Hello, Aces, welcome to module four, lesson number two, figuring how much to invest in your restaurant. In this lesson, you're gonna learn about the million dollar question. How much should I invest in my restaurant? And this is the reason why we went over your projected revenue range in the previous lesson. So then that way we can come up with how much you should invest, okay? If you don't know what I'm talking about, definitely jump back to the previous lesson because you definitely need to understand how to figure out your projected revenue range.  It's yours anyways, why should you care?  So definitely understanding your numbers definitely does help. Also, you built this restaurant to realize your dream, something that you're proud of, something to take care of you and your family to achieve financial freedom. So if you don't pay that attention in the numbers, then you'll never get there. And a lot of people, they don't do that. Why is it that they don't do that? It is because it's not sexy, it's not fun. Accounting is never fun. Numbers are never fun unless it's in your bank account. What is fun is marketing, is social media is basically serving your guests, creating the food. Those are the fun things. And that's the reason why so many restaurant owners fail within their first year or even just fail in general because they don't do their budgeting, because they don't care about the numbers, because they only care about the sexy things. And that's the reason why you are in a much better position to succeed because you're going through this lesson. Now, with your projected revenue range, you can figure out how much you should invest in your restaurant. And once again, if you don't know what I mean by projected revenue range, definitely go back to the previous lesson, understand it and determine your own projected revenue range. In the last lesson we talked about projecting your monthly revenue range from $3,000 to $4,500 is a typical benchmark in terms of the range.  You times that monthly income by 12 to make it an annual income, okay? So how much you're making per year that you're projected, okay? And you take two thirds of that. That becomes your investment amount. Once again, your annual income, projected annual income, two thirds of that, okay? Equals your investment account. And to give you an example, with Benzburger that we went over, and once again, if you don't know this example, definitely go back to the previous lesson. It is super important that you go through all these lessons in sequential order. Don't skip ahead because each concept builds upon another. And the examples that we'll be using will be built upon each other as well. And as you can see, Benzburger was an example that I was using in the previous lesson. So definitely check it out if you haven't done so. If you have, let's dive right in guys. For instance, Benzburger projects to make 2,400 per month. On an annual basis, we use this number times 12. On an annual basis, Benzburger would be making $294,000 in revenue. Now what do we do next? We take two thirds of this, okay? Two thirds times this amount equals roughly shy of $200,000. What does that mean? That means Benzburger should have an investment of no more than $200,000, okay? Once again, if you don't understand this, you can simply just pause this video and you can just replay this a few times. The concept should be easy to understand if you still am struggling with this, definitely jump into the group and let us know so then that way we can provide the support for you and help you figure out how much should you be investing in your restaurant's build out. Breaking it down, okay?  It should be inclusive of everything, okay? Even your run rate and your basically backup funds, it should include everything. And this is how much you should be investing in it if it's a 700 square feet burger joint, okay? The investment could be lower, right? And once again, this is only for reference purpose only. So if your investment, if you don't have $200,000, it could be lower than that.  Same thing if, for example, you need a lot of kitchen upgrades or you need a lot of different equipments that specialize to your product development, then the cost would be higher as well. The projection that you got from this whole exercise and the rule of thumb that I'm sharing with you is only for reference purpose only, okay? So it's not a strict make or do or die kind of deal. It is something for you to have an idea of to based upon the rest of the budgeting moving forward. Each country and each city will have their different pricing depending on labor and also the location that you're having your restaurant. And that's the reason why once again, this is a rule of thumb only and on top of that, this whole thing is all about projection. It's not about your real numbers as of yet because now we need to be able to have a benchmark to start from somewhere. That's the reason why we're doing this exercise. In this lesson, you'll learn about how much money you should be investing in your food concept. And the next lesson, we're gonna be talking about how much seating you'll need for your restaurant. I'll see you guys in the next video.


And I'm Keena Nisley and I am here with Think Tech Hawaii and the life of the land is in this real estate. And this week we have John Kiefer from comma I know mortgage groups and most of you know him as Johnny Loves. Welcome John. Thank you Keena. Thanks for having me. I appreciate it. I love what you're doing. This is a great show. So thanks. I'm glad you could be here with us. So today we are going to talk about mortgages and mortgage rates. So the first thing is what are mortgages rates? Not necessarily what are they today, but when are they? Yeah, that's a great question. I wish I wish more people asked that question actually because a lot of times someone will ask me what's the rate today? I'm like, well, I hate to say this, but it depends, right? So when you see the news and you hear the radio and they talk about today's rate is, you know, 3.875. What they're doing is they're complicating, they're getting like an average from the last few days of loans that were vanilla and giving you that number or that rate. So there really is no one rate. So what they do is rates depend on a couple of things. One is the 10-year treasury, traditionally it's been the 10-year treasury. This environment that we're in right now, it's kind of upside down, it's not really following the 10-year treasury. So for rates, you've got a par rate and it's based on how the, okay, let me just back up. Mortgages are bought and they're bought and they're sold on the secondary market as mortgage. They're securitized, so they're traded as a commodity. So that's why, that's part of the reason why there's so many variances in the rates. It depends on how they're trading, but when you watch the economic news, you may see like GSEs or MBS stocks, not stocks, but securities, those are the mortgage bonds. Okay, so when they're sold, when they're sold, they're, they're sold, they're bonded up in a big, a big group. So people are buying millions and billions worth of, of mortgages, the investors are buying them, right? And the rates all depend, a lot of it depends on inflation, unemployment, and things of that nature. So there's a lot of different factors. For an individual, a lot of it depends on your credit score, your down payment amount, the type of property you have, and the conforming loan limit in your county. So there's a lot of different things. It's like a Rubik's Cube to get to that point. So if someone's trying to buy an investment property versus a home they're going to live in, there's a different mortgage rate? Yes, that's a great question. So that's a great question. That leads me to what's called loan level price adjustments, LLPA. And you never have to know that ever again. You can just forget that. All it really is, is those individual adjustments to the rates called an add-on. So for an investment property, it's a little bit of an add-on to that base rate. If it's less than 20% down, it's a little bit of an add-on to that.  