Scaffolds are used in tissue engineering to provide a structure for cells to attach, grow, and differentiate into functional tissues. These structures must meet certain criteria such as mechanical strength, surface characteristics, porosity, degradability, and biocompatibility. In this study, polymeric scaffolds reinforced with electroactive particles were investigated for potential use in bone tissue engineering. The scaffolds were produced using an extrusion-based additive manufacturing system and then modified with varying amounts of pristine graphene. The surface properties and biological responses of these scaffolds were compared and it was found that the addition of pristine graphene led to improved cell viability and proliferation. Additionally, surface modification led to enhanced cell response. This article was authored by Weguang Wang, Guilherme Catano, William Stephen Ambler, and others.


What is going on guys welcome back to the channel Critical Overlord here So this would be my spoiler free review for Fantastic Beasts the secrets of Dumbledore This movie is coming to us directed by David Yates with a screenplay from J.K. Rowling and Steve and or Steve Kloves It is starring Eddie Redmayne Jude Law Ezra Miller Dan Fogler Allison Sudele Callum Turner Jessica Williams Catherine Watterson and Mads Mickelson So this film is taking place a couple years after the first two entries the crimes of Grindelwald and the original Fantastic Beasts And where to find them taking place in the 1930s. This is basically again us going over Grindelwald's rise to power It's taking place and showing us the Wizarding World's involvement in World War two and just exploring these different magical communities in Germany China as well as the ones you're already accustomed to in the UK and the United States and Again, it's just going over Grindelwald's power rapidly growing I was Dumbledore in trust newt's commander and his friends with a mission leading to a clash with Grindelwald's army Dumbledore must also decide how long he will stay on the sidelines in the approaching war So off the bat I have to say this movie does a great job at pushing things forward and getting you Invested in what's to come and what I mean by that is coming out of the crimes of Grindelwald I was more so like do I really care where this is gonna end up now? Now I'm back to caring with the extra writer in the writing room I think that was a big difference not to say that One outshined the other because I don't know who really contributed what to why this movie turned out to be as good as it did but JK Rowling to me just felt she was going off of the deep end a bit with The crimes of Grindelwald certain plot points the way she didn't really pay attention to certain Continuity things that have been established as well for longtime diehard fans of this universe and of the of the novel I know where you're coming from in that regard. So there's a lot of plot points here that are fixed because of this Dynamic writer duo that I think should be kept up going into the last two movies because I know JK Rowling is a talented writer We've seen that but we also know that Steve Klaw's is responsible for bringing a lot of the screenplays to life for the Harry Potter films I think these two working together going forward would be best for business if this is what we end up getting Certain plot points regarding a certain character that you I know a lot of people said didn't make sense It was a lot of source of plot holes for some that is going to be fixed I'm not saying it fixes a lot of the larger issues that you might have with this franchise But certain plot points and narrative reveals that you say don't make sense or a plot holes They don't become plot holes Thanks to the progressions here in this movie the way it explores Dumbledore is also very interesting because of how mysterious This character has been presented in this universe It was a nice opportunity to get to learn him a little bit better learn about other characters We've already been talked her talked about regarding his life search as his brother and also his sister Arianna who has been shown throughout this franchise countless times and Seeing certain fan theories even become a reality here was very exciting for me when it relates to this movie I Also appreciated how Newt's commander came into his own a lot more here There was times where I'm watching these movies and like oh, hey, we know it's building towards Grindelwald and Dumbledore's battle So why are we not focusing more on those two? we do spend a lot of time with Grindelwald and Dumbledore who share a lot of scenes in this movie actually and Every time they're on screen together. They share great chemistry, but going back to Newt really quick the reasoning for Newt's the frustration I had with Newt was just Why do you want me to be so attached to this character? What are you trying to convince me of here? This movie does a better job at just making him stand on his own making his role involved in this larger battle that's coming to feel a lot more important and We see why Dumbledore trusts him a lot more the fact that he shares scenes with Dumbledore Give me gave me a chance as an audience member to say okay. I see why this is our focus point I still hope that Dumbledore is the focus going into these last two movies But Newt really does come into his own here And I love the way that his beast are also factored in and very prevalent ways the creatures that these wonderful creatures We know exist in this universe given that the franchise title is fantastic beast They are also very involved in this narrative just like how they were involved in the Fantasties where to find them film I feel like they took a took a seat back in the crimes of Grindelwald other than just highlighting some unique creatures But with this they're involved in the conflict They're revolved they're involved in some of the resolutions in said conflict. They share a lot of humorous scenes Such as the crab walk that you have in the trailer, which is one of the more humorous moments in this film I just like the way the beast felt relevant to the overall plot and narrative and it was helping them live up to their Title making you feel for these beasts and some of the more Sadder moments that happen with them in this film. This movie is also very emotional. It bounces that romance Sadness humor intense action all so well and all the emotions you feel throughout the movie They are not outshining each other It's just like a roller coaster of emotions that feel earned by the time the movie comes off It has a clear beginning middle in which I didn't feel the crimes of Grindelwald had Again certain narrative progressions here were tremendous stellar performances as always. I do need to talk about the character of Jacob Kowalski really quick who is portrayed tremendously by Dan Fogler He his nomad self is somebody that all of us muggles watching these movies just associated with so well I believe he here he is in this in this world as a muggle doing what many of us wish we could do and He's so likeable Dan focus portrayal of him makes him even more likeable and just the way he Manages to maneuver his way in this world with without Barely getting hurt is just what many of us want to do as muggles So it's always nice to see that character and see him develop a little bit better here this time around as well I also liked the portrayal of Grindelwald from Mads Mickelson. He's very Evil in the role also very charming Also captivating and again his see his scenes that he shares with Jude law. They have a lot of great chemistry There's also a battle that's shown in the trailer when that battle happens. It feels earned There's a lot of great setups and payoffs that happen in this movie a lot of great camera work as well Also very nostalgic with the score that James Howard has put together here this time around that calls back to the Harry Potter franchise The shot that I'm speaking of that also was like my favorite shot for the movie was regarding a sequence between Dumbledore and Credence who again is portrayed brilliantly by Ezra Miller Where the camera is tilting and shifting from one realm to the next and I think that's gonna also make a few people dizzy But the way is the way it's done is also just very magical Also some tricks like that we saw in the screen movie if you watch my screams screen videos I enjoyed the fantastic be seekers of Dumbledore. I like the way they explore Dumbledore a little bit more I like the way they progress the narrative and fix certain narrative plot points that have made a lot of people upset Better pacing everything was just structured better here. I give it a seven and a half out of ten Let me know just think about this down in the comment section below if having a record Make sure you subscribe turn on post occasion and miss a video in the description links for social media accounts on Facebook Twitter and Instagram you can message me there of course There's any movies and reviews you'd like me to cover in the future a lot of my guys I will see you in the next video


Well as everyone knows that we have a problem in our ranks with sexual assault, sexual harassment so we still have lots of work to do and we have to do is continually assess and continue to adjust our training programs, our culture that accepts sexual harassment and we also have to continue to work at our ability to investigate and then prosecute those who conduct sexual assault, sexual harassment. So we have a lot of work to do, we're not anywhere near where we want to be and this could take a total army effort to get there. Well first obviously it's about our training programs continue to be incorporated at the institutional and then incorporated in the operational army. I want to see command climate surveys conducted, mandatory command climate surveys at every level of command in order to judge, give the commanders an assessment of where the command climate is inside of their own specific unit. And in addition to that I want to eliminate what I call the bystander mentality.  So I think I want to go after all of those in 2012 and start to whittle away at short falls we have in those areas. Again I think it's important that there's many different ways you can report an incident. You can report it through your chain and command. We have phone lines that you can use to call, we have help lines and we really want you to report this and we will try to protect you the best we can in order to ensure that we're able to move forward and hold those accountable who've conducted these incidents. We have developed programs and training tools that are being dispersed to all commanders at all levels. And so they are very specific, they are very helpful and that they have the ability to use these. So I feel confident that the resources that are available are consistent and will have the consistent theme.   We must develop those climates that make it easy and make people believe that when they report a crime action will be taken. It's about it's about soldiers taking care of soldiers. You know I mean we're supposed to be there for each other all the time whether we're fighting in Afghanistan or whether we're home we have each other's backs. We have each other's right and lefts and we're there to help them and we should never tolerate somebody else who is not living up to that standard. And so that's what I talk about the bystander intervening and taking care of those who are not living up to our standards and reporting it through the chain of command and making sure that a sexual assault, sexual harassment does not occur. The best way to combat this problem is that every soldier takes it seriously and does not allow this to happen. Our business sometimes is life and death. Our business is we must depend on each other in order to accomplish our mission. And so we gotta depend on each other in all environments, in all areas. And if you don't have an environment that is, if you have an environment that's tolerable of sexual harassment, sexual assault, then I believe it affects unit readiness, it affects unit capability, it affects the ability of soldiers to do their mission to the best of their abilities. And we can't tolerate that.


