I see that the lecture was very good one and that's also my opinion about that lecture because discussion is very hot. So that means that at least it touches in some way your brains. I hope you will keep concentrating until the end of my talk because I can imagine that you are at least a little bit tired because listening is also an effort, not only speaking but also listening is. Well, the title is commissioning of treatment planning systems. That's really important part of our work. Why? Because we treat our patients using the data we get from treatment planning systems. And that even can be very dangerous. Why? Because many young people treat a treatment planning system like as another game, computer game. And it is a game, but it's very serious game because you can really kill a patient if you don't use properly your treatment planning system. And we have such examples of killing patients by using wrongly a treatment planning system. And the accident, Panama accident, that's exactly the case showing us that system can be used in the wrong way by very ingenious physicists. So commissioning is a very important task and unluckily it's never ending story. Because every year you have to come back to commissioning of your treatment planning system. I will touch that problem later on because it's very serious problem. But again, before you start, it was very nice introduction to my talk. First of all is to understand the system you use. Understand means what you may and may not expect from the system. Professor Hartman told you that for example well two different algorithms. The first one in Pennsylvania and second one is collapse convolution algorithm. What is the main difference between these two algorithms? Where you can see the differences between these algorithms? Well considering this scattering is an issue but what in practice you will see the differences in lung. Exactly in lung. Where the transport of electrons is important. In pencil beam algorithm the transport of electrons is not treated properly. Of course it's treated much better than before. So as again remember that never our life is perfect. We go step by step I hope we go to the better solution. So collapse cone is better than pencil beam but might be the new algorithm which is implemented by variant into eclipse is better than collapse cone. Convolution method. But anyway you should understand what you may and you may not expect from your system. That's the first problem. The second one is problem of interpolation and extrapolation which is very often missed by people. You enter some set of data. Let's say you enter the depth doses for a range of beam between three and forty square fields. Three centimeter, forty centimeter square fields. And if you want to use your system for radio surgery where you very often use the beams of the size of two centimeters. You should ask yourself how the system will cope with that problem. Oh thank you very much for that comment. It's exactly the same for IMRT. If you use very small segments for IMRT. You should ask yourself how the system treats this data. Because extrapolation can be fully wrong. Well, you know that. If the person's dose is like this and you make the extrapolation. You know that there is a mistake. Let's say here is output factor. And this is size of the beam. We know that it's go like this. So that value differs very much from the real value. So well whenever you use the treatment planning system and you try to or start to use it out of the data you enter to the system. Be very careful. Bore's problem. You have air gaps. Somebody asked me about how to treat the problem. Because always we know that from our practice that we have some gap between Bore's and the patient. And that's real problem. Of course Bore's is just to create electrons. So if the gap is not very big one, doesn't matter. But anyway you should check that. Or you should realize that that's the problem. Okay. Do not expect good results without precisely measure input data. And that's dosimetry. If you well enter the wrong data you will get the wrong calculations. And well from my experience it's clear that people very often don't look carefully at the measure data. You should do that. Analyze your calculated data which is done in my department very carefully. Before the data are transferred from the dosimetry group to the planning group. Because my well center my radiotherapy is really very big one. We treat every year about 7000 new patients with 8 accelerators. So well the group of physicists also big one. So there is a dosimetry group. There is a planning group so we transfer the data. But we talk about the data. We analyze that. So for example of course the most important is how to how output factors were measured. Because that's the most important data for the treatment planning system. The second one is depth doses. Okay for example well don't forget that effective point of measurement for cylindrical chambers plates. A different point as the point of measurement for output factor. Sometimes people forget that. Because according to new protocol it has been changed. In the previous protocol 277 which is much better protocol in my opinion for physicists. That was exactly the same point. So you always have to move your chamber after setting the chamber at the place. Profiles. You should consider the finance size of the chamber. Because if you use let's say cylindrical chamber, farmer chamber for measurements of profiles. The penumbra is much wider than it really is. And of course your data cannot describe the reality that it should describe. So all these problems should be considered before you start to commission your treatment planning system. For example coming back to the output factors. When you prepare the table of output factors. You should graphically present the data to look whether there are smooth data. Along y-axis and x-axis. I strongly recommend you to make it. Immediately you will see that you made at least small mistakes, small errors in measurements. Of course you can smooth the data but do it also very carefully. Electron density conversion function. Very important. Because if you commission your system you always compare almost always. You compare your data measured in water phantom. So in homogeneous absorbent. So you just rely on calculations performed in homogeneous data. But you cannot have the good results if you don't have the right conversion. Function from electron density from Hansfield units to electron density. I know that not everybody has the specialized phantom for that. But in my country also not everybody has it. But we just, you know, we take the phantom from another center, use it for one to day. We measure the electron density curve and we enter the data to the system. That's really important. Okay, now that was introduction to my talk. What accuracy is needed in contemporary radiotherapy? You have TCP and NTCP. And you may see there is really a strong dependence between the outcome and the dose. So what we expect from radiotherapy is let's say 3.5% uncertainty of those delivery treated as one standard deviation. But I tell you that right now in a very good center we are at the level of 5 to 6%. So we still are far away from that. That's not because of the treatment planning system. Only partly due to the treatment planning system uncertainty of calculations. Mostly because of all these issues related to movement of the patient, setup of the patient, changing of the body of the patient and so on. But anyway, treatment planning system partly take parts in that uncertainty process. Here is definition of normalized dose gradient dimension to you so you may easier understand what it is. I don't want to focus on that. Well, commissioning of a TPS. Several reports were published concerning commissioning of TPS. APM, Dutch, Astro, IAEA. We have also published such recommendation. I don't want to criticize all these recommendations. But they are very complicated, very long, and it's really impossible to make all these tests they propose in these protocols. So in my talk I tell you what is the most important commissioning of the treatment planning system. Of course that is my personal view, but that's my experience I think can be also well accepted. Examples of these, they are accessible via internet so there is no problem to launch them and to read them. Just to be informed how the people propose to check the treatment planning system. Okay, sorry for leaving that slide. That also is important before you start commissioning of the treatment planning system, but not only for treatment planning system but also for any other activities. If you think about setup correction, you also before you start you should say what you accept and what you don't accept. There was a question during a break. What happened if two days I have two millimeter, three millimeter and the third day I have eight millimeter? What to do then? To calculate the mean value after three fractions or no. In our course we have the action levels. If it's larger than action level we have the special procedure for that. Before you start with treatment planning system you should also define what you accept and what you don't accept. And you should define what you do if you don't accept such a data. Okay, so there is range of acceptability and not acceptability maybe you may define three different ranges. But that depends on you how to deal with this. What we should remember, what you should remember that you always rely on comparison of measurements and calculations. But whenever you measure, you measure the actual, let's say output factors, PDD output factors. Let's focus at output factors, okay? But when you measure output factors you measure the actual output factors. Which not need to be exactly the same as the output factors you measured before when you measure the data to enter into treatment planning system. So you should correct your data for actual value of your output factors of your accelerator. And here is how to make it, it's very simple. It's just to multiply your result by the ratio of, by the ratio of output factor. You enter into treatment planning system and actual value, okay? Because, well, radical is saying that if your output factor should be one centigrade per one monitor unit. And today you have two centigrade per one monitor unit, of course you have big difference. But it's not because there is a difference between treatment planning system and, and your measurements. But because