It's an add-on for what that is. The better the credit score, the less the add-on. And that's how it gets built out. So when you see the news that says rates are, the Fed cut rates to 0%, we've talked about this in the past, but that's just a little bit of, how can I say it nicely, not messaging it correctly, because that's not the mortgage rates they're talking about. That's the Fed funding rate, which has to do with banks lending each other money between the banks and lending each other money. And it has to do with credit card rates and maybe key locks and things like that. So what are some things that can impact the mortgage rates? Is something that we see that happens that can impact the mortgage rates? Sure. Inflation is the main thing. I would say inflation is a big thing. So let me just give you a little bit of the history of what's going on with the mortgage rates and how they're really being impacted. So when mortgages are sold on the secondary market as mortgage bonds, if they conform to the government standards, they're purchased by two government-sponsored entities called, you may have heard of this, Fannie Mae, Freddie Mac.  They're all just construed on these conventional loans right now. So they're sold and mortgage servicers are the companies that they pay a premium for the rights to service that loan to collect the payment. It's who you write your mortgage check out to every month. So what they do, this is a little inside scoop on this, is they pay about 2% of that loan amount for the rights to service that. Okay, that's what they pay. And then it takes about three years for them to break even. So when mortgages are refinanced quickly, they're kind of left holding the back. It's a loss. Okay. And so what happened in the beginning of March of this year, just not too long ago, was there was a really big refinanced boom. And all of us loan officers were just getting as many loans in there as we could, conventional loans, all kinds of loans. We were just jamming up, filling up our pipelines, saving money, saving money, saving money, saving money. Everyone was like, yes, yes, yes. The world was beautiful place. And then there were two unintended consequences too. The first was the lenders didn't have any capacity left. They were maxed out. There's no, we can't take any more loans were full. The second thing is they were losing, they were losing money. The investors were losing money.  So you're expecting 4% return on this for the next eight years or so. All of a sudden that 4% loan was bought out for a loan at 3.25%. And now you, that's a big loss and you're not getting that back. So the mortgage servicers ran out of money. If they're not there, they didn't have any liquidity left. So they couldn't buy more servicing loans. And so everything was coming to a crescendo. And a bad way crescendo and, and the only, the result was they just put a break on everything. So they raise the rates and say, okay, we can't do no more loans. So we're going to price loans so that the demand is not there. So unfortunately there were people in escrow who didn't lock their loans in time and now they went from a 3% loan to a 4% loan or worse. The good news is that the Fed, the Federal Reserve started buying these mortgage backed securities. They started buying mortgage bonds to add the liquidity back. And they started off, they were buying like 50 billion with a B a day. They were buying 50 billion a day. And then it was 40 billion and then it's down to not today. It was, I think six, six billion they bought only six billion. And, and the, the, the great thing about that is that now the, the rates are stable, the market is stabilized. It's not crazy high. It's actually low, but it's stable. So, so there's, there's some stability there. So, okay, great. So where do you think right now we're stable? We're kind of holding steady. Where do you think they're going to go? That's a great question. Where would you predict? No guarantees. Well, I'm an optimist at my heart at heart. So I, I'm pretty sure they're going to get better when I'm not sure the good news is right now they're still really good. If you fit into the conforming box of loans, 20% down, good FICO score, you're golden. The rates are like best they've been in years. In fact, you don't even have to have 20% down still get a really good rate. If you're, if you have a low down payment, like 3%, then it's going to be, you still do it. It's just not as attractive. The rate's not attractive. The mortgage insurance is a little steep. You can still be done. So that's the PMI that people see on their estimates. Correct. So what's PMI real quick, just so people kind of get some clarification. Sure, sure. So mortgage, mortgage insurance is insurance. You as the homeowner buy to protect the investor in case you default. So here you're coming in because, because mortgages with lower down payments are riskier to in the eyes of a lender because there's a higher rate of default. That's just fact. And you know, they have all those actual tables that explain all that. Yes. And where the risk is everything. Side note VA buyers. Are the top. What's the word I'm looking for? The lowest default rate. Better than even better than the general public. It's awesome. Yeah. All right. So let's talk about what everybody's wondering. For parents. The F word. Yes. For parents. So first of all, I know what is it? So forbearance.  And it was a mistake. Forbearance is basically pushing the pause button on your mortgage. So you don't have to make the payment or you negotiate some, some reduced mortgage payment to with your lender. So that's what I'm looking for. So I'm going to talk about a couple of things, a couple of things with this. It wasn't. It's intended as a last resort. It's intended to help people. That's the intention. The intention. The intention was great. Everyone understands that. What, what wasn't messaged properly and wasn't handled properly by. By the. By the government. By the federal housing finance administration. Is. Is that. One, they made it look like. This is free money. It's like, I don't have to pay my mortgage for three months or six months. Yay. Right. It's not true. The second thing, it's absolutely not true. The second thing is that there is no proof of burden. Like all you have to do is raise your head and say, uh, yeah, COVID-19 is affecting that. I need, I need a forbearance. Done. So now you have people who first of all, they think it's free, it's not free money. It's not, and they think that it's for everyone and it's definitely not. So for those of those who need the, the forbearance on their mortgage. Do it. If you, if that's, if you have to do it, do it. If you don't have to do it.  Please do. Because if you don't, you take it a huge risk. Huge risk. And one of the risks. Is.  Even today, right? Um, I saw a statistic today that said. 19 million homeowners out of work right now. In America. 19 million people who have mortgages are out of work right now. That's a, that's significant. And 10% of mortgages are in forbearance right now. That's huge. That is. And hopefully. Not hopefully, but the ones who are in forbearance needed it. Hopefully they need, because if not, let's say, let's say you're a. Let's say you didn't need a forbearance. You could have paid your mortgage payment. You thought you just want to take a little break. Okay. You've got like a six, a three or six month forbearance period. And something tragically happens or your job is cut unexpectedly. And now you want to forbearance. You're going to have to pay it back as a lump sum. Well, you're already halfway into it. And. At the end of the forbearance period, you're supposed to pay it back as a lump sum. Another thing that wasn't meant. A message correctly. I'll get into that in a second. That's kind of changed a little bit.  