Hi guys, my name is Jen. I'm really excited to show you this. It only took a couple of minutes and a couple of dollars and I personalized some Easter baskets for my daughters. I know this isn't your traditional Easter basket but I absolutely love these. I picked them up from the dollar store and I personalized them with my daughter's names on it and I individually put things inside of these that I know that they would like. So I'm gonna show you step-by-step how to create these. They are so much fun and so easy to create so let's get started. All right so starting in design space all I want to do is make some text here so I'm gonna go to the text button on the left here. I'm just gonna write some of my daughter's names on here and I just want to go in and change the size, change the font, and change the color. And then the fun part begins when we put this onto the eggs.  So we're gonna put that in.  This is the one that I want to use for it. So here it is here and one thing with this is if I stretch it out I can show you guys. So if I leave it the way it is it's cricket is gonna cut this out so right where these lines are cricket's gonna actually cut this out. So the first thing you want to do with this is go to a combine here and unite them so you will see that these lines will go away there. So no longer have those lines there. So if you have any kind of font like this you always have to make sure that you're not gonna see those lines because those will be cut out and you do not want that. So I'm gonna put this one aside and I'm gonna grab the next one which is going to be Lily. I have four daughters but I'm not gonna necessarily show you each one of these you just kind of get the point. So here's Lily and I'm gonna make this a little bit larger and same thing with hers. So if I use this font which I'm gonna not but if I use this font I'm going to go to combine and then unite and then that will get rid of those lines there as well but once you unite it there's really nothing else you can do with this. I can't go back and change the font on it so I'm gonna go ahead and push this back button and I'm gonna find a different font for this one. So for hers I liked this one called FBC Merry Holiday. So I'm gonna go ahead and type this one in here and you might have ones that you have in mind that you want to use or you wanted to scroll through here. You can find all of these that you want. The ones with the A's here I am subscribed to Design Space yearly so I get all of these ones for free. Some of them you'll see where you have to pay extra. I'm trying to find it right here. So if I wanted to use this one I'd have to pay the $4.99 and download it which I'm okay without doing and the ones that are here like this without the A's those come with just Design Space alone. So if you don't have the A here they're probably gonna make you pay for those so that's why you see the A's there. So I'm gonna go up here and just type in what I wanted to use. I like this font BFC Merry and I'm gonna pick it here. So here it is here. I just thought that was a really cute one. So same thing with this. The only thing I want to do is just resize this. So I'm gonna quickly add the two other names that I have. I actually have four daughters and so I'm gonna add those other two and I'm gonna show you really quick what I do with the other ones. So I'm gonna fast forward this part so you don't have to watch it. Alright so these are the ones that I'm going to be using. This one is called DJ Flirt. This one is DC Honey Syrup. This one is the BFC Merry Holiday and then Katie's. Let's see I wrote it down. Is the double whipped one. So just in case you're interested in any of these like I said you can go to use whatever you want but these ones I just thought were really cute. So the only other thing I want to do is just change the color on these. So I have Emma selected here and the Emma one I want to have pink. So I'm gonna go up to the color box and I'm just gonna grab a pink color and it doesn't have to be this exact color that I'm going to be using. Just something similar that when I go to make it it's going to put it on a different mat. So for Lily's I wanted hers to be blue so I'm gonna do the same thing just go up here and pick any color blue it doesn't matter and then Alyssa's I was going to create a green one so I'm gonna go up to the color box and just grab green and then for Katie's she likes purple so I'm gonna grab purple for her. Let's just find some sort of purple here. There we go. And then the only other thing that I have to do is change the size. So I bought those plastic eggs from the dollar store actually dollar 25 store. I have a blue, a green, a purple and a pink. So I'm gonna just coordinate these colors that I have here with those egg colors. So with mine I figured the perfect size for my eggs that I want is going to be a 3 by 7. So the only other thing I have to do is just change the size.  So I want each one of these to be that exact same size. I'm gonna go up to the unlock box and then change these to be 7 by 3. So each of them are the same exact size.  So again unlock and then just change it. And yours doesn't have to be the same size as mine. Obviously you can do different sizes, different colors, different, you know whatever you want, different fonts. But these are the ones that I picked out for my girls. I actually have triplets. Yes triplets. So I, Alyssa, Katie and Emma are my triplets. They are gonna be 16 this year and my other daughter Lily is 18. So we were blessed with them so I have four beautiful girls. I'm gonna go to make it here and I'm just gonna cut this out. I'm gonna show you what it looks like on the side and then kind of talk about the vinyl that I use. So here they are on the side here you can see them. I don't know why but it's been, lately it's been going to the 12 by 24 but you can leave it that way or you can just change it to the 12 by 12. Doesn't really matter to me. I'm just going to be using the 12 by 12 mat. So here it is here. It's just Emma, Alyssa and Katie and they all come on separate mats because they are separate colors. So the only other thing I want to do is go to continue and I'm just gonna show you which setting I use to cut these out. I'm just using regular vinyl like Oracle 651 vinyl. I'm actually my two favorites that I found is Techwrap vinyl and then the HTV Ront vinyl. I absolutely love those two. Here we go. It says base or set to base material. These are the ones that are just my ones that I bookmark myself that I use all the time. So I'm using this premium vinyl. I'm using the Techwrap and then also the HTV Ront ones. I love these. You can use whatever kind of vinyl you want but you just want to make sure it's the 651 that it's going to stick on there permanently and not come off. So I'm gonna click this and then I'm gonna go ahead and cut these out. I have four different ones. So the green, purple, pink and blue and I'm gonna cut this out. I'm gonna weed it out and then I'm gonna show you the next step. This is really easy how to do this and then you can fill these up with whatever you want. So I'm gonna go ahead and finish this up and then I'll get my camera set up and show you what the next step looks like. Alright so I have my files done. I chose these colors. This is the Techwrap.   I just bought these from the dollar store so it was $1.25 for one but like I said I got four of them the blue, green, pink and the purple. So the next thing you want to do is clean the top really well. Any time you're putting on any kind of vinyl or anything you always want to make sure you have a nice clean surface. I just have some alcohol here and I'm just going to clean the surface of each one of these really quick and then let it sit and dry but that is very, very important. So you want to make sure you clean this really, really well. Get any finger marks or anything else off of here that is going to be on it. So just like this and you can tell there's a lot of stuff that comes off. So I'll let that air dry for a minute and then I'm just going to go ahead and do the next ones. I'm going to fast forward this part. You don't have to watch me cleaning each one of these but I just love how these come and you can reuse them every year. My girls are teenagers so they really don't need much for me but I thought this would be a cute project to show you guys how to do for just a couple of dollars. So I'm going to finish this up really quick and then I'll show you the next step. All right so now that they are dry I actually did two of them really quick to see how it would look. So this is how they turned out. Really, really awesome. Love how these look on here. I love the size of it. I love the color of it. So those are two that are finished and then I'm going to take the next two really quick and put these on here.  I'm using the TechRack transfer tape. I love this because it's easy to get off of your paper and it's also easy to peel off of here after you're done. So once you have your image all done and ready and I love the lines on it too. So I'm just going to take it and line up the letters on here.  But I love this transfer tape. Really awesome to do that. Then all you want to do is take your egg top and depending on which side you want to put it on, you just start in the middle. So I'm just guesstimating where it goes here and then I'll lay it down and then I'll just take my finger pretty much and varnish this in. So I just want to go through each letter individually and then go from there. So I'm just going to take it. I'm not putting the whole transfer tape down. I'm just going from where the letter is. That way it's not going to have any bubbles or anything. I'm not worried about the actual transfer tape. I'm just doing each letter individually if that makes sense. So I'm just working each letter in to this Y. Looks like it's going to give me problems. So just take your time with it. Like I said, let the transfer tape do your work for you. So they're much better. Okay.  And if you have it come up like this, you just want to push it on a little bit more and make it stick. So just like that. I absolutely love this transfer tape. And this color is absolutely beautiful. It's like a greenish blue color. So just like that. That one says Lily. So just like that. Very simple to do. Cost a couple of dollars to make a whole basket. Like I said, I finished the other ones. I just have one more to go here. I'm going to finish this up really quick. I'm going to use the same transfer tape that I just used.  But this was a really cheap and inexpensive fun way to create something for your kids. So stay tuned to see what it's all finished, what it looks like when it's all finished. It's so much fun to create. I hope you guys like this tutorial. You can use these over and over and over. I really love them and my girls are all teenagers. So I think they're really going to like these. They are individual things inside of them, not just candy. It's other things that they can use on day to day basis. So I hope you like this video tutorial. Please give me a thumbs up and hit the subscribe button if you're not subscribed already as I have more crafting videos. You're not going to want to miss this video that I have next. So don't miss out. Happy crafting everyone!


