Hello, my name is Paolo Press. Thank you to the organizing committee of the 20th annual Toronto Period of Tea Symposium for the invitation to participate this year. Again, this year with a very innovative program, including point-of-care ultrasound by TEE. Today I'm going to be speaking about the use of point-of-care tea in the period-operative setting for rescue purposes and cardiac arrest. To start with, to disclose any conflict of interest, my only conflict of interest will be that I'm part of the faculty of the resuscitative tea workshop. I don't get any remuneration for it, and I'm part of the collaborative group of the resuscitative tea as well, but again with no remuneration. Today we're going to be speaking about the role of the rescue tea in the operating room, review some of the literature that is available on that topic, and also focus and understand a little bit more about the role specifically for resuscitation during cardiac arrest of a tea. Now, what's a rescue tea? Like we know there's a basic tea study and it's been described by the guidelines published in 2013 by ASC, and this basic tea exam, it's with 11 views in order to diagnose and do a basic assessment different from the comprehensive period-operative tea assessment, which is the one often done in the cardiovascular operating room done by cardiovascular anesthesiologists. However, this basic tea is meant to be or not necessarily done in the cardiovascular operating room by cardiovascular anesthesiologists. So what is rescue tea then? So the way, although there's no very standardized definition of what rescue tea is, the way that I like to think about it is this is a cover from one of my favorite rock albums from the 90s by Nine Inch Nails, and it's called the Dunward Spiral, and this is the way I like to think about resuscitated pocus or resuscitated tea in the operating room where we often get cold when there's a patient who suddenly becomes hemorrhage unstable or have any other major crisis involving oxygenation or ventilation and quickly gets into a Dunward Spiral, and some of this time there's no sometimes there's no clear etiology or clear cause of why this is happening, and it's very undifferentiated, and that's when the role for resuscitated tea has a good importance because it can bring and answer questions to try to identify those etiologies in an undifferentiated shock patient. So when we compare basic to rescue tea, although again there's no standardized definition and if you read literature, different groups do different things in terms of what views they include in their rescue tea protocol or resuscitated tea protocol, but a different from the 11 or 16 views from the basic comprehensive assessment, it's usually between four and six views that have been described as part of the rescue TEE exam, and these views include the bi-cable view, the mediasophageal four chamber, the mediasophageal long axis, a trans-gastric short axis view, and some additional views that other groups include such as the ascending aorta and the RV inflow outflow, depending on which pathology they're looking for, and it's very important to remember that the intention of doing a rescue tea study or a resuscitated tea study is to help confirm life-run and situation diagnosis and ruling or rule out conditions such as pericardial effusion that is causing cardiac tamponade or a severe RV or LV dysfunction that could explain the shock, as well as major pathology from the great vessels such as artery dissection or a saddle pulmonary embolism as an example, and it's not meant to be do a comprehensive study, it's meant to help you answer these important questions in a very timely fashion to help you guide your resuscitation and management of these patients. There's been a few descriptions of different protocols, however not many are published in the literature, this is one of the few that's been developed and implemented in the perioperative setting by anesthesiologists and it was done by the group at Mass General Hospital in Boston and they developed this rescue tea team that consists on a team either at a cardiac anesthesiology fellow or a senior resident from anesthesiology will cover this rescue tea service after being certified and properly trained and they would review these images with an in-house cardiac anesthesiologist to help making the diagnosis and guiding the decisions. This team was triggered, the usual triggers were patients with severe hypertension, cardiac arrest, severe hypoxemia with no clear etiology and they will focus doing five use. They were able to follow and collect the data from a series of patients, almost 50 patients and they look at what were the indications for this study and if it during the exam would help them manage and diagnose these patients and from the 48 patients they were able to shown that almost 80% of these patients did actually had a change in management after the findings in the tea. Most of these findings were related to severe hypovolemia that helped guided the further resuscitation with a volume expansion but other treatments that were initiated or changed were the use of inotropic support using different type of a suppressors or using other type of investigations or treatments such as taking the patient to the cat lab putting an interactive balloon pump ECMO or pericardial drainage. So it was shown that a use of these patients in the non-cardiac setting using this resuscitative tea helped them guide them in managing these patients for the shot. Similar study was done recently in London, Ontario by a group in the intensive care unit in the med surgical ICU where they use a protocol with only four views and they look at patients who were in severe shock or severe hypoxemia with not clear etiology and the findings were quite consistent with the mass general group. They also find about between 70 and 80% of the time is in or doing a resuscitative tea did ended and changing the management or making new decisions for the management of these patients. They were able to collect this data in 274 patients and again a lot of these findings were more aggressive volume resuscitation, initiation or changing of inotropic suppressors and other things like changes in the ventilation, drainage, her surgical control. So both observational studies have clearly shown that there is a role for the use of emergency tea outside of the cardiac OR and both the non-cardiac perioperative setting but also in the critical ill patients who are severely unstable without undifferentiated conditions. This is a systematic review that it shows you fortunately it was published before this large two series were published but what is important is it collects the data from several small observational studies and case reports and case series where they use the resuscitative tea or rescue tea for non-cardiac surgery and it was done both in the context of liver transplant, multisystem, multi-organ transplant, trauma