the accelerator doesn't work properly, okay? So you should correct it. Tolerances can be expressed in terms of dose, but that should be applied in the low gradient region. When you compare doses and in terms of distances in high gradient regions, sometimes the concept of gamma is used. Well, gamma concept is a little bit complicated and I think it's better for commissioning to use these two definitions. In low gradient dose and high gradient distances between point in which the dose is exactly the same. So that's the proposal of IAEA, how to treat it. So in inner space you use dose comparison. At penumbra you use the distance comparison and outside of penumbra you use again the dose comparison is used, okay? So, but you have to decide before you start where and which data used to compare the data of measurements and data of calculations. Here are the more detailed description of that. It's difficult to read it, but it doesn't matter. You can look into the document which is accessible in the Internet so you can read it carefully. That's the really difficult question, complex question, overall accessibility of the treatment planning system. I just read, a useful way to compare calculation and measurement is to analyze the deviation statistically. So not if you get one wrong result, you just not try to remove your system from your department. Also a given tolerance may be assigned to individual point value comparisons. The decision of overall acceptability is not based on strict adherence to the tolerance at each point. Rather decision are based on confidence limit or other similar criteria. For example, a few points may fail to meet the tolerance of 2%, but this may be acceptable if 95% of points fall within 2%. Okay, my comment to that is as follows. You cannot change your treatment planning system. If you buy Eclipse, you have to use Eclipse. If you buy Monaco, you have to use Monaco. If you buy XIO or some of the both XIO for you, you have to use XIO, okay? Your aim is to check where and why you can expect this on that results. And you will understand that in that situation, you cannot expect better result, that result you got. And for example, you should say to your doctors, I don't want to use that system for that particular situation because I don't believe we got the right result. For example, somebody plays the ball and say, well, but I want to have that ball 4 cm away from the skin surface. You say, well, but please consider that it's very likely that my treatment planning system doesn't calculate the dose distribution for that situation properly. Oh, if somebody wants to use your treatment planning system for radio surgery with beam of 1 cm, you say no. I don't agree with that because you know I cannot rely on my treatment planning system. If somebody proposed you to calculate the dose distribution for total body radiation and you haven't checked whether your treatment planning system is calculating the dose distribution for 2 or 3 m distance properly, don't use your treatment planning system. Before you do that, check your treatment planning system. That's your responsibility, okay? Please remember about that. Well, for more detailed discussion of tolerance, please refer to IAA document or directly to very good Venselhar work, which is also how possible to get from the internet, however, it might be green journal is not fully open journal. Now it's again a very important question concerning the treatment planning system and that's why I told you that that's never ending story. Because the question is when to make and which test should be made for your treatment planning system. Certainly when you enter the new data to your treatment planning system, you have to check everything. For example, in my department right now, we decided to measure again the full set of data for one of the machines. Why for one of the machines? Because we have several, let's say, identical machines. We try to keep five of our CD to 2,300 CD accelerators exactly with the same data, the same output factors, depth doses, profiles. The differences we accept are less than, in terms of PDB, less than 0.5% in terms of profile, less than 2%. And output factor has been due at, let's say, a very tiny difference, okay? So we decided to measure again because we know that right now we have better detectors and we can measure more precisely our data. But before we use clinically this data, we enter the data and we fully commission the system, which is very time-consuming procedure. There is one medical physicist who is well obliged right now to make this commissioning of our treatment planning system. So whenever you have the new data, you have to perform, let's say, almost all tests. If it's new system, all tests has to be performed. But the problem is that if you get, for example, new software version of your treatment planning system, what to do then? That's really a very tough question. You cannot rely on your treatment planning system. What to do? First of all, please don't accept the new version of software very often. Accept the new software if there is really big change in the software, which makes your system much better. If it doesn't make your system much better, there's no reason to. For example, the colors are nicer. Okay, that's the case. Treatment planning system is not lady. It shouldn't be very nice. It should be very good. So please be careful with that. But anyway, if you have changed the software, you should analyze which part of the software has been changed and how it can influence on your calculations. And what is very important, never leave any, let's say, information which tells you that it's something wrong in the system. Because we have such attitude to our life that if we think that something goes wrong, we think now it's just by chance. Next time will be better. That's our philosophy. In that case, you should treat seriously all signs that something is wrong. New accelerator, that's another case. If you really set that new accelerator exactly as accelerator you had before, which I strongly recommend, it's much better to buy exactly the same accelerator, however it's not always possible. For example, Siemens disappeared from the market, so if somebody has Siemens accelerators, he will have to buy another accelerator, another type of accelerator. So then, well, try to keep the data exactly the same. And then you have to make but only part of tests. You should look at the data you enter and compare the enter data with the data you measured, but that's, I think, enough to check the treatment planning system. Well, what to start with, I have already told you about that, but again, the most important is to be sure that there is no errors in input data. So you enter the data into the treatment planning system, you calculate the dose distribution in the water phantom, and you have to compare measurement with calculations. And that is a must. That is a must. So if you enter, let's say, 10 depth doses, you should calculate 10 depth doses, and you should compare them. And the first step is to compare them just visually, by eye. Okay, I don't know how to say. Visualized inspection. Thank you very much. Well, because that's a very useful tool, just to look and to see whether there are big differences between what you calculated and what you measured. Next, you come to the numerical comparison of the data. And sometimes if something went to the system, it's very good just again to compare visually, compare the calculated and measured data. In most systems, we enter output factors, depth doses, and profiles. Sometimes you also enter the attenuation factor for your trace, if you use individual blocks. And that's also important to check that carefully. As I mentioned, visual verification of the data is obligatory. This is flattened filter fleet. Profiles, which makes us really a problem when we compare it, because you have to compare carefully this not very flat curve. So it's difficult to say where is low gradient and high gradient after beam. So that makes the problem. Okay, depth doses versus field sizes you should also compare. And as I mentioned, output factors. And that's the most important part of your work. After third part, you can go to another one. Just to make some tests to calculate spatial situations and compare results of your calculations with your measurements. So the first step is always to input the water fountain. If you measure some data in the plastic water fountain, you should scan your plastic water fountain. Never use the fountain which was entered manually. Just scan it via CT, enter into the system, and then calculate those distributions in that fountain if you want to compare such a data. Okay, and also very important as functional tests. These are qualitative tests that ensure that the right interpretation of the treatment plan parameters are get. For example, it's really crucial point convention of angles. So if you rotate right, that your angles increase. If you rotate left, your angles decreased and so on. Okay, and I've seen such situations that people made a mistake. Luckily, they check it before they use it clinically, but that's really very dangerous because you wanted to irradiate your patient on your left side, but the system shows you that you should irradiate that patient on the right side. But we have very serious problems related to the positioning of the patient on the CT because it can be head first, feet first, first left, right and so on. That should be checked very carefully from the very beginning to the end. So build a very simple fountain with the one, let's say, left side marked and head marked. Place your fountain on the CT, scan the fountain, rotate the fountain, scan the fountain, rotate the fountain, scan the fountain, send the data to the treatment planning system and compare whether interpretation of the data are correct. And that's really important. That might be one of the most important points. Many mistakes are made if we rotate the table, the couch. That also should be checked. Well, checking the treatment planning system is not only the checking of the treatment planning system, but the connection between your treatment planning system and your verify system because you send the data to a verification system and you should be sure that everything is right. So, well, it might be a very general message to you. As a physicist, you don't work only at the computer in the treatment planning group. You should have very strong contact