Welcome to ITU's headquarters for WISIS Forum 2019 as we celebrate the 10th year anniversary of the event. I am joined and delighted to be joined by the Deputy Secretary General of ITU, Malcolm Johnson. Malcolm, thank you very much for joining us. Thank you Charlotte, nice to be here. So Malcolm, as we reflect over the past 10 years, can you tell us about the journey of the WISIS Forum where we are at today, but what's been achieved over the past 10 years? Well, it's a very exciting journey. I was at the first WISIS Forum 10 years back. We had less than 300 participants and as you know now this year we have over 3,000. So it's very, very nice to see that the event has grown each year and we've always tried to innovate each year to bring in some new elements. So it's really developed tremendously over these 10 years. But one thing that's been constant throughout that is the original idea of bringing people together to exchange some best practices, some innovative ideas that others can learn about and take home with them and also implement their home country and benefit their own people and businesses. So it's really an exchange of best practices, innovative ideas, knowledge sharing. And we now have a lot more participants than we used to have. I find that they all really find it worthwhile. You know, they come voluntarily, they don't have to come of course, but they really find they come because they find it really worthwhile. And that's the nice thing about it. And of course we've got the prizes. It's nice to get a prize, but these prizes actually do make a difference because I've spoken to prize winners and they've always told me what a big difference it's made to them because maybe they've got better support from their government for their project or they've got some investment that they were struggling to get. Having this prize really makes a difference. I think it's very important indeed to emphasise the fact that WISIS Forum can lead to real change on the ground. It's not just a place where people talk, it's also a place where people decide on action to take to use ICTs for delivering the UN Sustainable Development Goals. Tell us more about that. Yes, well now of course we relate all that we're doing in regard to the WISIS Action Lines, to the Sustainable Development Goals and that's really the driving force now behind it. It is really looking at how we can use the technology to reach all 17 Sustainable Development Goals. So the discussion really surrounds that and the main challenges that we're faced today with the major technological advances coming along like artificial intelligence, IoT, 5G, blockchain, etc. We have to ensure that these technological advances benefit everyone everywhere and we can only do that by having all the various stakeholders come together and look at how we can really ensure that everyone benefits from these technological advances. As we know half the world's population is still unconnected. Most of these are living in the rural areas and in some countries that's you know 70, 80% of the population is in rural areas. So there's a lot of people there that are unconnected and that's the main challenge. So a lot of the discussion is around how we can bring connectivity to these people and then bring them the advantages of being connected. Of course it's not just the connectivity because they've got to be aware of the benefits of connecting and that they can see the advantages of paying whatever it is they're going to have to pay to be connected. So we have to get that across to people. People have to be you know have their digital skills to take advantage of the connectivity but also the content has to be there to their advantage. So we need to encourage more local content in local languages and that's another theme that's coming out a lot in all the discussion at the WSIS Forum. So addressing the paradox of connectivity and introduction of very innovative technologies. Is that what is likely to keep you very busy in the next 10 years? Yeah that's something that's keeping us busy now and we'll continue to do so because it's challenging. The reason why there isn't connectivity in those areas is because there's a very poor return on investment compared to the urban areas. So we have to encourage more public-private partnerships. Governments have got to really take a lead in encouraging investment in those areas and give incentives to provide connectivity in those areas and also to develop the digital skills as well necessary. And with major developments like artificial intelligence that has tremendous potential for improving the lives of those people in those areas. But the risk is of course that we won't be able to bring them those benefits if we don't have that connectivity. So connectivity and ethics are likely to dominate discussions in the years ahead? Yes I think everybody that's coming to this event doesn't matter which type of stakeholder and it's a really truly stakeholder event which is very nice to see because I often quote if you look at the contributions made in the open consultation in preparing for the WSIS Forum. We have thousands and thousands participating in that open consultation but we did a pie chart to see where the contributions are coming from and it's almost equally divided between the five main stakeholder groups. Government, private sector, civil society, academia and other organizations regional and international. It's almost an equal 20% for each of the five. So it's really a truly multi-stakeholder event and it's only by having discussion amongst all those stakeholders that we can really ensure that this technology is going to be beneficial for everyone everywhere. Malcolm Johnson, thank you very much. Pleasure, thank you.


and welcome to the latest edition of Telehealth in Hawaii. My name is Vikram Acharya. I'm the Chief Executive Officer of Cloudwell Health, an all virtual telemedicine provider based in Hawaii. We have an excellent show for you today. I am very excited to introduce to you Dr. Andy Lee. Dr. Andy Lee is the Chief Medical Officer at the Ohana Health Plan here in Hawaii, which is part of the Centine Corporation. He is also a practicing emergency medicine physician. So his insight on how to be a physician executive is going to be very interesting, and we'll delve into those details on today's show. Andy, how are you? Good morning. Aloha. Aloha. Good to see you. Good to see you. Hope you had a nice long weekend. Yep. Nice busy weekend coaching volleyball. Excellent. Excellent. Volleyball is fun. Volleyball is fun. Well, thanks for being on the show today. You know, Andy, you have a very interesting background. You see patients, but you're also the Chief Medical Officer of a very large health plan in Hawaii. To get things started on the show, walk us through your career. How did you get here? How did you decide to go into medicine and then eventually go into the role of being an executive? And we'll go from there. Yeah. Thank you. Good question. To basically start off, I think the basic is follow your passion. How I got to this point was my initial interest in wanting to serve and take care of patients dating back to high school and then going into college. I'm making, threading my way through the challenges of getting into medical school and then being a physician and really volunteering, getting to know what you're getting yourself into because it's a long road. And if you make the wrong choice, it won't be nice. But so you got to make sure you follow your passion and that's what I did through high school, through medical school. And as I look back, that was probably the easy part. Practicing medicine is challenging. Practice emergency medicine for many years now, over close to 20 years and still practicing, like you said. And as I learned more about healthcare, I started to understand that there's more to healthcare and more contributions that physicians could add to health of patients beyond just being in the clinical practice. And that's where I started to have some interest in the administrative roles. And for myself, I really kind of tested myself to see if that's the right role for me to feel like if I can contribute in a meaningful, impactful manner through administration. And I felt like did. So you start volunteering through committees in the hospital for your medical group. You start learning different aspects of healthcare at different angles, where you can contribute, how you can contribute and then you kind of build upon that. As you get yourself out there, you start to be recognized as a person of interest in terms of interested in that type of work outside the clinical practice. And people start noticing you and starting to recruit you. And I sort of guess my sort of leap of faith away from full-time clinical care to exploring the executive administrative pieces of healthcare was just saying what you really feel is right. Don't be shy to express your opinions, really in the best interest of the community and patients. And that's kind of, I guess, my turning point where I was on a board of an organization that spoke my mind, whether good or bad, right or wrong. But I felt that it was in the right place. And that's where you start getting recognized as someone who perhaps is innovative thoughtful, willing to express. And then it starts building up on that and that's when I got recruited to be the medical director of an accountable care organization in a healthcare plan or delivery system in Hawaii, a big healthcare delivery system. Did that for almost six years. And then I felt at that point, I got that organization to a place of an inflection point where they were going to take off to explore new heights. And I felt that my contribution there was full. And I looked to move to my current position as a chief medical officer in a health plan. It's a new place for me. I was never in the health plan side of healthcare. So I've been learning. So I think the real interest of how I got to this point is sort of the eagerness to learn, eagerness to explore, eagerness to contribute and make an impact to the community of where you live. Yeah. You've seen both sides of the spectrum, the clinical side with patients as well as the administrative side. Many physicians have an opportunity when they finish their education to pursue internal medicine or family practice. What drove you to emergency medicine, the ER? Yeah, thank you. For me, emergency medicine was exciting. That's where I volunteered in high school. I saw how much they did and really how much they contribute and have a meaningful impact to the most vulnerable population of your community. So a lot of the people who come into the ER, they're in high needs. They're vulnerable. They don't have access. And I do think emergency medicine was a place where it offered a breath of opportunities in terms of clinical practice. So at your skill levels from surgical, interventional, procedural, to also understanding the primary care sides of basic healthcare maintenance needs, like colonoscopies, blood pressure checks. So I thought it was a catchment area where you could really touch a lot of patients in many different ways. Everything is not the same. You treat a lot of vulnerable patients. I thought the impactfulness of that part of medicine was extremely high and exciting and worthwhile. Yeah, yeah. Now, what's a day in the life of Andy? So you're in a busy emergency room, taking care of patients, fast paced, a lot of patients coming in and out, and then you are serving as a chief medical officer at the same time. Do you split your day between seeing patients in the boardroom, so to speak, or how does that work? Yeah, good question. It's interesting because it's interesting for me because I see both sides at the same time. When I see a patient with healthcare needs, I understand the health plan side of how their needs are addressed, where they can be addressed, and how we're especially concerned about the rising healthcare costs in the nation. Hawaii's no different. So in that aspect, I'm really cognizant of delivering appropriate medically necessary healthcare in a responsible manner to our healthcare dollars, but also making sure that the patient gets access and their healthcare needs. So in the day of my life, it's busy. I'm working in the emergency room or helping the health plans. And then my main role at the health plan is really to take what I know the provider's need and making their life easier in their day-to-day care of patients. So the beauty of my ability to keep working in the EMBR, keep being on the provider side, makes my work on the health plan side much more impactful for the providers and also the patients and our members. So it's busy. The beauty of it is I'm still allowed to do community service. I do it through coaching our kids in the islands. I coach volleyball for the club and also for high school here at Kamehameha High Schools. So it's really rewarding to have that balance of giving