patients and they most of these series or other data is quite small to make conclusions and make significant contributions to make a systematic review analysis. When you look at most of the individual studies they show that there was a difference in terms of the management of these patients and it helped with the diagnosis and what is also important is that these studies some of them or most of them did report if there were any adverse events with the use of transesophageal echo and most of them did not report any side effects or any adverse events and the ones that it did it were a minor adverse events such as minor oral bleeding, discomfort from the patients after the use of tea but no significant complications such as esophageal perforation or other mechanical complications. So looking at this data although it's limited and it's not too many studies around and the ICU and peruptive this setting although there's more done in the emergency department setting in the context of a cardiac arrest but they all have a similar conclusion in terms that it can be a very useful tool and bring in diagnosis and differentiate a shock patient and guiding helping guiding the management. Now if you ask me like why would you bother doing TE where we're getting very good at doing Pocos TTE this is the answer like sometimes and a lot of the time these patients that are critical have not very good windows and that can be related to the fact that they are in positive pressure they are they have body habits that are difficult to assess or position there or even more important for us in the operating room where the a lot of the time the surgical drapes are covering most of the chest so we don't even have access to the chest to the skin therefore TTE offers the opportunity the patients are already intubated under a general anesthetic sedated and with an airway so it's easier technically to put a TTE probe and get a good assessment and good windows to assess and looking for the answers finding the answers that we're looking for. So what I'm going to do now is I'm going to present a series of cases that we have done over the past few years where TTE or Rescuti did make or was part of a change in the management of the patients. So this is the first case where this is a elective c-section and an uncomplicated pregnancy and after the baby was delivered the patient became in severe shock with decreased level of consciousness she needed to be intubated and was in a pre-array situation that required advanced resuscitation. It was not very clear etiology there was no signs of bleeding there was again uncomplicated pregnancy no other anesthetic complications and so after a few minutes of resuscitation without not a very good response we would call and put a TTE probe and what we saw was somehow consistent with the dilagum increased the size of the RV cavity and with severe RV dysfunction and an empty LV as well so in the context of the clinical scenario and the findings both of the Amidus of Agilophore with the dilated RV and even some what it looked like some anatomical abnormalities inside the RV this could have this brought the possibility of being amniotic fluid embolism causing severe RV dysfunction and the severe shock. This patient eventually had to go into a VA ECMO for mechanical support and did well and had a good outcome at the very end but it was it was a good example of how to help them or help us making the diagnosis. This is another case where a patient who came comes in for a young patient on the mid 40s with a laprod for an emergency laprodomy for a small bowel obstruction and during the intrap and after induction of anesthesia becomes severely hypertensive and not really responding to the initial management of fluid and pressers started on our norepine and aphid infusion with again not very a good response. Serical dreads were on so they were not able to put a pocus TTE so they asked us to do a rescue TTE. When we did the TTE it was it was we noted that there was quite a bit of hypertrophy of the LV H and septum and asymmetric with what it was seems to be a sigmoid septum and there was some what it looked like a decreased diameter or decrease of the LVOT with the possibility of doing a dynamic LVOT obstruction. We put color on we could see that there was acceleration of flow through the LVOT as well as MR which was consistent with SAM and dynamic LVOT obstruction. This finding help managing the patient with further resuscitation with volume decreasing the heart rate and pure base of pressers and eventually the patient got out of shock and was adequately resuscitated to continue with the surgery. Another example where we're a large trauma center we get a ferment of major traumas and this is a patient who had a multi-system trauma days before he was in the ICU intubated with a previous laparotomy and now has come back to the operating room for fixation of his multiple MSK injuries during the surgery he became again very unstable in terms of shock no obvious source of bleeding and no other signs of other injuries or other explanation why suddenly became hypotensive so T was asked to be done and we noted that again there was a although a hyperdynamic that would look like how the RV was dilated and on the short axis and the transgathric view we could see that there was a clear dilation of the RV with some flattening on the interventricular septum all consistent with it looked to be a acute RV failure and in the context of the the patient plus hypoxemia as well it was thought that we could be related to a major or a massive pulmonary embolism so eventually after further resuscitation with a vasopressor patient was taken to the CT scanner at a CTPA and indeed show a massive pulmonary embolism that require management with thrombolitis another case that illustrated the role of rescue T this is a patient who had a triple A repair uh which was completely uneventful got excavated at the end of the case went to the ICU and hours later started becoming hypotensive and increasing and rising lactate uh initially thought by the surgical team that it could be related to uh bowel schemia uh however a patient was taken back to the operating room for an emergency laparotomy and did not show any changes in the bowel and given the fibers to still quite hypotensive and portive responsive to the resuscitation and still rise in lactate decided to insert a T probe and what did is shown as an intramural dissection of the ascending order to extending all the way down likely a retrograde dissection from the previous clamp from the triple A repair so eventually this patient needed to have a full replacement of the ascending and this is a good example how prompt real time point of care T really made a change otherwise would have been a very difficult diagnosis to make and it probably would have been delayed until the patient would have been back to the ICU and not getting better probably got a full CT and they would have seen