So I guess I'll start talking about Griffin, even though I think he's tanking up on breakfast over there. You want to make sure he has the fuel to continue and give us his really important talk, which is anomalous head positions, force nerve palsies, and the three-step Bill Kowski test. I just want to thank Dr. Jardine for volunteering to take on many positions, being responsible for our wellness and being our assistant program director. I don't know if any of you know this, but he got tapped to be the assistant program director even before he arrived in Utah. So thank you. All right. Before I begin, I just want to say how actually how grateful I am to be here. I, in medical school, was a, I've told the story a couple of times, but I was kind of a wandering through your student, not having picked a career. And Jeff Petty pulled me inside and said, you should look at ophthalmology. And that's essentially what led me to choose to feel that I did. And my dream job was to come back here. So I really couldn't be more grateful to be here. Felt so supported and just loved the collaborative collegial environment of the Moran. So I'm sure you were all just dying to get here when you saw the topics. It's business today. It's arguably the sexiest stuff in ophthalmology, right? So the, hopefully, though, this talk is really targeted towards just the fundamentals of the three-step test, fourth nerve call season, and, you know, approaching the pediatric eye exam. So I may not get into a lot of the nuances, but I hope this, at the very least, will be helpful to residents for OCAS and give everybody just a really basic and appropriate knowledge of when these tests are appropriate and how to evaluate these children. I've no financial disclosures. A lot of these pictures were taken from my fellowship in Indiana. So I just want to acknowledge that. So as you can see, just like the boring title stated, we're going to go through novel side positions, three-step test, and then talk about the general versus acquired causes of the fourth nerve policies with some surgical considerations. So the case that I saw about midway through my fellowship, which I thought was quite interesting, is a five-year-old boy who came in with a diagnosis of torticollis and was scheduled by orthopedics for a sternoclindomastoid release because of the torticollis. The insurance delayed or rejected the, you know, didn't get pre-approved essentially. And so the family came to see us in the interim. And this is actually my son. This is an actor, not the actual patient.  We're kind of a Weasley family. So the patient comes in with this head tilt and he was a lot younger, a lot less cooperative than my 70-year-old son. But the, as he came in, it was really a tough exam to really figure out what was driving his head tilt. But in moving his neck and the neck was really mobile. I feel like there's any really tightness in the neck muscles. So we did one of my favorite strobe business or anomalous head position tests. And that is the patch test. So I got this kid's mom to put a patch over one eye and the head straight right out. So we're gonna come back and try to explain why that happens in these ophthalmologic driven anomalous head positions. But and forgive me, I hope this isn't inappropriate to be interactive in grand rounds. I just can't talk for 20 minutes straight. I'll start boring myself. So can I ask what is the differential for anomalous head positions that we see that ophthalmology causes? Classic way to catch the little, grab the little hanging fruit. Fourth nerve palsies. What else? Oh, nice. Yeah. Anything else? Nice daggers? Great one. Yeah, the no point in my staggers. Exactly. Anything else come to mind? Yeah, doing yes. So yeah, I'll form the strobe business like doings and more some of the more. So six nerve palsies we often see a head a head turn away from the the eye that can't add depth. The last time to no point. Do you think in strobe business causes of anomalous head positions is more common with combatant or incompetent strobe business? Incompetent, definitely. I know Bob's going to talk about A and B patterns. We see it with patterns for business as well, like an easter trope of the V pattern will often put their chin down to bring the use the V pattern to their advantage to actually try to potentially obtain fusion. Tosis and interestingly, we see it even in such an incident last week, about a five month old with unilateral congenital ptosis that have a dramatic head up position just to get know that one I looked just fine, but just to get the other I engaged and have to allow fusion this child as soon as they have control of their neck muscles was putting their head up to try to get that find that head position where they can use both eyes. Interestingly, we see it sometimes with refractive errors. And then congenital ET, you know, they have the cross fixation, but these patients are at high risk of developing amblyopia.  So this is an interesting case. Just to point out the differential of case in Indiana, a girl who once put in glasses, the anomalous head position went away. So it's not always true business or some of these nice daggers and more common things just even a refractive error can cause a head position. What was that? No, the rest of these are actual patients. So now after your causes, we do see so a lot of the pathology is generally kind of mastoid muscle driving toward a callus. Spinal deformity, injuries, C spine fractures, you know, so you get some acquired causes of toward a cost or anomalous head positions, dystonias, your unilateral hearing loss, they'll turn their good ear towards you. And so I can be, you know, easily mistaken for, you know, an ocular driven head turn medications like phenolthiasis can induce a dystonia, moving disorders. There's a lot a large differential, but but ophthalmology causes are a common cause of these. So most patients deserve an evaluation by an ophthalmologist if they present this way. So my question to you is what drives this position? A lot of these look pretty uncomfortable. At least let's let's talk about the fourth nerve palsy. Why would you know, we see kids suppress one eye all the time, develop amblyopia. I mean, this brilliant neuro adaptation that we have to avoid Diplopia, right is our brain just suppress one eye and that we just use one eye. Why would the patients go to uncomfortable lengths to obtain fusion? Any thoughts? Simply said, perfect, actually. I would even say they strongly prefer it's a powerful drive that the brain has instinctually from, you know, time to the child's four months old that can control their neck muscles. You know, binocular fusion is far and away.  I like this quote from Bill Chowsky, the patient chooses the least inconvenient position of the head by which the peretic muscle sufficiently relieved so that binocular single vision can be obtained. So we'll we'll talk about that. And going back to that original case that I was with a patch test, when you break fusion, that drive is no longer there because there's only they're now monocular. So the patch test is a great way to test if it's an ophthalmology cause for the anomalous head position, because all of a sudden they have one eye and they'll just straighten right up or give her that turn. So long as it's not the nice average no point that obviously is by an ocular or monocular. Do you assume in some cases it matters which eye you're catching? Yeah, if there is an ability, a lot of these cases that have the anomalous head position, they've been able to avoid amblyopia. So so it's a great point, like in a six nerve palsy, if you know, the right eye can't abduct, you'll get rid of that head turn way covering that eye up, but maybe not by covering the other eye, they'll still have that decreased abduction. So the three step Park Spilchowsky test, I didn't fully understand this until probably at least at least fellowship, when it's appropriate. So could any guesses? When is this test used? I'm just saying, what was that? Yep. Yeah, I would even say only vertical misalignments. And only in only in cases of isolated, but my husband, Bob's excited, you can barely hold my hands. Yeah. So it's isolated vertical peretic muscles. So one muscle is out. And that's it. If there's multiple muscles that are not working, or if they're postop or restrictive, it doesn't apply. So it's a pretty narrow patient population that you can apply this test to. So step is step 123. Step first step, which eye is is higher in primary gaze? Is it worse than left to right gaze, worse than left to right head tilt? So I want to talk just for a second about motility exam. So I feel like I feel like a lot of us memorize this pattern. And we probably everyone here probably understands it pretty, pretty well. But I find it extraordinarily helpful to overlay the anatomy and just think about how these muscles work in abduction versus adduction. We spent a lot of time and for OCAPs memorizing the primary, secondary, tertiary actions of the extractive muscles. But I find that actually almost just not unhelpful memorization. If you just look at the anatomy, when the eye is abducting, so the eyes looking out here, all of a sudden the vertical muscles are in alignment to just they're isolated in elevating or you know, in abducting the eye. So in abduction, you are essentially isolating the vertical muscles in their, or the suit, the rectus muscles. And I remember Dr. Christensen, a piece of my residency in Oregon, used to say, the