The first thing to notice about deep learning by Ian Goodfellow is a cover. At first glance, it looks like a university, but on closer inspection, you'll see this image is painted with puppies. This book will give any reader a solid foundation on deep learning techniques and vocabulary. Coming from the statistic side, I felt like the vocabulary was a big help. For example, when a statistician uses a word inference, they mean how little n generalizes to begin. And deep learning, inference, is what a statistician would call prediction. Another example is the word bias, and deep learning bias is what statisticians call the intercept. And statistics bias is a non-normal pattern in the residuals. So to recap, if you're coming from statistics, this book is a nice Rosetta Stone. This book has one of the best linear algebra reviews I've seen. If you feel like there are gaps in your matrix math, chapter two would fill those gaps. The notation is very standard to what one would see in a college level in your algebra course. I was also pleased to see a whole chapter devoted to Monte Carlo methods. This was much more my language, and was a treat to read through. They also have a little section on pseudo likelihood, which I thought was impressive. Everything you would expect to see in a deep learning book is here. If the terms, rectified linear unit, auto encoders, RNNs, deep ultimate machines are foreign to you, then pick up this book and read through it. It will lay a good foundation.


I remember that game, my dad, he was there, he was visiting because he was working a lot, travelling a lot between places and he came up to the game and he said, I'm nervous you can play like that. I think this program we've really discovered confidence, so confidence on the ball. There's mental health, that definitely has improved a lot, like just simple things like how close should I get to whoever I'm working or just whatever the right option is, you know, when you have the ball or when you don't have the ball, where to go when you don't have it or you do have it. It's just really helped, I'm just a much more disciplined, concentrated person, I think I've just like developed over the last year, not just as a football player but as a person overall. They told me later, they were so impressed by my attitude and that what caught me into the team and I trained so hard, like half the year and our season started and then I ended up breaking the record, goal scoring record for the second division. Wow, how many goals is that? Forty goals. And how many games? 27. Like I can dribble now, I can shoot, I can pass, I have accuracy on my left foot. I was scared to mess up and now in practice I'm in games and I just, I like I always walk the ball. You know, I get frustrated when I don't get the ball. Ball control, dribbling, shooting, everything, everything you can imagine, so technically it's a great program for every react player who wants to become a professional. I took the ball, I got past the first defender, I got past the second guy, I got past the third, the fourth, the fifth, this sixth and it was just me and the goalie at that point. I missed the shot but I'll say it was incredible just having the confidence to be able to dribble past that many people. It exploded my confidence, I went from a kid who didn't believe in himself to a kid who was willing to take on six defenders, you know. Some of your shooting videos get to the field, I can see the improvements the same day and it's, if you just really watch what you say and listen what you say and apply those things, it really makes a big difference. I've just learned to play simple and you know, prior to watching your videos I always try to overcomplicate things. I played every game, I played every minute of every game and at the end of the season I got players player of the season. Yeah, in terms of goals, it's been my highest scoring season in about three years. You think better, you know what to do on the field, so if you train hard, if you follow this program, I think that you'll be the best on your league, maybe one of the best players on your league. Wow, that's fantastic. You get more goals, assists, whatever you want to do. It's great, it's great. So my acceleration has increased to my first five steps, whether that's chasing down somebody's attacking or after you beat a player, sprinting past them or even so you're vertical when getting up for a header and just your strength in general to hold off players. My fitness has improved. I could only get 10 on the beep test. I got 15.2 on the beep test.  On the field I'm playing much quicker. I'm moving the ball a lot faster than I used to and therefore that's more opportunities. My teammates are more happier and just overall we're more successful now. It's that I just always watch your videos and I really do think they're really great, best in YouTube. I've watched a lot of videos but I really do think you're the best. I got picked up by the South Texas ODP. I'm playing with Dundalk FC and I'm second choice right back fighting for position against our captain and he's Irish International. I got there from starting your program. Your program has helped me so much. I get to everything paid and it's like playing like a professional. It's really great. We're a top half tier one team in U18 and we usually start every game. One of them was in NAIA Division 2 in Ohio and they were real grand university and another one was another NAIA Division 2 in Indiana. Anyone that has a weakness and they want to improve but you have the video for it no matter what it is and as long as you watch it and try it and stick by it it'll definitely work like this. Now I find that I've improved a lot. Each skill that I've wanted to develop I've watched your videos, I've stuck by it and that's what's got me where I am