My name is Donna Prosser. I am the Chief Clinical Officer at the Patient Safety Movement Foundation. We're excited today to bring to you our webinar on airway safety and taking name at zero preventable deaths and harm from unplanned extubation. So I am very excited to introduce to you today Dr. Art Canowitz, who is going to be our moderator for this session. Dr. Canowitz is the founder of the Airway Safety Movement and is also the co-chair of our Airway Safety Work Group here at the Patient Safety Movement Foundation. Good morning, Dr. Canowitz. Good morning, Donna. Thank you very much. I appreciate that. Looking forward to an exciting webinar this morning. I always like to start with why. Why do we do what we do every day? Why are we doing this with unplanned extubation, trying to get to zero preventable harm and death? And this is Drew, Drew Hughes. Many of you may already know Drew's story, but Drew died a preventable death not from the minor head injury that he sustained while skateboarding. He died from a number of medical errors that started when his life-sustaining breathing tube became dislodged. And Drew, like Naveen Marcos, Naveen suffered a severe brain injury while under anesthesia for a simple appendectomy and Mason Reston Wally, Mason died at eight days old when his life-sustaining breathing tube was dislodged in the ICU. And like Drew and Naveen and Mason, there are thousands of people who are harmed or die every year because of unplanned extubations. There's a lot of work going on around unplanned extubation. We still have a long ways to go. So I'd like to start by introducing our panel. First, I'd like to introduce Dr. Berkow. Dr. Berkow is a professor of anesthesiology at the University of Florida College of Medicine and is currently the president of the Society for Airway Management and is my co-chair for our Airway Safety Work Group. Dr. Candle is an assistant professor of pediatrics in critical care medicine at the Yale School of Medicine and is the deputy quality and safety officer for Yale New Haven Children's Hospital. Dr. Lofton is the senior VP of integrated and acute care services and the chief nursing officer at Parish Healthcare in Titusville, Florida. Dr. Lyron is an associate professor at University Hospital's Rainbow Babies and Children's Hospital in Cleveland and is the clinical director for the Children's Hospital's Solutions for Patient Safety Network. Kevin McQueen is the regional director of respiratory therapy at the University of Colorado Health Memorial Hospital in Colorado Springs and is the Colorado Society for Respiratory Care State President. And David Hughes, obviously Drew's father is the president of the Do It for Drew Foundation and a very active patient advocate. So I'd like to welcome all of our panelists. Before I start with our questions, I'd just like to let the audience know that we have a new Airway Safety video series that is available on YouTube. The links are shown on the slide here and will be available for you to obtain. These are excellent videos about the different phases of unplanned extubation and the things that are going on to try to get us to zero preventable deaths and harm from unplanned extubation. Okay. And so I will start by asking Dr. Burkow. Dr. Burkow, you've published numerous articles on unplanned extubation, stating that it's a problem that is both common and costly. Certainly there's a plethora of literature supporting this assumption, but I would like if you could summarize for our audience just how common and costly this problem really is. Sure. Thank you, Dr. Cantowitz. So first I want to give everyone a definition. So unplanned extubation is defined as the unplanned or uncontrolled removal of a patient's life sustaining breathing tube. This can be accidental. It can be dislodged or removed during patient positioning or transport or during suctioning or manipulating of the endotracheal tube. Or it can be a self-extubation where the tube is removed by the patient either due to inadequate sedation or restraints. It can occur in any location when a patient is mechanically ventilated, in the ICU, in the operating room, in the emergency department, in procedural areas or if patients are being transported from one place to another. Now the incidence varies in the literature. It's reported to be from 0.5 to as high as 35.8% in adults which adds up to over 120,000 patients per year who experience this event. And it may be as high as 80% in pediatrics and neonates which adds up to almost 80,000 patients per year. And there are many risk factors for why this occurs. Things like inadequate securement of the endotracheal tube, inadequate sedation, lack of physical restraints, delirium or confusion which can lead to agitation or an unclear or lack of an extubation plan or pure protocols to monitor these tubes are all risk factors for unplanned extubation. Unplanned extubation leads to a prolonged length of stay as well an increased cost and also contributes to many complications such as aspiration, pneumonia, damage to the vocal cords when the tube is removed, hypoxemia which can lead to hemodynamic instability, brain damage and even death. Then often these patients need re-intubation after this unplanned extubation and this can be challenging due to airway edema. So this increased length of stay and the morbidity and the mortality associated with unplanned extubation leads to 5.5 billion extra dollars that are spent yearly due to unplanned extubation. Now, despite these numbers, unplanned extubation is still under-recognized and often not tracked by hospitals. So the true numbers may actually be even higher than what I've given you. And the major reason for unplanned under-recognition of the problem is lack of awareness and education. Thank you, Dr. Burkow. So as the president of the Society for Airway Management, you started a special committee to increase awareness and prevention efforts around unplanned extubation. Would you describe for the audience what this UE Awareness and Prevention Coalition is? I'd be happy to. So this coalition began as a special projects committee that was formed by my Society for Airway Management to address unplanned extubation. So the committee had a few meetings and after we met a few times, we recognized that the most important first steps were to increase awareness and education about the problem. Since as I mentioned, many hospitals were not aware of or tracking unplanned extubation as a problem. And the committee recognized that we needed help to get this message out. So we reached out to many medical societies and patient safety organizations to collaborate in increasing awareness. To date, over 20 societies and organizations have joined this coalition, including the American Academy of Pediatrics, the American Society for Anesthesiologists, the American College of Emergency Physicians, the Society for Critical Care Medicine, the Society for Pediatric Anesthesia, the American Association for Respiratory Care, the American Association of Nurse Anesthesis, and many patient safety foundations, such as the Patient Safety Movement, the Anesthesia Patient Safety Foundation, CMS, and the Children's Hospital Solutions for Patient Safety Network. Now, together, this coalition has published over 20 peer-reviewed publications, both in print and online, in a multiple of different multi-specialty society journals. And we've participated in several social media campaigns. The coalition has also worked with the Patient Safety Management Foundation to update the actionable patient safety solutions documents, 8A, which addresses airway safety, and 8B, which addresses unplanned extubation. We've updated these yearly with the Patient Safety Movement Foundation, and the most recent updates just got published. We also recognize that 8A and 8B didn't really address pediatrics or neonates. So we worked with the Patient Safety Movement Foundation to create two additional documents, 8C on neonatal airway safety and 8D on neonatal unplanned extubation. And those are now available as well. Thank you. Great work the coalition's doing. One last question, Dr. Burkow. We are obviously currently in an environment where everything around us is about COVID pandemic. How has COVID impacted the risk of UE and who is now at risk? Sure. Yeah, I definitely think that we've tried hard to make unplanned extubation even more of an issue now that the COVID pandemic has started. The COVID virus has led to a very significant increase in patients who need mechanical ventilation. With severe illness, these patients often develop severe hypoxia requiring mechanical ventilation. They develop pneumonia and they may even develop adult respiratory distress syndrome which may require prolonged periods of mechanical ventilation. In addition, many of these patients are placed in the prone position to improve their oxygenation and ventilation. And proning is a known risk factor for unplanned extubation. And these patients are often altered between prone and supine and prone and supine often during the course of one day. There's also been a reported very high secretion burden in these patients which has resulted in obstruction of their anatrocule tube requiring urgent re-intubation. And that's another potential cause for unplanned extubation. Many of these patients develop severe hypoxia which can lead to agitation as well. And there's an increased challenge as well is that now we have an increased exposure risk to our providers who are managing these patients during aerosol generating procedures like unplanned extubation and re-intubation. So you really need full personal protective equipment to reduce your exposure risk as well. And that's something we really haven't seen before related to unplanned extubation. With some of these COVID surges we've had staffing ratio challenges and often there have been recruitment of less trained personnel to manage these ICU locations. And imperfect staffing ratios and inadequate training is also a risk factor for unplanned extubation. Dr. Burkow, thanks very much, appreciate that. I'd like to turn to Dr. Candle. Dr. Candle, in December of 2018 you published an article in the Journal of Pediatric Quality and Safety entitled reducing unplanned extubations across a children's hospital using quality improvement methods. Would you please describe for the audience the results of your study and tell us what was the biggest contribution in achieving your significant reduction in UE both in the NICU and the PICU? Sure, I'd be happy to. Thank you, Dr. Candle, and thank you, Dr. Burkow, for