with patients and with exerators. That's your responsibility to go there and check whether everything is right. Naming of collimator jobs, naming of orientation of wedges, for example, variant machine has eight different wedges. It's really very easy to make a mistake and to get lost using these wedges. So before you start to use, just prepare the plans of your treatment planning system, send to the record and verify system, go to the accelerator, check whether everything is right. That's clear. Oh, check of input and output image data, input CT and digitally reconstructed radiographs. I cannot tell you how to make it, especially concerning digitally reconstructed radiographs. But in my career, we found the error on Centra Master Plan system where there was error related to reconstruction of DRR and thanks to very, very strict work of my colleagues from my department, they noticed that there is something is wrong. They just made portal control and they noticed that there is a difference of, let's say, seven, eight millimeters. And according to our protocols, we tried to explain what went wrong. So we took that patient to the simulator, we repeat the procedure and we noticed that everything is right. So we thought, okay, it was just by chance. So patient again went to the accelerator, we got next portal control and again we had about seven to eight millimeter difference. Then we again went to simulator and again everything was right and then it came to us that something is wrong. And we start looking for a mistake and when we start to analyze the images reconstructed by the system, we took the phantom, anthropomorphic phantom, we prepared the plan, we make pictures, we were sure that everything is right because with rigid phantom it's quite easy to prepare the right geometry and then we understood that something is wrong. And we found that DRRs depends on the CT information. If CT information, well, the step between cross sections was, I don't remember, it was one millimeter, two millimeter, everything was right, but it was five millimeter. The system made a mistake and that mistake was corrected in the system. But that, well, please, the major message to you is, treat seriously the mistakes or the uncertainties you observe and try to explain them, not that everything is right, but try to find that not everything is right. When you then not find any reason to say that everything is right, then it's not right, then you are happy, okay, but that's anyway, that's really a problem. Qualitative test, check of input and output image data, okay, comparison of calculated measured dose. Some of these tests have already been performed and non-standard conditions. So you can measure in different situation, different geometrical situation and having the analyzer, so I mean the water phantom with automatic movement of the chamber, you can measure different, you can see more like different situation and you can measure dose distribution and in a moment I will show to you a proposal of some of such tests. For example, block geometry, you may measure the field size with block, in the beam and you measure the doses at certain points. Again, please remember that your measurements should be absolute one, not relative one because, well, you can imagine that for example, if you measure your profile, how much time I have? Sorry, I have no time, yes? Sorry, okay, let's imagine that if you have measured profile and profile is not absolute, usually it's not absolute value, okay, because you may measure also for accelerator in absolute values, then you may like this, calculate it, okay, it should be like this, but if you normalize it, you see there is no difference, but in fact there is. So always it should be the link between normalization and what you use for your comparison. Another proposal to make that test, just you can measure it with your phantom. Another one, okay, and we just performed this test where we put into operation our treatment and exist. Wedge beams also please take very carefully, inhomogeneities, that's the big problem. The first one is analysis of the algorithm, what is possible, what is not possible, and you may measure in the anthropomorphic phantom or in the slab phantom, you can simulate some situations, okay, but you never can simulate all situations you have in your real work. So you may also compare your calculations with the result published in well, recommendations and papers, but then use the data. If the quality index of your accelerator is not very different from the quality index, it's mentioned that for that accelerator the data were measured, okay. If the quality index is very similar one, you should expect very similar results for your accelerator, for your comparison. And stability of the TPS, I recommend to repeat the same procedure for the same anthropomorphic phantoms regularly. Let's say once a year, we repeat that procedure once a year. We have one plan. Once a year we calculate it again. We scan the phantom, send the data. We calculate dose distribution and we compare that dose distribution with the dose distribution and we calculate it once a year before, okay, to be sure that nothing happened to the system. It usually nothing happened, but it's, well, you know, it might happen. So please be careful with this. And very useful is so-called end-to-end tests. So you get the phantom, you examine the phantom on the CT, you counter the phantom, you prepare the plan, you calculate the dose distribution and then you irradiate the phantom with, I don't know, with films, with TLBs, with chamber placed somewhere if you can place the chamber and compare measurements with calculations. Of course, it's very time-consuming and, well, hard work to do, but it's better to have something to do that, do nothing. My guess, from time to time, it's nice to have nothing to do that. Anyway, okay? Okay, that's exactly the same idea I mentioned before. And, well, you may ask what to do in case of non-conventional machines. I cannot give you good advice. You just should follow the recommendation I gave to just normal machine, common machine, and you should yourself, well, prepare your test of your machines. And you should follow the proposal given by manufacturer in case of these machines. It's very complicated. To be honest, I don't have cyber knife in my department. I don't have tomo therapy, so for me it's difficult to talk about that. And summary of my talk, commissioning of TPs is a must, is a very labor-extensive and boring procedure. However, there are people that are very, you know, interesting in checking everything. Robustness depends not only on the system but also on the user, so the limitation of the system should be known. And, again, it's not recommended to change the version of the software because we are insisting to change the software because you pay some money for that. But it's not a good idea to do it because, you know, if system works, it works. So it's like with a good car you can rely on. If it goes, then don't change the car. Yeah? And please be especially careful when you start with using a new system because, well, especially if before you used another system because your experience is based on the previous system and you think and you expect that in that system everything will be the same. But it's never the same. Never the same. Very useful is to give students to use the system. Usually they find mistakes in the system because they are doing very strange things using the system and then everything crashes. Okay, thank you very much.


These people know more, 10 times more than I know and have been poured with so much knowledge more than what I have because I spend my time executing. You know, I don't spend a whole lot of time working on personal development. My personal development is, can I outdo what Ricky did yesterday? If you equate it down to the number of dollars you're going to make, you know, then sure there's some guys out there that are ahead of me, right? But at the end of the day, I even think some people that make way more money than me in the coaching, in the real estate coaching space, have a lot less love than I have in the real estate industry, right? I think if somebody did a poll, it would say, being, right? It would be very lopsided, let's just say, and I've already seen some polls that were kind of like that. And it's nothing to say, oh, I'm the greatest, I'm the best. I'm one of the most homeless guys you'll ever meet. Nobody even knew I was a number one remax agent in Alabama for like three or four years, because I was just a real estate agent, right? It wasn't until I started trying to coach, that's all the reason I ever said anything about it was because I was trying to give credibility to myself, to the industry, that I know what I'm talking about. Otherwise, nobody would even know I sold 100 properties a year or anything because I wouldn't be telling anybody because I don't care what other people think.  It's about how many people am I impacting, you know? How many people lives are really changing, you know? As far as being, giving everything away for free, it all just comes back to, okay, if I want to reduce the failure rate in the industry, okay, the whole industry, which is 25 million agents, let's say worldwide, okay, then, you know, if people walk into the door of Ricky and love what he does, love what they see from the front of the house, walk in and realize, wait, there's an admission charge to get in here. They're just going to turn around around. A lot of them are going to turn around and go to another house, right? Because that, let's face it, real estate agents are cheap, right? At the end of the day, I'm one of them, right? I mean, I didn't want to pay for coaching, okay? So I get it. You know, I don't want to, and plus, here's the thing, all the coaching out there is garbage. I'm sorry, not all the coaching is garbage.  