this and finally to finish with the cases this is another case patient who had a thoracolumbar laminectomy in the context of severe scoliosis uneventful otherwise medically perfectly healthy and patient was good after induction of anesthetic good and supine when it was prone it became severely hypotensive not a clear reason why there was no source of bleeding no medication error no signs of an aphrolaxis so it was decided to bring the patient back to supine position to further resuscitate and with further resuscitation he really improved and it was wing off all the medications so the situation was to continue with the surgery and once the patient was prone again it became severely unstable again with severe hypotension refractory to the usual vasopressor so it was not clear why that all you over this was so T was inserted and we could know that when he was in the prone position there was a mechanical dynamic obstruction of the RVOT and decreasing the size and compressing the ribentricle likely related to the fact that these severe scoliosis and change in the ribcage and thoracic cavity it was making it was a mechanical obstruction when he was going in prone position so after readjusting the ballsters filling up with more volume the shock resolved and the surgery was able to continue without any further problems so all these cases illustrate the utility of having a rescue T available and in the context of non-carry of surgery and some of them a couple of them were done by non-carry of anesthesiologists that were able to provide with the basic views to make and help the decisions to guide the management of these patients now the other thing that I want to really focus on or want to mention is was the use of the role the increasing role of T during cardiac arrest and this work has been pivoted and developed mostly by the emergency physicians and they have been using resuscitative T for the last few years and initially it was more like a diagnostic role to identify the usual Hs and Ts but now there's been more uses being described such as it can help you with procedures such as cannulation of ECLS or cannulation of other central axis and now there's also a role that has been identified that can help you enhance and optimize the quality of chest compressions during the during the resuscitation and even a prognostic role when it's able to identify different causes who have a very high mortality and very poor outcomes in terms of after resuscitation now again you will ask me why would you do T and because like Pocosti T has been described to be useful and it's been incorporated in the ECLS guidelines for a few years now however the caveat is one of the caveats is that it's found to be that the T T Pocosts sometimes have delayed the chest compression or interrupt the chest compression it's very important to remember that despite having very good technologies we have to stick with the basics when we're running an ECLS code and it's good chest compressions and early defibrillations the only two interventions that are shown that really improve the outcomes of this patient having said that so they sometimes Pocosti T can interrupt and can be in the way of these interventions having said that as transit of a ELECO because it's outside of chess it's not in the way of CPR it could offer LPP potential good for cardiac resuscitation and there is in fact a small study where they compare the use of T versus T T and pulse checks and T was the one who found interrupt the last and delayed the last the quality of chest compression and initiation of chest compression because it's again it's away from the chest it's somebody else dedicated of doing that while the ongoing resuscitation is happening and just to mention again like the idea during the cardiac arrest is helping with the diagnosis of the potential reversible causes and specifically things like severe hypovolemia severe pericardial tamponade, cardiac tamponade from pericardial effusion however there's also a new entity that's being described as pseudo PEA and is helps with the diagnosis of a very fine buffet that is not identifiable in the ECG and this pseudo PEA what it means is that there's some electrical activity where there's no palpable pulse but when the T is done there's some organized electrical activity that tells you that there are some activity that will probably require higher support from inotropes and base oppressors to restore the function and this is an example of a pseudo PEA this is a patient who had a cardiac arrest a PEA arrest there was no palpable pulse but when we put a T probe you could see that there is although very poor contractility there is some organized activity that with the help of more inotropes and higher doses of inotrope it could respond better and the resuscitation and this is just to highlight there's different studies done mostly in the intrahospital cardiac arrest scenario both intraoperative and outside of the operating room and they have shown they all have shown that there's utility in terms of diagnosis and the cause of the arrest now the new or the most recent application has been studies how to identify the quality of CPR and we do that because there's the maximal compression area where the CPR should be doing in the RV and LV and avoiding compressing the LVOT to avoid impeding the outflow or the stroke volume going through the arctic valve and it's interesting to see that there's been studies done with the looking at this and we have then been identified that it's 50 to 60 percent of the times the CPR is actually not done in the proper space and that's actually occluding the RVOT so now it's become a good way to assess the quality of the CPR and maybe changing the position of CPR to optimize the output during CPR and this is an example of a case we had where CPR ongoing and you can clearly see how it was done properly because the RVOT and LV are the one who have been compressed and you can see that the LVOT is free the arctic valve is open and when we put colored up we could see that there's a actually flow across the arctic valve so again this is an example of how the role of the it could be good during CPR and it's the reason why it's become and there's been guidelines developed for it mostly by the emergency physicians and in terms of training it's been shown that it's doing a simulation and and a quick or short training in the operating room with cardiac anesthesia has shown that it gives you the skills to obtain these basic four or five views and able to identify those life-threatening situations. There is even a way now to get certified for more basic D and in fact in our modern group we have two non-cardiac anesthesia that has been certified and trained for this and they are able to help and diagnose all these conditions so I encourage you to go and get trained and to take home messages I would say rescue D definitely can change your management it's has a very important role during cardiac arrest and here's here to stay here's our my email if any further questions and my email my twitter account if you also want to contact thank you again for the invitation


