna say yeah, we think that this person has got about six months or less to live And we're gonna do that. That's our job at hospice Hawaii to make sure that we we demonstrate that Yes a question about why can't you just take care of them in the clinic or why can't they go to the hospital? So you know as well as I do that hospitals don't have the space for this They hospitals need to have those beds moving for people that are really sick And if you've got somebody that's had an immediate heart attack you want that hospital bed for them and the person who? So has got just heart disease and Needs a lot of help doesn't really necessarily need to be in the hospital and frankly It's not the best place to be right and you can't go to their homes Yeah, well that was that was where I was kind of headed so hospice is you use the word philosophy Which I really liked a lot where it's a philosophy about getting people more comfort more care that they need While in concert with being in the last six months of life based on the best expectation that an assessment can do my uncle died at home and home hospice hospice care in Philadelphia some places have hospice centers right their facilities could you distinguish a little bit about what you do and what's done in Hawaii so Hospice when it was designed was really designed to be care-based at home Actually, the the principles of hospice came over from England and it married up with our visiting nurse associations in America And hospice became a home care-based model of care So primarily what we're doing is we're sending a team of professionals to that patient's home to help that family care for them Yes in Hawaii We see care for hospice being done in patients own homes We see it done in nursing homes that so hospice Hawaii has a couple dozen nursing home contract partners Yes, so we can go to the nursing home and provide care to that because that's a place of residence for that individual right We see care being done in some foster homes and care homes Wow, and then we do have a couple of inpatient units in Hawaii that we call them hospice inpatient units Or hospice residential units hospice Hawaii has our Kailua home Which is kind of in just one of the neighborhoods in Kailua. It's been there for 20 years five bed You just walk in and it's such a place of powerful spirit. It's just the mana is terrific there And we care for people in the last months of life around the clock with our nursing staff in our Kailua home That's it's really exceptional. Okay, so I'm gathering And I've experienced some hospice care because I over the years on occasion I was asked to be supportive as a doc for patients Especially when I was a primary care physician that we're very near the end of life and helping with orders a patient Is felt to be in need right they get referred to you and they get accepted into your program in this case You've done the assessment at home then what happens next do they suddenly get I'll toss out a couple myths or questions here. They suddenly get a lot of medications to make them comfortable. Is is it meant to? Help them to the end of life. Is it meant to make them comfortable? What's really the approach that that happens at the clinical the clinical level sure So the first thing that will happen is we'll ask the patient and families to sign consents and to To sign paperwork that says Medicare can pay us because we're gonna get paid by Medicare HSA Kaiser Right medicaid so that that's what covers it then the clinical team the doctor the nurses the social workers are going to Assess this patient completely and say ask a simple question What does this family need to be successful in taking care of their loved one in their own home? Free of pain and suffering as best we can do Yes Surrounded by the loved ones that are coping well and really to to live out the rest of their life in a way that reflects their values We've been doing this thing called their bucket list. Yes, right to say how do they do the things that are important in whatever time? They have left be it a horseback riding or going to the ocean one more time So we we simply ask that question Where is it that there's distress and how can we ease that and where is it that there's opportunity for? Bringing life to a closure And closure not meaning how do we help them die rather? How do we help them live as fully as they can? Yeah, it's great work Josh It really does seem so and you know I've seen a lot of people over the years in the hospital setting where they have told me Doc, please make sure I get home to die at home or please You know, they're very afraid. Please make sure I don't suffer and it sounds like Hospice at least your philosophy of hospice Is it perfect melding of those two? Some people have said If I get put on hospice care, is it to time the time to give up hope? Is that is that an appropriate thing? I don't sound like it from what you're saying It sounds like the opposite. It is kind of a renewed hopes. It is actually it's our mission We have a very simple mission which resonates very powerfully for us. Our mission is to bring hope Yes to reduce fears and to impact lives So hope can be anything as simple as I do want to go to the ocean one more time and see the ocean I want to go to one more roundup over on Molokai Hope can be that I want to have a night where I can sleep the whole night free of pain Yeah, hope can be whatever that person wants it to be see my grandson one more time Reducing of fears is a real important part of what we do I teach our staff that our job is to essentially walk through the Valley of the shadow of death and to shine a Light in the dark places because we have walked that walk so many times So how do I with my experience shine a light so that then you're not afraid? Because we know what we can anticipate and we can really ease that distress sure and then finally when we're able to See help this family care for the loved one at home even as even though it's difficult and hard to do They always remember I kept my