back to the community and also providing patient care, direct patient care, but at the same time on the health plan side to make sure that our providers are taken care of and also our members on the health plan side. Excellent. Excellent. Would you be willing to share an example of where you took some knowledge on the clinical side and brought it over to your CMO, Chief Medical Officer Roll? Yeah. I think on a high level, what I've been a provider for so many years, I've been on the hospital side, the health system side for many years in Hawaii. And now on the payer side, insurance side for a year now. And what I've really learned from that three-legged stool, I call it, the payer, the provider, the health care system. That's the three-legged stool. We all know a three-legged stool cannot stand with two legs. It's going to fall over, right? So I see the three-legged stool with the patient sitting right on top of it. And what I've learned is that this three-legged stool can jiggle, can rock a little bit, but it can't break. All right. So what I've learned is that each leg of a stool, the payer, the insurance provider, the physician or nurse practitioner or other clinicians, and the facility side, the hospital health care system, needs to be in a symbiotic relationship. And in many ways, they are. They all depend on each other. They all need each other. And they all need to work together. So I've been on each of those stools now. So I know a piece of each leg of the stool or a lot of pieces. And what I've learned is we're all trying to accomplish the same thing. Just need to collaborate, work together to accomplish the same thing. And that same thing is that patient sitting on top of that stool and their health care needs. So I've learned to just understand that we're all in this together. We're not adversaries in any way. We need to work to improve our relationship and collaborating for the patients. Yeah. You're taking a step back from it, Andy.  You're in the height of pandemic. For many of us that had COVID-19, you were the frontline physician. You were one of the very first, if not the first provider that many people in Hawaii saw when they had COVID. What was that experience like for you? And I'm sure it was just very challenging at that time. Good question.  For myself, I had a different challenge. Vic, I didn't actually work in the ER that much during the pandemic because I was actually the chief of staff at one of the healthcare systems in Hawaii at that time. So my role was an avalanche of administrator procedures, adjustments, managing resources, helping with supply chain issues, drug issues, and protective PPE, protective coverings at the time. I didn't actually work in the ER that much, but I was on the other side of the pandemic on the administrative side as the chief of staff. So my work was very heavy in that side and not so much on the ER side. But it was interesting in the ER, what we've seen during that pandemic was how things can change, how things can innovate so quickly. And in terms of being so innovative and everyone coming together, administrators, communities, high schools, kids making masks and shields, and just the love of the community coming together during these trying times was amazing and the amount of stuff that we could accomplish in a short amount of time is spectacular. So I think that human need and drive to help each other is very underestimated. When it's time to really put the pedal to the middle. Absolutely. Big shout out to all our providers that continue to fight the battle against COVID. It's an interesting example you mentioned of going from treating one patient to looking after thousands and thousands of people through the health plan. How do you work with your peers at Ohana to really make sure that the clinical needs are taken into consideration on key decisions that are made? Yeah, I mean, that's a complex question but a simple answer. And really, we look at this from the lens of what's best for the patient. Barn on nothing else trumps anything but what is in the best interest of the patient. So if that is the need of the patient, that's how we're going to execute. In that regard, Andy, what are your thoughts on things like telehealth and the future of it? Yeah, I think telehealth is an extremely powerful tool and the amount of telehealth that we figured out how to innovate during the pandemic. We hope not to lose going forward. The patients that need it are getting used to it and they know how to use it. It improves access to places and areas of care that we had trouble with access to in the past. I do think some of the regulatory barriers in the past have been chipped away in this area. So I do think in the end, telehealth is an important tool to help patients get the care that they need. I'm sure telehealth is playing a critical role in providing care, especially to folks on the outer islands where it's often much more difficult to receive access to a physician. Yeah, most definitely, especially behavioral health access, our unique situation of having islands in so many areas. We can't have possibly every specialty to service every island on island 24 hours a day. So telehealth is definitely a tool that we need to embrace, really utilize more swiftly, perhaps even push the envelope a little bit further than where we have already come because of our unique situation of the islands. I do worry a little bit about the outer islands, access to care for specialty care, behavioral health care, even acute care. We can't have a thoracic surgeon, neurosurgeon on every island. It's just not possible. So when we have our air ambulance service who's there for the patients in the community, but they're also stretched as well. So it's a challenge and that's why telehealth is a great tool for the patients and other quality outcomes. We've been using a form of not so much telehealth for a while, especially with some stroke care services where we do remote access camera, not initially telehealth, but it's access to our neurologist when the stroke patient comes into the hospital. We turn on the camera, the docs there within minutes for a stroke, which is critical. Time is brain tissue, right? Time is, whereas before we had to wait for the neurologist to drive in, that could take an hour, and that all that wasted time is not good for the brain when you have a stroke. So telehealth is important not just for the outpatient, but even for acute care. So from the ER, you and your team are connecting with neurologists in almost essentially in real time for patients that are coming in with stroke. Most definitely, yeah. I mean, that's the window of opportunity for a stroke patient is the shorter time, the better. Once we have a system at our healthcare hospital here where when a patient comes in with a stroke, we can call a cold stroke, which is all hands on deck. Just like a trauma patient who arrives in a trauma center, you have 20 people crashing on the patient a trauma room. In this case, we have a team mobilized from lab to neurologists to radiologists to blood draw texts, EKG texts, the physician to the nurses. We all jump on the patient and one of the causes to the telehealth neurologist as part of the integral part of the team, a very integral important piece of the team. And we access them through very efficient timing through a telehealth service. That's interesting because you have situations like what you describe with a telehealth neurologist where every second to every minute counts to provide the best outcome. But then there's also other areas such as like primary care, for example, where I'm sure that a lot of your, that in addition to what you mentioned around the behavioral health that a lot of your members, a lot of your patients could probably benefit from as well, correct? Once they see you, it'd be good for them to get access to a primary care doctor and so on. Yeah, most definitely. As we know, primary care access is limited. We have a shortage, an OI for sure, and I'm sure across the nation. Primary care is challenging. Medical school grads, a fair amount of them choose not to go into primary care because they know what they're getting us into. So making, taking care of patients easier for the providers is also extremely important for access. It improves their well-being, improves their ability to connect with the patients. So beyond just telehealth, there's other forms of sort of digital healthcare that includes things like in-basket messaging where you can email your provider questions. It's really, it's really become a lot more innovative than it was just two years back. So a lot of these just help patients get the care that they need, get the care that they answered. And I believe if we do it right, we can sort of solve the problem of the exponential growth of healthcare in our nation. And Hawaii, notwithstanding is the cost of healthcare rises at an exponential rate. And we all talk about GDP growth and health care. I don't know what is it now. Maybe 20% of GDP and it's a big chunk. So we need to sort of flatten that curve of rise of healthcare. And I think these digital platforms and being innovative and embracing them are a key component of brick and mortar ways of doing things in the past. Through the emergency room, as well as your role at O'Hana, is behavioral health becoming a more prevalent topic of discussion? How do we provide as a community the best services we can from a benefit standpoint, from a clinical standpoint? I'm sure that's a growing area, especially through what we've seen in the pandemic. Yeah, most definitely. Thank you for asking that question. In the ER, we see, like I said, the most vulnerable. The patients who are homeless, they don't have a physician. They don't have as much resources, transportation, digital platforms, digital services. And we're starting to see that there's a lot of substance abuse come into the ER. A lot of substance abuse in the community, they do need help. And O'Hana is in a place where we have the community contract for behavioral health. So we actually have a big space in making sure that these patients are cared for. So we take that very seriously. On the ER side, I see it. And the health plan side, I also see it. So it's really, it takes the community to figure this out and we have a role to play in that. Do you have any kind of, not defining moments, but real nice success stories that as a physician and also as an executive moments of, look, I've really bridged the gap. I've been able to serve my community the best I can. Any stories you'd like to share around that? You know, being relatively new to my new position, we've made some changes that I think that are good. I don't, but most of my biggest impact I feel in my career thus far is the relationships that you build with the providers and the communities you work in. You know, my time as an ACO medical director, I felt that a lot of the good things that we did there was really engaging the providers, helping them understand what we're trying to accomplish and helping them understand that, you know, they're a big part of the solution. It's challenging at times for the providers because it's a very different way of thinking. We're trained to do what's best in the best interest and do everything possible for patients because that's kind of our hypocritical to take care of patients. And, you know, rightfully so, there's metrics that we need to measure which adds burden to the day-to-day care providers. So I feel like my biggest happiness in my executive role so far is really to engaging the providers and helping them navigate through the waters of how things are changing now, nowadays. But I think as we work through that together, there would be better days ahead for not just them but also the members and the communities and the patients we serve. The, your role is so important because you can be the bridge. And at many times I would think the translator between what's happening on the front lines with the patients and what executive decisions need to be made at a macro level because sometimes that understanding may not be there but someone like yourself and your role, you're able to bridge that at a level that a lot of people cannot. Yeah, most definitely. And I feel that's why I feel like my role is extremely important and also to continue to practice in the community. I've made an intentional effort to practice in the outer islands in rural health communities. For my 15 to 20 years thus far in the emergency medicine, I've been in sort of a tertiary care center, community health center. Let's see the plethora of patients from all kind of specialty coverages and backups that we have where none of these you have on the outer islands. So I've made an intentional effort in my new role here at Ohana to be out there in the rural health community. So I've been starting to practice on the big island and Ka'u. I'm there this weekend working in Ka'u on the big island, working in Honoka'a