such, I think, a good overview of what unplanned extubation really is. So our journey with reducing unplanned extubations began probably over 10 years ago in our pediatric ICU. In 2014, we began to move these efforts to a quality improvement initiative that went hospital-wide. So this would include then both our neonatal ICU, our pediatric ICU, our cardiac ICU and our OR areas. The hospital campaign really was the focus of the manuscript that we published in December 2018. And we were very excited to report that over a two-year timeframe, we were able to reduce unplanned extubations by 75%. So we went from a rate of 1.2 down to 0.3, and this is in per 100 ventilator days. We were equally excited to show that we were able to eliminate unplanned extubations in our pediatric ICU and sustain that for over a year. And then when we looked, narrowed it down, the neonatal ICU rate was a low rate at 0.3 per 100 ventilator days. And this really was one of the lowest reported rates. In the article and sort of through our work, we really identified that there were several key drivers that included the standardization and securement of the endotracheal tube, strategies for higher situation, and probably the biggest one was the safety culture. We did several different QI methodologies. We had a lot of PDSA cycles, those planned do study ACT cycles to improve processes. We looked at each event. We did a full thorough review of each unplanned extubation. We, as I said before, we really think the main driver for the changes that we saw was around the culture of the ET tube securement and maintenance of it. We really increased vigilance and awareness. It really became everyone's priority, the attention to the tube, as well as accountability for the securement. We realized it was a team effort. It included the frontline staff, the physicians, trainees, nurses, respiratory therapists, even the hospital administration and the quality and safety group needed to be involved, as well as the families and the patients themselves. Overall, our goal was to build this culture of safety around the tube. And I think it was through this that we were able to reduce our rates by 75%. Excellent. Obviously, you guys are a best practice and thank you so much for sharing your work through publication and really getting the word out there on a best practice of how to take aim at zero. For smaller centers, there may not, for smaller centers, sorry, for smaller centers who may not have a large quality improvement team and they may not have buy-in from their hospital executives, how would you recommend for them to start this work? That's a great question. I think such a big task can be overwhelming. And so I think like any problem, you really have to start small. You need to know what's happening at your institution and sometimes that's walking into the unit and seeing how the tube is secured, you need to talk to the frontline staff. A lot of the work started when we realized that the two tapes that we had used to secure the tubes was being changed. And so all of a sudden there was a big concern from staff about how were we gonna change things, what new tape we were gonna use. So you really need to start small, know what's going on with your institution. And then I think moving from there to use those stories. So people need to know about the tube coming out and they need to know how that affected that patient and what that might mean for that patient, not just that it came out. And then really recognizing that safety is not something you can delegate. You can't just assign it to someone and say make this better. It really is an individual responsibility from the frontline staff all the way up. And so I think if you lead by example, if you're a present and talking to staff about it, it becomes contagious in a good way. And then last, I would say use the network. So there really is a great network out there. And I think Dr. Burkow listed plenty of opportunities of ways to get information about it. The PSM platform is a great opportunity and has many resources available. And really just get a lot of allies on your side and use that information and then share that with the leadership. Thank you. I noticed in your video that you produced that will be part of our video series that you had the word salad in your presentation, the names of many of the children who had been affected. And that really struck me as something that's important is that we always have to make sure that this is not just a clinical event. These are people who are being affected. And I thank you so much for bringing that to light. All right, I'm going to now turn to Dr. Lyron. Dr. Lyron, you're the clinical director of the Children's Hospital Solutions for Patient Safety Network. Could you please tell our audience about SPS and more specifically the work that is going on in your organization relative to improving unplanned extubation? Sure, thanks so much for the opportunity to share and participate. So the Solutions for Patient Safety is a nearly 12-year-old collaborative now of about 140 children's hospitals in the United States and Canada that has a mission to eliminate serious harm to actually both patients and employees in children's hospitals. The collaborative sprang up in the state of Ohio where an enterprising group of the eight CEOs of Children's Hospitals in Ohio frankly grew kind of tired of talking only about Medicaid reform and decided instead to break down the barriers of multi-institutional collaboration to keep patients safe. So since that time, the network has really grown obviously and enjoyed partnerships with CMS and the Children's Hospital Association and others to promote safety while standing firm to really some core principles including a refusal to compete on safety, acting with a sense of urgency, relentless attention to the culture of safety and organizations which we believe significantly contributes to harm. And really the need to explicitly support and address the safety of employees and staff whom we value as people and friends and colleagues and whom we also charge with keeping our patients safe. So our efforts that include like around 17 work streams at this point encompass many of the most common harms that happen in children's hospitals including old favorites like central line associated bloodstream infection and newly appreciated harms like nephrotoxic acute kidney injury and peripheral IV infiltrates and extravasations. We do leave benchmarking and research primarily to others and focus on process improvement and culture change. So there's a lot of job security and patient safety, right? We never lose sight of our mission and how much work there is to do but we're also proud of our progress. So we estimate that we have spared over 17,000 children from harm with our work and averted about $388 million from the healthcare system. We have published 10 evidence-based prevention bundles. So unplanned extubation is one of those and it became an official work stream within SPS just under four years ago when we first started we had some predictable pushback that will be familiar to many of you on this call. Things like we don't actually have that problem here. I'm sorry, you do. And this is just the cost of doing business and have you seen the size of a premature infant's trachea?  So despite that, in mid-2016, I think it was about 50 hospitals volunteered to begin to work together to understand and improve the rates of unplanned extubations. And we started with a session where we brought together passionate content experts from all over the US and Canada and said, what are those factors that we could test that in your expert opinion are potentially associated with a decrease in unplanned extubations? And that's really where we got started and really proud of the progress that we've made since then. Thank you, excellent. So in April of just this year, you published an article in JAMA Pediatrics, which I believe was the first multi-institutional national quality improvement initiative led by the Children's Network. Can you describe the results presented in that study? And perhaps you can share with our audience the QI bundle that was used that led to the significant reduction in unplanned extubation. Sure thing. So that was the result of the work of that group of 50 hospitals that I referenced. The study that I think was officially published in print in June, in case you wanna hunt it down, ultimately included 43 children's hospitals. And that group, I think Yale, New Haven, I think Sarah's hospital was part of that as well. But that group decreased unplanned extubations by 24, a little over 24% from a rate of 1.135 per 100 vent days to 0.86. So this included statistically significant decreases in the NICU, can you believe it? And the PICU, interestingly, as many of you know, one of the most catastrophic effects of an unplanned extubation is cardiovascular collapse. And this group was able to demonstrate a 37% decrease in unplanned extubations associated with cardiovascular collapse. So the way they did it is they had the 43 hospitals choose one or two factors to implement in their hospital and then measure reliability to them because there are many times that we think we're doing stuff, but when we actually measure it, we re-appreciate, it's sort of like hand hygiene, right? We, oh yeah, we all wash our hands until we actually watch and see that 62% do. And so the same was true with the unplanned extubations and the two factors that we tested were then independently analyzed to test their association with a decreased unplanned extubation rate. So the first one was standardized anatomic reference points and secure methods. So there's, when we started a typical hospital would have a tremendous amount of little individuals would have their own way of doing things with respect to secure men, et cetera. And the second one was a protocol for high risk situations. So things like turning a patient over that Dr. Burkow was talking about with COVID patients or moving them for X-rays, et cetera. And both of those were independently associated with a decreased rate of unplanned extubations. We also tested another factor that we, that's a multidisciplinary apparent cause analysis. So one of the things, this kind of gets at the culture piece of it. So every time an event happened, hospitals would be expected to immediately gather together the relevant people and have a structured discussion about the event and document what the issues were and of course that was a wealth of information to us as a collaborative