Mae'r cwmhwys yma yn y bwg wedi'u gweld yn y ffyrdd ymlaen. Mae'r cwmhwys yma yn y ffyrdd yma yn y ffyrdd yma'r cwmhwys yma yn y ffyrdd yma yn eu hunain. Mae'r cyfrifysgol yn 40 cwmhwys. Mae'r 50 cyfrifysgol. Felly mae'n ffantastig cyfrifysgol. Mae'n ffyrdd cyfrifysgol ar y cwmhwys. Mae'n ddweud i'r unrhyw yng Ngwysbeth erbyn, mae'r union yng Nghymru yn ychydig i'r asia. The US already has its pivot towards Asia, its rebalancing of every term, we might talk about. This comes from a Henry Clinton's article in Foreign Affairs in October 2011 when she talked about the most important tasks of American statecraft over the next decade being locking in a type of an investment of what basically she calls in the article Smart Power in the Asia-Pacific region while of course emphasizing the important relationship with the European Union, which is under a bit of discussion at the moment. So what if we have some US pivot? We also, and I'm happy to talk about this in question time, have an Australian pivot taking place. I live in Melbourne and this is the issue that is being discussed quite a bit in Melbourne. In Australia in general, Australia has issued a paper called Australian the Asian Century. They do not call it the Pacific Century, that is what the Americans call it, but they call it the Asian Century because many people talking about the Asian Century don't necessarily see it as an Asia-Pacific Century. It depends on how you actually look at it. The Japanese perspective has been very challenging particularly under Prime Minister Hattiyana in that regard. So in a sense the decision has to be whether the European Union wishes to actually go all the way with the USA as it were or wishes to show itself to be an independent actor, a coherent actor and a consistent actor and I would put to you very strongly that the European Union is not perceived as a strong, coherent or consistent actor by its Asian interlocutors, its Asian partners. It is working very, very closely on what I call selective opportunistic regionalism. In other words, using interregionalism when it works with ASEAN, the Association of Southeast Asian Nations but quite often it's signing trade agreements when for instance the EU ASEAN one collapsed in 2008 mostly because of Myanmar but not only because of that. It's now signing bilateral relations, bilateral FTAs. The Korean one is the most famous of course, the Singaporean one most recently and a host of others. So in a sense the question is does the European Union really need to think about its own interests and also what those interests are and how to define them, promote them and protect them in the Asian Pacific context. One of the challenges straight away is the fact that the European Union is not a united actor in the relationship with China but not only in that relationship. Germany, the UK and France dominate the relationship, national interests dominate the relationship consistently and David Sullivan in a talk he gave a few months ago suggests that the EU's value to the Asia Pacific region is as a rules based cooperative security context and I think that that perhaps is, I think is optimistic. I think it's more an expression of hope rather than of achievement and I think David knows I think that. I think then we have to see basically what are the sort of pivots that the European Union sees as the most important ones and who should it be working with. It is partly working with Australia and it's in the middle of a negotiation on something called framework agreement at the moment. It's already under a previous agreement called the partnership framework of 2008 is working very closely on support for development systems for instance working together on humanitarian issues and they signed an agreement on civilian crisis management in the region as well similar to the one that the EU signed with the United States. The US however has also become increasingly a partner of the European Union in the Asia Pacific. I would suggest to you that this brings with it its challenges. The possibilities for the European Union to be regarded as an independent actor, as a potential mediator in disputes such as in the HAA monitoring mission in Indonesia. In these cases I think that there is a challenge for the European Union particularly since the Clinton Ashton declaration of July last year where they expressed their wish to be more involved in the Asia Pacific and to talk about the Asian context and the Asian partners as a sort of less than significant other I think it's a very problematic document. The other issue is that I think the European Union has to be present. There is a history of abstention in terms of turning up to fora in the Asian context and whether it's the Asian regional forum or others or indeed ASEAN itself. It's a question of the European Union having a coherent presence, a coherent vision and a coherent message and it simply did not turn up. It is only in 2012 that you began to see Catherine Ashton turning up to meetings such as the ASEAN regional forum. This matters. It matters to Asian interlocutors because symmetry matters just as much as symmetry for Asian interlocutors and I think this has been a challenge to try and get that message across that it actually does care and counselling meetings in Asia as has been done by Catherine Ashton in the past is not a very good signal to put out to people who are face and showing up for matters. There are also some problems of both coherence and consistency in the European Union's message. Coherence and consistency in terms of whether it's a member state speaking or indeed whether it is the European Union and if so, which part of the European Union is actually talking and I think this is the message from many of the surveys that have been conducted. Really, the message is that the European Union is not regarded as anything other than a trade actor and even they're not necessarily as a trade actor for many of the Asian interlocutors and I'm part of a project that is run by Mybridge-Dwmbrang at Free University of Berlin where we're looking at some of these Asian perceptions of the European Union and I'm going to do a little bit of advertising if I may, excuse me. Mybridge is going to be talking about this conference along with many others and we're very happy for you to come along because Professor Louie Brennan, who is the director of the Institute for International Integration Studies where I am also privileged to be a research associate and he and I are running this conference together please feel free to have a look at this and to come along to a number of sessions and we do ask that you register for catering purposes but we'd be delighted to have you come along. So Mybridge will be talking about some of these issues along with the Australian ambassador to the EU for instance who will give his perspective on them as well. I think that I can't talk for three hours because we've been told we'd have to send out for takeaway ice creams if that was the case. So really I'm going to give you a sort of a, what I'm giving you is a snapshot so I'm happy to deal with issues in more detail afterwards but I think this consistency issue across policy is a problem and I think that to put it very simply trade drives diplomacy in the EU's negotiations and discussions so indeed does China, the issue of China drive any other consideration in the relationship. There is an increasing self-confidence in Asia. Barry Desker from Singapore has argued in a piece he wrote about a week or two ago that there is a danger of smugness among many Asians who are doing extremely well and to be careful of that it may not actually be the Asian century but nevertheless there is a great deal of growth and there is a need for the European Union to treat its interlocutors more in terms of symmetry and parity as partners broader than as recipients of the development assistance alone. And so the EU is in a sense challenged to develop its priorities and indeed its values. It's done this to a certain extent by its East Asia policy guidelines, its foreign policy guidelines which came out in June last year. However that document, very interesting document, very clearly written is really in a sense a listing of the issues that are challenges in the Asia Pacific region and taking adequate note of the important role of both the United States and China role within actually setting out a strategy. There is no way to strategy at the moment for Asia by the European Union. So one of the challenges is there's no coherent strategy on the Asian side either. So sovereignty matters, the embedded into governmentalism in ASEAN, the Association of Southeast Asian Nations for instance, means that there are differing commitments to regionalism, differing commitments to something that is held dear in the European Union to democracy and indeed to human rights. There are very differing political orientations as we know. The European Union is very much dominated by its own economic interest agenda by the pursuit of FTAs and by it's concerned about the TPP, the Trans-Pacific Partnership which is in some cases being referred to as the United States equivalent, economic equivalent of an Asia Pacific NATO. So it's quite interesting that that is also being regarded to security terms. I mean if it does come to pass now that Japan still looks like it's going to be and I know that China is at least being discussed as a member that's more problematic, 650 million people approximately within that MTPP. So that's also a challenge and the challenge is