That's what they'll threaten. Because they want their, they want their money back. So if you can make that payment, please do. And that goes with your water bill, your electric bill, your cable bill, your phone, everything. If you can make your payments, please do. You're better off in the long run. So as far as, as far as mortgage. Payback. So. So there's two government sponsored entities that we talked about a little while ago. Fannie Mae and Freddie. Well, yesterday. Freddie Mac came out and said, okay. Doesn't have. It's not good. You don't have to be hit with a lump sum. At the end of the forbearance period. We'll work something out. Because I think they've got the, they see the long term where if you've got. You've got. 10% in forbearance right now. You don't want to. Contrary to property belief. Lenders do have a lot of money. They don't. That's not their business. Their business is collecting mortgage payments, not selling homes. So they'll do whatever they can to not have to foreclose on your home. So I think that they've got the poor side to know that we need to negotiate with our clients. And let's, let's work something out. So we all, you know, because our economy needs to keep pumping too. So. So what brought on the forbearance? What made the lenders go, oh wow, we need to offer. What happened? What was that timeline? Yeah. Yeah. So the timeline. So we've got the, the March. Madness. March madness to a. I was heartbroken when the real March madness was canceled. By the way. So there was this Russian refinances, everything's great.  And then. Go forward about three weeks, four weeks. And now you've got COVID virus to the United States. So we've got the March madness, March madness to a, I was heartbroken when the real March madness was canceled. By the way. Hard broken MBA to. So there was this Russian refinances. Everything's great.  Stay home orders. And all these different states finally hit our state of Hawaii. And because of that, the government said, okay, you can go into forbearance as long as you, as long as you have a loan that's backed by Fannie or pray. Fannie may or Freddie Mac. The, the loan that you have with your local bank or a loan that's. And not traditional non-traditional loan. Those aren't eligible for, for, for, forbearance. Those people have to go to their actual lender and work something out. So it's just government sponsored entity backed loans. Fannie and Freddie. Okay. So. So where was that they, uh, COVID virus hit people lost started losing their jobs. And rates started really going higher and higher. This is a few weeks ago. And it was government loans were pretty expensive. It was really night and day from just the previous month. And it was, it was amazing. And, um, So what happened was they, uh, like it kind of got worked out in that, um, the government decided to help some of the investors by continuing to buy these bonds. So they're helping them out. So right now there's a big push in Congress with lobbyists and real estate mortgage and just economic lobbyists that are pushing for the government to help the mortgage servicers. Remember the ones that want the rights to service these loans. Here's something I failed to mention earlier. The, so the homeowner doesn't, if the homeowner is in forbearance, they don't have to make their mortgage payment. The mortgage servicer has to make that mortgage payment to the investor. So now you've got these, these mortgage servicing companies. Who can't collect the mortgage to pay the investor. And they're running out of liquidity. They don't have any funds left. So they're, they're folding. But they're right. And so, you know, the SOS, the 911 call was made up to, to the, the lead, the, the head of the, the FHFA, his name is Mark Calabria.  And he's not helping. And so there's outcry. People are calling for him to be removed from office. He's appointed. They're calling for him to be removed from office. I mean, if you Google this guy, his name is Mark Calabria. If you say his name to mortgage people, they probably won't smile. Because he is not doing our economy any favors. And he's basically saying, just let them fail. And we'll let the larger mortgage servicing companies buy up the little ones. What he, what he doesn't understand is that the little, the littler ones handled two thirds of the mortgage originations last year. And so he says, they can just fail. And it's fine. See you wouldn't want to be, is what he's saying. So, all right. So let's go back. And you're saying that the Freddie Mac and the, the Fannie Mae can be bought. What about VA loans? Can they go into forbearance? USDA FHA. Are they all in that bucket of they can go into forbearance? Also. Okay. One great thing is that they've helped the veterans out. So the veterans out. The mortgage servicers are getting. I wouldn't necessarily call it a bailout. Because they didn't do anything wrong. The coronavirus hit. Hit the country. It's not like, it's not like it was subprime lending or. You know, sleazy lending practices. This is just a pandemic that, that hit our economy and our government decided to shut down. So there was no fault of these mortgage services or lenders. Right. One great thing is that they've helped the veterans out. So the veterans that go into forbearance, they've helped the veterans out. So there's no fault of these mortgage services or lenders, right? So the government is helping the servicers of those government loans. So they're good. That's why VA loans are still fantastic. The rates are amazing for being able. Yeah. Amazing. So one, one. Okay. So I'll connect back up again to the conventional. With Mark Calabria. He, he was getting all this pressure from all these lobby groups, even senators were calling his office saying, what are you doing? Right. He said, okay, okay, here's what we'll do. You servicers make the first four payments. If someone goes into forbearance, servicers are responsible for the first four payments. After that, we'll take it. But you get this Kena. If it's a first time home buyer. We'll, we'll, we'll buy the loan, but it's going to cost you five points, 5%. And if it's, if it's a refinance, like if it's a refinance, a rate and term refinance, we'll charge you 7%. In other words, loan servicer, not the home homeowner. Yeah. The home buyer is fine. They're protected. Okay. But the loan servicer has to pay these extra percentages. That's, that's loan sharking by the government. Okay. Okay. So on that note, let's talk about the new guidelines that there's have implemented probably as a, um, maybe a ramification of all of this has been going on. Absolutely. Absolutely. That's, that's exactly what's going on. In fact, Oh, two days ago and today I got new guidelines from different lenders that we use. One said cash out refinances. We're not doing them anymore. None, zero. And the reason why is because, um, if someone doesn't make their very first payment, the government isn't buying that loan. So whoever funded that loan stuck with that loan. They're just not buying it because the risk is too high in their eyes. So, so one lender said, actually several lenders said no more cash out refinances. And the other one said, yeah, you can still do it, but it's going to cost you three points. So they're hedging, right? 3%. Yeah. On top of what. Let's tell them what a cash out refinance is. Cause maybe some people haven't ever done one of those. We did. Yeah. What's a cash out refinance. All right.  From the equity of your home. So for example, let's just say your home is worth a million dollars just for the math. Makes the math easier. And you owe $600,000 on your mortgage. So you have $400,000 of equity. You can take out 200,000. Into a new mortgage where now your mortgage was 6,000. Now your mortgage is 800,000 and you have 200,000 cash in your bank. So scale it that way. Those are risky. Yeah. You can see why when you hear it that way, right? Oh yeah, definitely. So what are some of the other new guidelines that we're seeing? Sure. You have to have a higher, a higher credit score. Now. Um, the debt to income ratios are. Tired or now. So instead of being 50% so that's income ratio is. Your gross monthly income. Has a ratio to how much your monthly debt is each month. Monthly debt. And your monthly income, whatever that ratio is. So we'll say you make $10,000 a month. Just because the map is easy. $10,000 a month. All of your monthly recurring bills, including the mortgage. The insurance, the taxes, your car loan, your credit cards, everything. The minimum monthly payment has to be under $5,000, which is half of $10,000. Some lenders are tightening up and now it's 36%. So your purchasing power just shrunk quite a bit. For some, for some. For, for borrowers who don't fit that conventional box. I talked about earlier. So if you have a great cycle score, a great credit score. Good size down payment. You know, 10, 15, 20%. Then. And you don't have a lot of debt. Then you're going to get a fantastic rate even today. For sure. So what kind of credit score. Are most of the lenders looking for. That's, that's actually gone through. So it used to be 620 and you can do a convention alone. 