to kind of understand where our failings are from a process standpoint. We were not able to show that having those events was associated with decreased unplanned extubations, but just not, I don't think there was a single hospital that didn't wanna continue doing that moving forward. So that's become a common practice among the children's hospitals in our group. So we are, those are again, those are reflected in the article we published. We have, we're not done, you know, 24% is a sizable decrease across 43 hospitals, but we have a lot more work to do. And I would say that it falls into two categories. One is we have 140 hospitals in our network. We still have some who say, oh, you know, I'm really sorry you have a problem with your unplanned extubations. And we're still working on the will end of it. Others are working hard to increase the reliability with this factors, but we've challenged our hospitals by the end of 2021 that we went, we want 80% of our hospitals to have UE rates under one as just a place to start. And we're also working on, we also have another group cohort that's working on a new factor that they're testing related to chest X-ray film quality. There's, we learned from our parent cause analysis that getting X-rays and then repeating the X-ray because it wasn't right and they couldn't see the tube or the lung fields or the clavicles are twisted or whatever was a major, a major problem. And so that's currently the factor that the group is trying to work on and increase reliability on to test its association with decreased unplanned extubations. So lots of work ahead from us from the C suite to the bedside to try to decrease unplanned extubations in kids. Great, thanks so much. So I'm gonna make a comment in the last year, three hospitals, three adult hospitals, Parish Healthcare University Health Memorial and University of California Irvine all agreed to begin work to develop an adult network of hospitals really patterned after your organization, the children's network. The plan is to try to bring these adult hospitals together and implement proven best practices from the pediatric and neonatal experience, track the data to demonstrate, do these changes apply? And then obviously what you guys do, share the best practices and help try to drive adult hospitals towards zero preventable harm. This group is really in the very, very early stage of organization, but hopes to be able to show similar results eventually once we get our act together. So Dr. Lyron, based upon your children's network solutions for patient safety best practice successes that you've already really proven, what is in the future for the children's network? Any major new things coming up in the future? And do you see an opportunity for some collaboration to help our new network as we try to get started? Sure thing. So on the first question about what's next for us, I think there's no one solution to this, right? And when you're looking across so many hospitals, where hospitals get stuck is very variable. So we're trying to acknowledge that and meet hospitals where they are. So I mentioned that there's a group working on sort of this sexy new idea around chest x-ray. So that part will happen and we'll see if we can get some new evidence on that. But we've got evidence on the other interventions. So now we just need hospitals to do it. So one thing that we launched a few months ago that I just two days ago got some data on that's really starting to work is we actually divided our hospitals into cohorts, smaller group cohorts based on what is the problem in front of your face right now? Do you have executives that aren't bought in? Do you have clinicians that aren't bought in?  Do you have equipment issues? Are you still struggling with the taping business? You know, so what are exactly the problems and putting people together in groups to address those specifically rather than one kind of massive group? And then we are hitting our executives and board very hard with stories that are compelling like Drew's and unfortunately many, many others in our network. We have one of the things that I would say compared to some of the other problems that we tried to solve in our network that's an advantage is if you are a clinician that has been in a bedside of a child that has died or nearly died by the grace of God, did not, from an unplanned excavation, you can be a real strong advocate and finding those people and using their story too in front of boards of trustees and things like that has been really, really useful and something we continue to try to, for lack of a better word, exploit or expose. With respect to the adult hospitals, I'm just thrilled to hear about that. I think that, you know, this is nothing proprietary about pediatric excavations and the opportunity for us to share what we learned is something that I would welcome. I'll tell you something that you should think about early on, which is that over 50% of the hospitals in the solutions for patient safety, are children's hospitals within large adult systems? And so they're actually just across the walkway from you doing it. And so maybe kind of cross-checking the folks that are interested and passionate about it on the adult side with the list of children's hospitals that are participating. And again, if there's some way I can help with that, I'm happy to. But those are gonna be great learnings. I'm sure Sarah, we often, many, many times hear stories of the work that's happening in our network, whether it's on unplanned excavations or something else, influencing the adult side. And this is a great opportunity to kind of take advantage of that relationship. Great. So much, so much appreciate all you are doing for this. I'm gonna turn now to Dr. Lofton. The Patient Safety Movement Foundation has published clinical guidelines, which are actionable patient safety solutions for reducing UE. You've heard several of our speakers talk about that. Specifically, the actionable patient safety solutions for unplanned extubation. So tell me what prompted your organization to address UE and what quality improvement steps have you put in place here in a adult hospital environment? Well, Dr. Kenowitz, thank you so much and appreciate everybody's input so far today. We began the journey of focusing on airway management and safety really in 2007. We've been very fortunate. We adopted performance improvement projects and methodologies at that point in time. And airway management, especially in the ICU was one of the early items that we adopted. We read, I read the book that everybody else has read, The Checklist Manifesto from Atul Gawande. And with that, we put in our checklist for airway protection back at that point in time. We've been very fortunate because during that time we have had no ventilator associated events or pneumonias since 2007. Since 2017, we have had a total of five unexpected extubations. And each one of those never resulted in a complication. When I saw the first time back in 2015, 2014, the beginning work within the Patient Safety Movement Foundation, I compared that checklist with ours. And we were almost identical at that point in time. And so for us, that was a validation of the work that we've been doing along with the safety events that we've been able to generate over these past several years. And more importantly to me, sustain them. Great. So I was gonna ask you the question, what have been the results of you implementing the apps? You've sort of already covered that. What do you see as the biggest challenges for hospitals starting this to, well, for you to sustain zero harm or near zero harm or death. And for others just starting, what do you see as the biggest challenges? Some of that's already been mentioned a bit to get started. It is taking a bite of the elephant, not trying to go too big, too fast. Remember that we are healthcare providers that have the honor to partnering care with a person. So let's start one person at a time. When a physician, when a nurse are at a bedside, there is only one person in our mindset at that point in time. Let's provide perfectly safe care to one person. When we do it one at a time and we add one plus one plus one, we start making a difference across systems, across networks and across the entire United States. To sustain it, that is a question we ask ourselves every day. And in today's environment of COVID and has already been mentioned, new challenges are arising. And so to keep the interest up, to keep the focus on people that have been doing it for some time and bringing new care partners into play to make sure they're being accountable to the standards that we hold. It takes leadership, it takes focus, and it takes intention on a daily basis. Thank you, thank you very much. So I'm gonna turn to Kevin McQueen. Kevin, as the Director of Respiratory Care for the University of Colorado Health Memorial Hospital, you were the leader to get your institution to join the initial cohort, which obviously is still in its very initial stages. But you got your organization to join the institution. Would you kind of describe, for our audience that's out there and they're thinking about that, what kind of things can they do to get their organizations, their executive leadership, to recognize that this is potentially a problem if they don't think it is, to join the network, give them some guidelines for that. I'd have to say one of the biggest problems is that all organizations have, there are so many multiple competing priorities. When you look at quality measures, core measures, joint commission standards, and state and federal regulations, leaders are pulled at every angle. If an organization hasn't really taken a deep dive and looked at what are their numbers on planet observations and are they having complex issues down the road after the patients pull the tube. I think one of the problems with UEs is that unless a patient has an immediate severe adverse event, especially in the NICU or something where you could see there's a problem, many of the complexities of the issues, complications are down the road. The patient pulls the tube out or the tube gets pulled out accidentally and then it may be dazed on the road before the aspiration has caused a significant event or the trauma to the vocal cords. So many people may just not be aware that there's a problem or that there's even any issue. Many times when I've traveled around and spoken at different organizations, I ask them what their UE rate is and they're like, oh, it's fine. It's not that big of a deal. And many years that