also that Asia is crowded. It's crowded with regional entities. There isn't just one major player in town like we have in the European context but you've got ASEAN, you've got ASEAN plus three, you've got APEC which stands for the Asia Pacific Economic Cooperation Forum though there are some people in Australia who refer to it as a perfect excuse to chat. So what you have is a very much a crowded agenda and then of course a crowded set of hegemons. You've got China, the regional hegemon and or aspiring regional hegemon depending on which perspective you take and you've got the United States, the external hegemon which has its own pivot and which has its seventh fleet which of course the European Union doesn't have. So this challenge of how much autonomy to take from the US strategy is also a problem. One of the ways of looking at it is to reimagine the security in terms of non-traditional security for the European Union to work on what it's really good at and that is non-traditional security, capacity building, disaster management, civilian crisis management, mediation, these sort of issues and here we see also the discussion of the European Union as a type of norms entrepreneur. It sees itself as a promoter of regionalism, of values and a promoter of good governance and this is again very problematic and we've actually got a session on it at our symposium on Thursday and Friday looking at these issues. We've asked the person in charge of this regionalism promotion to come over from the commission to talk about it so we're delighted about that. So the EU in a sense is dealing with rapidly changing issues with the tectonic changes that are taking place in terms of security with the fact that economic regionalism matters in Asia in so many different ways but that security regionalism is a problematic aspect in many ways and it's what Bill Tau calls a web of alliances, of security alliances and of course you've got this hub and spokes approach of the United States towards its interlocutors. Now the European Union can develop its relations with its four strategic partners in the region, China, Korea, Japan and India and one of the ways it can do this is by actually developing a strategic partnership with ASEAN. Now what exactly is a strategic partnership? We could spend a few years on that one but one person has been quoted in the European Union as saying it's a bit like love, you recognise it when you experience it. I'm not so sure that that's tremendously useful for us but really in a sense the strategic framework and context for the European Union in terms of its Asia strategy started actually in trying to develop one in 2001 following on from very much a trade and human rights oriented one in 1994 but what we begin to see is Europe's year in Asia is the term that was used by the European External Action Service for its achievements when Catherine Ashton attended the ASEAN regional forum when Catherine Ashton signed the Treaty of Amity in Cooperation with ASEAN when the EU developed its East Asia foreign policy guidelines and when you also had the signature of this transatlantic agreement on the Asia Pacific but in a sense there's still a danger I think of the European Union being crowded out in this rather crowded Asia regionalism context so David O'Sullivan has said look what we're doing is we're working on our 3Ds Defence Diplomacy and Development and I've come up with 3Ps in response to that and that is presence you have to have presence, it matters whether you turn up and who turns up credibility matters by actually being there you have to show I think a sense of partnership strategically otherwise it doesn't matter whether it's called a reliable partnership or whatever that's terminology that can be fixed up by the relevant people it's got to be a partnership rather than a donor recipient relationship or a China focused relationship only so that partnership is tremendously important and I think that is what is needed is a pivot which doesn't only focus on security because there is no 7th Fleet because the ASEAN regional forum is where Catherine Ashton and others are increasingly called upon to take part and because the East Asia Summit is the summit where Russia attends where the United States attends where all the major East Asian actors attend and where Europe and Australia and India and New Zealand and others but the EU is not a member and the EU has not been co-ordered membership despite quite a bit of diplomatic work in this regard and I think this is partly because presence matters summitry does matter so I'm going to finish by suggesting to you that there is a triple hierarchy problem there is a hierarchy of policies and this is actually true for both sides where trade drives diplomacy except in the case of the Asian side security is up there as a co-equal and the second issue is a hierarchy of interlocutors where China is the major concern in terms of trade in particular and the third is the hierarchy of national interests and indeed the dominance of national interests in the European Union strategy towards Asia and that is why there are so many tensions for instance in the context of the arms embargo in terms of trade access and this is a significant challenge for the European Union to be seen, to be speaking with one voice I think that the problem really is that the European Union needs a strategy coherence or a pivot coherence a coherence of policy, of personality and of tasks and at the moment the European Union is in danger of being a follower rather than a leader in the Asian context Thank you


Well hello my friends! Welcome back to my channel! Today is a fun day for a plan with me. I have so much stuff sitting around here because I actually pulled out all the crap I need, which is rare because I don't always do that as you all know. Let's get into the planning. I actually just got this washi and I want to use it! Let's get this party started. I thought it was kind of fitting for the month of February. You'll see it when it goes down here. It's just this really pretty scotch washi. I just got that... we're gonna get this office max and this is gonna be good for putting on the bottom this week. I have a really fun planner event to go to. Oh gosh, why does this not want to work for me? So I'm actually gonna be using the remainder of this washi for samples during my planner event. So that'll be kind of fun. Alrighty! Oh, I should say today we're working on Monday, January 30th through Sunday, February 5th. I should probably show you last week too, which I haven't finished last week because today is Sunday, but I will tell you today's been kind of crazy.  It's like six o'clock at night so it's super dark right now outside.  It just had to be that way this week. I just don't have enough time in the day sometimes to get all these like out and ready to go. Oh, I also need to just put a little thing up here. Will this work? Yes, it will work. I just need to put like a little banner up at the top because I need to do something that day, which I will explain in a moment. Here we go. I know I'm wasting washi doing that, like making a little tail, but it's better to waste a little washi. Like for me, it's better to waste a little washi than to like sit and struggle because I don't want to sit and struggle y'all. I also have this washi here that I got a really long time ago. Like when I first started planning, I don't even, it's been a long time you guys. This is just like really pretty pink with polka dots on it. Like they're like clear polka dots. I figured it was time to finally use it. So I'm working a regular week this week. My boss is actually out of town. He's out of the country even. He's taking his like first vacation and like, I don't know how many years, which is, which is by the way, most of you don't know this because you don't know me personally, but I have been like mega stressed out at work this last couple of weeks. Plus I still need to like get our taxes done. So I have Monday and Tuesday to do it. Yeah. Anyway, and my boss is not there. So that'll be interesting. Annie took his computer, which is even worse, but you know what? I'm going to get it done and it'll be fine. But I had been staying. I had been coming in early and staying late.  