So there's a lot of things that motivated me to go this route, but it all came from the way I built my real estate business in the first place, when I switched from deals to actually focusing on people and seeing what I could do to help people and offering free information. Like I would send a weekly email that I still send, I've sent every Wednesday since 2007, with all the closed sales on it. By the way, he was a huge influence on me for like starting, because I started following him when I started coaching, and then he kind of influenced me to like, well, I'm like, why don't I do all this for free? You know, and that's when things really blew up. But when you can build a brand and you actually have an audience behind you of people who love you, that you brought value to their life, you can build so many different businesses. You know, look at what Gary's doing. He's probably going to do 100 million off his NFT project he just did, where he's literally selling digital pieces of art for admissions into his conference and to come see him. I bought one. I bought one to do five minute face time with him once a year for three years. You know what I mean? Like I spent $11,000. So yeah, man, it's like free is the business model of the future. And I'll tell you a lot of things that I learned through that process and reading all those books and watching and thinking about how everything went down and trying to piece it all together. You know, outside of the things I did wrong, what I realized is that, you know, when you go through a moment like that, of course, I was in my mid-20s and there were guys that were 40 and 50 and even then they're 60s that went through the same exact thing. Here I was in my mid-20s going through what they were going through in their 40s, 50s and 60s. And I was like, wow, how fortunate am I? I wasn't worried about it. I was still in my 20s. Like I could still go out till seven in the morning, wake up at eight o'clock, go roof houses, feel fine.  So it wasn't a big deal to me. I didn't have a family. I didn't have any bills. I was in a very, I was very blessed to be on it. And I knew it at the time. I was like, you know, this is incredible for this to happen to me right now. Subconsciously, not on the front end. I wasn't thinking that. I wasn't telling everybody, like, thank God, you know, or anything. But that was definitely, but I definitely knew that on the inside. And a couple of things I realized, when you go through something like that, it makes you realize a lot of things about business. Okay.  I have DNA in me that will not stop.  You know, I hear them all day long. You know, everybody has excuses.  And, you know, like I said from the beginning, 90% of agents don't make it in this business, right? And if you're making any kind of excuse whatsoever, what side of that do you think you're part of the 10% or part of the 90%, you know what part of that statistic are you going to fall under at the end of the day? You know, you've got to be in the top 10% just to squeeze, just to barely make it, not to be like a millionaire, but just to barely be an average agent that barely squeezes by, you got to be in the top 10%.  So, you know, the power of words, right, is so powerful.  There's these habitual, you know, seminar goys and podcast listeners and stuff and they know every, they know more than I know. These people know more, 10 times more than I know and have been poured with so much knowledge more than what I have because I spend my time executing, you know, I don't spend a whole lot of time working on personal development. My personal development is, can I outdo what Ricky did yesterday, you know, and can outdo tomorrow what I'm doing today? That's my personal growth, but a lot of people, they go to seminars, they go to, they listen to these podcasts and they never do anything, you know, and so there's a line you have to draw.  If you've got some kind of weird thing going on, they can hear that and sense that and it throws red flags. And so it's trial and error, man, like I went through, you know, a decade and a half of making calls, you know, and trial and error and trying to figure out, okay, now, what is the script that I can utilize?  Do you want to buy or sell? Do you know anybody that wants to buy or sell? What if I could do this, would you then sell? Right?  And if not, give me all your friends and families information. Maybe they can sell their house so I can make some money. It's all about the agent making money, right? And it's driving agent's business in the ground. So what I'm trying to do is 180 that situation. And instead of trying, instead of the agent trying to figure out what the client can do for the agent, you know, I want to make it, I want to create this scenario where we're trying to figure out what the agent can do for the client. And we're trying to communicate that to our clients. So this is much deeper than just a script. This is an entire philosophy, right? Stacked on top of two decades of trial and error trying to figure out how to help the industry, you know, like when I say I want to reduce the failure rate, this is real. I'm literally trying to figure out how to help agents communicate, try to get to them before the mainstream coaches get to them, you know, to teach them that that's garbage, all right? And this is how you do it. You call people and see what you can do to help them. Not see if they want to buy or sell a house, but to let them know who you are, what you do, and you're here to help. You know, 10 years, that's a long way out. That's like, who knows? But, you know, maybe on Mars or something, I'll be doing conferences on Mars, like Elon will be there.  But I, let's just talk about like, I don't know, five years out, okay? Five years out, you know, money is just not even a, like a worry at that point. And literally, the way I feel is, I feel like, like when I, like my retirement year, year's type deal is gonna be me traveling, kite surfing the world, that's my thing. Kite surfing the snowboarding is my thing. And, you know, watching my daughter grow up, helping her learn how to kite surf and snowboarding stuff, of course. But as far as business goes, you know, spend a lot of time with the family and stuff at that point.  Like, I mean, I'm gonna have, like I'm gonna be in the best years of her life, of her young life, really, with no responsibilities on the work end, being able to so much flexibility. It's just, I can't even, like, it's like a, I'm still trying to digest how incredible that's gonna be.  And I'm also planning on doing South Africa because I have a team there next fall. And, you know, I wanna do a West Coast tour, like I wanna do all this stuff. But at the end of the day, like once this brand even goes to these higher levels and I, you know, get to this place that I wanna get to over the next five years, I could literally do one conference a year, you know, one zero to diamond conference a year in Vegas or something like that. I'm gonna let everybody come in, you know, and really just travel the world and continue to push out content. There's people that are being born right now, okay? That are gonna become real estate agents in 20 years. All right, and my content's still gonna be there, right? And I'm still gonna be pushing out content.  So for me, it's all about impact at that point, you know what I mean? And, yeah, who knows? Who knows, man? I'm just, I'm gonna keep pushing till, and I'll know when it's right to make the right moves and do what I'm trying to do. But I'm just enjoying the ride right now because it's a lot of work. A lot of people say, well, it must be nice to be you.  Because I can handle all this stuff. But, you know, let's let anybody walk through this door and sit right here for an hour and see what actually has to go through this brain and to compute everything that's happening on a day to day to week to week to a minute to minute basis, right? And be able to juggle all this stuff and keep it all level headed, you know, and make everything seem so, you know, so easy. And that brings me back to the same point, man. Successful people, they make it seem easy because they've got simple process.


What is up Marvel Squad? And welcome back to our channel. If you guys are new, my name is Bill. And my name is Maya. We gotta hurry up with this intro because our friends are about to be here and we're about to pull an epic prank that you guys requested. And then I've seen on YouTube, we got this video idea from Jack and Gab, but we did get this from somebody that messaged us on Instagram to the PDA prank. I was like, oh my gosh, we have to do this. And then I looked on YouTube and we saw that they did it and I'm like, okay, then this is gonna be a cool idea to do. So our camera guy Danny and his girlfriend, Meg, they are coming over. We're doing the PDA prank on them. I think it's gonna be crazy and perfect timing because we've never really done any videos like this. Danny has never really been on camera. Yeah, we're gonna be a little extra in this video. She's gonna be loving up on me. I'm gonna be loving up on her. Right? We're just gonna see how they react. And I feel like they're gonna be cringed out. I was gonna say something. We tried pranking Danny once and we reacted like he smacked me and he just goes, okay, let's just go watch him with me. And we're like. So he is a hard person to prank. But I think we're gonna get him this time. We have to.  I also just wanna point out, I know you guys are asking where the merch is. It's coming. Literally, we went to Florida, everything. We hit 100K in Florida, so we really didn't get to finish it all. Don't worry, our 100K giveaway announcement. Everybody who's winning, we're gonna announce that soon as well. We might announce that actually before the merch. We're already picking people actually. Maybe the next couple videos. So stay tuned. We're gonna announce the 100K giveaway. People that want the giveaways. Stay tuned for that. That's coming up very soon. I hope you enjoyed this video. If you're not subscribed to us, what are you doing? Click that subscribe button. Turn on your post notifications so you get notified every single time we post. And don't forget to shout out, actually goes to Drew. Because he did give us this video idea. So thank you Drew for the video idea. And anyone else that wants to shout out, you already know what to do now. You gotta hurry up and set up this camera. Let's get it. He's about to be here. And it's weird because we're pranking together. This is weird that me and you're on camera right now. I don't know. I'm so used to being alone. This is Team Marble. Team Marble. So this prank is Team Marble. Team Marble. So I hope you enjoy. Let's get it. Danny's about to be here. We gotta go. Let's get it. See you soon. Hi, it's Danny.  I'll be right back. Yeah, no. Because the watermelon one, I don't want to do the same thing with pumpkin. Because that one did good now. So we'll be able to do that. We just have to find like a perfect size one. It'll be perfect.  