I spent in risk management and patient safety, I've looked at organizations and say, how are you drilling down on these events? And some of us, well, we look at the real severe events and I always say, well, stop using the significance of the outcome to determine whether or not you're gonna make change. Start looking and analyzing 100% of all your UEs. You have to look so deep because every single unit is different. If you are working in a burn unit versus a surgical trauma unit, each one of them will have its own risk. So I have people, don't just look at adverse events. Be very proactive. Don't be looking for every negative outcome to look at what might go wrong. I've learned that dealing with certain patient groups, some are very creative of how to pull the tube out. So every day you're learning different from them. Usually the NICU babies don't pull the tube that as much as our adults. But looking proactively, doing a failure modes and effect analysis, doing deep dive performance improvement projects, to look at each unit or at least look at very detailed where the failure will occur throughout the intubation and ventilation periods. Just to really look at where you can build in the best practices. And that's what several of our speakers have talked about, the Actual Patient Safety Solutions. It details very simple information about how you analyze what you need to look at. It's not just real quick. They have sedation, did they pull the tube? You need to take a deep dive and really look. One example I've said is I've worked at very large, they'll have 30, 40 beds in ICU. And I say, okay, when are you planning your sedation vacations? And they say, well, we just do it whenever. Well, if every single nurse throughout the unit is doing multiple sedation vacations, how easy is it for the respiratory therapist and nurse really to be watching those patients closely?  So designing programs where you have systematic rooms that you do, we'll set rooms at certain times, just things like that can help reduce unaligned activation. So I think a lot of people who have heard me talk about UE, I clearly say frequently, I think the key link to us getting to zero preventable harm and death from UE is the respiratory therapist, because as docs, we may put the tube down, but the respiratory therapist really provides a majority of the airway management from there on out. So as a respiratory therapy director, and as the state society president for Colorado, how would you suggest for respiratory therapists to get involved and become leaders in getting their hospitals to start this process? So I have to agree with you. I believe that outside of the OR, in most situations, the respiratory therapist truly are at the tip of the spear. They're working directly with their nursing colleagues and the providers, but they spend a lot of time with their airway management. They're right there at the bedside. They're continuously manipulating the tubing or working on the ventilators. So they're right there. They have to really pay attention to it. I think really getting respiratory therapists to understand how important it is to be front and center for UEs and be right at the table with the nursing colleagues, with the providers, with the advanced practice providers, really promoting this. Some hospitals may not focus on this, so I'm always promoting that the respiratory therapists stand up, have a voice, and really spearhead the performance improvement around unplanned excavations. Great. Kevin, thanks so much for your involvement. So I'm gonna turn now to David Hughes and David has become a dear friend. David, losing a child to a medical error, I mean, I can't even imagine what it is like. It has to be absolutely horrible. But then there's the added insult of hospitals putting up fences, not being transparent or being honest about what happened, not communicating with the family or providing support to the family. There's a program candor out of MedStar Safety Program that encourages communication and optimal resolution. And this is a real paradigm shift from the historical delay, deny, defend. And the program has shown that honesty and transparency around medical errors and providing good support for families is better for everyone. Can you describe why you believe hospitals have the need for this resistance and the need to fight families rather than work with them and your thoughts about that whole process? Well, thank you for including me in this today. I really appreciate it. Yeah, we've got a lot of faults and it won't be said that I'm not wanting to speak what I say, what I think, and I will try to keep it, I won't be too harsh about anything, but the thing is, since we started the foundation, we've been contacted pretty regularly, which is, this is the most frustrating thing is how often we get contacted by families that experience similar events to Druze or different events that just want to know what to do because they're running into the exact same thing that we had to face. And two kind of, it's kind of a two-part thing, but one of the first things that they seem to run into is that many of the hospital administrators view their hospital as a business and a brand to protect. They have an image to protect. They feel like it's, they just seem to feel like that anything that would damage that image or damage their hospital's reputation or whatever needs to be discredited or proven wrong or they just immediately deny it and say, we didn't do anything wrong but begin with. I think too many of the administrators have forgotten how deeply personal and emotional healthcare is to the families that are going through whatever they're dealing with. And to this day, there are department heads that frown on any show of support for our foundation. This is only seven years later because they don't want to admit the errors that were made in Druze's case. And this kind of leads into the second thing that we've seen a lot of, and that is a lot of the egos you have to deal with because in a lot of the time, a lot of the cases, first thing that comes out happens is as soon as an event happens, as they confront the person about, I didn't do anything wrong. And honestly, in a lot of cases, they completely believe they did nothing wrong. The ability to admit mistakes and learn from those mistakes is what makes a wonderful provider versus someone who honestly might want to consider another line of work. There's a really fine line between confidence and arrogance as far as what is needed to be a healthcare provider. You've got to have confidence. You can't do what you do if you're not having that character trait. But I think the ego gets in the way of a lot of people. And every hospital employee to believe that they don't know what happens in a hospital and how it's dealt with, the hospital administrators are being pretty naive. How they deal with every event, how they is known by everybody, it sets the tone throughout the hospital as far as how all the other employees are gonna act and behave. Because if they see, well, so-and-so did the X, Y, Z, and this is what came out of it, it just eventually over time, it turns into what it is, which is a problem in some hospitals. And we had so many healthcare providers. Drew visited three different hospitals and we had so many healthcare providers from all those hospitals that knew exactly what happened in the back of the ambulance with Drew that wanted to come and speak to us. But basically they couldn't for either legal reasons or for job security reasons, they felt like they couldn't come and talk to us. And they knew, you know, they were like, I'm gonna get messages through different channels and say, please subpoena me when it gets to that point. And I can say this, you know, no family wants to go through what we had to go through. And a family should not have to go through to take legal action, to find out what happened to their loved one and to get the people who were involved to take responsibility for their actions. It's just adding so much more heartache to those families on top of what they're already dealing with with the loss of their loved one. And I just, you know, but like I said, it's frustrating because we continue to get contacted all the time.  I wish everywhere I had people like y'all. But it's the reality is, you know, there's 4,600 hospitals or so in the United States. There's, everything's not gonna be like where y'all are.  So, David, as you said, Drew died due to a series of medical errors. Would you share with the audience what you feel is the most important thing for them to learn from Drew's death? And just describe what the Do It For Drew Foundation is doing to increase awareness and prevention efforts. Um, the first thing I would say is, you know, your actions affect so many more than just the patients you're treating. You know, Drew wasn't just a chart number or a 13-year-old male or whatever. I understand having been in law enforcement, I worked in the hospital for several years right before this happened to Drew. I understand you can't get personally attached to every single, you know, case that you deal with.  And I, you know, I knew how to handle things when like when I was in law enforcement, bad situations, you kind of have to separate yourselves a little bit, but you can't forget what you're doing and what it means to so many that are affected by what happened like with Drew, hundreds, literally thousands of people at this point in time have been affected by what happened to Drew. And the families, those families when you make a mistake, those families will carry that loss with them forever. And when you find out especially when we found out, every one of the errors that happened to Drew's case was a hundred percent preventable. You know, like in most medical errors, there's nothing that you can't trace back and say if this hadn't happened next by the end, you know, so many providers, as soon as they would look at Drew's case, they're like, if this happened, I mean, if one thing had been done differently and that's so difficult to deal with, you know, for a family you're, you've lost somebody that you love and losing a child, I can't describe it. I can't, I won't say it's worse than anything else, but I've lost a lot of people and losing my son was probably the hardest thing I'll ever do in my life. But knowing that he should still be here right now is probably, it is so difficult. And so it's just so important that these providers train constantly. And if, you know, never hesitate to speak up if you see something wrong. Like in Drew's case, I feel like if they had just taken, they panicked in the back of that ambulance. When Drew pulled the tube out, when they administered vet uranium, they panicked. And I really feel like if, when his oxygen levels started dropping, when everything bad started happening, it was pretty rapid. If they had taken 10 seconds, there's three, you know, respiratory therapists, paramedic and a nurse by there. If they had just sat back for 10 seconds, 15 seconds, take a deep breath and said, what is happening? That might've, they might've seen what was so obvious that everybody who's looked at Drew's case. You know, 10 seconds, 15 seconds wouldn't hurt Drew that 30 minutes without oxygen killed him.  