So I think I might actually leave early a couple of days this week. The problem is is when my boss is stressed out, he stresses me out. So yeah, it's just not a good thing because he's like, well, what about this? And what about this? And he like puts way too much on my plate and I'm like, okay, I feel like I know what the high priority important things are, but then you're telling me something totally different. What do you want done first? And then, you know, I'm supposed to be gone at three o'clock and then it's like 415 and I'm still there. And it's just it's not not good for the working relationship. I'll tell you that. So it's fine. It's fine. I'm glad that he is leaving for the week because I feel like he's going to be refreshed. And that's just what he needs is to just get out of town and I can handle whatever needs to be handled. You know what I'm saying? So anyway, so I actually have these that I had a friend had given me and the I feel like the yellow works really well with the yellow on the little flower and these are already pre-printed and it says work. So I'm going to put these up here, which I think are super freaking cute. And then this is these are actually from Erin Condren. So I thought these were really cool. And you know, I wasn't sure when I was ever going to use them just because I you know, there's like a specific color. So obviously this doesn't always like go with every single theme and everything, but that's okay. But I feel like this works really well with like all the different colors in here. So it's like a gray, a darker pink, a lighter pink, and the yellow and white. So I'm going to try to try to stick with that theme a little bit this week. So yeah, all right, so my work is in and I got to go to my my coffee break planner stuff, which is like some of my favorite things. All right, let's turn this bad boy around. Do you guys see my problem? Like I have a serious obsession. It's it's an issue. All right, so I'm going to put this little recycle guy up here. All right, so I pulled some things out that I want to use from coffee break planner, the use. All right, so my dog has his monthly meds on the first. All right, so the monthly Doyle meds and that'll happen. I'll just put it down here. That's a good. All right, favorite system happening then. All right, so I'll put in the video thing in just a moment, but let's work on the weekend, which is like my most favorite thing to do really quickly. I'm just going to put in my FPU class because that's an easy one to do. Then I'll put in like a dollar bill because it's fun. I'll put in these coins too because why not? I feel like once I use the dollar, I want to like use up the coins too. That's dumb. All right, and then Saturday I am doing something really fun. I am going to the Minnesota Planner Crawl. This is the second annual one that they have had so far. I'm super, super excited and I actually it was last year on my birthday. So it was January 9th of last year that we had our last one. So I'm super pumped to go and experience it and I'm not on the planning committee or anything. So I have no idea what is going to happen, but I am pumped about it. So I am actually going to vlog while I'm there. So that'll be up next week for you guys if you're interested and yes, I'm so, so excited to share my experience with you all and I hope that you stay tuned for it. All right, so I'm just going to put in a little black camera here. I'm just right vlog on there and this little black camera is from Adriana Piper. If you guys are interested, I will be linking her shop down below too. There we go. So I'll just be vlogging the day.  All right, and the event starts at 12.15 in Roseville. So I have to plan accordingly. I'm also going to bring some things with me that are kind of a secret, kind of not a secret. Kind of let the cat out of the bag a little bit for some people, but I think I'm going to just put it on this little green one here. Just say don't forget. I need to put myself a little note at the top here. Just saying what I don't need to forget. It's one of these guys as well. Actually, I think I'm just going to put this in the center. I think I'm going to call it good. I think that looks really freaking cute. Oh, there we go. Fine, if I cover the date up. Oh, cute. I like that. So I have some gifts that I'm bringing if you guys haven't like figured it out by now. So I have some gifts that I am bringing and I need to not forget those. So that will be good. I also have some things that I need to do before this for the gifts, which I will put in the planner at some point. I am going to use some of these bad boys since it's Minnesota and all. I am going to use, let's see here. Let's see here. Let me use one of these guys. Kind of like, I don't know, I'm like into layering this week on the spread for some reason. Like really into it, your guys. I'm like really into it. I don't know. Layering planning stuff is kind of fun. Like mixing and matching like shops and I don't know. It's just, it's a fun time. And I don't want to like be only using one shop or you know, like I want to use, I want to use whatever I want to use and like whatever I have honestly because that's what I'm trying to do this year is just kind of like use, use it all up. Well, not all of it, but you know, a good portion I should say. All right, I'm going to use a pink state because why not? All right. I'm just going to say planter crawl. I'm very excited about the planner crawl. Last year was so much fun and that was actually the first time I had ever gone to any kind of meetup, like planner meetup at all. And I had a great time and I highly recommend it to anybody in their area, especially if you have an organization that does these kinds of events, just go and it's okay if you don't know anybody.   I'm going to put this little guy over here too. I grabbed like so many stickers out you guys because I knew, I knew I needed to deal with some things this week.  Oh, here it is. I found it. It's like a little time clock thing. Yeah. All right. I'm going to use one of these guys, my little yellow clock here. Since I live so far away from where the event is starting, I just want to put in like a time to leave. All right. So I need to leave around 11 a.m. to get there in time for all the fun to begin. So I'm going to put that around the 11 a.m. mark right here and put my little license plate thing above it. That's super cute. Okay. So for the rest of this, like the rest of this stuff, I'm going to wait because usually they'll actually end up handing out like a couple like really fun stickers and stuff. So I am going to wait on that. But I actually think I'm going to use some of these down here maybe. Maybe I'll mix in some like pastels. Yeah, let's do it. I've actually got four videos coming out this week. Spoiler alert. So I think I'm just going to do like two pinks. And then what should I do? Like let's do the greens. I kind of like green with the theme that we're doing, even though green is not in the washi color at all. But I don't know. I just, I don't really care. I think it would look cute. All right. So I've got a plan with me. I've got my favorites video for the month of January. And then I also have my FPU update. And then I think on Tuesday, I'm going to post my office did on Instagram actually today, while I'm filming this, that I was getting favorite daughter Emily headquarters set up. And there was a whole bunch of people that said, I want you to film a haul. I want to see what you got. It's just office supplies you guys. So if you're not into it, that's okay. But I think I'm just going to do it because why the heck not. So anyway, let me fill in all of my video titles and then I'll put them in down here. Okay, so plan with me is going to go on Monday. This little guy down here, whoop, there we go. The office haul we're going to do and schedule it for Tuesday. January favorites is going to be on Wednesday. So if I have those like extra random videos, you guys, like they're going to be up like probably Tuesdays or Thursdays. I'd like to keep things consistent Monday, Wednesday, Friday with like my content. But I'm always open for suggestions. So obviously like the office haul, I would have never done an office haul, but you guys all seemed really interested on Instagram.  So yeah, but that is how my week is going to go. Actually, let me pull this out real quick. And we're going to use one of these bad boys because I need to wrap some wash it, which I think I'm going to do tomorrow night. So I think Monday night, I'm going to wrap some washi when I get home to get that ready. That is going to be part of the present situation. You know what I'm saying guys? So I think that's going to be it for this week. I have some appointments Monday, Tuesday at work, but I can't remember what time. I know Tuesday is like 11 and Monday I think is like two. I can't remember. Anyway, but I'm not going to put those in just because I can't remember and I'm not at my office. So it doesn't really matter. I'm at work, but I might put them in later. But let me show you last week since I forgot about that. Pretty much exactly the same. So again, this is last week subscribers. Actually, hold on. Let's do something fun together. Last night I hit 13,000 subscribers because y'all are nuts. Like y'all are crazy and like the best kind of crazy, but still nonetheless kind of crazy. So let's put that in. So I hit 13,000 subscribers yesterday on Saturday. I was pretty shocked. It seems like every few days it's like another thousand. So gone with my channel and thank you guys so much for subscribing and enjoying what I do because that's how you keep my channel up and running and support me and I really, really appreciate it. So feel free to share this with your friends and share my channel and content with anyone online. So that would be awesome because it keeps my channel growing, which is awesome. So thank you guys so much. Anyway, so let me close out the video here. Thank you guys so much for watching. If you like playing with me, make sure to give this video a thumbs up as well as hit the red subscribe button if you haven't already. Like I said, I'm here every Monday, Wednesday, Friday and this week is going to be a sneaky little video, but you guys already know about the sneaky video because you watched my plan with me. So you got a leg up on everything. So thank you all so much for hanging out with me for a little part of your day. It means so much to me. I hope you're having a wonderful day no matter where you are and I will talk to you all in my next video. Bye guys.


This study found that the use of intravenous chlorfeniramine prior to ureteroscopy did not reduce the incidence or severity of emergent agitation. This article was authored by Qin Qichou, Min Hai Cheng, Subjean Li, and others.