620 some, some would go as low as, you know, 605 maybe for getting an exception. Now. They want you to 650, 660, 670 in some cases. I've actually, I've actually seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. I've seen it. With the. Six, 70. In some cases I've actually seen it go. Up. And then come back down within a week. Yeah. So it's just, it's just, I don't know. It's, it's, it's up to the independent lender and how they want to do it. So if somebody is ready to buy a house. And they want to get a loan. What should they do? give them a short version of what do they need to do first if they want to buy a house. The first thing they need to do is call me. That's exactly right. Call, text, or email me. Of course. And the next thing they need to do is all seriousness. The first thing you need to do is contact a lender. That's the first thing because you don't want, you don't want to send, you don't want someone to go shopping for a home if they're not pre-approved because they could be wasting their time. And they could fall in love with the home they can't afford. So let's, let's get them into a price range that one, they're comfortable with. Two that they, one that they can afford to that they're comfortable with. And then go from there. So depending on what kind of work they do. We need their one last one month pay stubs. Bank statements for two, two months. So that's, that's kind of things ID. It's pretty easy. It's much, much easier than it used to be, especially in the digital age. So, okay. So they can kind of do that over the phone, text, or maybe scan any of these documents and you can give them a number. Then you would reach out to your real estate agent. Yes, we always push for your approval. So this has been great because I've learned a ton. And I would love to have you back again because we have a whole much better business that we wanted to talk about. We do have to, we've used our time here. I did want to let everybody know on our next show, we will have Ron Salvador who works with Robert Kiyosaki of Rich Dad Poor Dad. He's a professional cash flow teacher. So he's kind of going to come to us about where we should be investing. Should you still be investing and the direction you should be going. But thank you so much, John, for being with us. And thank you. Tech Hawaii. And this was the life of the land is in its real estate. And I'll see you guys in a couple of weeks. Thank you. Thank you, Kira.


Welcome to Texas Heart Institute Educational Programs on Cardiology in the Time of COVID-19. I'm your moderator and host for this session. My name is Juan Maria Crazier. I'm an Interventional Cardiologist at Texas Heart Institute and CHI Health, Baylor St. Luke's Medical Center, and program director of peripheral vascular intervention at Texas Heart Institute. Our co-moderator today is Dr. Stephanie Coulter, Welcome, Dr. Coulter, and join me during this presentation. Thank you, Dr. Crazier. Dr. Coulter is assistant medical director at Texas Heart Institute and director for Center for Women's Heart and Vascular Health, and also program director of cardiology disease fellowship and director of cardiology education at Texas Heart Institute. Today, we're very fortunate to have two special guests dear to my heart because I'm also really an echocardiographer. And we have with us today Dr. Raymond Stainback, who's the chief of the non-invasive section of cardiology at Texas Heart Institute at Baylor St. Luke's Medical Center. And he's also the vice president of the American Society of Echocardiography and was recently tasked to write the guidelines for echo utilization during the COVID-19 pandemic. As well, we also have, fortunately, Dr. Juan Carlos Plana, who's the chief of clinical operations in the section of cardiology of medicine, section of cardiology and medicine at the Baylor College of Medicine, the director of the Cardio-Oncology Center and the co-director for the Center for Advanced Cardiac Imaging at Baylor St. Luke's Medical Center. So I think this is a wonderful opportunity to discuss how we have taken our medical center in this time of a pandemic and modified things that we are doing and we're going to learn from the policies that we've implemented here and within our division across the state of Texas to better able ourselves to take care of our patients and to protect our staff as well. Thank you. Ray and Juan Carlos, welcome to this program. Thank you so much, Juanco. Thank you. Let's start with the current status of COVID-19 pandemic. As we can see here, from many different countries, the rising number of patients affected with COVID-19. And we can see now that U.S. is leading the world in the instance of this deadly pandemic that's affecting us and increasing in numbers from day to day. As a matter of fact, COVID-19 is the worst viral infection that our society and the world community has experienced since Spanish flu in 1918, when 50 million people died worldwide and 675,000 people died in the United States from viral infection. As we can see, the numbers are increasing exponentially and not only the numbers of infected people but also mortality is increasing exponentially. And it's affecting every single segment of our society. Now, as we can see here, if we look at the forecasting model as far as potential incidence of infection is concerned, we can see that up to over a million individuals can be infected if we continue with the same rate of infection as we are expecting currently in the United States. And as far as peak of infection in most of the areas that we can anticipate, it might happen in a month from now or even a little bit later. So what are the numbers that we can anticipate as far as infection is concerned? It is estimated that approximately between 53 to 79% of population here in the United States might get infected with this virus if we don't take aggressive and very appropriate measures. And the question is, are we prepared for this type of a scenario? Because pandemic is here and it's involving every single sector of our society and also the way we practice medicine. We've noticed that there's, with the planning for COVID-19, there's been great disruption in the health services in our hospital and ECHO labs are certainly not an exception. So to improve the safety of our patients and our staff, we recognize that our patient flow, procedural steps and implementation of new restrictive measures were necessary to determine when and how we perform procedures. We have implemented these measures before the outbreak of this pandemic in our Houston area community in order to be ready for when it hits. So in order to reduce ECHO lab procedures, we've categorized elected and emergency procedures, we postponed unnecessary procedures, we're performing ECHO procedures safely and in certain instances, we've limited the movement of COVID patients into our lab. We're trying to make effective PPE decisions for procedures. And most importantly, we're trying to ensure the health of our healthcare workers and order to deliver the care that we have become accustomed to. So Dr. Plana, can you let us know what the current situation and impact of coronavirus on cardiovascular care is at our institution? So thank you so much, Stephanie. I think that I would like to start with this reflection. This was actually included in the email from the headmaster of the school that my kids attempt. He says we are building the cheap as it sells. And