We encourage everybody to visit our website and read the what happened page. It tells the story from beginning to end. And, you know, our goal is to reach as many people as we can to let them know about Drew's case and hopefully encourage them to never let what happened, let him happen again. And not just on plain estimation, but any medical errors. David, thank you so much. I've said this to you many times. I'm so sorry for your loss, but thank you so much for being willing to use Drew's story to help others so other families won't have to go through what you've gone through. That's what we're open to do. So with that, I'm gonna turn this back to Donna and we're gonna take questions for the panelists from the audience. Excellent, thank you so much, Art. This has been an amazing panel and I really appreciate everybody joining us today. We have several questions. So I'm gonna try to get to them very quickly. The first question is asking about what happens when accidental extubation occurs in the community, specifically with children. Is there some kind of simple infographic that parents can follow for a trach replacement when accidental extubation occurs in the community? Related to trach, because we've been talking a lot about unplanned extubation as it relates to an airway, an ET tube and a tracheal tube and at least at our institution. And I think probably across areas people are starting to look at it as well when a tracheostomy more permanent type of airway is dislodged. And so I think a lot of the same principles that we've been talking about would apply and just vigilance and being aware. And then at least in this might be community specific, but a child who does have a tracheostomy, there are certain practices that have to happen even before they're able to go home and be in the community. And part of that is having families or the care workers who are taking care of them properly trained. So they are trained to recognize if one's dislodged and replace immediately if needed. Great. The next question is about more training for parents specifically in the NICU. There's skin to skin is very much promoted in our NICU. So is there a training or what training are you aware of that happens with parents in the NICU to prevent extubation during skin to skin? This is Anne. I can jump in briefly on that. So skin to skin or kangaroo care, as we like to call it is really critical for the development of young infants and something that we need to promote. With that said, it's considered a very high risk situation. Not only are you dealing with someone who isn't a healthcare professional, generally speaking, but also it's just moving the baby around. And anytime you move the baby around, it becomes at risk. So that is one of those high risk situations that would trigger that aspect of our bundle to put in additional safeguards so that not only as the parent educated about the risk and some time is spent with them to help them understand, but also having two providers assist with the transitions. So it's not just a nurse all by herself trying to move a baby four feet from the bed to the mother and back. So it's a great question. And we learn from our parent cause analysis that we need to be very intentional about that particular situation if we're gonna eliminate unplanned extubations in babies. Excellent. I would just chime in on that. One thing we learned when we started looking at that process, there was a big jump with parents holding cell phones. So that actually became sort of a simple step for us. If you're holding the baby or holding the baby you're not holding your phone and looking or trying to get a selfie. And so sometimes it's even, when you're putting those processes and protocols in place sort of looking at the little things as well. Probably a good thing overall, no texting and parenting. That's right. The next question is related to restraints. There's a lot of conversation as you know about restraints from a regulatory standpoint. Hospitals are getting a lot of pressure to reduce incidents of restraint, but at the same time it is obviously promoted to prevent self-extubation. So can somebody address what safety managers can do to better manage both sides of that safety coin? Dr. Lopton, maybe you could take that one? Yes, I'll be glad to. With a focus on patient safety that overrides everything else. I've had this conversation with senior leadership at the Joint Commission and other entities. And while standards may be one thing to reduce restraints when we focus on the safety of the person that we have the honor to partner care in bed, that drives all decisions. The use of restraints for safe airway management will always be appropriate as long as we do the other assessments and the regular evaluation that we need to have. Feel free to have that conversation with your regulatory person focused on patient safety and you'll be okay every time. Agreed, agreed. Thank you, Edwin. And I think your point is very valid as long as we are also keeping them safe from the restraints then there should not be an issue. So the last question that we have is about, is we've talked a lot about unplanned extubation and David, you mentioned the misplacement of the ET tube. And that was a question about this. Any thoughts on how best to prevent the misplacement of the tube upon intubation? Done, I guess I'll take that. And I think this was Dr. Barker's question and really related to, I mean, there's two different things. There's the failed intubation, which in and of itself is not necessarily as big a problem as what happened to Drew, which was they failed to get the tube in the right place. It went in the esophagus and then on top of it, they failed to recognize that it was in the wrong place. In this day and age, we have a medical device to prevent that from happening. We have capnography. Now, I know Dr. Candle and Dr. Lyron will speak up and capnography doesn't work as well in neonates as it does in adults, but in the adult community at least, and then I'll let them chime in for the neonatal pediatric community. But in the adult community, we have capnography. It will tell you if the endotracheal tube is in the esophagus. And even if it turns out to be in the gray area, the tube should never be left in unless it's absolutely confirmed that it is in the right place. I'm a bit outspoken about this. I personally have said numerous times that in this day and age, in an adult patient, if you have a patient intubated and you don't have them on capnography, in my mind that's malpractice because if the tube ends up in the wrong place in the esophagus and is no longer in the trachea, capnography will tell you that instantaneously where pulse oximetry is really delayed. And a lot of times you can't rely on that, but capnography absolutely and capnography should become mandated. I will tell you that in Drew's case, it happened in an ambulance. North Carolina has state EMS protocols that requires capnography for all intubated patients, yet that particular crew did not have capnography. So I'm a critically care-trained physician and I would agree with you, Art. I think capnography is something that is available. It can be a little challenging in the neonatal population because it actually adds a lot of weight to the tube and can pull the tube one way or the other, which would put it at risk to be less stable and it can add a lot of dead space. But there are sort of ways to work around that. And I work in the pediatric ICU and we do use it even in the smallest of babies. I think in the premature population, there's definitely some variety that will cross the country. Excellent. And thank you so much to Ann for answering a question in the chat. Just in case other folks didn't get to see your answer there, the question was about the solutions for patient safety and whether it's available outside the United States. Can you address that very quickly? Sure, sure thing. So technically we are because we have many children's hospitals in Canada who participate, but we certainly haven't gone outside of North America. And the reasons for that are, first of all, we kind of have our hands full with the ones that we have, but also there are some pretty significant logistic challenges to whether it be language or time zone if we go outside of the US. With that said, we are gonna test participation of a hospital that's in Asia in the next year or so. But one thing that I did share in the chat that I want you to know is that for hospitals that are interesting, we actually, I mean, we don't compete on safety. We share everything on our website. So it's solutionsforpatientsafety.org and you can see all of our bundles and the details. And I mean, I think if there were questions that people had about that information, we always do our best to provide it. We're also trying to get our work published so that it's out there in the literature as well, but hopefully that's not the same as being a part of SPS and that's part of why I'm so excited to hear about the adult hospitals that are participating. But I guess before we tried to have world domination, we wanted to make sure that our experiment in local children's hospitals would work. But thank you for that. Thank you, thank you. Well, we are out of time, but I wanna thank all of you today for joining us. This has been a fabulous discussion. We're really excited to be able to offer CE credit to nurses and physicians for this event today. As always, a recording of this webinar is going to be available on our website for later viewing, but anybody who signed in today for the live event can expect an email from MedStar Health. They are our CE provider. You should receive that email within 24 to 48 hours with instructions on how to obtain your educational credit. So thank you again, Dr. Kanowitz, all of our panelists. We really appreciate your time.