promise to dad I kept dad at home and we we took care of many knew that we loved him even in his last seconds of life Yeah, that's our mission. That's very very special I think a lot of the uncertainty for people is the biggest concern that they have Not just when they're sick Because people sometimes need professional help to say how sick am I can I come out of this? What support do I need but also like you said those dark corners of the matter where you just don't know Will I suffer greatly? Yeah at the end will I have access to a nurse will I have access to? a doc or Physician assistant or whomever the right fit is for the for the time And you're able to explain those things. Is that part of the initial assessment? That's all of it It's and it's an ongoing part of how we relate to this family the The the team assesses what the needs of the patient and family are we work to the family to help them address those needs And then we recognize that as time progresses those needs change and they go back and forth That's okay. We've got nurses that are on call 24 7 Right so in the middle of the night a family can call because they have a question about pain Or they can call because someone has died in the middle of night and we're gonna send a nurse to that home Yeah, to ease that family's distress and to do the things that we need to do sure It's not you know, I you've mentioned so many things that I'd like to talk about But I should point out one of them is how valuable what you offer as a service is because many many many times I think people Because of uncertainty, and it's normal and it's reasonable. Don't know should I be going to the emergency room? Should I be in the hospital? Should I be calling my doctor or nurse? Should I be? is this normal and Too often I would say people end up in the emergency department when they don't number one want to be there to When the wait could be quite long and three when they're really gonna get better care And that is something to emphasize better care because it's personalized care It's care that people are familiar with If they're in hospice and we can probably deliver most of the care That's really needed for that individual in their own home with our doctors and our nurses and our AP RNs on call Then they can get in the ER you can do a good job in the ER But we can do it in their home and then they don't have to endure the drive or the ride because that's a big burden My mom had hospice care and the doctor said to mom when she began to care a couple years ago Was we want to have hospice so that you don't have to worry about needing to come back in the hospital And mom did not have to go to the hospital She had mainland did not have to worry about going back in the hospital And that's a promise that we really try to keep now sometimes patients do and that's okay Well, we'll follow them. Well, we'll see how they're doing and we'll get them back home as fast as we can Yes, because there really is no place like home. I hear you. Well, that's I think that's kind of a Perfect place for us to pause. We're about halfway through our program but we're tackling the myths of hospice care as Ken's area who's our expert today on the show says there's no place like home Hospice care is available to people in the state of Hawaii to ease their suffering to ease their concerns and really to give them Hope in the final stages of life. We'll be back in a moment Hello, this is Martin to Spain. I want to get you get excited I'm about to say For Hawaii and beyond we're gonna broadcast on Tuesdays 5 p.m. Here on think tech Hawaii For global connections, you can find me here live every Thursday at 1 p.m We'll be talking to people around the islands or visiting the islands who are connected in various aspects of global affairs So please tune in and aloha and thanks for watching Aloha, my name is Danelia D. A. N. E. L. I. A. And I'm the other half of the duo John Newman welcome we are co-hosts of a Show called keys to success which is live on the think tech live network series weekly on Thursdays at 11 a.m We're looking forward to seeing you then Aloha Aloha, welcome back to health care in Hawaii I'm your host Josh Green senator from the big Island Conan Kau and ER physician today. I'm joined by Ken Zerry who's an excellent guy I really like him very much He laughs, but he is doing just really blessed work. He is a leader here in hospice care He's the president of hospice Hawaii has been a nurse professional for many years And in our first segment was able to explain kind of what hospice care is we've discussed some of the myths about hospice It is a place that you get care usually in your home. It is something that can restore hope It's meant for people toward the end of life in the last six months of life And we're gonna unpack that a little bit more as well but Ken said many things about what hospice is and One of the things it is is a way to alleviate fear and suffering Yeah, some of the other myths here hospice is only for the last days of life So that indeed is a myth hospice was designed to be for the last six months of life And and it's about a 40 44 year old Way of delivering care in America that think the Medicare Hospice benefit. It's about 40 years old. I'm sorry. It's about 35 years old Yes, and and it's never been designed for the last days of life The reality of it is is that we can't do the great things in three days, right? Unfortunately though, Josh what we see is that 25% of our patients die in the first seven days 30% of our patients die in the first 10 days. Is that because they get you too late because we didn't get them into the system? because people are afraid of hospice sometimes hospice means I'm giving up or It used to be that physicians would tell patients old days would say there's nothing more I can do for you.  