motility exam is designated to get the muscles in the field of gaze where they sing their solo. And I thought that was just really catch you if you remember this. So in an abduction in elevation, the right superior rectus is really doing almost all the elevation by itself. Contrarily, when the eye is adducting, all of a sudden you see now if this eye is turning in towards the nose, this muscle is now the rectus is becoming more of a encyclotortor than an elevator and the superior oblique is now in position to move the eye. Now, since it's a oblique angle, it actually moves the eye down and the inferior oblique moves it up. So it's that that always to me is just really helpful and understanding motility. So we used to call these the dreaded nine pictures for OCAPs. We have to figure out what's going on here. So walking through this three step Otowski test, again, I often thought as a resident, you had to have a prison bar to sort this out. But that's not true because it's often evident just by looking at the motility. So any guesses which eye is up here, it's pretty subtle. The other guess, left, really hard to tell, but it is left. Now that one, you would be able to much more easily decipher with the alternate cover test. So so you've got a left hypertropia. That's step one. Is it worse than right or left gaze? Yeah, you see how much higher that eye is in that eye was over here. That looks pretty ortho. So let me walk you. So I'm going to walk you as one by one. So if the left eye is up, which muscles in the left eye are potentially not working? Now, we're thinking peretic muscles, right? Not restrictive. So would the peretic muscles be the elevators or the infraductors? If the left is up, it's the it's the it's the downplaying muscles that are that are one of the two are not working. You always have to remember that it could be that this could this patient could be having a right hypo, in which case the elevators aren't working. So that's step one, you've isolated.  We decided that it was worse than right gaze. So now now you know some muscles involved in right gaze. So you've limited now to two muscles and shorting out which which one is peretic. And then you can see that this much worse and left head tilt. So conveniently, when you when you diagram this out, you just circle the muscles in the same alignment as the head tilt. So if it's if it's worse than left head tilt, then you circle the muscles in kind of a tilt to the left. Yeah, and I often thought that third step always is throw me off as a resident. And then and also why it worsens so much in head tilt. Let me read this quote. So preferably, one should remember that there is a head position in which the peretic muscle receives a minimum of impulses to contract. This is the position in which a patient with a paralyzed muscle habitually holds the head. So, so again, thinking about the superior bleak, it's, it's a big intorter. So our eyes are incredible to maintain our horizon when we tilt left or right. I mean, they're they're really almost like those toys where the eyes stay still regardless of how you move the move the dollar the toy. And what we want to what the patient is trying to do is they're trying to find the position where they're minimally using a superior bleak. So in left head tilt, this patient has a left superior bleak palsy. And left head tilt that left eye is trying to in tort and the right eye x cycle tort. And in cycle torsion involves, obviously, the majority of which is the superior bleak. Does anybody remember what other muscle is responsible for in torsion? Synrad? Superior rectus. Yeah, perfect. So you think about this. So the superior rectus has in torsion is one of its secondary function and then the superior bleak. But if the superior bleak is firing is not firing or at least in balance and compared to superior rectus, what's going to happen to that eyes that tries to in tort. It's going to it's going to get pulled up because the superior bleak, when it's functioning kind of keeps it from pulling up and just they both in tort together, but you tilt the head the wrong way and then also in this in balance cause that superior rectus to pull that I out. So as you see this so conveniently, when you circle, when this patient is turned to the left, you circle the two superior muscles, both involved in in torsion. Now the three step test. Now, if you think about an isolated vertical peretic muscle, the superior rectus inferior bleak and inferior rectus are all innervated by the third nerve. So they they're just not commonly, um, peretic in isolation. So this test is far and away most useful with the superior bleak palsy. We actually do see it. We do see isolated peretic muscles of those three. But as you can imagine from kind of a neuro anatomical basis, it's less common. So so the the acronym for memorizing the three step test for fourth nurse is SOS. If it's a right superior bleak palsy, you get a right hyper worse than left gaze and a right head tilt. So same opposite same. So just just to do some quick practices to put this into practice. If you had to guess if you knew this was a fourth nerve palsy, which which side is the palsy on? Right? Yeah. So so they come in.  So they have a left tilt because this would be worse in right head tilt. And it's same opposite same that third step. So we this is so whenever I see a child with a knowledge head position, the first thing I do you're limited in how much the kid is going to participate in the exam. So almost always that a knowledge head position I try to get their head and I try to move them whatever head position they're avoiding. Because you almost always will see ice play or you'll you'll see my staggers come out.  So it's a right superior bleak palsy with a compensatory left head tilt. So where would this one be? Left and a side. What was that two rudimentary left? So it would be worse and right or left gaze. So yep, it's ours. And that left eye is trying to x cycle. So here that left eye is palsy. But in right head tilt, remember that left eye is now is being x cycle toward it. And that's the opposite function of the superior bleak. So that superior bleak is maximally relaxed in that tilt that's allowing for fusion. Do you guys see which one it is here? Which which side the palsy's on? Right? Yeah. So so part of the stock is hoping to and make everybody feel a little bit more able to identify for their policies without a prison bar not feeling like they have to have all the tools that we are using regularly in the pizza clinic. This is subtle. Can you tell which which way this man is tilting his head? It's a real subtle right tilt. So it's going to be worse and right or left gaze. So we assume it's a if it's a right tilt, what's what size the palsy on left. So it'd be worse than right gaze. Now you can see that inferior bleak overaction coming up as he looks up as he looks off to the right. So again, what do you think what gave what's worse than left to right gaze? What would you guess?  So so this is the compensatory head position. That's that that's what always threw me off, right? So you gotta make sure that you're not when you think about same opposite same, it's it's where the deviation is worse for the three step test. So it's a left head tilt, it's a compensatory head tilt, be worse than right tilt and left gaze. There is a left gaze again, not not over the obvious. But you look at the bottom of the limbus of the right eye versus the inferior border of the limbus of the left eye, you can tell that is actually higher. So just another kind of interesting trend, an interesting point about Forthner palsy says the majorities are congenital. Interestingly, a lot of people will have it come out later in life as their ability to fuse the eyes decreases or breaks. So can you tell which way this gentleman is tilting his head? Left. Interestingly, just by looking at him, you can you can tell if this is congenital or acquired. The way you tell is a congenital Forthner palsy actually will develop midface hypoplasia on the side that they're tilting. The way that you diagnose that is you draw a line from their kind of from there through their eyes, and then through either edge of their mouth, and you'll see that these are not parallel. You actually is developed from a chronic left head tilt, a unilateral midface hypoplasia. So it was one of the reasons that we try to fix these early is it actually does affect the way that your, your facial anatomy develops. So we tilt so again, you see a left head tilt, you just tilt them the other way. And then that there that hyper deviation comes out in a really big inferior leak overaction. Here again, you can see right head tilt. Now can you appreciate the midface hypoplasia there? The distance from the corner of his mouth to the lateral campus is shorter on this side than it is on that side. You draw the lines and you can see just just subtle. So this is a case from a textbook in 1967. This is a lifelong head tilt that drove that caused that amount of midface hypoplasia and deviation from Von Norton's text in 1967. I thought that was just a really striking picture. So I don't know if you can see these numbers. Can you see these numbers at all here is too small? That's probably too small. So this is a case that I saw just a week ago. I just want to try this is a three step test that a patient that seemed a little unusual because they had superior leak overaction in the left eye. So there's a right hyper in primary gaze. So what muscles should