Colgate dental cream to clean your breath while you clean your teeth and help stop tooth decay and palm olive shave creams For a smoother more comfortable way to shave bring you our miss Brooks starring Eve Arden Time once again for another comedy episode of our miss Brooks under the direction of Al Lewis Well her salary as a teacher covers all her basic expenses But our miss Brooks who teaches English at Madison High School has discovered that there are certain luxuries It won't pay for luxuries like clothing for instance However last Monday I dropped in to madam Amelia's dress shop to price some of the items She was featuring in a post Easter sale in no time at all I discovered that if madam Amelia would let me pay for it on time I could easily afford the sales tax on her cheapest dress But thanks to a proposition madam made to me I did leave the store with four new dresses at breakfast Friday morning My landlady commented on one of them another day another dress. It's a beauty Connie Thanks, Mrs. Davis You've no idea what it's been like to sit opposite you during this past week every day a new dress that looks like the first Breath of spring glad you like the mrs. Davis, but I wish you'd cheer up a little Your dress looks like the first breath of spring and your face looks like the last gasp of winter What's the trouble Connie well, you know the agreement I have with madam Amelia, don't you quite yes She said she'd give you a brand new suit free of charge If you'd introduce some of her clothes into Madison High School this week I wasn't only supposed to introduce the mrs. Davis There was also supposed to be an increase in business But since you've been wearing the dresses hasn't business increased 25% at do buries across the street That's ridiculous the jump at do buries is just a coincidence. You deserve the dress anyhow Look at the work you've done. How many other teachers would want to wear a brand new dress to school every day I don't know how many teachers are there in the United States No, I'm afraid I haven't lived up to my part of the bargain as a matter of fact our agreement officially Terminated last night. I was supposed to return the dresses then but you're wearing one of them this morning I just couldn't face my old blue jersey suit for at least one more day Besides I figured after all this time somebody's bound to notice me You mean no one's paid any attention to your new outfit so far. Well, I did get some encouragement yesterday I've been sitting opposite mr. Boynton at lunch for three days in a row and each day I had a new dress on yesterday. He finally noticed something different about me. What did he say he said miss Brooks You've got some eraser dust on your neck Of course a few of the female members of the faculty admired the dresses, but they're evidently too poor to do any buying How about your principal Connie? Did he comment on the transformation? Mr. Conklin hasn't commented on anything, but his newest economy drive another one But he just ordered a big cutback in school expenses last month that came from the board of education This is his own idea and you ought to see him enforce it Why I broke a pointer the other day while he was in my classroom and before it even hit the floor He had snatched up the short piece and filed down the rough edge And what did he do with it? He gave it to a teacher with long arms He's a beauty all right That's Walter Denby right there Walter. I've got to run Mrs. Davis Thanks for breakfast. You're welcome dear and don't look so discouraged about to deal with madam Amelia You've still got today to put it over. I'll try just remember this Connie whether it's modeling or anything else You only get out of something what you put into it believe me. Mrs. Davis everything. I've got I've put into this dress Please Walter keep your eyes on the road What in the world are you staring at anyway? Just the most scintillating vision in the world Huh? I wish I didn't have to drive it all I wish I could just sit here and drink you in and all your intoxicating loveliness Hand me a mirror. I'd like to get high, too Curry is overwhelming. Oh, it's only your do miss Brooks. Gosh. I've always admired you personally But the way you've looked this last week makes the way you used to look positively hag like I Should have quit when I was ahead The dress you've got on today's a knockout miss Brooks. What are those colors in it? They're chartreuse and cerise Walter.  That's funny. I haven't heard a thing Female members of the faculty look like Eddie canter Of course, I'll admit it took everybody a few days to start noticing your new wardrobe But I think I have the answer for that. Oh, what is it? Well, it's because everyone has seen me in that blue Jersey suit of yours for such a long time It got so that after a while nobody ever looked below your face It sure does got a Kleenex Glad that somebody's finally noticing these outfits. I wouldn't be human if I wasn't. Oh, don't you worry about that You're human. All right Thanks for the affidavit Harriet told me you got the outfits at Madame Amelia.  Oh, she is yeah My mother said she wants to visit the place herself, but she was wondering when would be a good time What is she doing yesterday? I mean Before I forget miss Brooks at when I spoke to Harriet on the phone this morning She said to tell you to please stop at her dad's office as soon as you get to school It's probably in connection with this new economy drive of his.  Oh, that isn't an insurmountable problem Walter What do you mean?  It's miss Brooks and it can wait indefinitely bye not so fast come in miss Brooks Now then I'll come right to the point the reason I wanted to miss Brooks Isn't that another new dress you have on? Yes, sir. Really remarkable miss Brooks. May I ask you a question? Certainly, sir. Are you able to dress this way on your salary or have you come into an inheritance? No, sir. No, sir. What? No, sir. Mr. Conkman Come into an inheritance, but these new clothes. How do you pay for them? Well, you see sir. You don't gamble do you? Well, I don't want to pry into your personal life after all you've worn that blue jersey job long enough Suffice it to say that in the past week you've given the rest of the faculty something to shoot at the dresses Can't be that bad On the contrary they're very smart But to get back to the reason for your being here as you know miss Brooks I am in the midst of a new economy drive here at Madison. Oh, I know mr. Conklin Mr. Boynton and I discussed it thoroughly at lunch yesterday. Oh, then you're beginning to feel the pinch Certainly not all we ever do is talk I'm afraid everyone's feeling the pinch. Well, believe me. It's a necessary measure in these parlors time Mr. Stone the head of the school board is coming over to