today. So I recommend to every young player who wants to achieve their dream to become professional any league, maybe Europe, Asia, whatever. So I recommend this program, buy it and you'll see much results in the future. What you're teaching your audience is really what's right. It's really what the coaches are looking for. Focusing on setting specific goals are going to motivate you and move you closer to the player you need to be. The ability to overcome problems, confidence in tough situations. So many players play well in training or play well with their friends but they crumble under pressure. How to get more out of the time you invest. I want you to be the type of player who gets more out of one hour than most players get out of ten. We're going to talk about hydration, nutrition, supplementation and how to have a better understanding of controlling your muscle gain and weight loss. Combine this with the technical training that you'll be doing on a daily basis and you will start to see a big change in your skills very quickly. Week six we're focusing on fitness, taking care of your body becoming faster, stronger, breathing efficiently and how to play with more aggression and intensity. This section will help you do all of that and more. We'll talk about individual defending, team defending and how to become a better defender on your own. Creating chances, scoring goals, dribbling past players making more assists, all of this covered. In this section we'll talk about how to play better in matches how to prepare more effectively for matches how to go in with the proper mindset so you can dominate when it matters most. To avoid injury you need to learn how to take care of your body and how to efficiently remove stiffness and soreness so while everyone else is complaining you are rested, rejuvenated and ready to go. In this section I'll give you very detailed information on how to achieve those long-term goals that many of us have. Each day you will do a different workout routine which will focus on a different area of your development where I'll break down movement, decision making, technique from the best players in the world to help you get a better understanding of what you should be doing when you're on the field. I'll give you access to programs I've created in the past. These range from interviews with professional football players FIFA agents, club scouts, college coaches at home cooking tutorials additional training routines you can use at home in the gym and on the pit. You're going to get all of that and all you have to do is click the button below this video


Efallai rydy i ni wedi bod yr modd yn gweithio. Yma. Efallai rydy i ni, rydyn ni! Yma. Llyr i'r rhodod o amlwod ym ni. Rwy'n dechrau iawn felly yma felly rhodod o iechyd mwy swydd o'r pan fel hyn. Rwy'n dechrau hynny. Rwy'n dechrau a'r pan fyddwch bydwch yn y rhai os ti'n byw nhw? Rwy'n dechrau a'r pan? Rwy'n dechrau i chi drw'r pan? Rwy'n dechrau? Yma. Byddwch chi, wych yn cymryd. Yn ymoli, rwy'n gofal i gynnig o'r ymlaen i Llywgrifell, nid yw eich teithaeth. Rwy'n gofal i gynnig. Rwy'n gofal i gynnig. Rwy'n gofal i gynnig o'r ff先ol. Hylŵr o'r Lyfr Llywgrifell wnaeth yn rwy'n gofal i gynnig. I'm kind of planning on the location to do that, and what I want to take you through now is kind of the site builders approach to Drupal Connag's to do that, and I'm pretty sure most of you will agree that the site builders approach to one of the experts is just going to install a module for this, install a module for that, install a module for this, and quickly you end up with quite a whole of a dependency tree, but also just tons of modules that are often kind of really bespoke bits of functionality that you would expect to be in court. And I'm going to show you now how some of that is in Drupal Connag. So just first slide, I was drinking some beers with my friends today and telling them I'm doing this Drupal talk, and they were like, what is Drupal? So they urban dictionaryed it, and I thought these were quite funny definitions about Drupal, and it kind of sums up the Drupal commerce 1.x approach of notably being open source and nothing else, designed to be totally useless after installation. You do. You install Drupal commerce 1.x, and there's not very much you can do. Out of the box you get kind of a store, but not really anything you'd want to put in front of a customer. And perhaps that's the same as Drupal as a whole, but it's probably a different argument. So yeah, yeah, so I thought that was pretty spot on. These were the only two that were safe to display. I wouldn't have yourself at some of the other definitions because they have nothing to do with Drupal, but apparently people use the word Drupal for all sorts of things. So yeah, so in the 1.x world you install commerce and you have a store. You kind of have to install all of these modules for things like tar exploration. This is actually a live site, so all of these are installed to just sell a magazine. We're installing checkout extra login page to sell a magazine, but this is stuff that you'd expect a modern commerce solution to have. And again, this is probably even better displayed with this slide. So these are the most popular commerce modules as of January 2017, as of this year. And we've also put the port status. So you see a lot of these now say in-core, in-core, in-core. So all of these modules that pretty much, well, yeah, all of around 50,000 active commerce sites would have to install most of these now in-core. So we're coming in a lot better. I say we, Matt and commerce guys are coming in a long way. I just used the stuff now. So that's kind of the contrary space, but also everyone pretty much has also a lot of custom code to achieve, again, really basic stuff that you'd want to see in the core of the project. So one of the most popular things that's now in commerce 2.x is varied checkout flow. So in Matt's presentation that he just mentioned, he talked about how if you're sending a digital product, or if you're sending a physical product, you want to capture different fields. In commerce 1, you only have the one checkout flow unless you install a series of conflict modules, various different bits happily, or some custom code where you are setting checkout pains and then un-setting them if you have this access and all sorts of horrible stuff that you don't really want to be writing. Don't look at my code. Skip that.  