we circle for the step one? Let's start with the right eye. What what muscle if it's a right hyper what muscles on the right do we think are not working? Perfect and then the left eye the opposite, right? So step two is it worse in right or left gaze? Well, in right gaze, there's a right intermittent hyper of 14 and then ortho and left gaze. So what muscles are going to circle for the step two? On the right eye, right superior rectus and right inferior rectus and the left eye. Left inferior left superior. Yep, perfect. And then if you look away over here, the comparison is but it's worse in right head tilt. As good a left head tilt. So I dropped to the right. So this patient actually had an isolated left inferior leak palsy. Which is you think it'd be extraordinarily well, extraordinarily rare again based on that kind of neuro anatomical basis but the it turns out you actually do see a fair amount of these, you know, in the literature. And so this patient had not had surgery, had not had any trauma in this, in which case this test was appropriate. So just review isolated credit muscles only doesn't work in postoper restrictive cases. So you yeah, this is a bad question, but you of course never use this in a six nerve palsy. It's not it's not vertical. And you wouldn't use it in a thyroid eye disease patient or myosinia patient because it's not an isolated parotid muscle. We see we see bilateral cases where they they sometimes will have a hyper but then you'll see alternating if you leak over actually look left to right and they'll have a lot of xyplotorchic and large v pattern. So not to be missed. So just wrapping up here, let me go through a couple of things to distinguish congenital from acquired. The in congenital fourth nerve palsy, which again, are even in adults that will present with the fourth nerve palsy, you can pick out some of these features that suggested it was a congenital palsy that decompensated with just with time. You'll see that facial asymmetry like we talked about in this patient. They have much larger vertical fusional amplitudes. So you'll see as you as you break them down, like that one patient had a vertical intermittent hyper of 10, you know, patients without this would never be able to fuse a hyper deviation of 10 prison doctors, with exception to these cases. congenital cases have less xyplotorchic and more vertical, whereas acquired are just the opposite.  So let me let me kind of start lasting the photo album, tomography scan, you go back to pictures of where their child that you'll see a head till in congenital cases. So so go through just surgical decision making. There's a lot of different schools of thought about how to approach this. Where I was trained a big probably the most prominent way to kind of think about these was traction testing in the OR. And what that was is that it came from the theory that congenital superior belief policy actually may be less neurologic and maybe more anatomic in that when you compare the superior belief tendon and traction testing, you'll find that these patients with the policy will have a very asymmetric laxity. And the tendon will feel like you can just tell that it's almost too long, and thus enabling the muscle to kind of optimally work. So before we do every case, we do traction testing and compare between the two eyes. And often that would drive treatment. If you felt an asymmetry in that laxity, you would tuck one of the eyes to match the superior belief laxity to the other eye. And interestingly, we would see a handful of cases where there would be bilateral laxity, in which case, you would just go after the inferior oblique, but warn the family that this your child probably has a bilateral superior oblique palsy, even though they're it's a little asymmetric is why they're still a head tilt. You would you would do the inferior oblique might be your recession on one side and then a year later, you come out and they have a head tilt the other direction. And so you have to go after the other the other inferior oblique. Another way to approach it is you can think about how large the prism that deviation is. So if it's if it's less than 15, you could probably get away doing one muscle and then you just based on their if your leak is overacting you address that if the there's restriction superior rectus on the same side, or you can always recessed it, recessed the yolk muscle on the other eye. Here's the inferior oblique and then here's the superior oblique. Large deviations you often need to do more than one muscle. And then the other way to think about this is just identify which gaze it's a problem. So I know it's kind of a busy slide. Let me just jump to a picture. So here's a patient. Can you tell which I if you had to guess which which is the superior oblique palsy and in this patient, I can contain myself. That was so enthusiastic. So the. So left hyper worse than right gaze and left head tilt. So here if you're thinking about surgery, if you when you when you see this, that's that's a good sign that it's not working the end. You could go after the left eyes inferior obliques. You can clearly see it's overacting. But then if they look down into the right, you often see you also see there's a lot of superior bleak underaction. So again, as you're watching this patient move their eyes, you find out what do you think is more useful the down and right or up and right down right. So this would argue me on this patient, they actually doing during this again, kind of overlaying the majority exam here, you can see that this patient has an underacting left superior bleak. And we also left inferior bleak overaction. This patient had superior bleak laxity in that left eye and was tucked. So the inferior bleak is now a little bit underacting. But you can see that with that tucked superior bleak, you really improved that down to the right gaze. So my references. Thank you. Any questions before I turn the time over to Bob? It's a great, it's a great question. You'll see it still work in patients who have fourth nerve policies that don't really come out into their 80s. So what happens though with the fourth nerve policies, you get a spread of competence. So although you'll see a much more dramatic hyper in, you know, like a left superior bleak policy will look much worse than right gaze.  And it can be much harder to tell over time as well. If you've had a chronic left hypertropia, your superior erectus on that same eye can get tight, because it's just been shortened. And so when you start throwing those things in there, if you've got a tight superior erectus or a spread of competence, it's no longer an isolated peretic muscle. But so to your point, it does longer you wait, maybe the less valid it can be, but we do see it working at all ages quite, quite effectively if, if it's used the right, right patient. Any other questions? All right, thanks.


So, my name is Barbara Irvin and I started in the nursing program on the SOC campus. Back in August of 1971, when the associate degree program was just about two years old that Betty Halgen had started that had come down from the operating room at OHSU in Portland. And she started that associate degree program, which was amazing in itself in lots of ways. And when I applied and came to work, I was taking the place of someone who was a specialist in the mental health area and the program, the curriculum as it had been adopted was called for integrated program.  So I ended up taking that person's position. I had been at Rogue Valley Hospital before that. So we were using a pretty innovative curriculum that had been adopted by various schools across the country. And one of the questions that Betty Halgen, who was chair of the department, asked me and asked all the other faculty that she hired any time on the years after that. If I would, starting with myself, would adhere to this curriculum because one of the issues that people have or faculty have is if somebody comes and is hired and doesn't follow the curriculum because they've got other ideas and they just sort of weave their way and their ideas into the thing. It makes it really difficult for everybody. And so that was something that was really important to Betty and became really important to the rest of us who got really involved in it. And that program was very creative in that the authors of that curriculum wanted students to have experiences of sort of playing at things so that they could learn some stuff without all the stress and anxiety that nursing students tend to have. So there were lots of little things like having little small doll beds and things to try to practice things on. In a sort of a miniature scale, that is something that moved over the many years till the more recent past where the students act out things according to scripts in nursing labs now and that things are videoed and things are prescribed so that students get more experience in lab setting and about making them as real as possible. So the beginning of that, as I see it, was way back then in the 70s, perhaps for the authors of the curriculum starting then they were in Florida, that they started that in the late 60s then I would say. So back in those days when I was hired, I became one of six nursing faculty that we had here and our offices were actually in rooms in the cottage up behind the science building where a parking lot exists now and we had a little cottage there and we had two faculty in the bedrooms that we had two that were in the living room and