on the big island, even working on Kauai in urgent cares. So seeing healthcare delivered in all different aspects in all different communities has been an intentional effort for myself because I wanna know what's out there, what's impacting the patients, the health centers, the communities. And a big part of it is I don't wanna forget that side of medicine. So I wanna stay in there sort of with the pit providers and keeping my feet hands, hands and feet dirty and never forgetting that aspect of why we went into medicine. That's really great. I mean, you're staying in the trenches on the outer islands, especially where there's a lot of need. And then that can help you further how a thing translate those needs to the health plan at a way that a lot of people cannot. Is there a certain kind of significant differences or notable differences you see right off the bat when you're in on working on the outer islands versus Oahu? Well, yeah, access to Oahu is challenging. I've seen access on the neighbor islands much more challenging, access to just primary care. Now, speaking of specialty care, a whole new level of challenge. Even acute care medicine, there's no backups on the neighbor island. I mean, sometimes as simple as an orthopedic backup, you don't have. So it's a big challenge that I've recognized working on the neighbor islands. And yeah, the resources are sparse and not just clinicians, but even just nursing staff and other outpatient resources is also limited. So never mind just the health plan and healthcare of a patient is beyond just maintenance, I mean, health maintenance, care, outpatient or inpatient. There's all different kinds of nursing homes. There's even home-based care is challenging. I've seen on the neighbor islands, and a lot of patients need like long-term care and it's hard. So, Andy, I wanna take a moment to thank you for being on the show. We have a lot of guests on the show, but it's exceedingly rare to have someone of your background who's a practicing physician out in the community, but also at the executive level at the same time, addressing needs on a patient level, but also a macro level. And especially you leading during the time of COVID, working with your peers during the time of COVID, I really wanna thank you for all your contributions and advancing the needs of the members of the state of Hawaii, the residents of the state of Hawaii. It's really, really great to have you on the show and you have a lot to share and I really appreciate it. Yeah, well, thanks, Vic. It's my pleasure to be here to share my story. I think my parting words would be to the people who are watching, thank you for watching and thank you for your interest in the discussions we're having today and beyond just today. I think we should not forget why we're all in this, from Telahel to Think Tech Hawaii and I've seen a lot of your other podcast speakers, all great conversations. So I know the subscribers and the people who are watching care. And I think we should not forget why we're in the business that we're in and it's really for the membership to be healthy and have a good life and to have access to care and that's my parting words. And I appreciate the time to share that with your viewers, Vic. Thank you for your time, Andy. Well said and mahalo, appreciate it. My pleasure, Lo. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram and LinkedIn and donate to us at thinktechhawaii.com. Mahalo.


So, basically, we are dedicating little political attention to those issues. And this is why I'm even more happy to have with us a prestigious policymaker and a very specific one because, as I said, you're linking in your role climate change and food security, which is quite rare. I'm sure that we are going to be united minister by your experience. Thank you so much. I'd like to start first by thanking World Policy Conference for having us here and talking about a very important subject. I'm sure a lot of you have heard me speaking before and linking food systems with climate change. It's a must because, as some of my fellow panelists mentioned, a third of global greenhouse gas emissions is coming from our broken food systems. I feel already much has been talked about about the situation we're in, the shocking numbers, the challenges that we have. I want to talk about solutions. I want to talk a little bit about the light at the end of the tunnel. I think the UAE is very much known for being a beacon of hope. And so I want to bring hope. We must do three things in my eyes. Countries need to plan more properly when it comes to food systems transformation. For every point I make, I'm going to show you an example of what we do in the UAE. We have a national food security strategy. We have the Emirates Food Security Council that governs all the programs we're doing under the strategy to make sure we're implementing. We're also always checking internationally how we are benchmarking ourselves. So we're looking at the global food security index. And by the way, the UAE has become number one ranking in the global food security index this year for the MENA region. Why? Because we've put a lot of effort into planning, understanding, improving. There are a lot of areas which need improvement, such as R&D. We need to put more investment in R&D for innovations. And so this closed back system, this feedback that we're getting is really important. So the planning is really important. Countries must plan because food security, friends, it's not just agriculture, by the way. It's food and loss, waste. It's nutrition. It's food safety. It's the way we consume. It's the way when you go to a supermarket, what you buy, what ends up in the bin, that has a huge influence on our food systems today. And most of us always think of agriculture, agriculture, but actually there's a huge part on the demand side as well. And changing and reflecting the way we are consuming, I myself, the last three, four years, because I've been involved a lot in the food system conversation, I've changed a lot about how I eat. I've tried to get my family to be influenced as well. The young generation is so much easier to influence, by the way. The elder generation, I'm still working on it. But this is what's happening in my own family and household. So now think of how to do this in a community, in a country. It's not easy. Then I think of the second point, and a lot of you mentioned this, investing in innovation. And I'm not just saying investing in innovation, but being also innovative. So the word innovation is huge, and I'll give you some examples. So we, in the past years, for example, in Abu Dhabi, we have the Abu Dhabi Investment Office under the Radhan 21 initiative, which is an Abu Dhabi Accelerator Program. We've invested more than $150 million in ag tech companies to come attract them to the UAE, to start growing clean foods all year round in the hot arid environment that we're in. We are a water scarce country. We don't have much arable land. And with that, we must turn to innovation. And we're so proud today, when you go to the supermarkets, you see berries grown in the UAE, salmon, quinoa, vegetables of all sorts, fruits are coming up as well. And I'm sure in the very near future, we're going to see grains being grown in closed system farms. This is going to be a breakthrough, ladies and gentlemen, because this means we're not dependent on the climate that's happening around us. It's a closed farm where water is recycled and you don't have to use chemicals. So this kind of innovation, there must be more investments done in this. And we are doing this and there's more we need to do. And then when I talk about being innovative, we're talking about we must ensure trade is open and no restrictions. And by the way, the UAE is very dependent on global food supply. 90% of our food comes from outside. But now I think of, okay, how do I not put any restrictions and protect local production, but still try to encourage local production to grow in an environment that is hard? You have to innovate. So we did something just a few weeks ago during our annual government meetings. The UAE holds every year an annual government meeting where we bring all the federal and local entities together and discuss challenges. And what we decided was government entities, the big consumers, such as the police, the armed forces, the hospital authorities, the ones that buy a lot of food and that are under the government control, they must buy locally. Let's not touch the trade. Let the trade keep going. But where you have a hands-on on your procurement and what you can buy, this is where you can encourage that a certain percentage of certain food items are bought locally. This I call innovation. Then the third point is about partnerships. I keep saying partnerships, partnership, partnerships. Let's look at an example. Bustanica is a vertical farm that is now operating in the UAE, one of the largest vertical farms in the world. This is a partnership with Emirates Catering Group, and I'm sure many of you have flown in with some of our national airlines, Emirates Airlines being one of them. You are now gonna enjoy salads coming from this vertical farm. It is now more commercially viable and more profitable for Emirates Catering Group to get their greens, microgreens, lettuce, salads from these vertical farms here in the UAE than importing them. So the business model is changing. This is a partnership between Emirates Catering Group and Crop One. This is a company from the US. We also have a lot of ag tech companies in the UAE that were supported because we're really supporting the ag tech ecosystem. They're now going out to Singapore, for example, to try and build the ecosystem there because we're now basically trying to showcase or showing technologies from the UAE from a hot arid climate on how technologies work in this space to other countries that are facing the same challenges. So these are the three key areas. Plan, innovation, investing, or being creative and innovative and partnerships. This for me is what countries must look into. It's so important that also during the COP28, by the way, as much as people are talking about the energy and the just energy transition, food systems transformation must also be on center stage with the energy transformation discussions. It's really important. And this is what we're doing because the UAE is really taking COP28 as a country effort. We're all trying to put everything together because everything is interlinked, water, energy, food, waste. It's all interlinked together. And we're really making sure, and hopefully we see many of you there as well, next year at COP28, where we're really linking all this together and showcasing projects and solutions that are working. Remember friends, things need to be easy. Every country has different challenges. Every country has certain resources that others don't. So that's why it's so complex the way it is. And by the way, solutions are there. You will be surprised at how many innovations and solutions there are that can really fix the broken systems we're in today. We have to do the matchmaking. We have to have the discussions. We have to have partnerships like Aim for Sea is another one that we're very proud of. The UAE and the US have spearheaded the Agriculture Innovation Mission for Climate. We have about 275 partners on board, more than 8 billion US dollars of commitments into this, into this food systems transformation. So we need to see a lot more of these things happening. Thank you. Thank you very much, Minister, for having so brilliantly introduced us to how you, in such a structured way, you addressed the challenge of having to import most of your food and working on that with this extremely structured policy around planning, innovation, partnerships, which I think is very inspiring. While you were speaking, you also addressed the issue of demand. And in Danone, my colleagues have a very strong policy around saying the best way you can change as people the world is by changing the way you eat. Of course, I think they have the products that can help you changing the world, but there's something very true about it. And many of our responses are there. But innovation, as you so rightly said, is also something that is often underestimated. And just briefly sharing with you that even in the poorest African countries, incredible innovations are taking place. We are funding with my shop in Senegal, a wonderful startup on baby nutrition using only local products. We are funding in Burkina Faso and all the startup which is using and raising worms for protein production, completely changing the way a poor country can access protein. So many things, in Kenya, we are funding vertical agriculture, which is also one of the ways one can completely change the issue of land availability. So so many things are taking place that can also provide up. And thank you very much for having sent this signal of hope. Thank you.