Hey friends today We are hanging out at Disney's Blizzard Beach water park and I am so excited because I've never been here before So I can't wait to go show you around the park and share my experiences with you They have some amazing attractions here including summit plummet Which is one of the world's tallest and fastest body slides and I can't wait to see if I'm gonna actually ride that and then I know I just want to hang out and enjoy the park So we're gonna eat some food ride some water slides and have a beautiful Blizzard Beach kind of day any who's Let's go do this. I Just love the fact that I'm going to a water park in November It is 77 degrees out right now and it's so cool that this water park is a winter themed water park Look at all the signs. They have by now slay later slay. I really love the theming of this water park already And it's kind of cool because they have a back story back in 1977 there was a freak snowstorm here in Florida and people decided to Actually build a ski resort with all the snow but not realizing that it's Florida all of the snow melted and it turned Into a water park. Isn't that cool? Like Disney never lets me down on the theming and I can't wait to just go explore. I Really love the idea behind a ski resort that is melting and turning into a water park I think it's genius and look at this little tiny like snow family. They're melting and it's kind of like a fountain I love it up there. You can see summit plummet Which is the water slide that I told you is one of the world's? Tallest and fastest and you can actually see a ski lift you have to take a ski lift to get to the top of it So I'm excited to actually try to ride that. Oh, there's a park map. We should look at it I brought my GoPro with me today So we're gonna be filming on the rides themselves And I'm gonna be able to show you what like some of plummets gonna be like and then that awesome raft ride And then also I want to get some of the food too. I hear they've got new food items I don't know what's new or not so I'm gonna have to look it up because this is my first time here But I kind of want to like explore the park in a whole try the food the rides the theming a little bit of everything I Feel like this water park is definitely a lot bigger than I thought it was I thought it was very small But looking at this map, it seems like there's a lot to do here Here's a list of all of the attractions with the wait times right now Everything seems to be less than 15 minutes on opening day, too Snow where else like it? Huh? Very clever and they even have some dining. So I want to try some of the food here They got something in the lodge frost frost bite freddies. That sounds fancy warming hut polar pub polar pub. Whoo I'm wearing my nightmare before Christmas Roosevelt today because I thought it was fitting for the winter themed water park You know, I got santi claws on there and Halloween just passed and now we're rolling into Christmas and I kind of liked it Because I have most of my electronics on me I want to go video the ski lift so I can show you a little bit of a better view of the park and Then put my stuff away, but you can't take the ski lift back down so it's either take a water slide down or Take the stairs down and we'll figure it out But at least it's good to know that you can ride the ski lift without actually having to go down any of the water slides So we're gonna actually go up now. Look at that. Look at some it plummet up there Wow, what a view of the whole park and it's only gonna get better once we get on. Oh Boy, look at this. It looks like I'm skiing and here we go Wow, it is so beautiful up here. It's a little bouncy It's a little bouncy. That's why the camera is probably going up and down, but look at the views. I love this Yo, like I'm not the biggest fan of coming to water parks But I would probably come here just to sit and ride this all day if they'd let me I wish it let you come back down, but they don't let you but can you imagine if you can just ride this all day kind of Like the people mover was back in the day. Oh It's also good to point out in case you don't want to actually ride the ski lift You can just take the stairs and I'm sure with Disney. They probably have some other Accessible way, you know, I mean Disney's really really good with that I feel like compared to other water parks and theme parks in the world To the left is summit plummet right there it is. That's the final Stretch you see people probably coming down now. That is pretty high up there We're almost at the top now. It was less than five minutes. I feel like it actually moves pretty quick Look at that. I keep on seeing people go down it. I get scared. I'm like, oh, no, I don't think I can do it Yoo-hoo big summer blowout That was so awesome and now we are at the top of the mountain they're playing Christmas music right now They're playing frosty the snowman and it was so cool as I was going up on the ski lift I felt like I was in that price The price is right game, you know the one I'm talking about and now well Let's check out some of the watersides and then go put the stuff away and get ready to ride. I Also love once you get to the top they have all of the rides Like immediately as soon as you get off the lift summit plummet right here slusher gusher over on this side They have Mount gushmore They've got the team boat springs over here the family raft ride and it's just so cozy up here Wow, I feel I feel like we're high up. I don't feel like we're in Florida actually especially with all the trees This is so stunning It's kind of funny because I'm not the biggest fan of water parks I've been to typhoon lagoon and I liked it a lot, but that's why I've never come here before And I feel like Disney does water parks right like they do like yeah, you know me most water parks It's not that like fun for me I don't know why like there's not like much theming the attractions are just kind of like thrill-based But I love like the way Disney does it so here I am gonna test it out And I want to see what it's gonna be like compared to typhoon lagoon I didn't think anything could top the ski lift, but wait till you see this view when you get to the top Wow, look at this. I Love it that right there is tower of terror directly in the middle of the screen You can see the swan and dolphin you can see galaxies edge You can see everything you see guardians of the galaxy. This is such a great view. I I'm like obsessed and we're not even all the way up like summit plummet is above us Look at that.  I hope the sound quality isn't gonna be too different because it's a little muffled That's how the standard GoPro is But yeah, we're gonna head back down. Hopefully the walk isn't that far I'll give you guys a little time lapse to show you how many steps It is in case you want to come up and not ride the ski lift We are switched over to the GoPro now and we're gonna go ride I think maybe the raft ride the one that I saw when I was up at the top there But I'm excited and I have the wrist strap. So I'm gonna actually strap it to my wrist I'll try to keep it as steady as possible, but we are going down a water slide.  We're going all the way up It was definitely harder to walk up the stairs than it was going down But I think I think we're gonna do one of the raft rides first then may maybe work up the courage to do summit plummet I'm not guaranteeing. I'm doing it. I gotta gotta get the courage. I Think we're gonna start off at runoff rapids. They have three Different tube runs up here one of which is completely enclosed, but I want to do the one that's outdoors Look at this. It's like we're in the woods. It's so nice It's definitely not what I was expecting and there's no lines Wow, look at this is like a major attraction, I think and there's no line We're walking right up and I like that. We don't have to bring our own tubes up either They have a tube lift a cargo lift that actually takes all the tubes up. Oh Oh my lanta it's going too fast. Oh, this is so beautiful though. I'm flying Oh We got some water there. Oh, oh my lanta what is his end? Now I'm floating into the lazy river Love that and now I kind of want to go do the one that's enclosed But it's kind it's dark so you guys won't be able to see it or should I go straight summit plummet? I don't know. I keep on thinking I gotta go do it. I gotta go do it But like I'm literally scared so I'm like, no, let's just do a couple other waterslide So maybe one or two more waterslides or you know water attractions Since we're all the way up here now, I think I should just get it out of the way and go ride it I'm probably gonna love it and want to ride it again But it does have some passions here take a high-speed white knuckle plunge down the world's tallest and fastest Free fall body slide, which drops you 120 feet. That's insane Clothing with rivets buckles exposed metal or Nia print is not permitted. I'm pretty sure I butchered Nia print But yeah glasses and loose jewelry should be removed. So I got take off the glasses I don't even think anybody's in line for this right now. Whoo more stairs lots of stairs here But we're gonna actually reach the highest up there. Oh also looks like there's a beesnaps. I see a lot of Yellowjackets there We made it all the way to the top. Oh Oh boy I'm actually a kind of hyperventilating. Oh, but that looks really fun. Oh, I want to go do the blue raft ride after this Oh, I think that's the rider was gonna do that looks like a lot of fun. All right, let's do this Okay I didn't know that did that Okay Okay, cross my ankles. Okay. I am so scared. Okay. I'm leaving back now.  