What are you guys doing today? But work. How's work? Long and hard. That's what she said. Hey, I work today. You at school. You worked out. You didn't actually work today. You at school. But what I was saying is we'll do with the pumpkin now. I feel like the pumpkin will be easier. Definitely. I remember that. It's hollow. Yeah. I don't want to do... Can you put your legs down? A big one. But I feel like a big one's gonna be top because of the size. Oh, I don't want to do... We have to do the same like an oval one. You know what I mean? Something like that. Wait, what day are we going to the pumpkin patch? Next Saturday. Next Saturday? Yeah. You better be off. Okay. I love you. I love you too. What? Sorry. Sorry. Going back to the pumpkin patch. They're coming. They're coming. They're coming. They're coming. They're coming here. They're coming here.   That is sick. Now look the other way. Why did you do that right now? We're all hanging out. You guys want to watch a movie? Do you see that? Want to watch a movie? Watch something. What? You guys had enough time alone. We're here now. You tired? What tiktok are you guys doing? We're doing all summer nights. Mid July. When you win. We're spending around stuff. Spending around? What song? Young and Beautiful. I like the one that we used. Okay. Okay, I'm talking. I like it getting out. Did you see the trampoline tiktok over there? It was decent. Decent? It was funny. I didn't even think I thought the prank would have gone by, but it didn't actually flip in the one over. I thought that was so funny. I didn't know if I wanted to post it though, but I guess it did good. I'm glad that people like that video. When are you gonna do that? Stop touching me. I'm gonna ink. No, you guys can do that. I don't know what we're gonna do. Can you guys do this summer house? What? Sorry. We're not making out in front of you, are we? No. Why is it a big deal? Because it's disgusting. Who cares? We're all hanging out. We don't want to see that. You are. I hate listening to that sound. The enclosure is... This is my house. I can do what I want with it. Okay, well, we're here too.  Why is that so bad? We did the same thing if I was making out with Danny right now. But we aren't. Exactly. And whatever pranks you see... Oh my God. Again? You're extra. I like it though. I like it. I want extra. Ew, seriously? No, I can't. I'm cringing out right now that I'm sick. Why? Mom, is this ready? Okay. I'm comfortable when you guys are just making out. I'm trying to spend quality time with quality friends. You guys can spend quality time when I'm working. Or not here. Sorry. That's what I was saying. But nobody listens to me. Fine, listen to yourself. Come sit down.  I'm sorry. You're uncomfortable, really? You're that used to it? I guess. This is how we act all the time. You can do it probably. We have never acted like that. That's like too much. It's annoying. No, because they're going to get annoyed. We already are annoyed. So I'm too like that. See, we just pet kiss. Like this. You guys alike. I don't care. This is what we want to do. Deal with it. If he wants to rock our world, he can. But let's just take it upstairs or something. We're good? We're not going to... Sorry. Just forget about it, move off the night. It's fine. Sorry. Do you want to watch vampire television? We want to film our tiktoks too. Let's just go upstairs. So sick of that. Wait, wait, wait, guys. Guys, wait, wait, wait. Where are you going? Actually, where are you going? Are you guys going to that man? Wait, wait, wait, wait.  I'm flying. Okay, what? We've been pranking you the whole time.  Where's the camera? You don't believe me?  Really? Yes. Danny Smith and Meg. So the video is... I don't know if you can tell. PDA, like an extreme PDA prank. And how do we do? Don't leave. Don't know. Danny, actually come back. Danny, come back. Danny, it's just a prank. It's just a prank, bro. I did not think we were going to get Danny in this video. No, I didn't think we did. Danny, did we actually get you? I think he doesn't want to admit that we pranked him. Danny, come down here so we can finish this video. Thank you. Everyone come in here. We literally saw this prank and we're like, oh my gosh, we have to do this to Danny. Now it's our turn. We want to see that. You guys are cringelers. Yeah, we usually do that in front of our friends. We don't even really care. We might attack or something, but I don't grab or jump on. That was just overboard. That was just crazy. Hashtag Team Marble in the comments because like, you know, Ryan, Bill, we're pranking them. We barely do pranks together and that's what the cool thing about this video is. What are you doing? Oh, yeah. Hey, actually, Danny's our videographer. Everybody go follow itchaboydsmith. Yes. Go follow itchaboydsmith on Instagram. The floor is wet. Why did you spit on my floor? I was literally about to end the video there. I was literally about to go like, bro, are you effing serious? Like, you know how nasty I am? Sick. That's gross.  Comment down below some of your video ideas. Make sure to give this video a big thumbs up. Make sure to subscribe so you always get notified of every single kind of posts. We're posting three times a week now.  Yes, which sucked. Yeah, too much, right? We're gonna give our end of the video post notifications shout out and this shout out goes to Andy Serna. So shout out to you. We love you so much. Shout out to you. Thank you for being a part of our channel. We love you because you love us. And we will see you guys in the next video. Until then, if you like videos like this, comment down below and we'll do more. Yes. Yes. Peace.


Some poor people believe that taking money from the rich and giving to the poor will bridge the gap between the poor and the wealthy. Let's say that happens. What's next? Some people will take their money, keep it safe in the banks for a while, collect it and waste it on wants and go broke again while some others will take the money from the bank and create streams of income for themselves. So, do you still think that sharing the wealth of the rich amongst the poor will suffice for wealth inequality? In this video, I will show you a better way to amass wealth by sharing with you 7 things that only poor people spend their money on. 1. Fancy toys for kids Who would not want to buy a fancy new toy for their kid when the kid is begging and looking at them with pleading eyes? Well, wealthy individuals are the cruel-hearted people who would not. They have the finest to build a toy house for their kids, but they don't. Successful people assume that too many toys can harm kids and cause them to be less creative. This conclusion was backed with a study. In the survey, 36 children were offered the chance to play for half an hour with 4 or 16 toys. It was found that the kids from the group, the ones who had 4 toys, showed more creativity and came up with more exciting ideas using fuel objects. Hence, many successful parents try as much as they can to avoid over-pampering their kids and to them, buying expensive toys for them is one way through which kids get spoiled. Instead, a typical wealthy parent will buy educative CDs and gadgets, storybooks and even if they buy toys, they will art for simple and long-lasting ones. 2. Give money to scammers These poor people do not give out the money with the mind of throwing it away. They fall into the trap of tricksters because of their desire to get quick wealth. Because of their unwillingness to learn, poor people often confuse Ponzi schemes for investment. Poor people are so in a haste to get wealth that they become prey to scammers who pose as money doublers. They are afraid to make long-term profit investments but are fast to jump into get-rich-quick Ponzi schemes. And this mindset of overnight financial freedom is the exact reason why they remain poor. Wealthy people on the other hand are very calculative. They take risks but sensible ones. They are not swayed by the sham of Ponzi schemes and do not make haste decisions when it comes to their money. In the words of Dr. Steve Mariboli, Get-rich-quick schemes are for the lazy and unambitious. Respect your dreams enough to pay the full price for them. 3. Numerous Credit Cards According to Tom Corley, the author of the bestseller, Rich Habits, the daily habits of successful people, only 8% of wealthy people have more than one bank card. At the same time, 77% of low-income earners carry numerous credit cards in their wallets. While your credit card can be a lifesaver, it can also be a money sucker. The bitter truth that poor people fail to accept is that the more credit cards you have, the more fees you pay. And the more it is difficult for you to track your spending, because with credit cards comes impulse spending. 4. Buy Cheap Things While it may look wise to buy the inexpensive stuff and save the remainder, low-priced things are most times inferior and do not last for long. People assume that rich people buy new stuff every day. No doubt, they have the money to replace things that get broken or worn out. However, millionaires would rather spend their money on investments than waste it on replacing broken stuff regularly. They understand that the cheapest item is not always the most profitable, hence they place durability over the price of commodities. Poor people, on the other hand, do not take time out to think through and compare the price tag of an item with the value of the piece over time. Thus they fall into the temptation of buying the cheap ones with the intention of saving the money or spending it on something else. But in reality, they waste their money, because sooner than they expect, they will have to purchase that item again. 5. Doing Nothing It is only the poor that do nothing with their money. The rich people save but do not allow the money laying their accounts. Instead, they make it work for them to yield more money. However, the poor always want to stay safe, so they will instead do nothing with the money, just saving without any plans. The irony of this action is that the money they keep in the bank is used to enrich someone else who is bold enough to do something with his money. The primary reason why the poor do nothing with their money is that they lack financial literacy. They work hard to earn and save money without mapping out what they are saving for. They hold on to the funds so tightly and keep it in the safest place they can think about, the bank. But little do they know that these same banks lend the money to their employers who are ready to take risks. These risk-taking employers use the money to expand their wealth and even to pay employees their salaries. 6. Fast Fashion The latest trends in fashion are information never lacking in the mouth of the poor. They will even beg or borrow money to meet up with the newest brands. Yes, the rich and powerful can afford clothes created by any fashion designer, but do they buy up all the latest collections? No, they don't. No doubt there are social events and conferences where they need to dress well for networking. However, on regular days, wealthy people wear simple and casual clothing. Research has it that Microsoft's chairman Bill Gates used to wear a $10 cashier watch until he upgraded it to a $42 Casino Quartz Diver 200m MDV106-1A which he wore all through 2019. Also, Ingvar Kamprad, the founder of IKEA,