I think that this represents pretty much the sentiment that I have and the rest of my colleagues have about COVID-19. We have the patients now in the hospital, but we are learning on the go how to treat them. The literature is just emerging in front of our eyes. But I want to talk a little bit about the impact on cardiovascular care from the cardiovascular service line standpoint. These are the list of things that we have been asked to address within the last few weeks. Number one, and you guys have already heard a little bit about these PPE. I think that this is the most important one. This is for me, the priority number one. We just want to make sure that our team has the appropriate personal protective equipment that they are safe, that they stay safe so that they can actually care for our patients. And there's not any other way of doing it. We don't want any of our staff, physicians, or fellows to get sick. And number two, cancellation of elective cases. We have got marching orders from the American College of Surgeons, the Surgeon General, and more recently from the Texas State Board about the need to cancel elective cases. Right now, they are allowing us to do emergent and urgent cases, which we call tier one and tier two. On daily basis, I get the list of patients that have been proposed to get procedures. We review them trying to make sure that they are appropriate and that indeed they represent emergent and urgent cases. Bear in mind that we have some guidance from the American College of Cardiology, but sometimes it's not that simple because the patients that we deal with are not necessarily black or white. I'm going to talk about two things in the next few slides. One of the situations that we needed to address. Number one is what is the telemetry admission criteria.  In fact, we talk a little bit more about the TEs and point of care ultrasound. There's going to be a complete section devoted to the management of STEMI cases that Dr. Junis and Dr. Perrin are going to cover. And I'm going to finish up by talking a little bit about the search plan that we have over here at Baylor St. Luke's. Before I talk about our criteria for telemetry and our criteria for echoes in the COVID-19 patients, I need to review with you this very important article because as you will see our strategy for the telemetry criteria and also for the echo criteria is completely based on biomarkers. This is the article by Chi Erol reporting on 416 patients in China. 57 of them died, which represents 13.7% of the population that they are reporting on. And very important, 20% of these patients had positive biomarkers. The one that they use was the highly sensitive troponin I. Very interesting patients who had cardiac injury, the ones that had positive troponins had a higher mortality. As you can see, it was almost 12 times higher were compared to the ones that did not have positive troponins and also a higher incidence of ARDS, 58% versus 14%. So cardiac injury and ARDS were independently associated with mortality, cardiac injury with a hazard ratio of 4.2 and ARDS with a hazard ratio of 7.89. So again, talking specifically about the telemetry criteria, we need to review how frequent these arrhythmias are. The manuscript from Wang et al. also from China reports that it happens in 17% of the cases. Unfortunately, they didn't specify whether they're dealing with atrial versus ventricular arrhythmias. To no surprise, the incidence was higher among those requiring ICUs. And the recommendation that they provide to us is that number one, patients with pre-existing cardiovascular disease should be in telemetry. Number two, patients with elevation in cardiac biomarkers. And number three patients that had severe COVID-19 disease, which most likely will already be in the ICU and will be monitored with telemetry there.  So if you have somebody that is COVID-19 positive or a PUI, then the first question that you ask yourself is, do you meet criteria by Baylor St. Luke's Medical Center telemetry criteria? If the answer is yes, obviously, you will go into telemetry. If you do not meet criteria, then we will do troponins. And if the troponins are positive in admission, then we will admit you to telemetry. We will keep you there for 72 hours and we will train troponins at least once a day for the duration that you stay in telemetry. If you did not get a positive troponin admission, we will get daily EKGs if you will be treated with the specific medications that are mentioned there, calitra, antivirals or plaque when ill. And we do not initiate telemetry if your troponin was completely negative. In terms of the criteria for echoes, as you know, we will frequently end up dealing with patients that have a troponymium upon arrival to the emergency room. We will not get an echo on every patient. We will only get an echo if you are having troponins that are going up with hemodynamic compromise or with evidence of signs or symptoms of cardiovascular disease. If your troponin is elevated when you get admitted to a hospital more than two times the upper limit of normal, what we will do before you get an echo is we will repeat your troponin 24 hours later and we will only consider getting an echo if, as I mentioned before, your troponins are going up. Yes, to finish up, let me share with you what is the search plan that we have over here at Baylor's and Luke's. It's color coded, as you can see here, goes from yellow to orange to red, depending upon the number of patients that we have on mechanical ventilation. So it goes from 19 to 59 to 148. As you can see, obviously, we will need to initially display patients from their original locations from so patients that were in CCU were moved to the cath lab holding area. Patients that were in the intermediate unit were moved to the cardiovascular pre-op area and patients that were in our LBAT and heart transplant units were moved to cardiovascular recovery. I have been asked to come with four different crews of cardiologists that could work along with intensivists and along with hospitalists in the different units of the hospital so that we can create enough manpower to care for 148 patients on mechanical ventilation. With that, I pass the torch back to you, Stephanie and Esbonco, and thank you for giving me the opportunity of being with you guys today. Thank you, Juan Carlos. I actually think that that schema that you've put up is super important. I'm part of an email blog with program directors from across the country who are concerned about, you know, upsurging their medical facility and how are we, can we add value to showing others how we've done it and how we're covering these units, which ordinarily a hospital of our size, which has maybe five or 600 beds at any other time, we really have 30 intensivists at any one time. And to go to a place where you have to cover 150 beds is going to take a lot of manpower and cardiology is one place in the hospital where we actually have a lot of manpower if you can teach us how to work the vents on the on the side. So we're going to have another session as well talking about ventilator management in the future. But Dr. Stainback, thank you for joining us and Ray's going to talk to us now about what we've done to make arrangements for really specifically the echo lab. So thank you. Thank you, Stephanie. And thank you, Dr. Crazier and Dr. Pona. Thanks for setting this up for me as Stephanie mentioned, I've been the chief of noninvasive cardiology and specifically the echo lab here at Baylor St. Medical Center for a long number of years and I have really been in a good position actually when it comes to getting advanced notice from other centers. And first of all, I want to shout out a concern for our patients ourselves and our families, our hearts and prayers grow out to the many patients and suffering from COVID-19. And as each of our speakers had mentioned, while dedication to patient care is at the heart of our profession, we also have a duty to care for ourselves and ourselves and our loved ones and protect all of our patients by preventing spread of disease. And this is from the recent ASC COVID guidelines