I'll keep my legs crossed. I keep my legs crossed. Let's do this Oh god Summit plummet was amazing and it was so fast. I screamed I screamed a high-pitched scream But I would definitely do it again. I loved it. I thought it was so fun That was my first time ever doing a slide like that I've never done a slide before where you are not in a raft like I've never done one before I was always too afraid and I picked a good one I picked a good first one so I'm happy about that But now I want to take a break and go get some food and see if they got any new food because like I said I heard that they have new food here Or maybe I just try some of the old food because I've never had it. It's all new to me A friend of mine told me they had some new churros over here at the blizzard beach arctic expedition And I love how it's like an arctic like vehicle and the churros that they have they have a s'mores churro And then they also have a banana split churro. That sounds interesting banana slices strawberries pineapple chunks of cookie brownie Oh, I think I'm gonna get that a banana split churro This might be the best looking churro. I think I've ever seen and I appreciate how they actually cut them up into little pieces And that way you can actually get a bite with every single topping on it. Isn't that cool? Look at that banana strawberries brownies pineapples, and it's huge. Look at that.  It's perfect. It's perfect for me. So cheers to banana spit churros Something I never had I didn't think banana split churros would be a good combination, but boy. Oh boy. Was I wrong That is amazing. That is so good And you got to make sure you eat them fresh when they're nice and hot and fluffy and I love this this is This is literally I wish I got the s'mores one though I would love to see what the s'mores one tasted like but I don't think it could be better than this one I really don't This is definitely the best churro I've ever had like not like a basic churro You know what I mean not like I love disneyland churros where it's just the churro But like uh like a churro dessert where there's other ingredients. This is the best one It is so good and I definitely would get it again Enough of the churro business. I need to get something a little bit savory and I hear they've got new wings here that are good I don't know what flavor they are, but I think we're gonna go look for them You got to eat now and then wait to get back in the water because we don't want to get a cramp Well, look, they actually have a like a semi-weight pool here Because it is a lot of stairs and also a long time to wait for the ski lift I figured I'd eat food all at once and then also ride rides or Water slides all at once so we rode a couple in the beginning now like I said, we're gonna eat some food And uh that continue eating food and then we're gonna go back and ride some more rides And I want to get in the lazy river. I love the lazy river It's my favorite thing and I could spend days just going around in it And I would like to see what this one's like. I see they got some fun stuff and uh, they were really cool Here are the wings I was talking about Garlic parmesan wings and honey sriracha wings. You can get them by the six or the ten piece. It's ten piece You get a souvenir pail a souvenir pail. I see Mickey Mouse there.  Well, maybe oh, I guess it's kind of everything. Oh, yeah, there's blizzard beach over here Made a universal sand pails sand pails First I think I'm gonna try one of the garlic parmesan wings And they actually look like pretty decent wings lots of sauce very saucy just the way we like it And here we go garlic parmesan one My fingers like it's a lot of sauce The chicken wings are good chicken wings. I'm not the biggest fan of the garlic parmesan sauce only because they don't like Cream sauces so now I'm gonna sneak down to the bottom See if I can find one of those honey sriracha ones. Maybe I can lift them up Nope. Oh, there it is down at the bottom. I see it. I see you down there. Oh, there it is They're all Yo, they are so saucy. Look at this. I'm gonna try to get this one down here at the bottom You gotta dig a little deeper Now it's time for the honey sriracha and look at those wings. I don't know. I'm gonna see You get not kind of focus in on there Looking good looking very good.  I'm gonna see if it works. Let's see So once you break that piece off you should be able to just eat all of the chicken wing and then the bones will come right out So we'll see if it works Oh, wow, the honey sriracha wings are so good and also I got a little bit of the garlic on there But it's not overpowering because the flavor is kind of blended together But that is Wow, I like it the honey sriracha ones not so much the garlic parmesan ones I would add a little bit of the garlic parmesan sauce in there, but not too much Um, but yeah, that's kind of cool. I like that you can get wings in a water park wings in a water park I think we're all done eating now and I want to get back in the water In fact, I think I want to go back up to the top and go ride that big family raft ride You know the big bluetooth ones that I was looking at uh when we were standing at the top of uh summit plummet So I think we're gonna head up there I'll probably take the stairs again only because now the weight for the ski lift is like a lot longer because it got Backed up because it was down. Uh, yeah, so we're gonna switch over to the gopro and uh ride some more rides We could take the green slopes back up and go down team boat springs Which is one of the world's largest group water raft slides. Wow, they have two world largest things here Uh, and then there's also slusher gusher take the plunge of this 90 foot long high speed body slide So there's a lot going on here or the toboggan races Ah, maybe we should do team boat springs. I don't know what they'll let me on on my own though Because it says it's like up to six people. So I don't know if they do single riders, but we'll find out Luckily I'm not going to be riding by myself because I ran into some friends I literally saw Nate. I'm like, Nate, what are you doing here? I had no idea this was your first time being in Yeah, literally I was walking up. Oh, this is us. We're going we're going in He Yo, I'm so excited. What's there? Oh my lanta Why my backwards Oh, wow That tape wasn't there before Oh, wow, this is actually longer than I thought it's a very long ride I Like it a lot This is nice actually No, no, nothing like summer plummet No, but it sounds like It just sounds like a double. Oh, wow. What is that? Wow That was nice I'll do that again. Huh, that is amazing It was nice to run into jojo and ryan and actually that ride was a lot of fun At first I didn't know what to expect because you know what I mean? I never rode it before and it looked like it was kind of thrilling But it turned into a very nice peaceful ride. It was very calming like it was funny because the video started off I'm like, ah, because I don't know what's gonna happen and then all of a sudden I was like, wait a second I kind of enjoy this It was nice. There's a beautiful family ride. So now we're gonna hang out a little more go ride some more rides and You know, just kind of enjoy the park. Maybe grab a drink Look at this. They have like a finish line. I love that.  I think this is the toboggan races toboggan racers I'll look at times and say, you know, who's the winner? That's not one That's cool. All right I don't think I've ever used one of these mats before It's since this is the toboggan races. Oh boy, gotta pull it out quick. There we go Oh my lanza for okay Am I gonna fly on this Okay, bud down The toboggins were real fun that was not like I said that was not the ride that I was riding Well, I wanted to ride I just ended up there like I don't know how it happened I was staring at that ride and I was like, oh that looks cool And I thought that was the one and then I followed and it took me to a different one But I like that ride too. And now uh, I got redressed. I'm ready to dry off the park closes at five and Think I'm gonna head out, you know start making my way out of blizzard beach, but it's been a fun day so far Another quick service location that they have here is like a lodge like a skiing lodge And I love how they have like snowboards and skis and a little fireplace over here It's closed at the moment, but it looks like they've got some pretty good food They got some burgers some french fries Some flatbreads Caesar salad roasted chicken rice bowl Look at that Everything in here.  I would have liked to try it I guess they close these before the park actually closes like they close up the restaurants first Surprisingly, I kind of like being at a water park where it's not hot You know like it's like in the high 70s right now and I'm not like sweating, but it feels nice It's not cold either if it dropped onto the 60s. I'm not too sure I could be out here in the water though You know what I mean? It would be a little bit cold But luckily florida it doesn't get down to the 60s that often. Well during the day it doesn't So, uh, yeah, I'm kind of happy. I'm kind of happy. It's happening in november I'm driving back home now and the sun is setting on the golf course Look at the buses. We're kind of at a standstill. This is where the Polynesian is and this traffic's been backed up for a while Hope I can move up a little bit The most beautiful dog on earth Gracie girl You like that song Nope, not so much.  