Come to Think Tech Hawaii. This show is the state of the state of Hawaii, and I'm your host, Stephanie Stoll Dalton. This show offers viewers news of state events and critical issues in top with expert and informed guests who share their expertise and critical viewpoints on state topics of business, government, economics, law, public health, policy, safety, transportation, education, and much more that we have to do. Today's show focuses on public health and safety, specifically Hawaii's effort to vaccinate all citizens against COVID-19 and hopefully its variants, to some degree, and officially report and record the state's activities. And that will be a report to the United States of America's activity on this and we'll get data for further use to make things even better going forward. Our local guest today is from the Department of Health. It's a Brooks Bear. He will share information on the state progress managing this enormous responsibility to vaccinate all against COVID, and he serves as a Department of Health spokesperson on issues of COVID-19 and Hawaii's pandemic response. You may know him from newspaper articles quoting him and his appearance on local newscasts. So we're really pleased to have him on the show and to bring up for this information through this medium. Welcome, Brooks, and thanks so much for coming back. I believe that it's really wonderful to have you put this time in and give us the information that we all really need to take so seriously and be assured that we're protected as the state of Hawaii intends to. I believe we can and regarding that, I believe we can say we are more safe this time this year, unlike a year ago when Hawaii had no test kits and no diagnoses and nobody knew what was up or down or coming in or going out. So since then vaccinations are available for selected groups and we had a stark reminder recently of our isolation and its risk for us in the archipelago that is the most remote in the whole world. That was of course the delay of the vaccination serum from the mainland due to the severe weather. Now distribution is back on schedule and the few people I talked to about it say it worked out fine, but at numerous sites and it gave everybody some confidence to feel more protected for themselves and others. So given that, is your in your view, is the program, the schedule, the distribution progressing well in light of what is known now? Yes. First of all, again, thanks for being able to come on and have an opportunity to share information with people because the more information we get out there, the better. So thank you for the forum. Yes, we think that the vaccination program is going as well as it can right now. There's always some bumps along the road, but given the issues we've really had with supply and demand and that being that demand has far outpaced supply, we're doing well. We would love to have more vaccine and as each week goes by, we are getting a little bit more incrementally more and more and that only helps the situation. So we continue to roll it out. We think in a safe and orderly manner, you don't see any long lines, everyone has an appointment when they come in and once you go to get your vaccine, you are in and out of that facility rather quickly and protected when you walk out much more than you were when you came in against COVID-19. Who decides how much Hawaii receives in vaccine? Where is that decision made? How does that happen? That decision comes from the federal government. Every state's allotment is based on state population. So we like to say that our vaccines are for Hawaii residents because what we get is based on our population here. The federal government looks at it and they look at our population and they give us a percentage of the federal allotment. I tell you what, I can show you some information that will illustrate or a graphic that will illustrate for you and how we've been incrementally moving along and let's go if we can to slide number six. We have a PowerPoint for you and I believe slide number six will help us illustrate kind of where we've been and hopefully where we are going. This shows the weekly allotments and I can tell you that I did just find out that this week we are going to be getting in the state of Hawaii 67,280 doses of Moderna, Pfizer and the brand new Johnson & Johnson vaccine and I don't know if we have slide six or not, but slide six would show us historically kind of where we've been. So things were really down the week of February 14th because that's the week that the mainland had those horrible ice storms. Well, we didn't get any Moderna that whole week and just some Pfizer came in, but the following week we caught up on all the Moderna, got us back up to speed, and we had more than 76,000 doses in the week of February 21st. That was really a double dose for us. Now this week we're getting 67,000 and that's a regular allotment. There's no catch up there. So there's this progression and now 67,000 because Johnson & Johnson was just added to the mix and we can talk about that vaccine if you'd like a little more. It has some real advantages over the other two. That's hot news. Yes, let's talk about that J&J if you've got some information. Yeah, that's the right out of the lab. We don't even have it yet, but it's coming. It is in the vaccine pipeline, so to speak. I don't know if we could be having an issue with my PowerPoint, but if it is working, we would maybe want to go to slide number seven and then slide number eight. So Johnson & Johnson, let me tell you a few things about the Johnson & Johnson vaccine. It is a one shot vaccine. The others, the Moderna and the Pfizer, they require two shots.  And the second one is the one that you might experience some more adverse effects from that second shot, maybe some muscle aches, some fatigue, that kind of thing, maybe a headache, but the Johnson & Johnson benefit is just one shot. So if you are someone you don't like needles or you've got a trip planned, then you can go ahead and take the Johnson & Johnson and get it one and done quicker. So that is one advantage that the Johnson & Johnson offers. Other advantages just to the Johnson & Johnson are that it doesn't require that ultra cold storage, the 70 below like the Pfizer or even being frozen like the Moderna, if you have a refrigerator with a good backup power source in case the power goes out, you can store your Johnson & Johnson in there. So it just takes a refrigerator that makes it a lot easier to store and transport. Right. So that's a great advantage. So you've got easier storage and handling. You've got just the one shot. And the thing that people really care about is how effective is the Johnson & Johnson? Well, Johnson & Johnson has proved to be highly effective, 85 percent or more effective against severe illness, hospitalization. Again, so super effective against severe illness or hospitalization. And in the trial of Johnson & Johnson, not one person passed away. So far, it has been completely effective in preventing death. So the Johnson & Johnson highly effective, just one shot, easy to get to rural communities and easier to administer, maybe two aid, maybe a transient community that you can give them one shot now, but you don't know where they're going to be in three or four weeks, they might be good candidates for Johnson & Johnson because you administer that one shot and they're done. They don't have to come back. So we're really excited about about J&J coming into the market. We ordered our first shipment of Johnson & Johnson yesterday, eleven thousand nine hundred doses. Those doses will be coming maybe tomorrow or the next day, but we're going to get a Tuesday or Wednesday, March 2nd or 3rd, and that's going to supplement the supply that we've already had coming in from Pfizer and Moderna and armed with these three vaccines, we can continue to accelerate the vaccination program. So Brooks, I'm interested to know now the big but slipping up to the big context. How is it that what is Hawaii's goal for getting everybody shot? OK, so I know there are issues along the way, but what is the state's goal or is this the Department of Health's goal, which would be, of course, the state's goal. But anyway, OK, so there's that question. I know you have a time and the quick that then followed up to is how many does that mean? I guess we can all do our own division here. But then how many does that mean we have to give out every day to get all of our folks here, all islands, everybody? Well, I'll tell you what, we're going to use whatever we're sent. We could we could without standing up any more pods, opening any more pods without bringing in any more nurses or doctors to administer vaccinations. We could easily administer upwards of 80,000 a day. And if we did 80,000 a day, we could be done with our vaccination program by the end of August. Now, having said that, it all depends on supply. So I tell you what I can do is if we can look at the very first slide, which is the vaccination timeline, and this is something I hope people have seen before by logging on to HawaiiCovid19.com. Again, if you go to HawaiiCovid19.com, that we believe is really your one stop shopping for all things vaccine related and it shows our timeline. Where we started was in phase one A and we all know we've been over this before health care workers and long term care facility residents and employees. Then we moved into phase one B. That's where we still are in phase one B. Those are those first responders, the front line, front line essential workers and Kupuna 75 and older. Now, within the next couple of weeks, for sure, we're going to be opening up the