Why is the Codependency company? Well, my mother, yeah, my mother. You were her manager? I wasn't her manager, but I think with both of them, when you have to react to them emotionally, where they weird out, or they yell, or they do something shitty, and then they're like, come in five minutes later and apologize, or they don't make decisions, like it was just this interface with this inconsistency that I constantly had to sort of manage. So yeah, you get real good at managing. It's a joke I've never been able to do, which is I leave most interactions going. Did I hurt their feelings, or did they hurt my feelings?


Section 18 of Viking Tales This is a LibriVox recording, or LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org Reading by Lars Rolander A Reading List Viking Tales by Jenny Hall Section 18 Geography Norway The Earth and Its Inhabitants Recluse The Appleton & Company, New York Iceland The Earth and Its Inhabitants Iceland Baron Goldsmith Elder & Company, London, 1863 Iceland, Greenland and the Ferrars Harper Brothers, New York An American in Iceland, Nyland Lockwood, Brook & Company, Boston, 1876 Greenland The Earth and Its Inhabitants Recluse The Appleton & Company, New York Iceland Greenland & the Ferrars Harper Brothers, New York Customs Viking Age Dut Chalur Charles Scribner's Sons, 1889 Private Life of the Old Northman Keiser Translated by Barnard Chapman & Hall, London, 1868 Saga Time, Vickery Keegan Paul Trench, Scribner & Company, London Story of Burnt Nial, Introduction Dacent Edmoston & Douglas, Edinburgh, 1861 Vikings of the Baltic, a Romans, Dacent Edmoston & Douglas, Edinburgh Ivar the Viking, a Romans, Tuchilo Charles Scribner's Sons, New York Viking Path, a Romans Holden Burgess V. M. Blackwood & Sons, Edinburgh, 1894 Northern Antiquities Percy, edited by Blackwell Born, London, 1859 Mythology The Pros Edda Northern Antiquities Percy, edited by Blackwell Born, London, 1859 Norse Mythology, Andersen Scott Forsman & Company, Chicago, 1876 Norse Stories, Maby Rand McNally & Company, Chicago, 1902 Northern Mythology, Thorpe Lumley, London, 1851 Classic Myths, Judd Rand McNally & Company, Chicago, 1902 Incidents Harold Saga of Harold Harefair, in Saga Library Magnuson & Morris, Volume 1 Bernard Quaritch, London Charles Scribner's Sons, New York, 1892 Ingolf, Norseman in Iceland, Dacent in Oxford Essays Volume 4, Parker & Sons, London, 1858 Iceland, Greenland & the Faroes, Harper Brothers, New York A Winter in Iceland & Lapland, Dillon Henry Colburn, London, 1840 Eric, Lave & Thorfin, The Finding of Wine Land, The Good Reeves, Henry Frude, 1890 America Not Discovered by Columbus, Andersen Scott Forsman & Company, Chicago, 1891 Credibility of Story Windsor's Narrative & Critical History of America, Volume 1 C. A. Nichols & Company, Springfield, Massachusetts, 1895 Discovery of America, Fiske, Volume 1 Houghton, Mifflin & Company, Boston, 1892 Other sagas easily accessible Saga Library, Five Volumes, Morris & Magnuson Bernard Quaritch, London Charles Scribner's Sons, New York, 1892 The Story of Howard the Holt The Story of the Bandit Men The Story of Hen Thorir Done into English out of Icelandic by William Morris & Eiriker Magnuson The Story of the Eredwellers with the Story of the Heath Slaves As Appendix Done into English out of the Icelandic by William Morris & Eiriker Magnuson The Stories of the Kings of Norway Called the Round World Heimskringla by Snorri Sturluson Done into English by William Morris & Eiriker Magnuson With a large map of Norway in three volumes Gisley the Outlaw, Dacent, Edmonston & Douglas Edinburgh Orkneyinga Saga, Anderson Edmonston & Douglas Edinburgh Voltsunga Saga, Morris & Magnuson Walter Scott London The Junger Edda Anderson Scott Forsman & Company, Chicago, 1880 A full bibliography of the sagas may be found in Voltsunga Saga End of Section 18 And end of the book Biking Tales by Jenny Hall Read by Lars Rolander


Emily is the hospital epidemiologist at the University of Chicago as well as the medical director of the infection control program and the antimicrobial stewardship program. She's become a close to a lifer here where she completed her internal medicine residency, her chief residency and her fellowship in infectious disease all at the University of Chicago. Her research focuses on trying to improve and prevent the health care associated infections as well as improve the prescription of antibiotics. She's one of the rising stars here in terms of clinical arena, quality of care and public health and I haven't shared the story with her yet but a couple weeks ago I was talking to the commissioner of public health in the city of Chicago, his name is Bashar Shakir who's an outstanding commissioner. But as you can imagine the Ebola virus has taken a lot of its time over the past half a year or so and the Chicago city has consortium of four of the universities including the University of Chicago but he's specifically singled out Emily as well as Steve Weber who is our chief medical officer as being particularly helpful in these citywide efforts. So Emily is going to speak upon a different title than what's in the brochure is the ethics of Ebola preparation in American hospitals. Anyway so I want to talk today with a little bit of evidence and a little bit of information about some of these prevailing ethics questions related to Ebola that are surrounding all of us that are in the media and all around everything that we're reading about this and if you're a hospital epidemiologist they're sort of the only thing you think about. But the point being there are three big sources here. First we did an ethics, I asked for an ethics consult from the McLean Center back in July about a lot of these questions and that's a big source of the information that we have for how we're doing things at the University of Chicago. Secondly there's an Ebola, the Chicago Ebola resource network that Marshall mentioned has an ethicist from each of the hospitals that are working together. I'm representing us and we are creating consensus guidelines that can be published soon for others to use about some of these thorny issues in infection control ethics. And lastly there's a paper that's going to be submitted I think today where we actually sent out a survey to the all sort of bad metrics aside to US News and World Report top hospitals and top medical schools asking them about their current policy decisions about how to take care of patients with Ebola and you'll see that data here today. This is the first time anybody's seen the data. The last survey came in less than a week ago. So getting started you know the important thing to remember we're going to talk a lot about how we manage Ebola in American hospitals but the real issue of Ebola is happening in Western Africa but we need to begin this discussion by understanding that the way we take care of patients in Western Africa is very different than the way that we take care of patients in Chicago and in every other city in the United States and that's an important informer in the way that we approach some of the ethical issues of caring for Ebola patients here in the United States. But this is the first time that Ebola took root in a incredibly poor war torn urban area and that's what's allowed it to spread so rapidly and spread to other parts of the world. But that's no reason to believe that we're going to have a massive outbreak in the United States so please don't be too afraid. But the bottom line is that preparing to care for patients in the United States is really hard. It means we have to rethink everything about how we do medical care in the United States and there are as I sat down to address these thousands of questions when I was making the slide the font got down to size six and I decided that I would take some off but you can see the point being there are hundreds and hundreds of questions and buried among them are a lot of ethical questions about Ebola and that's why Mark was very gracious and let me not talk about hand hygiene and about Ebola today which is the only thing I've done since mid-July. And I want to address some of these today so let's start with the biggest of these issues and that really is who should care for these Ebola patients when they come to our hospitals and that answer is going to be given in the context of what we're seeing now which is onesies and twosie patients not this massive outbreak of 100 or more patients in any given city at any given time because that's not likely to happen and so I don't think we need to spend too much time worrying about it based on what we have right now. So these are the results of the survey that went out to these hospitals. We had a 76% response rate. We have 27 responses to the survey and you can see here that those that are marked in red are not allowed to care for Ebola patients regardless of volunteer status. Yellow is allowed to care for them if they volunteer and green is you're expected to care for these patients regardless of your volunteer status. And you can see by the caregiver types that most hospitals are not interested in having medical students care for these patients or nursing students. There are a couple that are allowing interns if they volunteer and residents if they volunteer a few that will allow fellows if they volunteer but most hospitals have decided to go with a volunteerism method involving staff nurses and attending physicians and then some other support staff. So is this the right thing to do? Well, there's a lot of talk about duty to care and Ebola and the history of epidemics and pandemics suggest that some doctors stay and some doctors run and there is not a consensus about what exactly one person is required to do and what one is not especially as a blanket group of physicians the generic or nurses the generic. The truth is that the duty to care for a patient is not infinite. It does not, we are not required to exchange our life for that of another human being. That's not what it means to be a doctor. But there are also very substantial competing duties that many physicians and nurses have such as caring for their own families such as caring for patients with whom they have an existing relationship not the one that walks in the door with whom they do not have an existing relationship. Nonetheless, that would make us believe that many physicians and nurses have the ability to opt out of caring for these patients but institutions do have an obligation both legal and moral to care for patients that arrive at their doorstep and that has led us to believe that in our consensus at the University of Chicago and as part of the Chicago Ebola Resource Network that there is something to be said for expertise and proximity. In other