document that was just published. I did participate in the editing of that document as part of the executive committee. And this was published online. I really recommend that you go to this website. It's published online and the authors on this document included Dr. James Kirkpatrick, who is at the University of Washington, which was one of the earlier centers to experience a large outbreak. This also was presented on a webinar on March the 20th very recently that also came from the ASC. It's a YouTube video as you can see here, and that will cover some of the material that I am going to talk about. However, I think some of this information can be a little bit generalized and one of my aims today is to get very specific. What exactly are we doing in our medical center that you can modify and what are specific strategies you can use? I've given a couple of other sides. The American College of Cardiology, who has actually endorsed our statement from the American Society of Echocardiography. So as we've heard, ECHO is essential to patient care. Its portability is tremendous. That's always been an advantage of our procedure, but the portability also causes a risk. We can spread infection. We can spread infections from outpatients coming into the facility. The machines we use can be vectors that can spread infection all over the hospital and to each other. So very key technique, but also very high risk. And for any facility this and don't forget EKG testing other noninvasive tests, it's a very high area of risk. As I mentioned, today's discussions will be focused on specific strategies to mitigate risk. With that risk individuals, we've talked about these other things to consider our appropriate use criteria. Dr. Pona mentioned that. And I actually participated in the writing of most of the ECHO appropriate use criteria. And I can say this is a complete rethinking of what is appropriate in the COVID era. It's very much focused on what's going to benefit us now in the near term and we can defer other things. There are specific ordering and schedule policies that you can admit, administer in very precise terms so that they're followed out. We've talked about patient classification and whether the patient's low or high risk makes a big decision point on what your plan would be. The procedure type in the ECHO lab we're talking about surface echoes, would they be in the lab, portable, their handheld options. What about T and stress echo, we'll mention those and we've talked again and again about personal protective equipment. And what are the noninvasive other noninvasive equipment environmental vectors that we need to cover so let's go through this. Quickly, I'm going to post this as a PDF to because there's material that you can print out and use as handouts and also modifying your own institution. This is just a screenshot from the cover page of the American Society of Echoes protection of patients and echo cardiography service providers during the COVID outbreak. And it's formatted in this way starts out with whom to image indications where to image how to image and this would include protocols protection for personnel equipment, the role of learners in your lab if you have trainees and other considerations that you may not have thought about. Who to image. I think we can look at the appropriate use criteria mainly from the standpoint of really trying to eliminate any rarely appropriate exam as a start and many exams will come as an order in your lab that they're actually appropriate but are they may not be appropriate in this circumstance. So you need to really think is there a clear near term benefit for this patient that will very much influence your management plan. If not, then you have to question the procedure. Can another high risk test be avoided if we do an echocardiogram look at it in context. We've created, I think it's important to create a triage and approval process and not just perform the echoes that are coming into your lab that sort of the workflow that we've had in the past but you have to really be on top of it and just not have people go out and scan patients. There really has to be a consultation with the ordering physician and a prioritization that's very active and engaged. Patients under investigation. Can we await the coven test results sometimes you know what you know you can tread water. A lot of our patients get orders and we'll have the conversation look at things. And the good thing about this if there's one good thing is under normal circumstances, the lab is running full out doing all the work that we can do. Because we've ratcheted back so much our usual care we actually we actually have more time to think and that's a very good thing to use use that time to really study every case. Discuss the limitations you know in this case could a handheld device be used or could another imaging tests suffice you don't need an echo for everything. A highlight is that the TE procedure is a risk for aerosolization of droplets you can get into the airborne precautions phase and so there you need the N95 mask. PPE conservation becomes an issue if you're doing too many teas you're burning through supplies. Stress echo is one of these things that came up literally after we did a revision of the document and we hadn't thought about the fact that we really should eliminate treadmill or any form of exercise stress testing in the lab even if it's an elective outpatient because of the heavy breathing and perspiration in the room with somebody so we really made a rule that pharmacologic stress only and particularly with our nuclear lab. Some labs do echo research studies that are scheduled. They just appear so you have to actively work the list. What is the research pertaining to. Is it something that can be really deferred unless it's life safety life saving procedure. All of this to say is you have to actively manage the echo order list. It may require calls and consultation but number one identify elective or non urgent exam request and defer. Identify urgent or emergent exam request and perform only these and defer all others so if you got those two for lines of thinking you should be okay and mitigate some of your risk risk is related to the numbers of studies that you're doing and exposure to outside patients especially in this situation with this virus where we have we really have seen that there is a symptomatic spread so you really have to limit who's coming into our lab what is our hospital policy at this point. This is something that's more specific that's in the guideline document this is something that we wrote it's been handed back and forth a couple of times between our nursing supervisor and our technical director because sometimes when I would write things in a bullet last it wasn't exact enough for it to be complied with so we have a policy where outpatient procedures if they're non urgent. They cannot be scheduled. We don't want to backfill where it's something appears on the schedule and then we have to call and cancel and so that's been very effective it's a huge change of practice. Outpatient urgent exams sometimes need to be performed. And they can be scheduled if they're approved with a direct communication actually with me and if I'm not available then I'll refer them to the core medical staff and people have gotten on board with this has been very low maintenance in fact. The inpatient low risk. These can be performed in the non invasive floor area, but we prefer not to perform any exams in the lab if possible we can do portable studies. An exception for low risk is inpatient TEs that need to be done in the lab they need suction sedation we have the procedure rooms downstairs but we don't want to bring bring anybody to the lab that's covered positive or a patient at interest if we rule that out we will bring the patients down.  One thing we were a little bit blindsided by and I didn't really pick up on this and for a while as we have a holding area in our echo lab.  