Hi, my name is Andrea with Foodimentary Adventures in Food and today I'm sharing a simple and tasty recipe for ice cream sandwich cake. So let me show you what you'll need. You're going to need some ice cream sandwiches. I'm using the traditional ice cream sandwich, but if you'd prefer, you can use strawberry, you can use Neapolitan, whichever sandwich you'd prefer. You're also going to need some Cool Whip, some chocolate topping and caramel topping, and then you're also going to need whatever type of candy bars you prefer. I am using a mixture of Snickers bars, Twix bars, and Reese's Peanut Butter Cups. So let's get started. Okay, we're going to start off by preparing our ice cream sandwiches. One thing I wanted to share with you all, this is on the bottom of my cutting board. I have this little bottle gripper. You know, you use it to open up your bottles. In order to keep your cutting board from slipping all over the cabinet, if you put one of these down and then put your cutting board on top, that will help out a lot. But all I'm going to do right now is just cut my ice cream sandwiches up and get them ready. Okay, so I've got my ice cream sandwiches unwrapped and ready to go. I've got a loaf pan here that I have lined with parchment paper. A little tip I like to share is to use clips on your pan to hold your parchment paper in place so that it's not sliding everywhere. So I'm probably going to try to put about four ice cream sandwiches on the bottom. So I've got one in right here, another one right here. And depending on the size of your pan, you may have to cut your ice cream sandwiches in half. I think I'm going to be able to squeeze it right down there, just like that, and squeeze the other one in as well. And yes, your hands are going to get messy. So I've got that in. And now you're just going to put a layer of whip topping down. And then you're just going to repeat those layers. Now of course you could do this in a larger pan, like if you have a 9x13, that's fine. Of course you're just going to need more topping and more sandwiches. It'll work in any size pan. Okay, so I just put the second layer of sandwiches on and I discover that it's easier to put them in this way instead of this way. These ice cream sandwiches are a lot smaller than ones that I'm used to. So I'm just going to put on that second layer of the whipped topping. Now I'm just going to sprinkle on my candy. Okay, so now I am going to loosely cover this with plastic wrap and I'm going to pop it in the freezer for at least a couple of hours. And then I'll show you how I finish this cake off. Okay, so it's been about five hours and I lifted the cake out of the pan. It was so easy. Just pulled it up by the parchment paper and then I just stuck a large spatula underneath there and then just put it on my serving platter. Now I am going to garnish this cake with some caramel. I warmed up just a little bit. If I had to guess maybe a fourth of a cup of caramel and a microwave and I'm just going to drizzle it over the cake. And now I'm going to take my magic shell topping and if you have just regular hot fudge topping that's fine too but the magic shell it hardens. So here is the ice cream sandwich cake. And so easy to make and it is sure to be a hit with your family and friends. Cut it open so you all can see what it looks like on the inside. And then here is a slice on the plate. I hope you all enjoyed this video. If you did please make sure to give us a thumbs up and if you have not subscribed to our channel we'd certainly love to have you. Thanks so much for watching and we'll see you all next time.


So our last speaker, Dr. Jose Diaz Gomez. It's my pleasure to introduce him as the final speaker of the conference. And Dr. Jose Diaz Gomez is a staff cardiac anesthesiologist and intensive care physician at the Baylor College of Medicine in Houston. Dr. Diaz Gomez has trained extensively in both anesthesia and critical care medicine across multiple sites in both Columbia and the United States, including residency at the Cleveland Clinic where he went on to serve as both cardiac thoracic anesthesiologist and intensivist as well as assistant professor of anesthesiology. He has subsequently worked at other prestigious institutions such as the Mayo Clinic in Jacksonville and the Baylor College of Medicine in Houston. He is currently obtaining a master's in applied science in patient safety and health care quality at Johns Hopkins Bloomberg School of Public Health. Dr. Jose Diaz Gomez. Thank you. Can I share my screen? Is that okay, Dr. Perez? Yes, Jose. Yes, you can share your screen. Thank you. I want to thank the committee for this invite and especially my dear colleague and friend, Dr. Paolo Perez-Dampar. I really want to show you what I consider is the highest point of contribution to utilize point of care ultrasoundography in estercorporeal life support. And I take this from one of my favorite books, this graphic where I always making sure whatever I'm doing, there is a reason why I'm doing so. So the way I have put this online, I will tell you what is POCUS, what is ECLS, when we are doing that and why we do it. So there is a disclaimer and everybody knows here that when we are doing ECLS, patient selection will be essential on that. And we have kind of optimized our acting flows and doing band strategies based on echocardiography. I work in a cardiac thoracic ICU every day. So probably that's different when you work in another setting that is not that so specialized. And ultimately, I really care about those longer outcomes, especially as I need to provide some bridge to recovery or actually transplantation to those patients who have such a catastrophic event. So what is the point of care ultrasoundography? I will give you 10 seconds to read the definition that we put together back in 2021. What is that important? Because these definitions empower us that we are not cardiologists or radiologists. That doesn't mean to be divisive at all. And it gives us the opportunity to go and collaborate with those colleagues so those colleagues know what we are using this for. And what really the cardiologists have loved about this definition is that immediate clinical integration. I know that you can plug this definition in whether you're doing critical care echo, whether you're doing an assessment as a hospital. So this will be at the bedside utilization of ultrasoundography in ECLS. Okay. What is the future for Parkers? Well, I have some news for you. We are going into details. The handheld ultrasound system will be more available. There will be less buttons. The images will be faster and will have artificial intelligence. So the future of Parkers is extremely bright. However, we still have some issues and you can see in this paper how the older societies or our colleagues continue complaining that apparently we haven't paid that much attention about training and experience. And that's probably the reason I'm bringing this definition as a very good first step. I'm assuming that everybody who's coming to this course at least have the skills to utilize the tool in the right manner. However, you see here in the right, they are acknowledging that pretty much we, intensively, so critical care specialists are probably the ones who can do better Parkers. And I can take that as a good sign that we have evolved in this collaboration with our cardiology colleagues. And definitively, it's a very good point. It's a very, very specific moment for us in collaboration with cardiologists. Okay. So what is the ECLS? You can see the definition there. And pretty much we try to really do this in selected patients who present cardiac arrest. Right now, my center is close to 200, you know, at most this year. So we have a significant volume and that's the reason I accepted this invite by Dr. President Park. Okay, when we do it, based on the data that is available, chocolate rhythm, and pretty much we are able to do this in less than an hour after starting CPR. It's better if the patient has a higher pH and lower lactic acid. Those are good, good, good things to deploy this. I need to take this paper that is actually coming out of Europe when in Germany, you can see now there are two things here coming to your mind. You're seeing they are doing the providing ECLS. They are doing ECMO. They did this for 254 patients. But guess what? Beside the fluoroscopy, they put ultrasound. And you will remind this in the end of the presentation. Let's go to the why, which is the core of the presentation. Number one, it's good to characterize what is the theory of the cardiac arrest? Number two, we'll try to see where the cannulas are. Three, how we'll start that support, and then we can face some complications. In this case, this courtesy from one of my colleagues at the Powell here, and yeah, we are trying to see how well we are doing the compressions. Okay, and then this is something I have developed over the years that there are protocols that give you with doing the pulse check to see what will be the theology.  