We still struggle with that here and on the mainland Yeah, I see that a lot. I you know, I've referred many individuals to hospice care and for full disclosure Probably I don't know probably to your hospice although. I'm on the neighbor islands as a clinician, but I've seen a lot of people Come into the ER several times even though they have a like usually it's a severe lung or heart problem or cancer and I finally mentioned to them, you know, there is this service called hospice care where I think you might get better care at home Not that you can't still come in if if God forbid it's you know, you're very scared or we need to give even more services I don't know what they might be but even more services than hospice might offer at that moment and they didn't know about it right and Then they realize oh, I'm gonna have a home care team a team, you know, and that's incredible You had mentioned some people worry that they can't keep their own doctor when they go into hospice. Is that a myth? It's a myth. Okay, so we we do want people to keep their own physician So if you were a primary care physician for a patient and you've been there PCP for 10 years, right? You may have a relationship with them that you want to sustain You want to be able to be a part of this part of the reason you got into medicine was to care for people Even in the midst of their dying and so we want to work with you in much the way that you want to Some physicians really prefer to hand it off to the experts at hospice and palliative care at hospice Hawaii To just say once you handle this and let us know what I can do Others say you know what I want to stay engaged and it's our job to ask that physician How do you want to be engaged right and they and they know them very well? I remember I'll tell you this kind of funny story. I was in Ka'u on big Island providing hospice care for a patient of mine very very sweet guy who had came to me With an advanced lung cancer and he was not that old he was in his late 60s he had been a Worker in the nuclear field checking warheads actually and He had PhD his wife had a PhD and they lived in the very rural parts of the state He knew he was gonna die and I would through hospice be able to get extra services to him Right and get him medicines at home and get him oxygen at home And I just remember when this guy Right before he died he his wife made a lasagna dinner for me and the local Catholic priest actually who used to come and hang out socially and he said green. I'm dying and He was very appreciative of the hospice care and he didn't want to go into the hospital And you know, he was happy that he was able to live out his final Period of time I think he was in for about two and a half three months before he passed and he said there's a present for you in your car Don't shoot yourself and I said well, what do you do it? Turns out he had given he was thankful for the home service and he put a Kayak had his wife who was this little short person I put the kayak on my Jeep and a spear gun and He gave that to me, which I then nothing re-gifted to some nurses on my team Who are just wonderful people but the sense of comfort that he had the sense of being able to live at home To the end of his days in his own bed. Yeah, these are the kind of things you seem to be offering Everybody that needs it. Yeah, Josh So as a physician involved in the care you can say I want him to have these pain medications and I and he needs this medical equipment in the home and he needs oxygen in the home and All of those kind of typical barriers that exist to getting stuff in the home Yes, they just dissolve when hospice is in the way. I'm sorry when hospice is involved, right? We get those out of the way so we we don't need qualifying Oxygen saturations to get oxygen. We say is there distress is the short of breath great get the oxygen out there? Yes, that's simple. So we're able to to put those medications We use we use local pharmacy service that delivers medications And so first of all we're going to pay for that pain medicine. Yes So that pain medicine is costing four thousand dollars a week because it's a very expensive infusion We'll pay for it and there's no cost to the patient and family We'll do what we need to do to keep them at home and comfortable I wanted to ask you about that because it um, we've established very Clearly that hospice is a civilized and compassionate way to provide care that I I like that that I feel strongly about But then we go into these other questions You've described and I've described a lot of services that people might think. Hey, is that expensive? Is that how does that get afforded by a patient? How does the health care system afford that? I mean I've on the show many times had health economists insurers and so on We always seem to be talking about how expensive health care is how is it that you or I Can be providing so much service at home to an individual who is really ill possibly Um without the worry about cost. What is the mechanism? Well, um, so as a president I always worry about the money, but as a nonprofit, we're very generously supported by our community So that the community essentially says to me you don't worry about this. You just provide the care And I love being that kind of a relationship with our community. Yeah Medicare pays a daily amount of money. It's about an average of $195 More or less on a while who it's about that a little bit less on the neighbor islands So we have to make that work So even on the days that we don't see the patient we're still being paid And it's kind of a whole risk model for us So we may have a patient that their care costs thousands and thousands of dollars a week And we may have a patient whose care costs, you know a couple hundred dollars a week We lump it all together and we make it work. Yes I'm really happy to say we've never had to say no to somebody who didn't have insurance and couldn't pay for it That's the beauty of being a local not-for-profit. Yes So for the family though, there's no Payment for this. There's no co-pay for this. They don't have to pay this, right? You know the question is why does it work because this is how I grew up in the world of hospice This is the