I didn't PR that one. You have to read it, didn't you? Yeah. And again, this is a live commerce site. This is a checkout step at the start. Most of the time you want to capture some information about your customer. And in commerce 1, you have to install commerce extra login step or a variety of different modules just to do that. But it's okay because there is no future. I had almost like a wait for gasp. There we go. So it begs the question, how far can we go out of the box without installing any conflict modules with commerce 2.x? Hopefully I will now show you. So this presentation is kind of aimed at site builders. What I want to show is I'm going to show a lot of forms and I'm going to describe the kind of concepts and entities that build commerce 2.x. And if you have any questions, I'm just going to refer you to Matt. So I kind of crack on. The first thing when you come to installing commerce is we have this notion of a store entity. What we didn't have, what we had when we installed commerce 1 was everything was sold from this one location. If you had an office in Nottingham that was shipping out your digital product and an office in London that was selling your magazine or whatever, you couldn't really model that very well. What we have in commerce 2 is this notion of stores. So once you're in store commerce you have to configure an A store. If you have local stores you can configure more than one. You can select which countries and which currencies that this store belongs to, which lends itself like really nicely to either the market-based model if you have lots of consumers selling a different product, or if you have lots of different stores that you want to only focus on one currency, for example, or if your requirements in different countries are being specific. So, for example, one new case that we had was payment gateways charged varying amounts on international orders compared to UK orders. So if you want to use a different payment gateway per store that is possible, not yet, almost, will be possible very soon. So if I have PayPal as a payment gateway that charged me 4% on international orders, but also 4% on UK orders, I can have a different store and you strike in the UK which charges a lot of that. So quite simply, commerce stores have one currency, one store. So it models the multi currency model a lot nicer. And it's kind of an overview of the architecture. So there will be stores, your products and your orders, and you can have multiple stores. So once we've set up the store, which I will try and show now, this is going to be hard when it's not moving. I'll do that in my area. Yeah. Moment. Are we good? Can you see? Cool. So in here, I have stores, I have one store set up already called Swiper. Don't ask why. I can add a new one and call this Scott's demo store. And here we select the default currency for the store, but I've only got one currency enabled. So before we set up a store for a new currency, we have to import a new currency. One of the nice things about commerce is it lets us add new currencies if we wanted to. You may ask how I can't make up a currency while I want to do that. And there's a couple of use cases. A Mac refers to one called Bitcoin. The currency data set that we use doesn't have Bitcoin in it. But there's also another one where one of the clients out of the common sky to do it in Westwood, they used to sell products in Australia and New Zealand, both in Aussie dollars. A slightly different rate. So they had New Zealand Aussie dollars and Aussie dollars. It is a justified use case to make up a currency. That's probably the quick question. Yes, sure. What about the format? I don't think we had a lot of custom format. I think you did it in your example. I think that's predefined by Google. The Euro symbol in France appears on the right-hand side and in the UK we expect to be on the left. That's all kind of baked into the data set. I guess you could overwrite it with the format and probably without too much. You can't do it in the UI but you probably... I won't go for that. I just wanted to make a Brexit joke because it's quite funny. But yeah, so I can import all manner of currencies. And then the store that I was trying to create earlier. What's that? A docker. It's a future. So once I've... I'm not going to go. I can just show you this one I made earlier. I can select which currency this uses somewhere here. So once I've imported the currencies I can create a store that is backed by that currency. Two slides. So we have a store and presumably now you want to sell some products. This is actually directly from the commerce 2.x documentation. So it's pretty much the presentation. It's just me reading the doc. This is quite a common use case and you quickly end up with a lot of products and a lot of different skews.  