then I shared with another faculty on what was like a sleeping porch or a sun porch type thing. But anyway, so we all had, we had two in an office and it was such an interesting thing. We had our faculty meetings in the kitchen and Betty, our shared office was down in the science building. We taught our nursing labs in what is now one of the anatomy physiology labs. In fact, it was before we started with nursing and there were a lot of bargaining that had to go on over a number of years where there was competition between science and nursing for space and for dollars where it was like really important for the nursing students to have science courses just like they also needed psychology courses and English and speech and sociology and anthropology. There were various courses from all the other departments because nursing was always a conglomerate of all these many things, sciences and the arts and so there's often we talk about the art and science of nursing and both are really, really important. So anyway one of the things that stayed with the nursing faculty probably even till now but although I have not been active in the more recent past but as long as I was there way up until 2007 we had many interactions that went on in the kitchen of building even up in Central Hall because when we moved from the cottage that got moved to another place so that the parking lot could be built we moved to Central Hall and over the years we were on the first floor of Central Hall and then well not in the basement except well actually we did have a couple people in the basement in an office but we were on I guess would have been the ground I call it first floor and second floor so we shared on the second floor when we were up on the second floor we crossed the hall from math and down the hall from English and so we formed really great relationships with people in these other departments and many of us or several of us I should say at any given time we're very active in anything from the building committee on campus with everybody else or the faculty Senate different things so we were really a part of the main liberal arts college campus and many of the student the parents of students who sent their sons and daughters to our program here were very they liked the idea that we were on the liberal arts campus and and that there was such a close relationship with faculty in all the departments it wasn't just in nursing so that was a real strength of our department and then associate degree students didn't needed to be any clinical a lot so one of the things that we had to compete for space in the community both in Jackson County and Josephine County were with road community college for units for pediatric experiences and obstetric and maternal medical and surgical nursing things and times out in the community and clinics and so forth so that was only something we always work these things out but that did take you know effort sometimes unfortunately there weren't any thing that wasn't was too hard to work out you know we could always manage to do that so there were a lot of these facilities that were shared and we would have certain days one of the solutions was to have certain days of the week that we would have students in clinical and right road community could have those floors at the hospital on different days that we were in stuff so all that impacted how we implemented a curriculum so one of the other thing in the early days was looking for mental health facilities for the students in the early days we had a pediatric unit on the second floor at Rogue Valley Hospital where the mental health unit behavioral health unit as they called it eventually got built and so pediatrics went to a wing outside you know that projected out from the hospital into that circular wing that they still have now at Rogue Valley and there was some pediatric place experience with opportunities for experiences with babies and and children at Grands Pass also and so and then we used the clinic so we did a lot of things that would have students in places where things were less acute than in the hospital and so they would have a chance to interact with families more and things along the way we ended up feeling a great need to help nurses who were prepared at either at the diploma in a diploma school or at the associate's degree level to get their baccalaureate so that there would be more nurses in the community available for leadership and management experiences and and positions in the hospital then the clinics and also for there had to be a way for them to do that so we put we developed then a to what we call the two plus two programs so we had ended up developing a baccalaureate program that probably started in the mid 70s maybe in 1975 or so roughly the back that program allowed nurses to come in and get a pretty good amount of credit for what they had already done which was a change because people were kind of stuck and in the schools and the call at the collegiate level or university levels it was really hard to get any transferable credit and nurses had lots of years of experience sometimes but there was no way for them to progress without starting all over again and that's expensive and time-consuming and people have families and so having this develop a program where you could come in as an RN be given quite a bit of credit for what you already knew and then to have a coursework that was really focused on leadership and management and community health and and in some educational opportunities so because nurses were teaching for example myself when I started out teaching in 1971 I only had a baccalaureate degree I had a teaching credential from California but I didn't have a like a certificate type of thing but I didn't have a master's degree and it really wasn't required except in certain positions and in the universities it became much more in demand but even here over the years it became necessary for accreditation purposes to be able to teach with have your faculty prepared at the master's level so then many schools would have the faculty who were prepared only at the baccalaureate level they would be teaching in the clinical areas and those that taught in the classroom then or were trying to do research would have to be prepared at the master's level so there was always this staggered of figuring out what nurses needed to learn and what was going to take what kind of preparation was best both for them to work in a future setting but also to be able to teach the students who were going to be graduating and working in you know down the road in five ten fifteen years so it's sort of the same issues people in the faculty in other disciplines have is how to prepare the students to be good citizens in the world and and be able to earn money in and so forth but in a rapidly changing field with with technology the technology changing very rapidly and science behind things right or wrong as discoveries sometimes turn out to be disproved and you know the and science changes but those became it really was necessary for nurses to really not only keep up with their field but identify what the field was and because nurses the nursing discipline or profession draws from so many different disciplines so in order to develop a doctoral program for nurses for example for faculty to go to or researchers to go we had to figure out and identify this I say we this is nationwide it's global but it's particularly nationwide in this you know for us in this country had to identify okay what content from in throw and or sociology or English or biology and how necessary is chemistry and you know many of us because we all had chemistry we decided that's absolutely we got out chemistry in order to understand the pharmaceutical effects of medications things like that but at some point we developed a consortium and when we so that they would have more students prepared associate degree level who could then get their upper two program that for two years all over the state they didn't couldn't just be limited to coming here or to Clemeth Falls or eastern Oregon that there were a lot of places where they were they were able to get that first two years they should be able to get the second two years so it was always a matter of a kind of then determine what was necessary so if one of the associate degree campuses did not teach chemistry I mean it likes you know I could pick anyone and I don't want to really do that by name but it's just if one of the other schools the community colleges you know they didn't have a chemistry offered on their campus then we couldn't require it as part of the consortium so we had to give up things so we used to talk and faculty talk about the sacred cows of curriculum and chemistry had been one of them and we had to give it up at some point but we finally did come up people work really long and hard across the curriculum and some people from our campus in particular did that I really work make it work and it did work and so for a lot of years we were doing that our campus meanwhile was told we had to drop the associate degree program and leave it for the associate degree programs for the community colleges to do that level and that we would focus only on baccalaureate so these mandates come from higher authorities that are for decisions that are made on higher levels in Oregon so sometimes political things get in the way you know how much is cost effective to do this versus that you know so as is oh before I go on to the next little piece