only reimbursement model we ever had so it works because we make it work You know, it's we know how to live within our our means in general So we do it seems like it also is a very important adjunct to the hospital based healthcare system Again, I on the show I've talked about how we don't have sometimes enough hospital beds or we don't have enough providers in the hospital Or people getting readmitted to the hospital. That's a very big issue now for Medicare, right? And it seems like hospice Care by providing care at home rather than an individual going to the hospital and all due respect to my hospital friends Who I love. I mean they do great work at Queens and Straub and HHSC But it's very expensive to spend a day in the hospital Especially if you have significant health needs could be five six seven thousand or more dollars a day This is way less Is there some kind of balance that's been struck so that some of those resources that are getting saved rather than Having someone number one didn't want to be at the hospital because they were afraid and chose not to be but two You know, if someone who is otherwise sick 85 year olds got bad cancer spends their last month in the hospital that bill could be Hundreds of thousands of dollars hundreds of thousands. So are we saving money as a health care system? By having services like hospice. We are indeed so study after study has demonstrated that for And these have been studies that have been done by Duke University, right? That says that for the last three months of care Yes, that if the patient has hospice and they're compared to the patient who does not have hospice Then on average Medicare saves 2,900 Change interesting on that individual. So when you look at a million, uh, 1.5 million people Having hospice care Do the math fast billions of dollars are saved. It's over a billion bucks every year at least Yeah, that would be three billion right there, right? Yeah, because we're able to to save that money Now there is a trade-off Um, when you have your loved one in the hospital, then there's nurses around the clock caring for that person When your loved one is at home, you're doing the work as a family member most of the time A hospice team Intermittently visits so the the nurse might visit once or twice a week the nurses aid might visit two three four five times a week But most of the time you're caring for your loved one. So that's the trade-off Yes, and we're going to support you and teach you how to do it Right and and then from time to time if we have somebody who can't do it Then we can bring them into our kailua home, right and we have a copay there. It's more expensive But we also do a lot of charity care there as well. Sure. Yeah, I mean, I think that It is a different system. No doubt. It is but Again, this is just one person's perspective who I'll be very honest. I think that that hospice care is extraordinarily important and valuable to to people and to our state Um, when you go into the hospital There's lots of chaos in mayhem and there's Flashing lights and there's beeps and there's buzzers and it sometimes even drives me baddie in the er And I think that when people are headed towards the end of life There is a special value of tranquility And that's at least it occurs to me that that's what you're offering. So I'm laughing because frankly In my family when when you would come into our family's household There's lots of chaos, but it's it's laughter and love and teasing and and honest expressions of fear and loss And and what you really do see in hospice care is that when you go into home Hopefully the family is living the way they've always lived even in the midst of this love one dying Yes, I've been to to homes where I did a death call as a patient had died I went to their home and it was one of those towers out in Hawaii Kai area right and and I way up to the top of the tower and the trade winds are coming through And there was beautiful jazz music playing and it was such a peaceful and tranquil time that this person had their transition from Life to death in that place and I've been to places where it has been wailing and gnashing of teeth And this is perfect for that family as well And so you get to see Life in its reality at that sacred sacred time and that's what we try to help families achieve Yeah, and you're achieving it in a more natural setting because whatever their home setting is It's their natural setting and frankly the hospital is always A comparatively unnatural setting foreign territory unless you're working there all the time right and Even me I feel more comfortable at home right where the kids are going to be and the dog's going to be on the bed Right or the cat's going to be saying I'm hungry feed me, right? Yeah, that's life I I think you're absolutely on it. So we have only a few minutes left in our show You've touched on many of the myths Hospice care is it for any age or is it just for the elderly hospice care is for any age We have a the state's kind of only formal pediatric hospice program where we can admit Children as young as newborns And as old as 105 years old and everything in between if God forbid a young one's going then they also could get supported home Choosing hospice means giving up all medical treatment. Obviously No, we change the focus of your medical treatment Yes, and it's not just for the end of your last days of life because some people Even graduate from hospice. That's a good thing The bad part about graduating from hospice is all those wonderful wraparound services We have to pull them back So we work hard to to be careful about that and to and to plan it right To to make sure that that transition is smooth and when we need to bring them back on we can indeed Okay, so if I were going to sum up can An important service here in the state of hawaii and in all states hospice care You guys provide it if anybody ever has any questions they call you where hospice hawaii is 924 9255 or hospice hawaii dot Org Okay, and I know we've got many viewers and listeners across the state on the neighbor islands If you call hospice hawaii and you happen to be living in hilo or kona or elsewhere We'll get you in touch. Ken will get you there to the local group. I've been very honored today to have mr. kenzari He's a hospice executive. He runs hospice hawaii has for many years He's on the critical boards across the country and he knows what's happening in this discipline If your family member is suffering or if someone is in need of extra services Toward the end of life. This is a great service to avail yourself of it's a civilized and humane way to get health care So thanks for sharing today. Thanks, josh. The pleasure to be here. You bet