my home this afternoon for tea Naturally, I'm interested in impressing him with the strides. We've made it Madison naturally and it has occurred to me that an excellent Weight convince him of the wisdom of my economy policy is to show him what a teacher such as yourself can do on a limited budget Me yes, miss Brooks if you'd come to our home this afternoon My wife and I would be most pleased to see you in one of your new dresses. That is well That's very nice. Mr. Conklin. Oh, and since it's a bit late for her to pick up anything But would you consider lending mrs. Conklin one of your other new creations just for the day, of course Well, mr. Conklin, I don't want you to think that this is a command performance miss Brooks, but you will be there at four, won't you? Yes, sir Oh She's in my office right now. It's for you miss Brooks be brief, please Yes, sir. Hello. Who is this madam who? Oh Yes, I know last night was the last yes, but I just Have them back today, but I very well as quickly as possible. Goodbye Well, if you'll excuse me, sir, I'd better be getting into class nothing wrong Is there wrong or what could be wrong? I just don't want to be late. You know how hungry my pupils are for learning Starved is the word Well, you'll be at my house at four sharp miss Brooks is that correct mr. Conklin? I'll be there with bells on if nothing else Brush your teeth with cold gates cold get devil cream it cleans your breath What a toothpaste what cleans your teeth cold gate toothpaste What a toothpaste what cleans your teeth Cold gate dental cream cleans your breath while it cleans your teeth and the cold gate way stopped tooth decay best Yes, the cold gate way is the most thoroughly proved and accepted home method of oral hygiene known today Over two years research showed brushing teeth right after eating with cold gate dental cream Help stop more decay for more people than ever before reported in dentifers history the cold gate way Stop tooth decay best no other dentifers amniated or not offer such conclusive proof And you should know that cold gates while not mentioned by name was the only toothpaste used in the research on tooth decay Recently reported in Reader's Digest so always follow the cold gate way to clean your breath while you clean your teeth and Stop tooth decay best Brush your teeth with cold gates cold gate dental cream it cleans your breath what a toothpaste And the cold gate way stops tooth decay best Well by lunchtime I had almost decided to confess to mr. Conklin that I didn't really own any of the madam Amelia dresses But before making that decision. I thought I'd discuss it with mr. Boynton when I arrived at the school cafeteria I purchased my lunch and I just sat down to a table when who should come walking by but mr. Boynton himself Naturally, he stopped immediately Sorry, miss Brooks. I I didn't see your foot there in the aisle Forgive me mr. Boynton. I didn't mean to trip you so hard Your lunch isn't all wasted. Oh no miss Brooks.  I sat in does it look terribly messy miss Brooks In fact, it's rather attractive.  Boynton there's something I'd like to ask you oh before you do miss Brooks I'd like to pop a question to you first of course it it might be considered quite personal But with your permission, I'll pop it anyway if you're going to pop the question. I've been waiting for you to pop pop away pop Miss Brooks that dress you've got on isn't that another new one why mr. Boynton you've been paying attention after all You like it? Oh very much. It's a very interesting shade Yellow isn't it just where the butter landed when you dropped your tray It's mostly chartreuse mr. Boynton. It's very exciting almost identical in shade to the skin of a young frog Third or fourth lovely new dress you've put on this week. How do you do it miss Brooks?  You know, that's the suit you were wearing when we met. Yes four years ago I must admit I wasn't too crazy about it at first, but well it really grew on me me, too I had quite a time chiseling it off last Monday About those new dresses mr. Boynton Miss Brooks the fact that you were able to acquire such garments on a teacher's salary is extremely commendable Well, thank you mr. Boynton I've always admired a woman who can budget herself properly a woman who can do that could be a real asset to a man She could a man could hunt for such a woman for years and years four of them to be exact With a clever and thrifty companion. There's no telling how far a man could go go go Well to to sum up my feelings in the matter I I can only say that this type of woman is downright marriage timber I'm serious miss Brooks seeing you in these new outfits has opened my eyes and well There's something I'd like to say to you. Pardon me miss Brooks, but I've got to talk to you for a minute. Oh for heaven's sakes Walter Interrupting anything. Am I just my future? What can I do for you? There's a delivery truck outside for madam a media's dress shop. The driver says you've got four dresses to send back Send back. Yes, it's just a temporary measure mr. Boynton You mean the dresses are all gonna be altered miss Brooks. No Walter like I said before just my future Hi miss Brooks heading for daddy's office. Yes, I am Harriet. I just left him I've never seen daddy in such excellent humor miss Brooks He's sure that your new gowns will make a big impression on mr. Stone this afternoon In fact, he said that your little visit this morning was like a tonic to him. Waitly. Here's the Mickey. I've got for him now I'm afraid I won't be able to come to tea this afternoon won't be able to come But why not miss Brooks and where's the gorgeous madam Amelia dress you had on this morning in a delivery truck on Main Street But I don't understand. You're wearing your old blue jersey again Where did you get that out of a bundle I had ready for the Salvation Army? It's a long and gruesome story Harriet, but I had to send the dresses back. You see I never really owned them I was just modeling them for madam Amelia if business increased She said she would give me a free one, but it didn't so she didn't and I'm back where I started last week Shall we dance? Well don't look so desperate miss Brooks all isn't lost then where is it? You're going to love me for this I was so captivated by those new gowns of yours that during your English class I secretly sketched two of them Then I took the patterns to home economics class and we spent the past couple of days making exact copies What I know you promised to lend one to mother so it'll work out. Just perfectly of course We made them out of air sats material But beggars can't be choosers and after all the main thing is not to disappoint daddy But don't you think your father and mr. Stone will notice the difference?  