So we had to formally close our non invasive her holding area patients have to be received by a sonographer in the lab taking directly to the exam room and then they're discharged from the, from our exam rooms on the third floor and they go back to their room directly there's no holding area there's no way station where patients are commingled or can that that that really is something we recognize pretty quickly. One of the most important things that you need to do is echo machine modification you need to strip that sucker down, because everything on that machine. If it's a cart model, you have to decontaminate it afterwards and the more stuff that's hanging on the more difficult that can be it increases your risk so our carts have only one probe the probe that will be used. No cables so we have deferred any EKG capture during studies that we've removed the cables. There's no stickers on the card. We do two second capture with normal rhythm if it's tachycardia we can if they're brady cardiac we can go up to three seconds. That's driven by the sonographer. No gel bottles. We only carry single use disposable gel containers they become in foil and you can use them if you're worried about your supply you can create your own squirt some gel into a bandage cup something like that use it and then throw it away. And these are for our low risk patients. Now, what about the high risk patients. These patients may not be transported to our lab area. Only nuclear studies are an exception that we have we can sterilize the pet scanning room if we have to it's a closed environment and base of dilator stress only this would be a rare indication. The studies are always performed in the patient's room. Very important here. We have an ordering system where almost by default it gets people to order a comprehensive exam and this is a long study which can if you do all the images it can be up to, you know, 80 100 loops. We have defined a limited protocol exam that will be performed by default, as opposed to a full echo but a full echo protocol can be done if needed, and we just adjudicate that on a case by case basis it certainly can be done. Another thing is with people calling down and wanting studies on patient under investigation or high risk we we are keeping a log system if it's a patient under investigation, particularly we note it in red so that we kind of go back and make sure we determine whether that patient had a positive or negative test and that person had to perform that study. Lab surfaces is something that actually came up in the guideline documents we weren't as attentive to that even at baseline as we should have been so daily assignment for am and late p.m. are in the afternoon and update any two or three times a day, who's going to take responsibility for surface cleaning of all your keyboards, your computer mouse door handles and other surfaces. Again stripped down machine for all all the machines we don't have any machines that have all the paraphernalia anymore. Protocols I've already mentioned the problem focused limited protocol now I have to be very clear that a limited protocol never means just a two dimensional study we need for the text to do a limited protocol but they apply all the 2D views they use m mode. As appropriate and the Doppler protocols to address the indication and to detect and adequately assess unexpected pathology so these can be short exams are more extensive but this. But the main thing is to defer all non essential exams and avoid these long exams where there's more protocol you know exposure. This is also a limited 2D and mode and Doppler protocol. I get this question all the time this is the one that we use in our lab is the default protocol now this is a new thing, regardless of the order type. A comprehensive exam can be done with approval and the thing is here we found that you know this is kind of a scout exam we would use before some of our stress echo studies where we had no prior. And they did sort of a stress study in a high risk patient so it's a 10 to 15 minute at most study with 30 to 40 views. Okay, we're going to get wall motion ejection faction pericardial fusion yes or no significance required right atrial and PA pressure LBOT stroke volume screen and appropriately evaluate for significant valve disease we're not going to bend over backward if they have mild to moderate MR. And if there's a pericardial infusion so this is our protocol you can adjust it. It includes IV sailing contrast when appropriate contrast agent when appropriate so take that there you know don't you don't want to have to go back. Key understand the indication and a properly address without having to go back be prepared. So we have our to go packs. We take IV sailing contrast infusion with paraphernalia if needed. Evaluate the patient risk you really have to understand that and be prepared for the proper PPE which I'm not going to go into here. The exam can be extended or abbreviated if you've got a physician standing there and says this we have everything we need done in our ICUs that the first COVID patient we did I went up. We have a glass door. She asked you know I could have gone in to do it and I was ready to she was far more experienced with PPE than I was. Because they they use these for influenza patients I mean it's part of their routine. I had was more deer in the hairline headlights and she was but she did the exam. I could see the screen through the window and I said we're we're done you know you get out of there with all it was a half a half patient with no valve disease. The right atrial pressure was high we got the pressure we were done. And so if there's somebody kind of guiding the state that's one thing that's possible. You don't want to take any paperwork folders or worksheets into the exam room if you bring those back to the lab and they're contaminated. It's bad. No end of you know no bottles the jail packs like I said in the how to image category in our guideline document there's personal protection we talked about this this is not something I'm going to review in great detail. Other than to state again that with standard care we have to assume everybody could be infected meticulous hand washing hand sanitation gloves. I think we're going to have more discussion about wearing mask more often than we have been. Droplet precautions for patients that are suspected or proven positive gown gloves head cover mask I shield airborne precautions if there's a risk for aerosolization so that's the transesophageal echo patient suctioning a vented patient and you're in the room high flow oxygen this has to be something that we're very careful about. This is a slide capture from the very wonderful webinar that's it's not very long that's similar to this you know it's this is Dr. Daniel chair towel from the NIH allergy infectious disease he gave some great perspective on this. Human to human red human to human spread. I think it's very important to teach your sonographers about this if they're not. You know, savvy and just even lay people who are coming into the hospital these large respiratory droplets are thought to fall to the ground within six feet and a mask can block them airborne is not what we normally would treat on the street. CDC guidance for personable protection. Again, I'm not going to cover that in detail in this specific talk other than to say that we are really having to balance risk with the potential for scarcity in this environment huge topic of conversation. How to image probe and cart disinfections. Again, these should be integral to the usual standard of practice and labs at baseline a hospital should be experienced for donning and doffing PPE and decontaminating machines for hospitalized influenza cases, which is very similar to coven and mechanism of spread.  