words, an ophthalmologist who is wandering through the emergency room as a patient comes in does not have the same level of expectation to care for that patient as the attending physician on duty in the emergency room at that time and the attending physician who's been trained to care for a patient with Ebola has a much greater obligation than one who has not and that I think is important to remember as we make decisions about how to take care of these patients especially when we run out of volunteers. That said, volunteerism is clearly the way to go and I say this is largely from an infection control standpoint as I do from an ethical standpoint. When you have volunteers you're able to concentrate your training resources. Physicians who volunteer to take care of Ebola patients at the University of Chicago get eight hours of hands-on training in the suits putting on and taking off the suits and then doing procedures and sort of simulated patient care and they have refresher training every three weeks. That's a lot of time nurses get double that and so that is what we can provide to people to make them safer when they do care for the patients and that's a big reason why volunteerism is catching on so broadly. It's really hard to train thousands of faculty and staff members at that level. That brings us to the question of when we run out of volunteers is it time to start thinking about physicians and training or should we be requiring other people to care for these patients and I think that this is a really serious question to be asking. Training is evaluative in nature and so trainees may be very enthusiastic about caring for these patients but that may be partly because they want to go to valuation for their training program. They also may not really understand a third month intern may not really understand and their inexperience with caring for patients in general may lead them to be at increased risk of contracting infection. So this there's clearly good reasons why we would not want trainees to be involved. That said they are as inexperienced as they are in providing independent practice. They are the most experienced people in our hospitals when it comes to day to day care including things like how to manipulate the medical record and how to get things done where things are and that's really important knowledge when you're trying to care for a patient. So I think that there are some real benefits to including trainees but the CDC does recommend from a very pragmatic infection control standpoint that you should minimize the care providers. That means that we can't be asking all of our trainees and their supervisors to be caring for these patients at the same time. We believe that that means that fellows and senior level trainees in training programs who would be expected to care for these patients as they proceed into their physician their sort of accredited physician roles probably have already bought in and understand the risks of being a critical care physician or an ED doc and they probably are capable of making an informed choice about volunteerism. In other words a competent trainee volunteer may be a better choice than asking unwilling attendings to participate in the care of these patients and that's a very you know iffy ethical question that I some of you will probably disagree with but that comes down to sticking with volunteers allows us to concentrate those training resources whereas if we require one attending physician to do it we have to require them all. Which brings me to the question of now that we have everyone in the room to take care of the patient what are they and what aren't they going to do for that patient. There's been a lot of discussion about this in blogs and newspapers all over the place and I think it's very telling that the graphic you see here basically shows you that academic medical centers in the United States are all over the map on this. You can look that CT scans and MRI scans are things that really honestly can't be provided to these patients without having to disrupt the care of every other patient in the hospital making them very unlikely to be provided. Think about this practically CT scanners are in open areas they're not separately ventilated if you put a potentially Ebola patient in that CT scanner it can't be used by anyone else until you know whether or not the patient has Ebola and it's been cleaned properly which usually involves vaporized to hydrogen peroxide cleaning of the entire area which can be days away because there's only one company that does it in the entire country. So you can see that that's just not feasible you wouldn't be able to provide care to any of your other patients. But there are other things like vasopressors massive transfusions dialysis both intermittent or continuous renal replacement therapy intubation and things like that it's surgery and CPR that are a bigger issue and people seem to be all over the map on. So the reality of treatment limitations for Ebola are largely based on fear and you can see a picture here of the suits that we ask our people to wear and the once people have undergone training in these outfits and they feel much more confident providing some of these procedures that we otherwise wouldn't think would be a great idea because they are really impermeable to fluids and if they're trained well on how to get them off correctly and there's adequate staff and support they probably can provide these things very safely with very very little risk. And so PPE training and planning ahead to do things semi-electively as opposed to emergently can really mitigate a lot of the risk and make some of these things make it easier for us to provide a usual standard of care to patients even those with Ebola. The other important thing to think about is that rule out patients are very different from confirmed Ebola patients. Rule out patients in the United States there have been 350 patients at least tested for Ebola. You haven't heard about all of them because only four have tested positive. Two nurses, Mr. Duncan and one physician in New York City. That's it. That means 99% of people who need to be tested for Ebola will be negative and they will have something else wrong with them and that's where we need to think about whether we're trying to protect our staff or whether we're trying to predict outcomes and so clearly staff needs to be protected when they take care of these kinds of patients that are being ruled out but at the same time the outcome may not be as grave as what we expect for any Ebola patient if the patient just has malaria and you can't avoid giving them care in the first two days while you're waiting for testing results. That makes a careful wing of risks and benefits essential and at the University of Chicago we do a lot of training, we teach our, we limit it to doctors and nurses, they do all of the x-rays, they do all the point of care testing, they do all the spill cleanup, they do the intubation, they do the daily cleanup of the, they do the transport of the patient because it's easier for us to train one set of people to do everything than it is to train 50 sets of people to do one thing each. And so I want to point out that this Ebola risk benefit balancing act is complicated. In real life we have the risk to the patient and the potential benefit to the patient and we try and explain everything to the patient and then we have the patient's preference and that's what we go with. When you have Ebola you have this risk to the provider which is a very heavy weight on the side of not doing things, especially if you overestimate it because of fear. And as we saw earlier physician recommendation often trumps and influences what patients want. And so when you have a fearful physician who feels like their own life is at stake in caring for a patient, they're much less likely to recommend things. And that is something that we don't usually take into account in the way that we make decisions in with patients. And it's something that we need to really be very careful that we eliminate that risk as much as possible and we help our physicians and providers to feel as comfortable as possible so that their fear isn't getting as much in the way. It is really, we need to make that as real as possible and not as overbalanced. Which brings me to the question of the unilateral DNR. So this is controversial even in regular patients whether or not we can decide that something is futile. I'm sure we all agree that there are times when it's clearly futile to do a code on someone but there are other times where it's in the middle. And I think it's important to remember that even with Ebola patients there are codes from which these patients could survive very easily. They're very likely to present with electrolyte abnormalities early in the course that may result in an arrhythmia that's actually very savable. They may have a PE as they're recovering from Ebola when they're no longer very infectious. And those are times when we may want to code these patients. So making a blanket statement about all Ebola patients from the moment they come in the door, even if they haven't been diagnosed yet, all the way through to the time we discharge them, doesn't make any more sense for an Ebola patient than it does for any other patient coming into the hospital. But a code in a patient with Ebola would look very, very different from a pragmatic standpoint just like all the care looks really different. It looks very white and full of Tyvek. And it doesn't involve the usual code team. It doesn't involve training every single resident who is leading a code team to be able to provide a code on an Ebola patient. At the University of Chicago, it looks like a constant ongoing risk assessment that includes ethics, includes infectious disease, infection control, the attending physician in the room, their skill level and the patient's current condition, what other conditions the patient may have. And it's two quarantine doc providers, two nurses and one doc. There's always a nurse and a doctor in the room of the patients that we have at the University of Chicago because we need to have that back up there. It takes 15 minutes to get into the suit and a nurse outside who's half dressed and ready to go, which means we can do a code with three providers. And that means we need to be able to do as many things ahead of time as we can. So all of our Ebola patients will get central lines early on. This allows us to be able to take that off the task list of a code or an emergent situation. It also means we don't have to stick the patient with a needle every time we draw blood, thus reducing the risk to the providers. So there are a lot of things that can be done to