vaccination program to those 70 and older. So we're really not moving into phase one C yet. We're kind of flexing one B instead of 75 and older. We're going to extend it a little bit lower down the scale, the age scale, the 70 and above, because, you know, we've taken care of a majority of the 75 and above, so soon we feel we'll be able to get the 70 year old in line to be vaccinated too, because they're also at risk. And then we'll open up one C, which is 65 and above of people who are 16 and older, who have medical conditions that may put them at high risk. Essential workers who are not considered front line essential workers. But you see the last one up there, which is summer of twenty one. That is phase two. And by summer of twenty one, we believe that we will be able to offer a vaccine for everyone. OK, but here's my question. It has to do with the fact that there are those that are getting in much younger. So, in fact, the military did the distribution this past weekend, I mean, up to the tune of twelve thousand or something like that, eleven thousand employees and veterans. And they were able to get the vaccine from 60 years old on up. So many people scurry advantage of their military privilege to do that. But what that's an equity issue, isn't it? So did the health department approve that? Why did they get why would they allow to to prioritize people that can't get it here in the state? Right. So a couple of things are going on there. That is through the Department of Defense Department of Defense program. So when I tell you that this week we're being allowed at sixty seven thousand vaccines, that doesn't count what the Department of Defense is doing. They're doing their own thing. We're not exactly privy to all their numbers and all their information and how many doses they've administered. That's that's for, I believe, for national security reasons and have kept within the Department of Defense, but certainly the DOD has its own vaccination program or active duty military and other people who are in that federal community are vaccinated. So, for example, the VA had gone down into the phase one C category a few weeks ago. We're not there yet as a general population, but the VA had already taken care of with its federal allotment of vaccines, the people in the older categories. And then now they've worked their way down to one C. And apparently the DOD is able to do that, too. So but this is really good news for all of us because if you're this is because they're federal and the state doesn't right, so the federal comes her so with that in that regard, I wanted to ask about the reporting for the state of Hawaii because I also have been reading that the military will not share their numbers with Department of Health or with the state's reporting. So we're so we're not getting the benefit of that that achievement of getting those people taken care of, too. Although I did hear and they kind of throw in a number for the total number.  Well, it does it does create some confusion because we don't know exactly how many people who may have been vaccinated through the DOD program. And again, that's their prerogative for the federal government to share that with us or not for the Department of Defense to share it or not. And to this state, they have not. But here's so you said we don't get that benefit. We don't know the benefit of the numbers. But what we do get great benefit from is they're being vaccinated. And that's great because if my neighbor has been vaccinated through the DOD program, that benefits me because if I have contact with them, they've been protected, maybe, you know, so the guy you might run into in the grocery store, maybe he's been vaccinated, so it reduces the possibility of people getting sick and it's going to lower that transmission. And that benefits us all. So even if I haven't been vaccinated, if this guy next to me has been vaccinated, I'm better protected. So that really helps us all. So, you know, I imagine they're going to I would believe they vaccinated tens of thousands. But I think that's a very positive take on it and good. But I also know there's a lot of tension about when am I going to get my shot? I mean, that's one of the issues is who gets the shot first and why? And there's a lot of difficulty and even those eligible right now for the shot. They can't get an appointment. There's difficulty, even though they're within the range of here. So what this is just putting us in a situation that's making for some extra tension about the matter. Right, I can understand that if you're not able to get it, but your neighbor, who's got the same age and yeah, he's got it frantic or frantic. So, you know, they're and they can't understand why they can't. But anyway, so the Department of Health doesn't have any rules or isn't in control of all of this. That's whatever is federal is going to be a part of that. Well, I mean, I think and so isn't there any community between the Department of Health in Hawaii and the federal and the military? They just don't work together or they're really. Yeah, no, certainly there is communication between the two, but they have their own program and their own priorities. Just as we, the state, have the leeway to set our priorities for the people we think we should vaccinate first, that the federal government is doing that on the military basis and that their federal installations, they're prioritizing and taking care of the people they think they should take care of first. So certainly there's some communication, but we respect the Department of Defense's, you know, position in their mission and protecting their mission and really protecting us by performing their mission. And if they believe that, you know, withholding some of that information for a while is important, we respect that.   They took care of older populations. They took care of people who have very important jobs for national security. So I heard you say a little earlier, I wanted to be clear about this. You said that Hawaii's timeline for having all vaccinated is in, did you say August? I just wanted to get that clear. Is that the end of the timeline? Well, is that when they they're moving by August? That's the end of this. Yeah, well, believe it or not, and this is hard for me to believe, but summer ends on, I think, September 22nd. And certainly before September 22nd, we want to have offered vaccine to every person in the state of Hawaii, no matter what their age, no matter what their occupation, if they are 16 and above. We believe, certainly by the end of summer and hopefully sometime in August, everyone's going to have an opportunity to have been vaccinated. So that's kind of the timeline we've looked at. But look, it all depends on the vaccine we get. If we get more vaccine, we could accelerate the whole process. And the fact that JJ is coming now is only good news. And there are other bits of good news of the new federal administration has started something called of the federal retail pharmacy program, which is getting now tens of thousands of vaccines right to CVS longs. And now they are additional distribution points that are around the state. That would be just ideal. Well, what's happening then so far? Is it my question is, is the Department of Health or do you know, or if this is appropriate to ask me, the coordination of all of these distributions and of the vaccination has seemed to be kind of rocky. In other words, kind of actually inequitable, unequal. I mean, so there was a big start on the Windward Coast. And then there was others starting up and then nobody knew where it was going. And then all of a sudden it's that fear too. So can you comment just on what happened there at the beginning? And are you all in much more is DOH more coordinating this whole process now, except for the military part? Well, I guess I would take exception with that because I believe the program is exactly equitable. What we're trying to look at are making sure all the counties get their fair share of doses according to your percentage of your population. If you have 20 percent of the population in your county, then you should get 20 percent of the vaccine or as close to 20 percent as possible. And it's going to fluctuate a little just just by nature of like a Pfizer tray has one thousand one hundred and seventy doses in it. So you ship a tray at a time so you could ship a tray to one island and they might go just a little bit above their percentage or a little bit below. Kauai has been ahead of the game because Kauai is such a small island. They're able to get to roll out the vaccine plan much faster, but we think it's been very equitable because again, you want to think of who we're targeting and actually if we can, let's take a look at a slide here that I think will help illustrate who we're targeting and why. And let's go to number four if we can. Does this talks about outcomes? OK, and this will explain why the Department of Health thinks that it is so very important to do reverse age targeting when it comes to vaccinations. On the far right, you see so far, these are numbers as of last Wednesday, one hundred and sixty five people age 80 and older had died. That is the greatest population age wise. And you go down to the 70 to 79 year olds, 111 of people in the 70 to 75 year old age group had died. And then you go to the 60 to 69 age group, 79 people. So the older you are, the greater at risk you are of of severe illness and certainly death. And and the younger you are, the more your body is able to fight off COVID. And if we go to the next slide, number five, this is really something. If you are 75 or older, you are eight times more likely to be hospitalized from COVID than someone who is 20 to 24 years old. And if you are 75 or older, you are a whopping, and this is really sad, 186 times more likely to perish from COVID-19 than someone who is 20 to 24. So you look at that 186 times more likely to die. That's why we're focusing. Yeah, but many factors, you know, I mean, I understand obesity has a lot diabetes, you know, people that are immune problems so that there's many, many reasons why this might be a factor for young people to keep in mind because it isn't just an old people's disease and and the young many, many reports of the incredibly young, including children who have been affected by this nasty bug. So all these efforts that we're making are very important and the best that needs to be done for everyone. So I think that Hawaii, I mean, Hawaii has