How do you model that? That model is pretty much the same in commerce 1 as it is in commerce 2.x. I don't think there's a better way of doing it. So it's the same but quickly show you here too many windows. So I have product attributes and here's... I kind of wanted to do a bit of a demo that wasn't just the old t-shirt. So this is a case of a digital product where I have attributes that are plans. We might want to have a yearly plan, a quarterly plan, a monthly plan that has various different bill rates or prices. So I have my product attributes here. The element type which Matt talked about in his presentation earlier. This is now in core where in commerce 1.x it was really difficult without installing the contrary module to have your product attribute list rendered nicely. So no one really wants to go into a commerce checkout, buy a t-shirt and have to select red, blue, green. You'd quite like to see the product. So what you can do because the product attributes are fieldable, you can attach an image to it, have a red, green, blue t-shirt and actually be able to click it. It's a lot nicer. So quickly show you on the slides. You can have that end up like this. So it's a lot nicer when you can actually visualise the products rather than just see a drop down on select list. So once I've configured my product attribute, then configure my product variations. And I already have one there set up. Again these are fieldable so on my product variations I have a description. I mean t-shirts are pretty self-explanatory. If you change to a red t-shirt, you expect your description to change to this is a red t-shirt. This is a blue t-shirt but you might want to add some more information. So in case of the kind of plan model, my description would change bearing on plan. So under coursely I would say that you get 25% off if you buy it yearly and I can upsell them or I can trade that description to whatever I want. This is an important step on the actual product itself. So if I flip back to my variation types. Yep, here. Why is that required? Because you have data. You can't remove it if it is. So on the product variation itself, I can tick which attributes I want that to display. So if you have attributes that are shared between different variation types, that model is possible. What model that quite well? What attributes would you share with different variations? Anything? Anything, size? So if you had a small, medium, large, you would share that across most of your catalogue. You wouldn't recreate small, medium, large, rich of your variation types. So once you've set up your variations in the attributes, you then in a nice place where you can actually add a product. So here I have my swipers description. And you can see here I can select on that which variations I want it to support. And now if I view this product, I end up with a nice ticker form. So I've configured a store, some currencies, and now I've configured a product. I get the quantity field, I get the variation selector in the description and all of this. One of the notable differences between this and Commerce One.net is this whole idea of product displays. A lot of people can find this quite confusing to explain to clients of this idea of you have a product and a product display. Did people find this confusing as a model? Made my life a woman come. So in Dupal 7, we had this idea of a node type that was a product display because it had a entity reference or a product reference field onto a product.  Whereas in Commerce Two, all of this belongs on the product. And using things like twig and all of the stuff that we get in Dupal 8, we can theme it however we want. You wouldn't theme it like this, but this is just kind of the seventh theme. So I can add that to cart. And as you see, I've got products in a cart. Payment gateways. So now over. Just ask. The attribute where you've got no stock of a certain size of product, is that easy to have? So stock is being imported. But Tim, do you have to change attributes or what? Do how does it get represented? So you would, because the way the model works, you'd have a different skew for each of these. A large red t-shirt would have a different skew. Your stock would be against the skew item. So if you change your selector form to that skew, it would be out of stock and we would display an out of stock message. Remember this screen from, you probably do remember it, because you're still working with your Commerce 1.x sites. But payment gateways are all powered by rules in some weird concoction of rules that split off slightly and it got really messy and horrible. In Commerce 1.x, because we have different order types and we can have different checkout flows and different stores, we can have a payment gateway attached to those without having to edit this payment gateway at a rules condition that says something like, if the skew has this in it used this payment gateway or if the currency has this used this payment gateway, we can model that without having to edit the actual payment gateway definition itself. We can have that at a per store level or per order type. Amazing. He likes it. Amazing. Why, why, why? Because we should be interested to be available to the audience. So one of the ways we use this at TES is if you are an existing customer, you probably already have a payment method associated, so we display different payment centres and use your system card. That becomes a lot easier in Commerce 2.x. So that's it. So I recently ported, plug me, I ported it. The strike payment gateway is probably my only contribution to Commerce 2.x. I think maybe I have two commits in documentation probably. So I ported the strike payment gateway. If you're a module developer and you want to port a payment gateway now, we used to quote at Commerce guys to clients like Amex or Braintree or whatever that would, around 20 to 15, 20 days of development to build a payment gateway. This took me six hours to port using Boyen's brilliant payment API. So it's a lot easier and it's actually really simple. If you're sorry, the scratch rather than the porting, how would that escalate? It depends on the payment gateway. So Stripe, Braintree, they all use this kind of JavaScript tokenisation method. That's really easy. Providing