You can see how you can probably rule out some of the pathology. So this is important. This one was not running. You can see even during compressions, I have developed that skill. And I'm not saying that in a, in a way different that as you're able to refine how to do this with your teams, I just trying to make a parallel with what you can do with your T or TT. I don't have any distinction. I don't have any bias. I should be capable to do both, both techniques depending on the patient, depending on the situation. I can challenge you in those cases where we have probably a couple of hundreds of years a year. You can put a T probe so it is your responsibility to really become proficient in both techniques. So in this case, for example, we are trying to really characterize diagnosis here and this is so meaningful just to, to see how you are facing now. Okay, you can address these pathology. And in this case, how this patient has have P and it has under-filmed and you have better characterization what you're doing here. You can save it as this patient. And this is a transfer yield view. I can see very typical subtle P. How can you rescue a patient after a cardiac arrest without having this image. In this case, sometimes we got surprised. Look at this was one of my recent cardiac arrest and then the patient had actually a type A dissection. Then we go, we start doing cannulation and of course, the surgeons or the interventional calories or another intensive is can make guidance regarding the position of these wires and this means of ideal view, as you can see that. And then you complement with by cable view and trying to see how to do a wide advancement as you put in the penis canola, then avoid cannulation noise in the body position. And then this is important as well. And you have to really make sure whenever you are so the beans on the figure where they are landing. And I'm showing you here how after a femoral period of cannulation, I can see my wire. Then we start, we now initiate, let's say that the vehicle. And after doing that, we try to see what is the response. And then we started seeing a new finding here, for example, now you, you have, you have a new issue.  So this is very, very important as an initial complications. Okay, and sometimes we got called to the bedside, and we need to reassess the flows and it's important to see when or what is expected in this case, we have the ability to really use color for Doppler and evaluate the flow. Or sometimes we need to make a call and say, you know what, we probably were trying to decompress this is ventricle but it but it's too much. And then, because of that, we can readjust the management. In this case, for example, and we have this private response in the new, and you have that then you can really readjust your therapy. So it's a real way to personalize management after, you know, ECLS. Then sometimes we are in a very bad shape. And then when you have this kind of minimal flows. And this is a really bad complication and able to have a better discussion with our surgeons and determine futility. So I, you can see the wide spectrum of what these kind of imaging brings to table. Of course, it's not only for VA ECMO, primarily, that was the main indication. But sometimes we would need to put a balloon pump and some of our surgeons believe there's a good way to combine with VA ECMO or even right now we are really trying to determine the best way to do so. But once again, you can see the application when utilizing enter out the balloon pump in patients with VA ECMO and using three dimension eco-friendly to ensure that it's in the right position. So, this has been a really explosion over the last two years in our institution and the utilization of impella supports going really, really high. And for any new hypertension, any alarms, they know that definitely will do eco-friendly assessment. So once again, this standstill image here allows you basically to have the measurement and thus direct communication. And we have even the capability to, you know, communicate with our interventional calories that are not here, they're at home. And this is the way you can really excel in that regard. So, but why then does has the role. I have show you what, when and partially the why. But there are three questions that should come to your mind right now. Number one is that, can I provide safer care when I'm calculating vessels, especially in these emergency situations? How can I make sure I tell whoever is doing it or even myself that the calculation was appropriate? How can I make it faster? You cannot spend half an hour just can already in a picture. Okay, is it easy or less? So, there are the evidence is as follows. And improving the cannulation time, just being partners and the cannulation time. You can see here how when you do with partners, 20 minutes, poroscopy, 15 minutes, and Lamar, 22 minutes. So, okay, is that the real answer? And that's to be focused in the time. However, however, when you're seeing the misplacement of cannabis, then we can't follow them because you can see here, meeting the partners or in the poroscopy group, there were any misplacements in the camera. But here you have three, and I will tell you so only three Jose. Let me ask you this, what is that? Any of those three patients are even a friend of yours. We should really maximize patient safety in 2023. We have the tools which need to be better organized and apply these tools better. And that's the central message regarding this application. So, it appears, and again, even not in my own institution, and I will be happy to take that question and interact with my colleagues from Toronto. But the vast majority of institutions in the world cannot achieve the combination of both modalities. So, my dream is to have both ultrasonography and poroscopy. And I know there are some advancements regarding having more portable poroscopy units. But to me, to do this at the point of care, we really need both. We need both. And any intensities should be incapacitated to manage linear probe, to trans-terrace it, to transesophageal, and do poroscopy if they really want the safest care for these patients. So, you can see in this study, when they were using poroscopy-guided cannulation and ultrasound-guided cannulation, you can see here the complications. Okay? The complications. Wow. There was a difference there. And you can see when, in my institution, at interventional categories during the NCLS, most of the time they try to put a patient in the cath lab or what if the patient is crashing in the ICU? We try to bring the poroscopy. But for the most part, I'm the one providing basically ultrasound guidance, including PE. So, what we have, so what we have is the following, is that ultrasound guidance, you start with your linear probe, and then after that transesophageal, and then we try to really make sure that we don't have issues with the limbs. And that's probably the very first really early complication that triggers a lot of back problems. And then we have to take a look for 10 seconds, this KUB. This is a previous case that I have. And why do we pay attention to this case? Only afterwards, only when we're doing winning of the ECMO. We discovered that the patient was not a VA ECMO. And it was a cardiac arrest. We have venous-venous because these arterial cannula went from the artery was crossed and then pierced the vein again. So actually this patient was on venous-venous the whole time. So, this happens. So, once again, this case has made me so humble that we really need to be the best efforts to provide poroscopy and echocardiography. Cardiac arrest, minor number 10. I have very clear the patient selection. I should have in mind poroscopy and my point of kerotationography. And then basically this is the goal to provide VA ECMO. We can try to see how energy we need to go to the cath lab because we need to rep refuse. And then here, we know what to do with echocardiography, optimizing the ECMO flows, and then making sure that it involves, it involves this opening, preventing every extension, and even considering preventing morality. That's what we do. Lastly, now we're going to share with you a case that happens to me earlier this year. This is a 44-year-old patient. He had a lung transplant. She arrested. I took over. It was the evening. Wow. I'll say this patient has, you know, their low-flow alarms. I don't think this is, these are the legs, basically. And she has access, you know, both, both groins. I'm like, wow, okay. So, I was trying to see what was going on. This was, if you can see, I'm not going to say the brand, but this is a handheld transom system. No, not a big, it's a portable one. Again, this is my personal one. That's the way I do it here. So, I'm not thinking that, okay, well, you know, I can see that this is working somehow. I have the color flow dropper. I'm probably suspecting that, well, the volume wise is low, and it's starting to see here some fluids. So, I continue doing it just because I was there. This was a porno vein assessment, which is more consistent probably with volume started being on the lower side, and I continue doing my point of care rotation of it. Now, I'm seeing actually free fluid in the abdomen. And I didn't like it. I really didn't like it. So, I continue scanning and then it's free fluid in the abdomen. And the patient has cardiac arrest, and then they put a VA act on what I go from here.  