I wanted to say so that that worked and in the program it worked but while we still had the 2 plus 2 program we had an extended campus program what was developed so that our we had quite a few faculty who would travel then to a community college in Roseburg or up to the Dalles to Redmond to various places over to Cuspe delivering classes and when we finally set up some structure with where there was a an administrative assistant in Roseburg and one in Cuspe and associated with those community colleges there and then our faculty would go and we would and that we would teach classes in maybe an evening and then the students didn't have to come to to to our campus except maybe once or twice you know here or there they come for certain things but basically they could get everything they needed on their campus either by us taking it to them or them getting it on their own so the students started getting being able to do research projects and to teach but what was so wonderful is because of the independence of those students who had already we you know they were already independent nurses or I should say they had you know they were earning money as registered nurses and working in really good positions and so by having this set up similar to how many disciplines will offer courses for people on extended weekends and we did some of that where students would come and take an immersion for a weekend you know or several weekends during a term to get a course that needed to be taught from here only because the faculty couldn't travel or something and then we moved into distance education where things were televised and then we could they could just sit in class on their own campus and take a course and it could be delivered from Portland or from here or anywhere so around 1991-92 there was a lot of upheaval where things looked like they were going to assign their school of nursing or the department of nursing here to be merged with OHSU in Portland and in about 1993 that I think the year that actually happened and so that the use of the television or the distance for distance education became imperative at that point and when I earned a master's degree from OHSU school of nursing I had to commute and that was like to 77-78 and I think I finally finished that master's in about 82 but I had to do the commuting where by the time we got distance education going in the cameras and everything we've made it so much easier that we could we could enroll a whole class of masters students working on their masters and stuff which was actually a huge step forward in helping our community to have nurse practitioners and I mean that was wonderful and then that on down the road became that was the forerunner for the doctoral program that became possible for students to be able to get some classes down here and participate with a cadre in Portland at the same time so over the years and while I was still in nursing here in one way or the other at the baccalaureate level and the people were working I mean community local community people here could go ahead sometimes including our faculty could take courses in the doctoral program so we made that was a lot just um in 30 years you know 20 30 years it's just it's quite quite amazing at resources though I mean you know the money for all these things it's always hard to come by and and so over them those many years they're getting really good working relationships with the community agencies the hospitals the foundations just local groups of interest that we wanted to support wanted nurses in the community that were prepared at higher levels wanted well-prepared faculty in the state of Oregon you know there were a lot of contributions made that helped so that we could they would make facilities available to for our students to practice and he thinks that I mean sometimes it like was over above and beyond sometimes to make these things happen and certainly that was true in the outline communities like in Coos Bay and and Roseburg and and other areas Klamath Falls we had really good relationships usually with the faculty with Klamath Falls OAT and they would come over here they also were part of the OAH belonging to OHSU and so it was it was quite a wonderful time for developing leadership and and and great relationships among between faculty and leaders nurse managers at these hospitals and the health department and so forth when wonderful to see like one of our one of my first students in fact there were several of them from that you know they kind of stuck together through thick and thin and earlier you know how it's wonderful to have students buddy up together and and they really helped support each other through a program and and one of ours Gwen Bowman became director of the nurse of nursing over at the health department in Grants Pass and see these students from beginning all the way through you know to where we're they're providing clinical experiences for our students it's it's pretty amazing and very rewarding you know and even now in this community there are many many many nurses who started here and one or maybe both of the more basic programs and continued on so when we became part of OHSU there was a lot of resistance to that here because the nurses and faculty I mean we were all very very partial to having our own you know what was SOC and then it became SOSC and then it was SOU we always were proud of it and glad that we had right here on our own campus we had our nursing program and at some point the resources just became really so tight it's not much different nowadays sometimes departments have to be reorganized and the budget's always you know there's always the crunch time and our faculty going to be able to stay or the faculty have to leave because we can't afford that and so forth and so on so we went through many of those times and there were it's more than once that I remember Betty Hogan getting a a note sent to her and perhaps one o'clock in the afternoon or something to show up at three o'clock for a faculty senate meeting to to explain why we should keep nursing on this campus because the chemistry and biology and these other departments needed the money and and yet they needed our students to you know we fed them students and they prepared our students I mean it was a great exchange excuse me but but when money's tight there's a lot of balls in the air it's like okay house is gonna end play out so eventually we did end up going with becoming part of OHSU and while there was resistance and there was some resentment there was also some prestige that came with that for the students and more opportunity more money available which because of that we were able to develop research projects more because we had the facilities and the support from the Portland campus people could write for grants and and fund the video projects that started there you know we started with the for the nursing labs and so forth so that students could go to clinical and much better prepared and as the hospital environments became more and more acute it became more and more necessary that students be more competent as well as have a more confidence you know when they were there so that they weren't shaking and appearing so nervous to a patient who is being asked if they would be alright they would accept a student for today you know so there's it's just pretty amazing we have a lot of people to thank for having been patients but on the other hand most of them are really happy to have nursing students because they got a little more attention that way and I mean I can't say that was 100% that way but you know it was a good program and it's still a good program and and that's pretty awesome well we used to have a huge waiting list I mean like 300 maybe you and there was always that thing about we used to have interviews and then it was like there were all these things that would come out from seems like affirmative action that you couldn't ask for this and you couldn't ask that and but he said we did away with those interviews and at some other point we had them back for a while and so there's always that issue about fair admittance and that sort of thing but we would take trying to think we had 24 maybe at a time sometimes as facilities would change sometimes we could take more sometimes less but we tried to it used to be when we could take 36 because we could have 12 in a group and we could have three groups but that was hard to manage 12 students in the group as clinical facilities and the patients in them became more acute how it was harder to do the kind of supervision that nursing students needed to be safe and to be safe for the patients and for patients to feel like they were getting good care you know and the nurses that we would pair put them together with did not feel like they don't have time they don't have time for the students because things were so busy so we would get down to about eight students then in a clinical area that became much more doable more realistic and they were getting more preparation in the labs we there's always been things in the beginning when we always had a nursing skills or fundamentals left way back when I was a student in the dark ages you know but but it became with that students had to learn how to think on the feet and move faster and make decisions in a setting like this and not wait till we get into the clinical area to have them realize oh they couldn't function in that kind of environment they really wanted to be in a calmer setting and things