It's not bad I'm glad we got home ahead of daddy miss Brooks It gave me a chance to reinforce some of the weak places in this dress now stand still while I pin this basting in back Where are the pins? I ask you to hold I've got them in my mouth Harriet help yourself Well, that's no place to put pins ouch neither is that We've got a hurry though I heard daddy and mr. Stone go into the living room about five minutes ago I must admit you copied the style of madam Emilia's dress perfectly Harriet But tell me what kind of material did you use? Well, we started with rayon and when we ran out we used muslin Some of it feels like cheesecloth to me. Oh, it's loaded with cheesecloth But don't worry miss Brooks the way I've got it basted no one can possibly tell the difference I'll bet your mother will tell the difference when she puts hers on well frankly miss Brooks I haven't had a chance to tell her it's a copy I just left it on her bed when she was getting the tea ready and then rushed back here to you What you mean to tell me your mother doesn't know there's nothing between her and a life of shame But some cheesecloth and a fervent prayer Gee I never thought of it that way if mother bends over sits down too quickly we're sunk We're sunk your mother won't be in such good shape either You both got to be very careful I tell you what I'll do miss Brooks if I see anything beginning to go I'll give you a verbal signal a verbal signal Yes, since we'll be having tea. I'll just say something like sugar and cream miss Brooks or pass the lemon Now come on everybody's waiting for your personal appearance with the wrong kind of a break This can be the most personal appearance I've ever made But mine not to reason why I lead on Harriet ride in here miss Brooks Well, here we are daddy. So you are you know my daughter Harriet mr. Stone certainly. Hello Harriet How do you do sir and miss Brooks? Well, that isn't attractive dress you have on. Thank you, mr. Stone I've been telling mr. Stone about the wardrobe you've acquired recently miss Brooks It certainly gives impetus to an economy drive when a teacher can do what she's done Hey, mr. Stone very impressive conch and thanks to the way I manage my personal budget Mrs. Conklin has been able to enhance her wardrobe recently. He's probably jumping into her new duds right now I don't advise it Oh, I see she's left the tea right here on this table. May I act as temporary hostess? Please do I'd love some tea miss Brooks sugar and cream please so soon I'll pour it for a miss Brooks. You stand still Hello, mr. Conklin. Happy to see you again Say that's a stunning dress you have on. Yes, you look positively ravishing my dearest and just as you are Don't move a muscle. Yes, hold it for about 45 minutes I don't believe I've ever seen you looking lovely a mother you and that gown or a match that was made in heaven Oh now Oz good Honestly, mr. Stone sometimes when Ozgood pays me a compliment. He gets so extravagant with his praise. I could just split You're holding the wrong thought mrs. Conklin And may I pour you some tea? Oh, thank you, dear, but I can pour it myself bending over is good for me Oh, but you mustn't bend mother here. I'll get you a cup Oh, I'd rather do it myself Period after all the more one bends over the more one takes off around one's middle But mrs. Conklin one can take too much of one's middle after all it's nice to have something between one's bottom and one's top Yes, yes, but Why are we standing let's sit down shall we very well. Oh wait, it's not healthy to sit down after a heavy meal Heavy meals but none of us has had anything to eat since lunch time. I know but why take chances You and your quips mrs. Brookes Now let's all be seated just a moment What is it now? I propose a standing toast to our host and hostess here here a toast to our host and host Now can we sit down? Uh, would anyone like to hear some music? Oh, that's a great idea Harriet Get out your phonograph record of john philip suzer playing the star spangled banner Now stop the horse play you too Sit down mr. Stone. Now just where were we in our discussion, sir You were pointing out to me osgood what a teacher could do on her present salary if she really tried Ah, exactly exactly and not only a teacher but anyone who lives on a budget take that dress my wife is wearing Now let's not talk about me anymore osgood.  I think I'll open a window in here. It's not that warm in here Perhaps not, but I thought I'd like to let in a little more air. Now, please Martha just sit down very well What was that that was mrs. Conklin letting some more air in Like something ripping Is that your dress mrs. Conklin? Oh, certainly not. It's still the same lovely three-piece suit. It's always been Three-piece suit Martha stand up a minute. Yes osgood Or did I tell you it's the same lovely four-piece suit. It's all With two pair of skirts This dress is coming apart at the seams But I don't understand it neither do I but I better get into my bedroom and change. Excuse me, please Miss Brooks, perhaps you can explain what's going on here and not now mr. Conklin. I'd better go in and help mrs. Conklin change I'm sure she can manage by herself now sit down mrs. Brooks. Yes, sir sugar and cream mrs.  Stone, but an awful lot is coming off I think I'd better pour myself a cup of tea the lemon mrs. Brooks. Where's the lemon it went that way I think I'm beginning to see what this is all about I beg your pardon first you give me all this talk about retrenching Then you demonstrate that what a teacher can buy on her salary these days is actually nothing but junk I've got to give you credit conklin. Your idea is brilliant It is Certainly You've given me a graphic display that too much economy can't possibly work in these days of rising prices Osgood conklin You're really clever Oh come After all my wife and miss Brooks were a considerable assistant, you know Yes, indeed you you and mother would make a fine pair of actresses mrs. Brooks. Well, thank you, mr. Conklin I know one theater in town that would love to have us Which one is that mrs. Brooks the star and garter burlesque I promise Brooks returns in just a moment now the case of the close scrape featuring arthur griffin male carrier Here's what mr. Griffin told us listen. Here's exactly what happened Shaving was just one close scrape after another for me And then I discovered palm olive lather shave cream and a new different way to shave Palm olives oceans of rich thick lather ended my worries about scrapes burns and nicks Why even in cold or hard water that palm olive lather way is super smooth super comfortable Take arthur griffin's advice men the new palm olive lather way gets beards really soft And it provides a protective film that actually floats your razor's cutting edge You get a clean close shave every time without worry about scraping or nicking even in cold or hard water arthur griffin and 1200 other men tested palm olive lather cream Following package directions and three out of four reported smoother more comfortable shaves the palm olive shave cream way No matter how they shave before better get palm olive lather shave cream Remember even in cold or