This is a situation. So, the main risk with coven is just the increased numbers of exposure so we have to be very careful and meticulous and just not let our guard down take that extra time and think. Let's talk about environment of care which is huge in an echo lab their desk keyboards computer mouse phone doors doorknobs people love to come to our reading room and congregate and hang out and socialize and we love that. It's toast right now. This is our reading room. Look at the gel thing that Lynn had placed by the front door I was like, yes, because you know you have to go find these things it needs to be right there we leave the door open so that's one less doorknob. Look at, look at the social distancing here. The fellow is on his phone there's one attending reading as old as analyzing a study. So that's, that's what I call real social distancing some echo labs are very crowded and you have to keep that in mind. And you may really have to do remote reading to do that distancing, keep any paperwork out of there and somebody.  I had to do a personal disinfectant inventory because I saw the stuff around and our text know how to use it but I what what are these different things so know your facilities approved disinfectant agents and approved applications we've matched these to our vendor recommendations. The purple one is for all surfaces it can actually be used in different situations the other ones are either bleach based or alcohol based primarily and they have to be very adequately available and in the right numbers you can't really run out. You have to read the instructions, I want to emphasize that if you've got a contaminated probe.  Look at look at probe sheets and use of handheld devices also these are a couple of different types of facility probe sheets that we had their sterile that can be used in the cat lab they can be used in procedures where you really need a sterile probe because of a wound. There's blood also in line placement so the one on the right actually a line placement kid and it comes with the gel pack and little little gizmos to put your needle in and the reason I'm talking about handheld devices here is because the handheld devices are actually an opportunity to have a completely contained system.  And so this can be very helpful notice that the smartphone this is one vendor their other vendors other types of devices which all work very well in this environment. Many of them are working with smartphones in the face of these will work through the sheath cover allow you to visualize the exam use controls very important I think cardiologist in particular and pulmonology is going to learn much more about the progression of illness looking at the lung windows and these things. And remember to if you've got a trained person that can do an adequate handheld device, they can do a study while they're already in the room taking care of a patient. Rule out heart failure reduce versus normal ejection fractions you scratch screen for pericardial effusion plural effusion screen for valve disease. Sometimes you know look at the right age pressure they can do this and and may negate the need for an echocardiogram to be done where we go in with a sonographer attending and burn through another PPE set. We are actually implementing that strategy. And we are going to be doing that in a very very short time period. And we will very soon catalyze by this whole movement. Here's a cart that has a cream covered a clean green covered T to go pack. So this is a pack that's got our t pro Bennett, or any of your other equipment's in a in a nice green clean bag, and that includes a contaminated bag for return. and is returned, although we do clean outside the room directly inside too, if necessary. Here you can see one of our machines outside of the room and she's put a screen cover on it. So this controls the screen and the console, which has lots of little nooks and crannies for droplets to get in, impossible to clean. We like to use these from the CAFLAB. They're actually the screen covers for the X-ray covers. I don't know what if we'll run out of them. To me, they look like laundry container bags, but they're much tougher and you can work and easily remove them. There are sterile console covers, which I find tighter and hard to work around. There at the bottom right, you can see her in the room. She's scanning a patient under investigation. She's got the screen cover on. She's gowned, gloved appropriately and she's got an eye shield mask over an N95 mask. The N95 mask in this condition was thought necessarily because of the high flow oxygen the patient was on. I will note the absence of a head cover. After exam probe disinfection for a high-risk patient, many labs, especially peripheral vascular labs, have a closed system, high-level decontamination, device and we forget that at baseline, we're supposed to use this, especially in PV lab where there are a probe, may touch a wound, blood, a mucus, membrane. We actually have been using it as belt and suspenders for cases where we don't do this. It's gonna, this can kill C-diff spores and everything, but we like to use that. If you don't have that available, then try the probe sheath usage. If you have the sheath available and there can be supply issues there, you can use the probe sheath. Then when you take that off, wipe it down. If you're going bare, no sheath, immediate post procedure, wipe down in the area of that wet time up to two or more minutes where if it dries out, you wet it again and keep doing that, that's the sidle period. Then you can take it downstairs, it dries out and we wipe it again. And then it gets this seal of approval. So we see if this little, this covers on it, it means, hey, this probe's ready to go, it's clean. And we treat them all this way. Huge headache, but worth it. Here's the individual gel packs. Like I said, you can make your own. Remove, this is what the stripped down machine, this folder would stay outside the room. We've got that covered, ready to go, clean probe. There's nothing on the machine except one probe. No miscellaneous equipment. And to wrap up, I really love this, seeing this particular presenter at our webinar that the ASC put on. This is Anita Sajapur. She's at Duke University now, but she represented her hospital at the Rajay Cardiovascular Medical Center in Tehran, Iran, which has had one of the highest outbreaks. And I think it's very representative of the fact that, we have a great debt to these other institutions that sort of paved the way, we've learned from them and we've had this window of opportunity that we can take advantage of. And she said that the current time until now, none of the Echolab personnel who had followed the PPE have been infected with COVID-19 at that facility. This is tough to measure. I think some of our staff, we don't know if they got exposure outside the hospital, very difficult, but I found this, I did sigh a relief when I saw that. And so I wanna encourage everybody that this stuff works. It is very scary, but if you follow the recommended precautions and protocols and really in a detailed way, and it gets to be your practice, then I think we're gonna be okay. In conclusion, I'm showing a summary of recommendations. It's nice to have some bullet points just to refer to without going into so much detail. These are from the ASC's guideline statement. A review of what type of PPE is recommended in different situations. And I'll say that these are from the CDC guidelines. Indications, I will not review anymore. There are a lot of indications for echocardiograms. The other societies are recommending that we use these judiciously despite the indication as much as the echocardiogram can be crucial in caring for patients. So thank you. And here are my email addresses if you have any questions. Right. Thank you very much on this very detailed information, particularly related to the ASC guidelines that have been done in advance. I believe this will be available in a PDF format for those that are interested. I would like to conclude this program by thanking all the participants, Dr. Coulter, Dr. Plana, and Dr. Steinbeck for your very valuable and very up-to-date contribution to this program, COVID-19 in cardiology. Now for those of you that have tuned in to this program, I would like to inform you to join us for our next program on the impact of COVID-19 in cardiac cath lab that will be available soon. Thank you very much for your participation.  And I think it's important, not only for saving lives, but also for educational purposes. Thank you once again. Thanks, Dr. Grazier. That was great. That was great. Thank you guys.