like that which is how you sort out what area you might go into later we started out with all females and all female faculty one of our we did have a our token male student Rick Daniels who was recruited out of central Oregon he was an OHSU graduate initially he had and he had some background in the military so he's a great teacher the students loved him we did have more they have more male faculty I mean male students over time it wasn't always a really good match some one of the students I remember male students way back in the early 70s actually wanted to be an anesthesiologist but he came in through nursing and so he wasn't really wanting to be a bedside nurse and of course then I should interject here nurses went nursing itself went through a big change so in the public perception was finally able to catch up with that I think but as it did more people were willing to accept a male student we were always careful to be sure that a patient was willing and that during if during at any time a patient a female patient did not want a male student you know we accepted that or if they were did have a male student for a given period of time certainly during anything that was more required more privacy we would have a female student you know cover for that or have the the nurse that was assigned that patient I think some people it's like when I was in working in the south and initially when I was in school we had people come in who didn't want a black black nurse you know they oh no I mean I really we had to tell a patient she would have to leave I mean we had black nurses in that hospital you know and so that's the like in the now some of our best nurses really in the environments of like emergency room a lot of them are male nurses but a lot of times it's a personality that is coming along so it's not always a good match and with a patient and a student some students came in from forestry from the mills or other places where then they were able to adjust and do fine but but and largely that really didn't always work that well because of that what they came into nursing because they knew they could get a job and they get done and it didn't no fault I mean I'll blame it's just and the lumber industry here was changing there's a so you know everything affects everything else so but definitely some resistance about having a male student some people had ideas about gender orientation and so forth that may or may not have been accurate but you know it's always something that we just have to accept and work with you know of course over the years yes but to this day there could be somebody who wouldn't want a male student and they might or might not be able to get another one I mean you know it's like there's not that many different nurses to choose from on a shift sometimes so it depends we we didn't see not early on what we did do is work at the we had we took our students to the VA and I mean that's how where when I started out we would take our students out there to learn how to do insulin shots I mean we showed them here on campus and they could but that in order to get many injections just like now we will have students work flu clinics and things to learn injections you know we we went to the VA as to other community facilities for student experience but I didn't see until probably as they would come maybe in the baccalaureate level and I personally I'm not real familiar I just don't remember in particular we did have some we had students actually that would come like from cave junction and other places and so in those instances there would often be we might deal with things like that relative to vaccinations you know meeting the requirements for school for the young kids in their family the babies that they were had in tow going to have well baby checks or if they were sick a lot of times those could overload emergency rooms well I think for for some people it was just very shocking and hard to accept I know some families who lost sons to HIV to AIDS and hadn't even realized that that anything until it was like so late they just really you know hardly had time to try to repay our relationships before they want to die you know or anything so I mean it was really a lot of blind nonic just judgmental judgmental things that would keep people from trying to understand things sooner but in it did affect people in the hospital and so that we would be involved with our students taking have we have patients including children although many babies born with HIV you know everything it's just like it's just hard we always were having to deal with precautions for hepatitis always for tuberculosis was a big thing because people wouldn't take stay on their medications and so in the community focus became huge for making home visits to people to see if they were taking their medications and you know as the drugs got they became drug resistant you know the idea one of the things that was so helpful with with whole hiv thing is using combinations of drugs and to try to get at things and that was so much better but there were many many many years of trying to gain understanding of even how to care for the people and properly in the hospital and in the end to give them the support because anybody in a hospital with a communicable disease not in isolation so last thing they need is to be isolated from everybody socially you know and emotionally and yet it was necessary to keep the spread of things and that was way before Ebola and some of these other kinds of incidents so but anything that involves gender identity both whether it's staff or I don't mean staff of caucus but the nursing staff or medical staff I mean or patients or community visitors it's just really hard it's difficult to deal with and so over the years that I've been in nursing and that I work with students in different facilities including when I was working on my doctorate in Austin I had students in the hospital and we had lots of people with hiv and working through all the issues and keeping everybody safe all the precautions that we had to use it's you know we thought it was so tremendous at the time the effect the toll it took on everybody and at the same time the growth of us as a human society was was huge too because you know everybody started to learn you know oh once you know somebody that has this has whatever it is you know you realize that oh they're just like my family just like me just like just you know kind of thing and so there was a lot of social adjustment that I had to come along with it was not just the acute care and the community care that followed all of which was difficult in a lot of ways but so rewarding with the development of compassion that people could have for another human oh I do I remember in my own family I have sons there's a lot of there was a lot of denial about all of that but when I had to tell him one of his best friends from school had died is you know it's just he didn't believe there was such a thing you know it's just I know so but then he became more aware it's just one by one it's because I do remember very early on we were we had to discuss this about what happened when you have students applying to the program if they were known to be and not have that disease which did turn up when I was in Texas that was an issue there about protecting with affirmative action there with with the all of the rules for privacy that came up where you can't reveal any of this and that you have to keep everybody safe yeah that that was a big issue down there I was I was not here at the time but I was in Texas and down there people's parents were worried about well if you go there you might get TB because the the organisms had gotten more virulent at the time you know and so it doesn't it doesn't matter so much which communicable disease it's scary for parents it's scary for people in the environment and and and it's really a faculty where we had to develop a lot of policies and things around all of that but I remember before we were talking about HIV we were talking about gender identity and and about having a nurse perhaps who's a different orientation than you think they should be or something and and do do reactions in there so that we had to have discussions you know and about all of that just with relationships before we ever got to any disease things that and that will might be associated with these things more of it was with related to poverty and malnutrition and you know the damp environment that people lived in that was a would foster disease versus being out in the sunshine in the fresh air and you know some basic things people just didn't have you know you can't just we just take so many things I say we but you know many of us do take a lot of things environment that we have clean water and that it's safe to drink except when in so many communities that isn't the case so yeah it's just and look what I mean if you think about it's just different scenarios but now we have shootings in the school and we have do you know we have fires oh we have so many things that floods so many there's earthquakes that can affect school so when we would have students in the schools working which we did you know you have to think about that kind of thing as well you know so we're not setting them or us up as we go to make our rounds and visit with that one so so there's a lot of factors that involve definitely they're just different issues now and some of the same as many years ago but the importance really of having nurses prepared here