I say, listen, I have this situation where there's fluid that it might be, it might be blood. Can you help me out? So, okay, sure, Jose. So, I completed that with this is the assessment of the heart. You can see, you know, the audit box is open and nothing like out of proportion, and then you can see then the thoracic vein. And you can see the part of this patient was almost 310 pounds. So, here we have the apical view. Okay, I brought them. So, basically, I did a synthesis of telling them, okay, if blood is coming out and it's not temporary anymore, you have to help. So, now I have, you can see here, 1.5 liters of blood. I put a pigtail. Okay, we went to the OR. You can see here the ECMO, all this blood coming out. Now you have open abdomen that removed like my brain. You know what happened? With the CPR, there was abrasions of the capsule of the liver, and that was causing the hemoperitoneal. It's the first time I'm facing that in my life. Once again, it's handling, but I wouldn't have the hand held to some system to have another complication. I wouldn't be able to catch that. And only the first time was low flows in the ECMO because they increase interdominal pressure. When I was able to drain that 1.5 liters, the patient gain flows right away with the ECMO. So, in conclusion, the highest point of Parkus contribution in CLS is achieved when we are able to recognize what ECLS is and we apply it alongside Parkus at the right time that the candidacy. And Parkus seems to facilitate safer, more reliable, and timely cannulation in CLS, especially when it's combined with fluoroscopy. With that, I want to thank you here from Houston. I don't call today, but it has been a pleasure joining this prestigious panel. You have put together. Thank you. That is the part for you to invite again. Okay, thank you so much. So, I have the honor now of opening up the Q&A session. So, unfortunately, a few of our presenters, including Dr. Wiskar, Dr. Nicol Van and Dr. Toran are unavailable to answer questions just due to unforeseen circumstances. So, luckily, we have Pablo here and Jose, but Dr. Dano has also agreed to help answer some questions, especially regarding Vexus with which he is familiar. So, just going to the Q&A to start, we have some questions. So, Julian asks, what is the physiological explanation of hepatic S reversal without any TR on the Vexus score? And Dr. Dano, would you be able to provide some insights into this? Yes, for sure. So the question regarding why S is reversed when you have tricuspid regurgitation, is that it? No, I think it's in the patient without tricuspid regurgitation. Why does that happen? So what happened is that the S wave is really during systole. So, typically, what will happen during systole is normally you have the motion of your tricuspid annulus that's squeezed toward the apex. And that creates the systolic flow from the hepatic vein to the right atrium. So when you have RV dysfunction, even without any tricuspid regurgitation, what will happen is that there's going to be no motion of the tricuspid annulus. But then during systole, what can happen is that the tricuspid valve might bump this way. And this motion will create the reversal of the S wave that you can see in the hepatic vein, even if you don't have any tricuspid regurgitation. In addition, what you'll see also in your CVP waveform will be a big V wave also. That's the other element that will be complementary with this element. So actually, Dr. Nero, I just have a question regarding the use of exis in an ICU population. A lot of the studies that were discussed talked about using it longitudinally during an ICU stay starting from postoperative day one or immediately after the operation. So can you use it longitudinally before and after extubation or before and after the initiation or the discontinuation of positive pressure ventilation, and then in an extubated spontaneous ventilating patient, would you be able to correlate the before and afters or not really? That's a good question. The studies that we did that were mostly by William Bobien Sudini, who was a nephrologist who presented yesterday, the way we did it, we just did one measurement, you know, every day for three to four days. And that's really how we got our experience. And I would typically do it, you know, more in a more longitudinal fashion than necessarily acutely. Because if ever, and you can, you can, you can look at this, if ever you take a patient, for instance, and you give him a fluid ball is very, very fast. Okay, you'll see instantaneously a portal possibility. And we see this even when you give it to normal people because you're what's happening is that you're raising suddenly the right to pressure. And all the vexus issue is basically transmission of the right to pressure in the periphery, which should not be transmitted in the periphery. So anything which will increase suddenly your right to pressure will increase the possibility. We just completed a study in which we look at an element which eventually might come into the vexus core, which is the femoral venous Doppler. And the femoral venous Doppler should be continuous, like the portal vein. So what we found is that if you do it just before and after the intubation. Okay, so what we found is that at baseline about 20% of patient of possibility, you know, before cardiac surgery, but after intubation that goes up to 50%. Okay, and that's probably because you're increasing the right to pressure with positive pressure ventilation. On the other hand, what we observe, and that's why every patient is different, is that we had a certain number of patients in which the possibility was present before the intubation, and resolved after the intubation. Those were patient with mitral regurgitation, aortic regurgitation. And you know that with induction of anesthesia, you create vasodilatation. So the benefit of the vasodilatation in those patients was greater than the effect of positive ventilation on the right heart. And that's why in those patients, we saw normalization. So these values can change rapidly. And then the significance of these rapid change, I'm not sure the meaning of this, but when the signals is constant and when you see it changing over the days. And in fact, what we observe is the peak change after cardiac surgery was on the second day.  And that's really on the second day that we observe this. And this is really when you're really, if you see this, that's really when you don't get fluid. You know, we remove fluid in those patients. So that's been a kind of our experience with the Vexus Core in our institution. Thank you. Thank you so much. So, Pablo, I'm going to ask you to comment on lung ultrasound.  And the question that comes regarding lung ultrasound is can you comment on adding color Doppler on lung with consolidation for optimizing the diagnosis of pneumonia. So, for the diagnosis of pneumonia, one of the things you want to look for in lung ultrasound is the dynamic bronchogram that Sarah showed a couple of slides where you feel like bubbles popping up, where you can, if you will, add colors to it, you could also see that changes in different directions of the flow. But to my knowledge, it doesn't really offer an active advantage in terms of diagnosis for pneumonia itself. Yeah, I agree with that. I don't tend to use the color Doppler in order to add any kind of diagnostic utility. Dr. Danone, do you have any, any insights? Well, I have one of my colleagues who was doing a study looking at pneumonia and looking at Doppler tissue Doppler in the in the vessels is hypothesis is that when you have a severe pneumonia you're going to have a shunt. Okay. And but if you have a consolidation where you don't have so much epoxy that means that you have visual constriction, you know, epoxy visual constriction. So his hypothesis was that maybe the velocity would be different. You know, if you have a true consolidation with pneumonia in which you would have a shunt versus a consolidation in which you have preserved epoxy visual constriction. So, but I think he's still under the recruitment phase so I cannot tell you more but the idea is also based on this on this concept. People also in pulmonary embolism and in peripheral pulmonary embolism people also use color Doppler to see there's no flow in that in that region but I personally don't have much experience using color Doppler in those situations. And Dr. Jose Diaz Gomez, do you have any insights or any additional considerations I know you're advocating or trumpeting the utility in the need to be able to be very comfortable and fass out with both point of care ultrasound using handheld modalities as well as TE floscopy these different modalities. Do you use color Doppler specifically when when helping increase the diagnostic sensitivity. Let me let me take one step back and I think something I really need to advocate for is that do not forget your primary role as a clinician. I will tell you I'm not aware of anyone. This is continuing antibiotics or not giving empirical antibiotics on somebody who has a clinical suspicion based on the ultrasound imaging, or I'm trying to say is that the value of using color flow code or power Doppler. I don't think you have enough evidence to say that would really should influence your clinical decision making. If a patient has clinical suspicion of pneumonia, you should treat it and it's the same in parallel, if you will have a CT scan or you have a chest radiograph but I will be opposed to try to put an ultrasound modality over the clinical picture, especially with the patient population I deal with that are transplant patients you know I'm going to suppress patient I cannot apply that and I've been always challenged by very reputable cardiologists or