All done All right, do you want me to rub your belly? I see All right, you're on your leash though You're so funny you're on your leash though. I only do that All right Me and Gracie decided to run to Dunkin Donuts so we can grab ourselves a little coffee and a pup cup I got my coffee. You want your pup cup? Huh? You want your pup cup? All right here You can have some of yours. I'll have some of mine. This is the way Taking the back Thank you Gracie is all hyped up on her pup cup now. Look at her What Gracie freaks out whenever you take her collar off watch this I always like to show it because she's And with that we are done here today. I hope you like the extra clips of Gracie girl I know she loves being in the videos or I think she does She really does sometimes she looks at me and she's like she just gives you that look and I'm like, oh Gracie And I gotta take her to the pup guy gotta get her a pup cup and went to a dog park We actually go to tons of dog parks every single morning me and Gracie go on an adventure Like I have a real like kind of schedule and the only schedule that I keep is with Gracie Every single morning we go and we have like 10 dog parks that we go and uh, we kind of like rotate and we visit And we go everywhere we go to celebration. We go to Kissimmee Davenport Claremont, I think the farthest I probably went was winter park Just to go to the dog park with Gracie because she likes variety I wanted to see the world, you know, and we've been up and down across states together So all right enough of the dog business. I don't even know why I went down to the dog park business But uh, oh blizzard beach I want to give you guys like my final thoughts on it because you know, I said I wasn't a big fan I'm not a big fan of water parks in general And I've only been to like five water parks in my whole life Like I I I've just never been like kind of excited to go to them typhoon lagoon. I love I think it's great and it's big and the way pool there is amazing blizzard beach I think is all about the thrill rides the water slides are so awesome But the way pools not that big and the food from what I heard the food that I tried today That was really good the banana split churro and those wings and like I said the parmesan sauce. I mean I just didn't like it because I don't like that creamy sauce But once I got a little taste of it with the regular like honey sriracha. I was like, all right, that's good But before that people said the food was bad So I don't know, you know, I mean, I think typhoon lagoon is a better park as a whole But blizzard beach is so much fun for like, I think adults maybe I know that they have like that new splash area there But I didn't even get to go in and see it. I didn't even go over there Honestly, I went into this place thinking blizzard beach is a small water park And I'm going to knock out everything in a couple of hours and it was so much Weirder than I thought I mean I feel like I got a lot done But the park was only open 10 a.m to 5 p.m And I'm definitely going back just for this the ski lift. I thought it was worth it and some employment Honestly, when I first went down that I screamed and I was so afraid But now I just keep on thinking I want to go back and do it again I do But anyways, I hope you enjoyed the video and I hope you guys are ready for all of the holiday videos coming out Because like I said, uh, I have so much planned for the next week or two And it's everything that's happening here Right at home. I love it. I love it when there's tons of events home so that you know what I mean? I'm like, I'm like, all right. We're gonna do this. We're gonna do this. We're gonna do this And that's what this week's like. I got mickey's very merry christmas party jollywood I've got universal studios grinch miss orlando informer the mini meetup all this week Oh, I got also a super super cool thing that I'm doing. Um, I'm not too sure what date is It's really really awesome. I can't wait for you guys to see some of the clips from it Uh, actually, oh, oh man, I've been talking a while, but I want to show you something cool. Hold on I just picked this up the other day and I wanted to show you guys because I am in love This is an original ad for the, uh, New york's world's fair in 1964 and 1965 and I think it's just so cool. Look at this world's fair postcards by dexter So cool. I'd like vintage little advertisements in anything I love anything from the, uh, new york world's fair in 1964 and 65 I will buy anything usually as long as it's affordable Isn't that awesome? I saw it and I was like, I gotta get it. I love it. It's and you know what? I can't wait to decorate it once I move I can't wait to put it up and I want to make like a little, uh Treasure room. That's what I want. I want, uh, I want a room to put all my thingabobs My thing of my day my my thing of my days So anyways, I hope you enjoyed the video. I enjoyed making it and uh, we'll see you next time Bye


My husband loves almond joy candy bars the chocolate the almonds and the coconut and So for Valentine's Day, I like to make him some homemade almond joy bars Lots of coconut almonds chocolate and also a lot of sweetened condensed milk and powdered sugar They're loaded with sugar and loaded with calories So I finally came up with a more helpful version that still fulfills his craving for almond joy bars So he's gonna be so surprised when he gets these for Valentine's Day I've got my ingredients ready to go I took two cups of almonds just raw almonds and I toasted them on a baking sheet in a 350 degree oven For about six to eight minutes just until you can smell the fragrance and they're starting to turn color Take them out put them on a plate to cool Then also ahead of time I took half cup of shredded coconut and this happens to be unsweetened coconut Put it in a skillet and stirred it over medium heat until it just started to turn golden brown And then I put it on the plate to cool now These little almond joy bites or bites of joy I like to call them have a natural sweetener no sugar But dates and I like to use the medjool dates which are the larger dates because they're really moist and creamy And caramely they have pits must take the pits out before you prepare these So you can see that a deglet date is the more traditional date And it's a lot smaller and it doesn't have all that creamy inside that the medjool dates have and you can find them in the produce Department in most grocery stores So I've got two cups of the medjool dates and I'm going to start putting things into my food processor So first in go the toasted almonds then I'm going to put my dates Two cups of dates and I also have half cup of coconut that I have not toasted So that's going to go in at the same time Along with about a quarter cup of cocoa powder and use a nice quality cocoa powder So you get a really good chocolatey flavor and a half teaspoon of salt so I'm going to put that in and Start pulsing it until it gets nice and crumbly When it just gets a real crumbly consistency I'm going to add three tablespoons of almond butter also I'll put in one tablespoon of pure vanilla extract and once again.  Happy Valentine's Day. I'm Stu Dodin sharing good food for good life 365


Let's go. Seven and a revolution. Can we get our first foil? Fusion recovery. I knew it. I knew I was going to jinx myself and pull this. Giroid. It makes another appearance. Doitsu. Fusion recovery. And we got the UFO. It's super. There it is. It's a pull. Hey, one for one. We take those. Arrival appears. And is this our first foil? Come on. Why does this set hate us? Desfrog, let's get Steve K something good. So far, we have nothing out of his first pack. And we have a, there it is, the double UFO roid.


I'm Sam Baknin and I am the author of Malignan Self-Love, Narcissism Revisited. The personality is not a static structure, which immutably permeates our being. Personality is a dynamic, ongoing process. It is a series of cognitive and emotional interactions compounded by extraneous, external input, and endogenous internal feedback. The personality is ever-evolving, though following our formative years, or subsequent personality changes are subtle and infinissimal. This labyrinthine complex of reactions, behavior patterns, beliefs, and defense mechanisms consumes a lot of psychic energy. We invest a lot of energy in maintaining our personality. And so, the more primitive the personality is, the less organized, the more disordered, the greater the amount of energy required to maintain it in a semblance of balance and function, however precarious. The predicament of the narcissist is even more multifarious. People suffering from this all-pervasive and pernicious condition externalize most of the available energy in an effort to secure narcissistic supply. These people have a fluctuating, vicissitudinal sense of self-worth. They never know what they are really worth. In order to regulate this fluctuating sense of self-worth, they consume narcissistic supply from the outside. They seek attention, admiration, adulation, and generally feedback. But to secure this narcissistic supply, the provision of this supply requires investing a lot of energy in constructing and then projecting a forced self. So these people have very little energy left for the functioning of their own personality for the daily ego functions, for the daily routine of maintaining their personality in some kind of balance. All their energy goes outside to secure a narcissistic supply. Normally, one's energy, as I said, is expended on the proper functioning of one's personality. The personality disordered devote any shred of vitality to the projection and maintenance of a forced self, whose sole purpose is to elicit attention, admiration, approval, acknowledgement, fear, or adulation from others. The narcissistic supply, thus obtained, helps these unfortunately to calibrate a wildly fluctuating self-esteem, and thus, as I said, fulfills critical ego functions.  All these activities inevitably deplete the narcissist's vigor. His emotional exoskeleton, his emotional outside skeleton, outside scaffold, is derived and specifically constructed from the outside. This is far more demanding than the normal endoskeletons, inner scaffolding, inner skeletons that healthy people possess. The personality of healthy people relies on an internal structure that is well-balanced and well-constructed, agile, flexible, adaptive, and reacts to the environment. The personality of narcissists relies on an external scaffolding, an external structure whose maintenance requires enormous amounts of energy in securing narcissistic supply. The narcissist is an artist, with himself as his sole creation. His entire energy is committed to the theater production that is his full self. Hence the narcissist's constant fatigue and ennui, his short attention span, his tendency to devalue sources of supply, even his transformed aggression. The narcissist can afford to dedicate resources only to the most promising founds of narcissistic supply. He doesn't have energy to spare, he can't dedicate energy to people who may not be or are not sources of supply. The path of least investment, or the path of least resistance if you wish, is very tempting because it conserves energy, scares energy which the narcissist needs to secure supply. So narcissists resort to criminal shortcuts, violence, cheating, cornered history, lies and confibrillations. This is because these shortcuts ostensibly help the narcissist keep a larger share of his energy available to other ends, the ends of securing narcissistic supply. The narcissist's alarm, force of life, life force is run down, his vitality is drenched and his verb is exhausted by the unusual need to secure from the outside what most people effortlessly produce internally and take for granted.