Hello friends welcome back to another video here on the channel. I hope you're all doing great for anyone new to the channel My name is Lee also known as Osiris and in today's video We're gonna be discussing a lot of issues some of you've been having with the duplication glitch the cloning glitch There's been going around going crazy at the minute everyone trying it and a lot of you have been having problems with it either That by having a bad egg that you can't get rid of Having a black screen having game freezes and a lot of issues along the way that I'm making it Not as enjoyable a glitch to kind of me may be doing as it should be So in this video because we have put a video up already about the cloning glitch we're gonna just discuss all of the issues and show you some other methods and Ways to go about this cloning glitch so you don't get any issues going forward So let's hop into game what we want to do is just show you how to avoid the black screen in the first place So what we want to do is have a couple of Pokemon in our party We've got obviously the Cresselia there with the master ball or something that we're gonna be and cloning and we've got kind of just a Pokemon that we don't the the sacrifice Pokemon that we won't be getting rid of because to do this We're gonna need at least another Pokemon in our party So I'm gonna set the glitch up go into the check summary of the Pokemon and we want to be hitting remember It is Z R Z L Z R and a all at the same time So hit those three buttons at the same time and I should set up the glitch So when you exit out of here You get this menu overlay over everything else So you want to just hit be hit be hit be hit be and then you're here in the other world Don't hit be on this or it'll deactivate the glitch Okay, so you can see that we can run around if you've been doing this glitch already you'll know about it what we want to do is go into the battle and The issue that people have been having with the black screen is hitting into the Pokemon boxes Before the battle is loaded so on that white screen or before it being hitting into it Let's say we'll move Cresselia and then we'll come out of here You see we're still in the battle there and then we'll run we'll run. Okay. Oh No, we've got the black screen of death the black screen of death here. It is and people have been experiencing this all the time all the time and it is an issue but it is because You're going into the The you're going into the boxes too quickly What you need to do is wait for that white screen to disappear from the battle You need the battle to actually load completely that white screen to go away And then you can access the boxes and do all of the glitchy things But if you do before then no matter what you do you're gonna end up with this screen right now So we're gonna reset the game and we'll be back in Okay, 20 minutes later and the game is eventually loaded and we are back in the game again So we know what to not do for the black screen You don't want to be clicking into any menu screen too early when the battle is loading So you need to wait for that white screen to pass and the battle to fully load and then go in and do the glitchy stuff If you do before then you're always going to experience that black screen like we have done So we're back at this the point that we were before you can see that we've got a Cresselia Shellos still in the box. So what we want to do is If some of you have created a bad egg now with the bad egg glitch is pretty good It's pretty there's basically the fastest glitch out there So you want to come into your Pokemon summary screen again ZLZR and A at the same time to set the glitch up If you've done it right We haven't that time not every time we don't get it every time we'll try it again ZLZR and A We should get it There we go. Okay, we got it.  Where are you? Where are you Pokemon? Here we go. We've got one you want to be waiting till this screen right now is is done, right? Once that screen is done the battles loaded we're fine to go in and do what we want to do Okay, and you will not get a black screen. Okay, so at this point. We want to just come into our boxes and we want to clone Priscilla so we're taking out the top we're going to clone it put it in our box and we're going to just Run from the battle It's as simple as that simple as that we want to exit the grass and What we're going to do is just go into our boxes and you'll see the shell us has disappeared But we've got a Criselia So the Criselia is there in the party and that is how to avoid the black screen all the time Just let the battle load and you will be fine You will not experience that battle screw in that black screen after the battle after you exit You will not experience any frozen screens after that So just let it load let that widescreen pass the battle load and you can go into the boxes and do everything So we've got a duplicate of our Criselia here now. We're going to create a bad egg So we've still got the glitch active. We've still got that menu screen there We want to go back into the grass. So we've turned that shell us into a Criselia And now battle loading widescreen passes we can go into our Pokemon box We can go into our boxes what we want to do is just take this Criselia here move it into our party Okay, and then we want to just come out of