pulmonologists. Jose, are you taking the decision on image. So we're not an image in a specialist. We're primarily clinicians using a powerful tool that have diagnostic capability. So another question regarding Vexis. Dr don't know I'll direct this towards you. And do you see any additional value of doing renal Doppler on top of portal vane Doppler interrogation Vexis. That's a good question. The portal then is much easier to get you know the success rate you know experiences more than 95 90 98%. In fact, the situation where you don't get it. It's often very obese patient where you have a very steatosis very bright liver. And in those patients what you can do is can you can just look at the spleen and look at the spleenic vessels which will give you also the same similar information. In the, if you have significant portal possibility. It's rare that the kidney will be completely normal unless it's a false positive. Okay, and this can also this is also part of the limitations. But I think the whole idea is when you look at the Venus system is try to have as much as possible evidence that there's general Venus congestion everywhere and if you have a good signal on the kidney. I think that's additional evidence that this kidney is congested and definitively will not improve with more fluid. So that's, I would say, that's the advantage it supports your finding. And the idea of the vector score which was developed at the heart Institute by Dr. Surini originally validated is to try to, to take more than one elements and if you take more than one elements the probability of a response or the association with with the outcome was much better than if you just take one on his own. So, I think, I think it's a it's a good, it's good habit to, to have a quick look and to see those, all those elements put them together and take a decision. And I agree with Dr. Diaz Gomez.  And we try to put this together. And also when you do the vexus where I'm lucky I do cardiac anesthesia all the time and I can correlate it with the CVP waveform with the right denticular way form also so I know that it's it's all related to RV dysfunction and and then you can take the better decision regarding how you manage the patient particularly in terms of fluid management. I think what we all kind of advocate for is the use of ultrasound as another point of data for triangulation as opposed to, you know, so reliance and I think the more familiar and the more comfortable you are integrating these various imaging modalities or diagnostic modalities to probably closer come to the truth in all of these various diagnostic dilemmas that we come up with. I'm going to ask you because I know you're very experienced and you lecture a lot on use of transesophageal echo during resuscitation acute CPR and rest situations. And do you think there's any concern for esophageal perforation when you have a transesophageal echo in during active CPR. That's a great question. Sorry, just a doctor trying to connect but he's Wi-Fi is not helping so I'll I'll I'll answer. Yeah, that's a great question. To my knowledge, although it seems like a very honest concern. No increase in incidents of major complication from T during chest compressions and and the complication quoted in the literature, which at this point is still there's quite a positive of the literature and in the in the terms of cardiac arrest and use of T, it hasn't been shown any increased risk of performing T during during chest compressions so far. But it's clearly a potential concern. You just need to keep in mind the usual. We'll have an any other patient having a T and the relative and absolute contraindications and the same in terms of performing an adequate technique for probe insertion to avoid any any any further trauma or injury so far. Most of the injuries or complications have been reported as being due to insertion, most in the orference and the or cavity. So let me ask you, like Pablo in a hospital kind of wide and spread out a sunny book is what are the logistics or some of the practicalities of, you know, getting the arrest call being able to mobilize a team with the T getting the machine and the probe to the ward where the rest is occurring finding out enough information in order to recognize whether it's safe or not to proceed with tea and then actually performing the study in in a way that's clinically useful. How does that unfold like what are the logistics of that at at the hospital where you are because I know you're able to do it with some success there. Yeah, so this is also a great question. So we're lucky enough that in our emergency department, there's a very strong point of Carol Georgetown team and program. In fact, Dave, they're the one to perform the interest. If there's a cardiac arrest in the emergency department, they have the capability in terms of equipment and personal to perform the reciprocity and get the information from that. In the operating room, since obviously we're a cardiac center, there's always cardiac within normal hours. But other than that, we have been training and we have trained now a few small group of non cardiac anesthesiologists, then at least being able to obtain the resuscitated four or five years in the context of a cardiac arrest. And in fact, not only using the full cardiac or the machines, but a couple of our focus machines like the portable ones. They also have the pros that can be used for and we can save those images and the same applies for the ICU a couple of years ago. So we started training a couple of our intensivists, like a non anesthesiologist intensivist and also resuscitated. Logistically, they also have the machine and the capabilities of doing the study in the ICU. Out of the ICU, out of the war and emergencies, it's not, it's not feasible, not possible so far. So maybe we'll get there at some point, but the idea to like build that collaboration between those three departments, the ICU, the emergency department and the NDOR to have the capabilities of first help each other, collaborate to each other. And now, in fact, we share the archive system, we share it among the three departments. So we can all upload our scans, studies that we can all share and look at each other's studies and work as a QA process in terms of that. So you feel as most of the utility is in the emergency department in the ICU as opposed to general medicine. And in the operating room. Yes. Yes. So far, yes. Yes. Like, I don't think we'll get to the point like even doing a trans thoracic in the ward is still, still not easy. Okay, because unless it's mostly because of training, unless you have somebody who's always available to perform a quick point of their ultrasound in the context of a cardiac arrest. And it's just challenging to have it at every single cardiac arrest that happens in the hospital outside of the period of their various or the ICU or the emergency department. Fantastic. Okay, so that's all of our questions and that brings our Q&A to close. Thank you for all your involvement and Dr. Dono for adding his expertise last minute. So thank you very much, everyone for your participation and your attention over the course of the weekend. And now I'll hand over to Annette for awards and closing remarks.


Boy, I love the smell of justice in the morning. There's nothing more satisfying than knowing the good name of Sword and Shield has traveled so far and wide that not even the Pokemon games are free from their incredible awesome influence. And it's about time, too.   And if anyone were to step out of line, I'd bring down the wrath of which tear-ass children tell their parents to scare them before bedtime.   Do you want to tank? Do you want to fight? Do you want a class that'll instill fright, take up some plate, and keep the goblins inside?  The paladin is the first on a short list of hybrid-style classes, stealing a mix of features from both the fighter and the cleric. Meaning it's better at physically painting the walls with blood than a cleric, but more good at grammar and spelling than a fighter. But it's also one of the few classes where role-playing becomes somewhat important. What? Role-playing in my role-playing game? They really should have put some kind of warning label somewhere.  If I wanted to follow some sort of code, I'd become a pirate so that I could at least plunder some booty while I'm at it.  Like the other all-up in your grill-style physical fighting classes, you gain proficiency with every goddamn combat-oriented item in the universe.   That's true for just about every combat-focused class, but the paladin is especially good at it, what with having the aforementioned fighter-cleric combo skill set.  And lay on hands, a pool of health you can use to heal yourself or give a single hit point to your ally because that's all they deserve for not letting you rogue check the obviously booby-trapped room first but we all know the real reason anyone picks paladin and that's to never cast any actual spells but instead use your spell slots to imbue your weapon with various flavors of SMITE because what good is striking down the heretics and heathens of the realm if it's not in the elemental attacking equivalent of your god sports team colors. You can smite with fire, laser pointers, brain freezes, and cheese, cheese for everyone! Sorry, I meant force. Force is what it says. And now you know how to play... Wait a minute, what the hell is that noise?