their API documentation is really good. I didn't actually refer to the original Commerce Stripe module when I was porting it. I was just referring to Boyen's work around Braintree. He says with confidence, it's easy. Does it deal with lots of variations? Yes, so the whole fourth capture and my frame is that the PayPal uses the other flow that isn't the same one as Braintree and Stripe. The PayPal flow of the payment gateway. Yeah, offsite. Offsite redirects. That's in the payment areas that model that and there's onsite. So the way, what happens behind the scenes when you add a payment, you can have a capture and auth or auth. So in that situation, you could build a payment gateway that was, I'm going to capture the payment but not going to authorise it. And then later in the back end, you could say, OK, this has been received now. It seems like a check. You wouldn't confirm that order straight away until payment has been processed. It would be easy. It wouldn't be hard to port that. So after we've configured a payment gateway, we are on to order types. So in one I made earlier, I have order types here. When you install commerce, it comes with a default order type. I wanted to create one specifically for digital products on this idea that if you're selling a digital product, you don't need to capture a shipping address. I still need to capture a billing address and there's some funny issues about BAT depending on what country you're in. So you might need to capture a place of consumption address. But I can usually just be the billing address. I won't get too much into tax details because it's boring. So in here, I can configure which checkout flow I want my order type to use. So I only have one checkout flow configured here, but in commerce to the X as I'm really excited about is the fact that I can have multiple checkout flows. So here is the default one that ships to commerce and Matt said in his presentation for this one, there was a lot of UX effort put into analysing Apple, Amazon, pretty much every e-commerce store under the sun. I really need to tell the United States why I went and I tried to not pay for anything with similar data. Matt pretty much added everything to a cart, noted whether it was a one step payment gateway, a one step checkout, multi step. If they had a sidebar on the side or whatever to try and find what is the best UX for a checkout flow. Commerce analytics has this whole section where you can analyse the funnel. Your client, I imagine, would really want to analyse this kind of data to get the best possible checkout flow. If you get people dropping off in the review stage, then you can say maybe we don't need a review stage, maybe we just go straight to payment process. It's important to really, really look at A what you're selling and B what people are actually doing on the site because this is money, this is really tangible. If you make several tweaks here, you can increase your conversion, which is kind of what we're all about with. So with commerce 2.x I can have multiple checkout flows and probably without too much work I could A, B test this. So if you wanted to set up checkout flow A, checkout flow B and switch between the two and see which one converts higher. So I will add a new checkout flow so you can create checkout flow plug-ins but out of the box you have a multi step plug-in. So here I can say okay, I don't want the review page, let's stick that on the page and then I've instantly gone down to two pages instead of three. It makes the checkout a bit quicker and it might increase conversion. But I can also say that I don't want the review page at all. This is a digital product so I don't need to capture contact information or whatever location it may be. The possibilities are infinite in the TES example that I showed earlier that we built on commerce 1. We have two checkout flows, one for B2B customers and one for B2C. In the B2B world we want to capture which agency they're from and various different other fields and the only way we could do that in commerce 1, aside from a few contract modules, was to physically form alter the checkout flow and unsets these pains and fields. This is a bit messy and horrible. Commerce 2.x, the future, we can have multiple checkout flows. Once I save this on my order type, I can say use my new Scott's checkout flow. When I check this out, it will go down that flow, which I gathered Chendi that solves some of your problems. I've set up a new order type, I've set up a new multiple checkout flow and now I can buy my product.  I haven't got a payment gateway set up, but if I have, I could check this out and buy several monthly subscriptions for Swiper, whatever Swiper is I think. One of the things that I'm trying to get ported into commerce, now I've got a patch waiting if Matt wants to review it. This idea that not all of your products need a cart. If I'm selling a digital subscription, I'm not going to buy four monthly subscriptions to the same thing. I probably just want to disable the cart, so I have a flag there. If I save, I should have thought about this before I started demoing it but maybe this isn't going to... So if I hit add to cart now, I go to a cart now and it's not working. Don't review that actually. So that's pretty much setting up stores, currencies, products, product variations, product attributes, order flows, order types and that's all out of the box. To do that in commerce, one would have, I'd have just been ticking modules and then configuring them. Pretty painful. So if you have any questions, happy to answer them or if I can't answer them, I'll refer you to one of the maintainers of commerce who's sitting at the back. Thank you. Shipping is in beta. That is a contrary module. We didn't take beta 6 yet, so if you use beta 5 with shipping, it will break. We have a