hard water the palm olive lather way means smoother more comfortable shaves And now once again here is our mrs. Brooks Well, there wasn't much sense in sitting around in my drafty dress So I said goodbye and backed out of the conglance when I arrived home Mrs. Davis was most helpful and had just finished sewing me up when the phone rang Hello, hello, miss Brooks. This is mr. Boynton I've been thinking of how lovely you looked in your new dress today And I wondered if you'd like to take a little walk this evening Oh, you you took me by surprise mr. Boynton. I'm afraid I dropped the receiver Hold on a moment. I'll pick it up I'm sorry mr. Boynton, but I can't see you tonight But why not? It's a beautiful night The moon is out the stars are out. If this wasn't the party line, would I give you an answer? Mr. Burns Next week to another hour mrs. Brooks show brought to you by palm olive shave cream For a smoother more comfortable way to shave and cold gait dental creams to clean your breath While you clean your teeth and help stop tooth decay our miss Brooks starring eve arden is produced by lary burns written by Al Lewis and author alzberg with the music of wilbur hatch Listen to this with marvellous vell vell You can save 90 of dishwashing work a quick soak in vell suds gets dishes and glassware shiny clean Even if a bit of food should cling a touch with a dishcloth gets rid of it fast Yes bells activated suds lift off and carry away food in greece So all dishes need is a quick rinse and they dry sparkling without washing or wiping all pots and pans Need is a soaking with vell suds Then you can wash them shiny clean without hard scouring. What's more vell is a miracle of mildness So get new vell save 90 of dishwashing work If you like mysteries that are full of chocolates as chills be sure to hear mr. And mrs. North every tuesday over this same network and be with us again next week at this same time for another comedy episode Of our miss brooks bob lemond speaking Stay tuned now for jack fennie. This is cbs with columbia broadcasting system


So this question comes up a lot. Since this whole deal with the ISPs could potentially sell all your data in your browsing history, which is a whole other controversy which I've talked about before. I've made another video about what creepy things your ISPs could do since this law has now actually passed. And when I said the video, it wasn't signed into law or removed or redacted, depending on your perspective on it because they removed the protections that say they couldn't do it. So we're gonna give you a demo of how a VPN works with ink pens. And to give you some perspective here, I'm an internet user and Marvin's gonna represent a VPN. So the first part of this, he's not gonna participate in because you are the internet service provider. So you wanna know what the internet service provider sees. So we're gonna do the internet based on ink pens as well as noises you hear. I got ink pens. So each one of these pens is, well, okay, most of them are different, but these represent the different websites you go to. So because each of these pens are represented for a website and you as the ISP can see what pens I have, you can see when I browse the web that you're watching my browsing history. I'll let you guess what this one represents. It's kinda late. So you can then take that information and sell it. Now, this is always where the confusion comes in, is how does a VPN protect me? Well, we're gonna show you. I need all the pens back. We have a tunnel. This seems really inadequate. We're gonna go with the bigger one. Put in a bigger tunnel. There we go. All right, so a VPN represents a tunnel between me, the internet user, and Marvin.  You can see that I'm using a VPN. So you can see that Marvin, the VPN provider, he knows what my browsing history, you, the ISP, does not. So now when we do it this way, the pens go through and I'm gonna hide what pens I'm going so you have no idea what pens or websites I'm going to. Now Marvin still does. That doesn't change. So you have to pick a VPN provider that you trust because even though you, the ISP, can't see where I'm going, you do know that I'm using this as a Marvin as the VPN provider. So one of my thoughts has always been on this and now, and I can't say this for any of them and I brought this up before, is the VPN provider now has an opportunity if they have personal identifiable information to sell that browsing history. Whoa! So you have to pick a VPN provider you can trust. I've been going through them and did some reading on them. There's a lot of different reviews. So far I signed up with, I did a demo video on PIA VPN. I'll do a few more. Their service seems pretty straightforward. They don't claim to keep any logs or anything. They also have a way to help de-anonymize it. So you're in a provider because you pay your bill. They know who you are, it comes to your house. So you, the ISP, know a lot about me because, well, I pay you every month and you know my home address. So you have really personal identifiable information about me. Well, the way PIA and some of the other VPN providers as well do this to de-anonymize and disconnect you from you is offering things like gift cards. You can pay with a gift card that you went and bought with cash. So then you pay them with a gift card. That's one of the ways VPNs create a disconnect between you and your data. Now, the VPN provider does know who your internet provider is because they see it going from there, but the internet provider only sees the tunnel to the VPN. That's how you hide your information.  So you really didn't get any more security from that. And the VPN doesn't necessarily directly offer more security. It just offers obfuscation about where you're going on the internet from your internet provider, that's you. So you may not see where it websites. Now, VPN can offer certain protections if a website is not secured and you're on an open Wi-Fi. That's a whole nother topic, but it's most websites are moving over to security and login. So that's less of an issue of why you want to VPN. But if you want to VPN and your purpose is to hide from you, the ISP, then it does work. It's not too expensive. You can talk to us about it. We can talk about how to set those up, but you're not adding a layer of security. You're adding a layer of obfuscation from you, the ISP. So that's just what a quick explanation of that because a lot of people have been asking, share this video with other people who don't know what VPNs are. And if my explanation makes sense to you, do a thumbs up, subscribe to our channel and let me know. If I got something really, really horribly wrong, you're never as wrong as me. You're wrong on the internet. Let me know that too. We'll find out, that's for sure. Yeah, so this is VPNs explained with tubes and now we can anonymously throw pens at Marvin versus when you can see me throwing pens at Marvin. Thanks for watching. Bye.