mitigate the risks of these code situations. And those are things that we all have in my opinion and in our opinion, both the Chicago Ebola Resource Network and the University of Chicago, it's our obligation to mitigate the risks to the providers to as much of an extent as possible in order to be able to provide patients with the standard of care. Which brings me to the recent ACOG practice advisory. That's the American Congress of Obstetrics and Gynecology. And it will sound like I'm picking on them because I am. They have written, it may be prudent to avoid the usual obstetric interventions such as fetal monitoring, cesarean delivery, induction, or surgical repair of lacerations in this select group of extremely ill women. They go on to qualify this saying that people who've recovered from Ebola or who are in the very earliest stages of Ebola may benefit from some of these treatments and you might want to change, you may want to do them. However, they go on to say for people who are being ruled out for Ebola. In other words, the woman who comes in for all women with EVD, there will be a window in which EVD is suspected but has not been confirmed with laboratory testing. These women should be treated in a similar fashion to that described above, recognizing that a portion may prove negative. That portion is 99%. And 99% of women who have traveled to Western Africa will come back without Ebola. And if they happen to be pregnant, they deserve to not be put into a room without a monitor and without a physician and they deserve to have some level of treatment as safe as we can provide it to everyone. Yes, the outcomes are very poor in Africa for both moms and fetus, but that's not the same as the United States. We have no experience with this here and we have no idea whether or not we can survive, whether what mothers or babies can survive this. We also know that cesarean delivery in the throes of DIC is contraindicated and dangerous for mom and probably not a good idea, but there are a lot of stages of Ebola that are not disseminated intravascular coagulation. And so even vaginal delivery is messy and fluid producing, putting providers at higher risk. Some of the obstetricians I've spoken with don't even want to participate in vaginal deliveries until I remind them that these patients routinely make 15 liters of stool a day. And so we're not talking about something that's significantly different from the other care of any Ebola patient. But it remains very unclear what to do about rule out patients. There are probably some circumstances in which it is not a good idea to do a cesarean section in a rule out patient because it could be dangerous for everyone. It's certainly not a good idea to take them to your positive pressure operating suite in the labor and delivery area where you're now contaminating all of the other areas where everyone else can now can't get a C-section. So at the University of Chicago we have a very complex plan and this is the same plan that most of the other hospitals in the Chicago Ebola Resource Network are going with, which is to do active ongoing assessment with fetal and maternal monitoring. The argument that you don't do fetal monitoring because you're not gonna do a C-section is a bad one. Fetal monitoring can lead to other interventions like fluids and positioning which can improve the outcome for mother and baby. And so should be included, they are standard of care, they are non-invasive, the belts, you know? These need to be included in the care of patients with Ebola and I would strongly discourage anyone going home and advising their own hospitals from following the ACOG guidelines or the ACOG practice advisory in sort of word for word. But we do avoid but don't prohibit surgical management. The other problem with the ACOG recommendations is that it suggests to hospitals that they don't need to be prepared to perform C-section on a patient that may have Ebola. There may be a very low risk patient for whom it would be appropriate to perform a C-section because the risk to the mom is very low, the potential benefit to both is very high, but where the providers still need to take all of the precautions that they would otherwise take for an Ebola patient. And if you haven't prepared your staff to do that, you won't be able to do it. And so I think it's very important that we be prepared to provide care, but we make every effort not to do any additional care, probably a little bit more like we should be practicing medicine all the time. But you know, ethicists are available so are, oh now I have the red light, darn it. Ethicists, all of these hospitals have ethicists, all of these hospitals have infectious disease specialists and all of this can be done more nuanced way than making blanket recommendations. So I just wanted to thank our ethics team, the CERN ethics team which is made up of Cathy Neely from Northwestern, Clayton Thompson from Rush, Kelly Mickelson and Joel Frater from Lurie and the University of Chicago Ebola incident command team and the co-authors from the paper that has not yet been published, but you all have seen now. And our volunteer providers because they're doing a great thing for all of us and they're allowing many of us to not have to go and take care of these patients. So I'm really impressed by them and appreciative to them. And my infection control team that works really hard to make sure the University of Chicago is ready to take care of these patients safely. And I'll leave you with this lovely thought. You like that? I think we should put that up in the clinics although I haven't gotten approval to do so yet. Are there any questions? Hi, I'm Michelle Harrington of the University of Chicago. I was, that was a fascinating and very informative presentation and I just wonder from an epidemiological perspective about the duties of care providers, both professionals and perhaps lay persons. Have you all thought about survivors of Ebola who are presumably... Yeah, survivors of Ebola are great candidates to take care of these patients. Unfortunately, most of them are, it takes a really long time to fully recover from Ebola and this is moving pretty rapidly. And I don't think the good news is that people that medicine's on frontier and Samaritan's Purse do a good enough job taking care of their providers that we don't have very many survivors to create a usable workforce. But yeah, I agree, they'd be great. Hi, Dr. Landon. I had more opportunity to talk with physicians in New York, primarily emergency department physicians. And one of the things that emerged from the panel that I was on was that they were going to have teams. Teams that would come in at the time than anyone suspected of Ebola was going to be admitted. And I apologize, as much as I was down at UIC this week, I did not look at the Chicago Medical Preparedness to see if there is a line that says that you bring a team in because they have done enough rehearsals, tabletop exercises that they can deploy this readily. That's, so comment on that. So each hosp... The four Ebola resource hospitals in Chicago, Luri, Northwestern, they're not quite ready to take patients yet, but Rush and University of Chicago have teams that get called in and they take over the care of the patient. Our frontline providers do have to provide what I like to refer to as bridge care for the first hour or so until those volunteer providers can arrive at the bedside and take over the care of the patient. And then CDC has a go team for every area of the country. They will send a team within 24 hours if you have a patient. We've taken care of a rule out patient here at the University of Chicago and it went very smoothly considering all of the difficulties involved in doing this. And then given that there's only 55,000 supposedly in our area that could likely be from West Africa, one of the questions emerged, I trained at Cook County and it was a Cook County physician who said, it's the distinction between the workup and the rule out and then the protections that come on the floor where the gaps are. And so what specifically, other than the preparedness you've talked about, I see that. But in terms of a non-complicated pregnant woman who you disagree with the ACOG as much as I do, could there be the possibility she would be delivered in an intensive care setting? For example, similar to a malaria patient. Yeah, so we have a quarantine unit that we stand up within three hours of having a patient that's walled off from the rest of the hospital, all in ICU beds, the patients would be delivered there. But if they, and rule out patients go there too, because rule out patients require all the same protections from an infection control standpoint of a patient with full balonibola. You just don't know and so you must take those precautions. And we're prepared to deliver a patient in labor and delivery if they need to deliver in the first three hours before they can move up to the quarantine area. Marshall, I just wanna thank Lainey Ross because I read your blog along with Joel Freider. Yeah, it's great blog. Before I was on that plane and I just can't thank you enough because it gave really good insight and thank you again, Dr. Landon, thank you. Thank you. So we'll get to a last very short Oh, Shola. Before Emily short insert before our lunch. I'll make it very brief. Great presentation, Emily. You know, there are about 18 countries in West Africa. And I think we start, when we start stigmatizing everybody coming from West Africa, we make things uncomfortable for people that travel and not in any Ebola related country. As part of a network, can you try to influence how we characterize where Ebola is so that we can be a little more country specific because they're just a handful of countries where there is Ebola. And when people come from there and you put them through all this ridicule. Yeah. It's not what we should be doing. As Jay Leno pointed out many times on The Tonight Show, Americans geography is awful. And that just goes to show. I mean, I get calls to triage patients all the time that are from Ghana, which isn't even in Western Africa. And it's horrendous. And so I can keep showing maps all I'd like and encourage us to, yeah, we definitely, no one needs to be stigmatized. No one needs to be, it's not their fault, regardless of where they come from, but patients coming from places like Nigeria where Shola's compadres did an outstanding job eliminating Ebola from the entire country are safe. And they're perfectly, there's no reason to believe that there's any risk for those kinds of patients. It's a great point. Thank you. So thanks, Emily. And maybe one more hand for our standing panel with Stacey Grange and Anouk. Thank you very much.