All right, we are live. Great, thank you, Matthew. And good morning, everybody. And welcome to the January 22nd meeting of the House Energy and Technology Committee. We're going to meet twice today. This morning, we have a committee discussion on a presentation received and a request from the administration and agency of national resources with regard to a budget adjustment appropriation for a million dollars. We're going to discuss that right now with the committee. And then we will adjourn this morning, this afternoon. We're going to come back, I believe at 1.30 to have a presentation from the Department of Public Service. So that information is on committee's website and our agenda. So I will just kick off the discussion for our hearing just to review some of the things that we heard earlier this week. And I know that Representative Pat also touched base, or at least said it on some testimony that was given to the Appropriations Committee and heard some of the discussion over there as well. Earlier this week, we heard from the Secretary of ENR, Julie Moore, who presented information to our committee about a request for a million dollar appropriation one-time money through the Budget Adjustment Act, which is in the Appropriations Committee right now. Our task this morning is to determine whether or not we want to support that recommendation from the administration and pass that message of support back onto the Appropriations Committee. The million dollar request of one-time money was essentially to support the work of the Climate Council, which was set up under the Global Warming Solutions Act last year. The Climate Council began their work in November, I believe, and has met three or four times since then. There's a very aggressive timeline that has been set up for the completion of the work of the Council. And even though the Council has met a few times since November, I think our understanding is that the work of the Council is really just beginning, and the subcommittees are in the process of being established right now. There was an ongoing general fund appropriation last year that was made to support the work of the Council in the form of three positions that are going to be staffed through the Agency of Natural Resources. What we're talking about this morning is not that money. That is general fund money to hire those three positions. This money very specifically was primarily to support technical work that the Council needs in the form of economic and emissions modeling, as well as money that would support the facilitation of the work of the Council, public outreach work that's got to be done over the next, I think it's 10 or 11 months. So even though this is one time money in FY21, I think it was presumed by the Secretary that some of this money would actually be spent as we get into FY22. It wasn't just going to be money to be expended by June 30th this year. Some of the money would actually spill into the next year. Some of the things that the Secretary talked about, which I was particularly appreciative of, was the work she had done in looking to some similar work that had been done in the state of Maine. Maine is somewhat similar state to Vermont in terms of the rural nature of the state. In the past year or so, the state of Maine has gone through a very similar exercise. So I think it's particularly relevant to look to Maine in terms of the work that their Climate Council has done in the last year and some of the work that they needed to do to accelerate their process and to make that process of greatest utility as they kind of pushed forward with climate policy in their state. One of the things that I heard the Secretary say was that with this type of work, I think she said it's like engineering work. It's good, fast, and cheap. You pick two. And we have definitely looked to the Climate Council to work quickly. They have to complete their work and present the work of the Council. I believe it's by December 1st this year. So we have definitely set a fast timeline. Clearly, we want the work to be good and supportive of policy work that we are going to do and that the administration is going to do going forward. And again, I think looking to the work that Maine has done as well as Massachusetts and New York, the Secretary has, and the administration has determined that this additional information, particularly for the technical work, is necessary. So having heard the Secretary's testimony in our committee, and I also listened, I think 1.75 speed in the Appropriations Committee heard her testimony there and some of the questions there. I would just open it up for conversation and thoughts that other folks in the committee might have. So go ahead, Avram. I see your hand up. OK. Yeah, I just wanted to, I sat in, actually, or listened in on two Appropriations Committee hearings. The very first one was several, a few days ago, was when Commissioner Greshin, Finance and Management, Commissioner Greshin, gave an overview of the entire budget adjustment and walked through everything that's in that proposal, including what we're talking about today. And yesterday, I listened after the fact, specifically to Secretary Moore's testimony, after the fact only because we were, at that time, hearing from the electric utility folks, and I definitely wanted to be part of that. So Secretary Moore's testimony, she did not give, when she was in our committee, she started with a sort of overview high-level summary of activity to date, organizing activity to date, and all of that. She did not go into that with the Appropriations Committee and just went to the Appropriations, the budget adjustment request directly. And her presentation was basically the same as what she gave in our committee. There was not a lot of discussion after that from the committee. There were a couple of questions, which were also covered when she was here. One was about what was the basis for the estimate for the consulting work and all of that that needs to be done. And she mentioned again that it was based on experience in other states, particularly Maine. And committee chair, Representative Cooper, asked why this needed to be in the budget adjustment and could it not be included in the budget proposal that we're going to be working on for the coming year. And Secretary Moore's answer was that there's a huge amount of work, as the chair just said, that needs to be done in a very short time frame. It can't be done on a volunteer basis, relying on the expertise of members of the commission or by the staff that have been hired to basically do the organizing work and the process work of the council. She used the phrase, it's simply not enough hours in the day to do what we need to do. So that's really just telling you what I heard in the appropriations committee. And I'll finish by saying that I think this proposal was well thought through. And as I said, when Secretary Moore was in our committee, I, although no one, it is additional money, but I was impressed by the commitment to get this very ambitious project done in the time frame and in the spirit of the bill that we passed last year. So I support the proposal. Thank you, Abraham. Laura, I see your hand up. Yes, thank you, Mr. Chair. We did pass a bill with an extremely aggressive timeline in it because we have an extremely aggressive problem in climate change and also adaptation, economic adaptation and infrastructure adaptation throughout Vermont, particularly in our rural and poor areas of the state that are being left behind. Of course, we know that those who can adapt already are adapting. And so I am quite pleased to see that this request has come in from the administration to ensure that this work can be done in a timely fashion and in a thorough fashion. And I absolutely support this request. So thank you for that, Laura. Something else that I would say that has made me appreciative of the administration stepping forward with this request is that the Global Warming Solutions Act is something that the House of Representatives passed, I think it was 11 months ago, almost exactly. It was at the end of February last year. It was pre-COVID. We didn't know what was going to hit us two weeks after that. And ultimately, this bill didn't become law until the end of September or early October. And at the time, we were envisioning this process and this work starting probably three months prior to the time that it actually did. So the COVID pandemic has even, whilst it's created a lot of challenges for us, it's even more compressed the work that's got to be done here, which is one of the reasons, I think, that these additional resources are necessary to get this work done on time. So I agree with you, Representative Sibilia. I appreciate the administration coming forward with this. We set out an aggressive timeline to begin with, which has become more aggressive because of the pandemic. And I believe this money is essential to get this work done on time. Are there any other comments or thoughts from folks in the committee? Go ahead, Mike. Yeah, I generally tend to agree with that. I would definitely support it. And I think it's a good move. Laura? Mr. Chair, I'm mobile, so I'm not quite seeing the dynamics of the committee. But if there are no further questions, if you're looking for a motion on this, I would move that our committee recommend funding this request to the Appropriations Committee. Great. So we have a motion to make a recommendation to the Appropriations Committee. Is there a second? We'll split them. OK, thanks, Mike. Auburn, did you want to chime in more? That was your second. That was your digital second? Yes. OK. We don't I don't think we need to take, well, I know. We don't need to take a formal vote in terms of a recorded vote. But just for the purpose, what I'm going to do is, and this is what the Chair of the Appropriations Committee had asked for, we don't need to do a formal letter. And you'll find that when we get into February and the formal budget process, the Appropriations Committee will come to our committee with a handful, maybe even more, things in their budget that they're looking for our input on. Typically, our feedback will be to send a formal letter with each item in the budget that is in our purview and give feedback on that and a recommendation to support it or not. This is going to be a little less formal. I'm going to send an email. I'm going to copy Representative Pat and Representative Feltas on it. But I'm going to send an email to the Chair of the Appropriations Committee, just mentioning that we discussed this and what our recommendation is, just so everybody knows how this process will work. So Sally, I see your hand up. Go ahead. Well, maybe I interrupted you. So you're saying there's not going to be a vote? Well, we're about to do a vote right now. I'm going to ask for people an expression of support or not. And so the idea is that we can tell the Appropriations Committee that whatever, six of our committee members supported this, three did not. And by that ratio, we are offering our support or not for this. That's what the communication will be. Typically with a formal bill, we will take a recorded vote where it's clear for the record which members of the committee supported and did not support a bill. This doesn't fall into that category of formality. This is, again, it's just going to be a recommendation. But I think it's important to let the Appropriations Committee know whether it was unanimous or not. And we'll provide that level of feedback. OK. Except I think we should note since everything is being recorded, it essentially. Well, I'm going to ask people to answer that. It's on YouTube, so it will be out there to voted, but. Well, and I think it's a really good point. I mean, typically how we will do this when we're in our committee room is I will literally ask for people to raise their hand. And folks who support it, raise your hand, folks you don't. And then we'll record the vote that way. I'm going to do the same thing right now. Ask for people to literally raise their hand. Which, how about if we just show our hands on screen as opposed to our digital hand raise if that works for people? I don't know if Laura can do that. Oh, that's right. Can you do that, Laura? Yes. OK, OK. Well, like other members, you could certify who you are and provide. Right, exactly. All right, so I'm going to ask for a show of hands to support the recommendation of this budget adjustment request from the administration. So if I can have a show of hands for support of this. And OK, so I see your hand, Laura. And those you can put your hands down. And if you do not support this recommendation. OK, great. So so what I will express to to the chair of the Appropriations Committee is that by an eight to one vote, the committee recommends supporting this request from the administration. He's not here. Oh, I beg your pardon. Thank you. 711. Thank you. 711. Beg your pardon. Got it. OK, so folks, that is our morning business. We are going to reconvene this afternoon at 1 30 with with the with the energy team from the Department of Public Service. And so we'll adjourn our committee hearing.