Income tax 2021-2022, accounting periods and methods. Get ready to get income to the max, dive into income tax 2021-2022. Most of this information can be found in publication 334, Tax Guide for Small Business 2021, income tax formula line number 1, income, noting that we would have a sub-schedule, basically an income statement with income and expenses, basically being deductions the net, then flowing into line 1 of the income tax formula, income and first page of the form 1040 line number 8. So in essence, we would have the schedule C, the net income flowing to schedule 1, which would flow into page 1 of the form 1040 line number 8. This is the schedule C, profit or loss from business, basically an income statement. We're now looking at the accounting periods and methods, which gets into basically bookkeeping type of topics. Now this is another area where as a tax preparer, you would want to be thinking, what kind of clients am I picking up here? Do I want to be picking up more simplified clients? Or do I want to be picking up more complex clients? When I'm picking up, if I am picking up more complex clients, what are the kind of complex clients that I would like to focus in on? Are they going to be business related clients that would have something like a schedule C? And if so, then how much do I want to dive into kind of bookkeeping needs that are going to be questions with regards to that type of business versus just simply doing the data input on the tax side of things, because the accounting methods and periods gets a little bit more into the bookkeeping side of things. So when we start thinking about like accounting methods, we could think about general accounting methods in which are going to be best in general to report income. And then we have accounting methods as are applicable to the tax return with regards to what is allowed to be reported with regards to on the actual tax return. So usually we have like an accrual method and a cash method and then we could kind of have a hybrid of those two methods. But the key is that once you have chosen a method and you've dedicated yourself to that method, you can't change easily you have to basically get authorization to be able to change because the iris is skeptical that if you were to change from say a cash method to an accrual method or some variant thereof, then you would be able to use that to kind of fluctuate your income over the over the cutoff periods, which could kind of adjust your taxes. So the big thing that the iris in my opinion is kind of trying to incentivize is to get to one method, pick that method, stick with that method so that you're held to it over time and you don't have this kind of fluctuation unless there's a need for that fluctuation. We also have a couple of different things that would require people possibly to go to a more complex method, which would be the accrual side of things as opposed to the cash method, one of the big ones being inventory. So if you have a lot of inventory, you would think you're more likely to basically be doing an accrual method because your inventory is usually accounted for kind of like on an accrual basis. Okay. So you must figure your taxable income and file an income tax return for an annual accounting period called a tax year. So it has to be an annual accounting period so we can define, well, what is an annual? It's like 12 months of accounting period that we have to have it. And usually it's going to be the calendar year for a schedule C business, but that's the general rule. Also, you must consistently use an accounting method. So notice consistently as a keyword, an accounting method that clearly shows your income and expenses for the year. So it didn't name the accounting method right there. It just says it needs to be consistent. So publication 538 accounting periods and methods. You can look at that for more information. We have the accounting periods. When preparing a statement of income and expenses, generally your income tax return, you must use your books and records for a specific interval of time called an accounting period. So obviously when we're reporting the income on the income statement, we're looking at the timing statement. If you know financial accounting statements, we have the balance sheet which reports as of a point in time. And we have the income statement which is the performance statement. That is in essence what the schedule C is. Notice we don't have the balance sheet when we're reporting just a schedule C type of business sole proprietorship as we would if we were reporting like a corporation type of entity more likely having both the balance sheet and income statement in that case. So then we need the time period that's covered. Usually going to be what's going to be some kind of year. Oftentimes a calendar year but possible have exceptions. So the annual accounting period for your income tax return is called a tax year. You can use one of the following years, a calendar year or a fiscal year. So the calendar year, January through December, a fiscal year, something other than January to December and that would be the more complex kind of situation generally. Unless you have a required tax year, you adopt a tax year by filling your first income tax return using that tax year. So when you do your first tax return, you're going to lock yourself in to a couple things here because of consistency. So that means you want to make sure you get it right. So if there's something other than the calendar year, you want to make sure you get it right from the start because it's difficult to change because they want consistency. So a required tax year is a tax year required under the internal revenue code or the income tax regulations. So calendar tax year. Calendar tax year is a 12 consecutive months beginning January 1st and ending December 31st. You must adopt a calendar tax year if any of the following apply. So calendar tax year, most likely the tax year that most Schedule C businesses would hear, but you have to have it if the following apply. You do not keep books. So if you don't have any bookkeeping, they're going to default to the calendar year. You have an annual accounting period. So if that's your normal accounting period, you would think that would then be your normal period for the taxes for the Schedule C. The present tax year does not qualify as a fiscal year. Your use of the calendar tax year is required under internal revenue code or the income tax regulations. Calendar tax year. If you filed your first income tax return using the calendar tax year and you later begin business as a sole proprietor, you must continue to use the calendar tax year unless you get IRS approval to change it or are otherwise allowed to change it without IRS approval. So once again, when you try to change things, then the IRS wants approval because they're going to think that you're trying to shuffle around the income on the cutoff dates to lower taxes, and that's not what they want. For more information, you can see change to change in tax year later. If you adopt the calendar tax year, you must maintain your books and records and report your income and expenses for the period from January 1st through December 31st of each year. Then we have the fiscal year, the more complex type of situation generally. A fiscal tax year is 12 consecutive months ending on the last day of any month except December. A 52, 53 week tax year is a fiscal tax year that varies from 52 to 53 weeks but does not have to end on the last day of the month. So generally, if you think about there's 12 months in a year, there's about 52 to 53 weeks in a year, so they're defining it in the weeks because weeks are a little bit more specific there. And so 52, 53 week time frame, but it doesn't have to end on the last day of the month. So if you adopt a fiscal tax year, you must maintain your books and records and report your income and expenses using the same tax year. For more information on a fiscal tax year, include a 52, 53 week tax year. You can see publication 538, so if you have questions about that, the more unusual kind of deviation from the standard calendar year, you can find publication 538 on the IRS website. Change in tax year, so now you're saying, well what if I've already have a tax year set up and I want to change it? Well the IRS doesn't like that, but you got to have like a good reason. I've got a good reason IRS, listen to this, this is why I want to change it, that kind of thing. So generally, you must file form 1128 application to adopt change or retain a tax year to request IRS approval to change the tax year. Again, this is why it's very important to try to get things lined up the way you want them lined up in year one, so that you can remain consistent throughout, but if that didn't happen or you can blame the prior accountant, the prior accountant messed it up and now we got to fix everything, then you do this. So see the instructions for form 1128 for exceptions. If you qualify for an automatic approval request, a user fee is not required. If you did not qualify for automatic approval, a ruling must be requested. See instructions for form 1128 for information about user fees if you are requesting a ruling.