Kauai who has almost no cases. They've been relatively free of of COVID. Haven't they? Have you all got data on why are they so? Well, that's that's because Hawaii Island, Kauai County, Derek Kawakami took a very aggressive stance on Kauai to protecting his island, protecting his people, so they have more. They have had more strict travel restrictions for many months now. And it is, you know, you see maybe one case or two cases new pop up over there. They've been zero for the last several days. And that's really important because Hawaii does not have the hospital capacity in the health care system that we do here on the island here on Oahu, for example. So if Kauai were to have a real big outbreak, they would have a real big problem and they would have to rely on bringing people over here, separating people more from families, it would be a real burden on the hospital system on Kauai, Wilcox Hospital. So that is one reason that Derek Kawakami has taken such an aggressive stance. And look, he's saving lives. And so thank you, and I think that the lesson learned. One of the lessons learned through this has been the impact on our medical health system, our hospitals and clinics and our medical resource people. I mean, if they get sick and there are no doctors or nurses, it is really not a matter of having a hospital. I mean, so we've got a couple layers there of really valuable resource that can be affected by COVID if precautions are not taken. Well, I know we've talked a little bit about the equity of the distribution of the vaccine and Hawaii's goals to get it done in that, you know, by the end of summer, maybe, but I also wanted to know about the resistance side of the COVID vaccine. As this, do you have estimations or expectations about what level of resistance is going to be encountered by the DOH and what that number might look like? I don't know if you're specifically talking about like what we might need to achieve herd immunity or if you're talking about, oh, well, in other words, there are people that are not. Oh, gotcha. When do I get it? Where can I go for the first? And then the other side of that is, well, I'm not taking it at all. OK, I'm not taking it at all. So what is this? Yeah, I'm really glad you asked about that because this is something that is working in all of our favor right now. Before the vaccine rollout, we did a survey and it was kind of disappointing in that it just showed that 50 percent of people were willing to take the vaccine at that time or we're going to think about taking it down the line. But there was there was very significant kind of vaccine hesitancy, right? But that survey stopped on December 14. That was the same day that the first vaccine arrived across the street between the medical center and after December 14, we started seeing people, Kukuna, your neighbor, your doctor, your your your pastor getting vaccinated. And you saw that they got vaccinated and they were fine. There were they were very few adverse effects. So as we got to see that, we began to accept the vaccine. And our most recent survey shows that up to 91 percent of people now say they plan to get vaccinated. So we went from 50 percent before the vaccines were being administered to after we got to observe it and had some time to learn more about it. Only 91 percent of people are willing to do it. It was 55 percent of those people said, I'm going to do it right now. And another 36 percent said, I'm going to get vaccinated. I'm just going to wait a little more. I'm not in any hurry. The 91 percent and if that number is accurate, if we can get to 91 percent, I'll tell you, we'll be in good shape. We need really good news. I mean, it's and we might be a leader in the state like leave the nation in certainly with the Kauai circumstances of almost nothing over there. And then for this participation and of course, the respect for the kupuna here has just been so we do model things for the rest of the states to pay attention to. I hope we get some credit for that or that only does. You know, we've got about a minute left. What do you want to say and share with us in that remaining time? Well, yes, thank you. I'll tell you another area where we're leading is the acceptance of the vaccine by residents and employees of long term care facilities. We are way above the national average. The residents are accepting the vaccine. The employees are accepting the vaccine, which is great news for the employees, their families and the people they work for at those long term care facilities. So that's great news. And I would definitely love to point out the fact that look, we've had a couple of variants arrive here in the state lately, and we need to protect ourselves from them, even if we haven't been vaccinated. And you know how to do it. Mask up, practice physical distancing and stay out of large gatherings, whether it's a variant or just your common old COVID-19, those things, the mask, physical distancing and avoiding large crowds will keep you safe. So we need to do that now more than ever to keep those variants away while we all wait for our turn to be vaccinated and when it's your turn. We hope you want to be back. And then we must go on with the masks because we do have these variants and also some other vulnerabilities that to that COVID virus too, right? So that we go on with masking for quite a while, probably the rest, at least the rest of this year, is that what people are thinking? What if they're thinking about this at all as far as afterwards? Yes, that is very likely. We want to keep masking afterward because we want to squash this thing, right? Let's banish it. Let's get rid of it completely. And so we we got to keep doing the good practices. Well, thank you, Brooks. This has been so informative and it's good news for the most part. Everybody is working so hard to make it happen and make it happen on that timeline, because everybody wants out of this as fast as we can go. It would be so lovely to go back to the movies again and a few other things. Everybody's missing, but it's a low time and we'll have to wrap it up. I'm your host, Stephanie Stulldahlton. And this show is State of the State of Hawaii on Pink Tech Live. We've been talking with Brooks Baer, spokesperson from the Department of Health about Hawaii's COVID-19 defense and public recording of vaccinations across the state. I'll see you again in two weeks for the next show and Mahalo for your attention. And Aloha.


So this is a demonstration of gynecomastia, which we have designated out before I talk about the gynecomastia This is the right side and this is the left side. Let me tell you why this patient had gynecomastia If you look here, this is his liver He had a microdenodinous erotic liver Most probably alcoholic also referred to as larynx erosics. He had very prominent Engorged Esophageal varices. This is the esophageal gastric junction and we can see the dilated veins Submucosal veins, the esophageal varices inside as well as outside and he had a very dilated left gastric vein So he had cirrhosis with portal hypertension and he also had Testicular atrophy. His testis were small and we can see them here. So therefore this patient had Cirrhosis with portal hypertension with esophageal varices and we know that cirrhosis is accompanied by Gynecomastia in quite a few percentage of cases. So let's take a look at, we decided to dissect out the Gynecomastia to see how it looks like So this is the right side. This was a larger gynecomastia and we made a circum-aeroline incision and we removed the gynecomastia So this is the gynecomastia that we have removed here It was completely covered by fat anteriorly which we have removed and it was covered by fat posteriorly which we have retained here So this is the Gynecomastia itself with the nipple and the aereola attached to it. We notice that it is well encapsulated On feeling it, it feels very firm in texture almost like skittish capsule When we cut it open We found that the interior had a very coarse gritty sensation But there were no distinct low-views as we see in a female breast We turned it around and we split it open in many places And we found that extending from the surface capsule there were indistinct Partial septae which were going inside and dividing the gynecomastia into Incomplete indistinct low-views which were partially filled with fat So this is what we noticed about the gynecomastia Well circumscribed, very firm, no clear low-views on the right side Now let's take a look at the left side This was the gynecomastia which we have excised with the surrounding skate And let's lift it up And while lifting it up, we notice that this also had a similar external It was covered by fat on its outer surface It was covered by fat on its inner surface on which it was resting It was resting on the pectoralis fascia and there was retro-memory space And on splitting it open we notice that it had the same gritty texture This is the appearance of the gynecomastia on its internal side No distinct low-views but there were spaces filled with fat So, and on the retro-memory surface also we had similar We had partial septae dividing it into incomplete low-views And filled with a little bit of fat So what are the differences between a gynecomastia and a typical section of a female breast? In a female breast, there will be a skin, then there will be a layer of fat Then there will be a well-defined capsule And when we remove the capsule, there will be yet another layer of fat And when we remove the second layer of fat, we will see a mammary lobules Which will be collections of alveoli And in between the lobules and alveoli also there will be fat But here we see that there is only a layer of fat outside And on the retro-memory surface And though it is well encapsulated, there is no distinct lobules and alveoli Because this is not the secreting organ in the case of males And the surface is very hard It is almost cartilaginous and thin This is how it feels when we have in a female breast What is known as a skierus carcinoma This also feels something like skierus carcinoma And this is what we see in the gynecomastia of a male So we thought we would make this dissection Just to demonstrate how a gynecomastia in a male looks like and feels like And how is the architecture of a gynecomastia different from that of a female So thank you very much for watching If you have any questions or comments Please put them in the comment section below Dr. Sanjay Sanyal signing out Have a nice day