in the way that we want them prepared so they can take care of us you know and our families we do lose some out to either they go on for further education or they go back to maybe where they had always wanted to go or their families came from or or whatever go travel the world and you know and they should do those kinds of things but we do keep quite a large percentage here and we gain some from other places who come here and because we have a nursing program here even though it's an OHSU program that we have here now people come here for the wonderful area that we've have here at all the outdoor facilities and all the the theater and and music we have wonderful facilities here I mean and tremendous talent in this community so people come here and realize what a great place it is to live here or to be here and they move here so we gain some from other areas too and but I do think that has been a key reward even is that we do have nurses in our community because we have this school here and starting with the original department so I don't know if that's that part enough but I do think it's been really important and I think it's worth putting a reason that's to put money into it and to put really high quality faculty into it and that really helps that we have it's not just a school of nursing by itself but that it's associated with this university you know and then the other the other thing you asked me about greatest reward for me I think as I was just starting to talk before I think for me it's just seeing the nurses that seeing the students that we had from way back in the beginning and then we see what great people they've turned and great nurses they've turned out to be and some of them return having gotten their doctorates and their teaching you know or things it's just it's so rewarding to see that and it's kind of not exactly the same but it's comparable I think fairly comparable how I feel as a parent I have three grown children love seeing them parent how they do things the decisions that they make relative to their work and the chosen things that they do but but seeing how they teach or the patients they have with their kids like the love that they have and how they live their life that's one of my that's my greatest reward as a parent you know and I feel kind of like that that you know there's a group of us a faculty that talked together for years and we get together regularly and that's one of the things we are always saying we was so grateful that we were nurses we would do it again in a heartbeat you know and it's just the greatest reward is just having been able to have been a part of the nursing profession


Hi everybody, it's Sam at Mixed Up Craft. Thank you for watching my tutorial today. I'm going to be showing you how to use this really cool self-adhesive vinyl by Arteza. I've made some fun shaker cards and I've also pretty much labelled everything in my craft room using this vinyl. So I got sent this a few weeks ago now. I've been slowly working through my latest package that I received from Arteza. So yeah, this has been something that I've wanted to do in my craft room for a while, i.e. labelling things. I do like to label stuff. And yeah, this has just come in very, very handy. So you get 42 sheets self-adhesive vinyl. It says on the back here the Arteza vinyl has stronger adhesive properties and comes in vibrant colours, making it perfect choice for the most permanent indoor and outdoor projects. The vinyl applies easily to most flat surfaces including glass, wood, plastic, metal and walls. So yeah, you can use it in many, many places. So I did briefly show you, I think it was when I done my what did I get video, but I mean these are all not in order anymore. There's just so many, like I said, 42. So just to give you a quick overview here of the colours that you get, look at this lovely silver. Oh look at that, it's like a brushed silver, it's gorgeous. And then you've just got lots of different greens. You've got a, that's almost, yeah, it's like a matte gold. And I'll show you the other gold that I've used. You've got some great Christmas red and that green there, so they're going to be great for Christmas projects.  And then also this one here. And then there's these colours here as well, but I've already made projects with them. So this is a gorgeous yellow. I love that. This pink, which I'll show you what I've done with that in a minute. Then I've got all my scraps here with that beautiful turquoise and that hot pink. And you've got like a baby pink. And then there's that gold, the same as the silver, so it's like a brushed gold. Absolutely stunning. So there's so much here, it's going to last me a very, very long time. But the beauty of this is you cut it in your, on your digital cutting machine, but also it die cuts beautifully. So, and you can cut it, obviously with scissors and so on as well. So I'm just going to show you a few things that I've done. Okay, so here are a couple of shaker cards. This is using that gold. And I mean, these are just really easy to make. I know shaker cards can be quite frustrating sometimes, especially if you've got cardstock and you're trying to add glue and it can get a bit sticky. Whenever I do use these dies, because I've used them for making shaker cards before, I usually add a double-sided backing sheet to the back of the cardstock.  But the nice thing about the vinyl is, is it's already has its adhesive on the back. So this was so quick to do. And there's another one there, which has got all those shaker bits in it. So I'm going to make a shaker card today and just show you how well that does all cut. But also this is using vinyl on other things. So I shared this lazy Susan little, it was a kitchen piece by the pampered chef, I think. I picked it up in a charity shop for a pound. And as you can see, it's getting well used, I've used it loads. But what I'd done, it was plain wood to start with, hopefully nothing's going to fall out. What I'd done is I lined it, I need to got a bit of white there actually, I need to just brush that off. But I just popped some masking tape all the way around the top. And I went over this with Gesso and then using my Cricut machine, I just cut out the word brushes and some stars using the pink vinyl sheet and then just stuck it down. And I've doubled it up, so it's on this side as well, so that when it spins around you see brushes on both sides. But you'll see this better in the pictures at the beginning, and there will also be better pictures over on my blog. But I just love how I've been able to personalise what was once, you know, a kitchen kind of storage piece into, I think, a really fun craft room storage. So that's one thing that I've done using the vinyl. Now I'm limited on space with my camera where I can have it positioned, but this is a drawer unit that I have. And you can see there that I've just labelled the drawers. So I've got two at the top with gems, and I've got two at the bottom with my washi tapes. I do have a lot more washi tapes in the process of sorting lots of things out in my craft room at the moment. But again, just to show you how easy these things are to use. Again, I just use the font I will list on my blog. I think it's just a really nice style. So yeah, that's another piece that I've done. And then what I'll do now is I'll just link in a few pictures just for you to see some bigger pieces that I can't actually get into my camera space here. Okay, so what I'm going to do first of all is make one of these shaker cards and just show you how well it cuts and how easy it is to use it in our card making. Okay, so I'm going to use this turquoise colour and then this cardstock here for the card. And this is from the Chasing Rainbows Fest Edition Paper Pack. This one here is the turquoise colour. They always give you their swatch on the back of all of their products where there are multiple colours. So that's all there as well. Now these are X-cut topper dies. I've had them for a long time and they are just those handy kind of go-tos when you want to make a quick card. So the happy birthday was this one here. Okay, and again if I can link them in I will over on my blog then just for you is this one here. Okay, and then I'm going to use today the Congrats Let's Celebrate.  So if you imagine this pink here actually comes up a little bit higher all the way around. So yeah you just want to give yourself a little bit extra. So you don't have to be exact with it but just roughly make sure that you do have that room.   