this screen Run and then we can actually just get rid of the glitch here So we can get rid of this menu overlay here just press B It will get rid of it that deactivates a glitch and what we want to do is just come into our party again Now you will see there is an egg with no HP. It has fainted. So this is a bad egg Whatever you do, you can't get rid of it. So there is a way for you to manipulate this egg without the glitch active To duplicate Pokemon now duplicate Pokemon items, but be very careful from this step So that you don't want to go into the boxes and hit anything else other than what i'm telling you to do Or the game will freeze. Okay, so this is very important So you go into your boxes now The first thing to do don't touch anything else hit Y twice to go to multi-select This is the only way you can access anything in these boxes If you do anything else in these boxes other than go straight to multi-select It will freeze your game instantly and you have to reset and come in and do it again. Okay So the bad egg is not there, but it is there. It is there. I promise you it is there What you want to do at this point to duplicate or clone the top pokemon is just Grab it go down two spaces don't drop it on the egg because even if you try you'll not be able to I can't I can't drop it. I physically can't drop it. So you go down two spaces into that third slot and just drop it There's a chrysalis appearing and then you want to just do it again And maybe we'll do it again You always want to avoid that last slot and do it one more time. There we go and now we got four Clone pokemon and we can do it again And we can do it again and we can do it again And we can do it again and you can see how quick this is to clone pokemon Oh, we can't yeah, we can't we can't we can't take all five out But you can see how quick it is to clone pokemon and clone items And I said in my last video that that was probably the quickest method to cloning Well, I think I was wrong. I think this is pretty much the most the quickest and most effective method to cloning in the games But the issue is now that you're stuck with a bad egg, right? So what what what can you do to get rid of it? Okay, now this is this is the this is the issue that a lot of us have had So what we're going to do is just exit the boxes here Okay, so what you do to get rid of the bad egg you want to come So you can see it here in your party you want to come back into your Boxes screen remember hit that y button twice come across to your chrysalis And you're going to have to make a duplicate of whatever pokemon you've got on your party You need two of them in your party make a duplicate. Okay, so you come out of this screen now And what you want to do is activate the duplication glitch one more time You can see you've got three pokemon in your party You've got whatever pokemon you started with the duplicated one and then that bad egg So this is a method to get rid of the bad egg So you want to click on summary of pokemon you want to hit that z l z r an a button Again, hopefully we've activated the glitch just exit out be out. Yeah, we've got it So just be out of here and what we want to do is go into the grass and wait for the white screen so we don't Have that black screen issue and then we want to come into the pokemon into the boxes Hit y twice to get multi-select you need to do this and then move that second Okay, we need to do it quicker because We need to move This pokemon into the box and then we need to exit out. Yeah, if I okay the battle hasn't finished. Okay, we're fine We're fine. So, yeah, basically what you want to do is go into the box multi-select on move the second slot pokemon into the box and then come out of here and then run You're going to wait safely the egg will be there. You want to just get rid of the glitch screen and then click into your boxes and the bad egg will have gone and Chris sell it. Well, it'll have turned into a chrysalis and Everything will be fine. And you can just drop this in here and you've got all your pokemon You're going to be able to do whatever you would do normally You're going to have no issues and you're going to have all these clones duplicates And that is how you created a bad egg So to create a bad egg if you want to do this glitch really quickly It is by moving a pokemon when you've got the glitch active Into your party But remember after that when you close that glitch the overlay menu down make sure that you're doing everything with that multi-select the green finger um, and that is Even when you're getting rid of the bad egg So and that will make sure that your game doesn't freeze If you just follow all the steps that we've done in this video, you'll be fine. Just make sure that you're letting the battle kind of Lord properly that white screen's passing and everything will be fine So friends, I hope you found today's video useful. I hope you found the tips and and what we went through in this video Useful, especially if you have been having difficulties with the the duplication the clone and glitch that has been Come in quite popular these last few days And and if you have been having issues with it, hopefully these solve it for you And we have went over a different method in today's Episode and it's probably a quicker one than the other method that we discussed on our last video But if you've had that black screen at least we cover how to get around it in today's video So hopefully that does help you friends Right. Thank you so much for tuning in if you have enjoyed the video I would just ask kindly if you would drop a like on it if it has been helpful, of course And if you enjoy this sort of content and want to stay up to date with all the new glitches that we're getting in all other Pokemon content for Brilliant Diamond Channel Pill Do drop us up on the channel and I would be very appreciated. Of course it will So have a great rest of the evening friends. Thanks so much for tuning in I'll see you all for another video very soon. So until then. Bye. Bye