I used my big shot so it has cut it perfectly. Again depending on what machine you have you know you might have to crank it through a few more times but I'm just going to move this paper out of the way to get all the bits out of the way so you just want to take it out. Again everybody's going to be using something different but with this one here I just need to carefully just take out all of the bits now. So next you well you don't have to have this but it will help a lot and these are just transfer sheets so you can pick these up again I'll share links to and you know any that I can find these I've had again for a long time and they basically just allow you to be able to transfer the image perfectly onto whatever surface it is that you want and make sure everything's lined up. So they're great to use if you're using maybe a word and it's all separate letters you want to make sure it stays straight so for example if it's on your cricket and it's on your mat you can put the transfer sheet on top straight away rub it down peel it off and it will come off perfectly onto the transfer sheet allowing you to then exactly transfer onto something else. So for this here because I've got all these obviously bits and stuff if I was to peel the backing off of this now and stick it straight onto my acetate I'm likely to not get it perfect and maybe stretch some parts of it or some bits might stick onto each other. So again for anybody thinking I still don't understand what you mean so you get the transfer sheet I've used this like quite a lot of times as well so you can get you know more than one use out of it so I just want to stick this although it doesn't cover everything you the transfer sheets you can get in all different sizes this is just a strip one but if you kind of arch it like this and drop it down kind of into the centre first and then kind of go out okay flip it over and push everything down okay so that's now all stuck next I then want to take the backing off and everything stays perfectly square because it's attached to that transfer sheet so okay so now that is ready to then stick on my acetate then I peel off the transfer sheet okay so I've got some acetate here and I'm going to stick focus on the square okay so I'm going to bring it right up to the corner so I can obviously cut the rest of the acetate away and again just sit it down from the middle out like so and then I'm just going to just use this here and just go over and just make sure that it's really stuck well like so and then I can peel off my transfer sheet and when you peel off the transfer sheet you want to peel it off at a real sharp angle so I'm almost kind of pulling this along you know I'm not lifting it up like this and pulling it off just keep it nice and flat and if anything lifts just kind of go over and rub over it again and then pull it off but I'm pretty happy this seems to all be coming off really well so it's just a low tack kind of transfer sheet like so and then I'll stick this back onto this again and I've got that to use so yeah you will get lots and lots of uses out of those so now I have my window for my shaker card so it's just really really easy this is no mess and now I love it so next I'm going to bring in my trimmer and just trim this down okay so that's now more manageable and this is going to go on our card and then I've cut this piece down here so whatever size card you're using this is six by six so this is a five and three quarters by five and three quarters these six by six card blanks are by dovecraft it's their essentials range again I will link them in but this is going to be like this then you want a square that is slightly bigger or if not exactly the same size this is slightly slightly bigger than the piece that you're using okay and you're going to sit that in the middle and run that through your die machine okay so I've just die cut that so we can see now this is going to go on there and then you want to go back to this piece and sit it over there and you don't want anything kind of coming out the edges but you can see now that's going to sit really nicely with this nice frame that's why cut a nice amount around here because what you can do is if it does end up coming over bigger than your frame you can just trim that off okay but I'm really pleased with how that's all coming together so next I'm going to add some red tape because I'm sticking it against acetate just flip over whatever it is that you're using for your frame and I'm just going to run some red tape just along the four inner sides here and then you just want to carefully again always arch things it's a bit easier because then you can focus on the kind of middle if you get that all lined up the rest should fall into place like so okay so now we've got this all ready to pop on the front of our card and add our little sequins in so now you want to flip this piece over and then I'm using the this is the Dot and Dab range by Trimcraft and it's a silicone foam tape the great thing about this is it's clear so you don't see anything when you look in on the side of the card and it's super sticky it's great stuff okay so I'm going to run a strip of it just kind of about a quarter of an inch away from the inside square here and the key when you're using the foam is you want to make sure that you join it right up to each piece because otherwise your sequins will find a way out so when you get it right up to it just really kind of push it in against each other there you don't want any gaps okay like so and then that when that sits now on there slightly raised up and we can pop all the sequins inside so I'm going to use these beads now some people like to tip the sequins or the beads into this part and then flip this piece over and stick it down I on the other hand like to tip whatever it is I'm using onto this piece so decide what orientation you want your card to fold I'm going to have it as a top folding and then because these are beads I'm going to be very careful I do want quite a few in there but I do want to keep them you know inside here as much as possible so just keep adding as much as you want really until you're happy and kind of spread it out making sure you don't go obviously go into these areas because that's where you need to stick it down but bear in mind when you tip your card up everything falls down to the bottom so it might look like a lots in there now once it starts to congregate to the bottom I like mine to kind of fill up quite high okay I'm happy with that so just don't rush it just take your time but I've got a nice a nice amount there and then you just want to remove the backing so the red here so make sure it's up the right way and then carefully sit this over and I just want to make sure I've got an even border on all four sides it's about a quarter of an inch so I'm going to stick that down so you can move everything around look at that it's so cool this is a really noisy card but I just think that's so fun I love making shaker cards so now that will stand up and this is what I mean you want to make sure that you haven't got any gaps because these beads will find a way out okay so as soon as I said water bottle I thought I'm going to go and do it so here is my water bottle this is the one that I usually keep on my desk and yes a good way to remind me to drink water because I always forget so what I've done is I have popped this through my cricket and I've already got my font here so I'm just going to peel this off so you can see exactly what I've got okay so I've just done drink up and I'm just going to take out any of those pieces that we don't want so that one there and then okay now this is where the transfer sheets come in really handy because if I was now to pick these off and stick them and get them lined up and equally spaced it just would be really really difficult so I've got my transfer sheet here you want to make sure that you clean your bottle so I've cleaned mine so it is obviously a nice clean surface I'm going to lie this over the top and then just go over the top here making sure it's really stuck to this because you want it to make sure it picks it up like so and should take it straight off the backing which is what you want again very carefully I'm holding my release paper almost flush with the mat as I peel it back okay so now I have this perfect for me to now bring in my water bottle so I have cleaned this and I've also used some surgical spirit over the top just to really make sure that that is spotless and then I can line this up it doesn't really matter I made sure it was the right kind of length stick that down doesn't matter if there's bits on your transfer sheet because as long as there's no bits actually on the vinyl itself just go over use this as well just to make sure it all sticks down I don't know how long this will last I mean I don't wash my drink bottle like that I rinse it maybe give it a good clean every now and then because I'm just constantly filling it up so we shall see but it's a bit of fun and then again very carefully I peel that back and there you have it my own personalised drinks bottle I think that's really really fun and it's stacked down really really well it's not going to come off unless you really pick it so I'll be interested to see how it does hold up with water on it but yeah for a bit of fun to make a nice little gift again personalise it pop someone's name on it okay so there are my ideas on how to use the self-adhesive vinyl I really like it especially for making shaker cards so I think you're going to be seeing me use it more when I make those because it just makes cutting them and sticking them just so easy love how this has turned out I think it looks really cool and my lazy Susan storage is is my favourite I think but also it's just nice to have everything yeah labelled and I can see it and yeah I probably should tone it down now otherwise everything will get labelled but there's a couple of other bits and I will share those photos either in this video or over on my blog post but yeah I hope you like it let me know what you think let me know if you have any of this vinyl already or if you've got any other ideas I'd love to hear them so pop all of that in the comments below there will also be a 10% off discount code and just pop in the code that there is listed in the video description box and yeah until next time give me a thumbs up if you enjoyed today and subscribe to my channel so you get to see more thanks for watching bye