class that's missing. So once we take beta 6, it will be rockin' and rollin'. So just use it out. Always use it out. I guess one of the hard things, especially in the contrary space, is deciding what should be in core and what should be the area of contrary. Like my flag on the order type of, take this straight to check out and skip the cart, I think should be in core, but it's quite easily to just spin that up as a contrary module. Shipping, I don't know why, I can't argue for Boyan as to why he wants to have it in a separate module. It's a lot. It's quite a lot. It's a big module. It keeps it more nimble. We can't break commerce, but we can break shipping. We're not going to make commerce 3, but we could do a new version of shipping if we're risking the worst. So yeah, shipping is in beta. Yeah, commerce guys, when I was there, a lot of our clients were all selling digital products. No one really needed shipping, and those that did, shipping was fine. So, right? Support 3D secure? Is payment gateway dependent? Yeah, it is, but there wasn't a commerce 3D secure module. I'm not sure of the problem either. No, it's, you're going and you're paying cyclists' dollars. That's not in core, like multi currency is just, you set the price per. Well, not actually, you can set a conversion rate. You can't do that in two days. I have no idea. You can't? I have no idea. Yeah, that's not in core two days. Is it? I think so. I'll look into it. One point, one point. Find out. I'm not sure. Have a word afterwards. Robin, must I come? So, out of the box, it's designed that you're going to build up a cart of multiple products, and there's no leveraging this idea that I want to skip the cart and go straight to checkout. So, my patch is... I could find it. I won't be able to find it. Sets a flag on the product to say that for this product I want to skip the cart and go straight to checkout. I don't know. Boyan is the opinion as it should be in core. I just haven't got around to doing my patch. It's quite clear because it doesn't work. So, that's the checkout flow. That's nothing to do with the cart. The way that the model works is you add a product to the cart and then the cart you take to the checkout and the cart is just a different body state. What's that? It's a product I'm working on. I know what it is. I won't take my reputation on that one. It's not, isn't it? What would you call them? Offline payment methods or manual payment methods? For like, check, cash... Offline? Yeah. Check, cash. Your example of people walking down a post office to post it. Would the time have been made depending on the cash? So, an offline payment? The invoice credit. I'm too glad you don't credit. All of these payment methods that require some sort of manual intervention step where... See what you did there.  You can actually do that with Stripe. You can say, I just want to capture these details now and say, it's quite much to have acted for subscriptions. You want to say give them three days free and then later charge them. So, if they capture the subscription within the first three days you don't charge them. So, you capture the payment and then walk it later. And that's done automatically with Stripe and there's full backs for it. But in the absence of a bank or straff or a check or whatever, you just go into the order, edit the payment and say, this is completed. One of the things that's actually quite nice out of the box I can't demo it because I don't have a Stripe API key is refund. Not only did it just take me six hours to implement the Stripe payment gateway. That also included full refund support and partial refund support. So, that was a touch on the back of the site, because there's a brand new intervention in what's the back of the site in two that's in three months of study. Was it a problem? Well, views is in core. Views is in core. So, we never showed it. I didn't show any of that. Do you use JIRA at all? It was heavily inspired by JIRA. Not configuration. No, not the configuration. So, we're much more explicit in how we do things. Do you have an order out there? So, there's transitions that happen. So, let's say you need to reassign an order to a new customer. You click reassign cards. And if you need to place an order, you click place. Or if it needs to be fulfilled, you click. Then you can hit cancel. So, you know what? One of the exercises is to prop down the status. Now it's much more explicit in what you can do. And we've made certain items immutable. So, it will show up in the sidebar as just like the customer info. You can't really edit it because it's just there. Or once an order is no longer in a draft state, you can't change it. You can only transition it and add payments. So, that's using state machine? Yeah, so state machine which... I'll try and find a definition for companies. So, it needs some work. We just added logging. So, the order of logging, we have some default templates that you actually look the same as the sidebar. It needs some more attention still. So, in the code, it's a lot more restricted as to say, you can only go from this state if you're in this state. Or whatever. It's quite easy to configure in YAML. I can't find somewhere in there. We'll take some custom code. Here you can show it. I just have to go to my demo module. You can just show it real quick. It's one file. It has a service. The answer is quite poor. I don't know if that would work. Yeah, it's a class. It's called a Checkout Type Resolver. I want to actually try to look at it. We'll come over there. I feel like I'm going to say talk and sort of pet it. Is that some people that like context perspective in the new user? It's a code. We probably won't give a UI to it. So, as a tag service, you go into the new services.gynw, you say, my class, what type resolver. And I give it a priority. This is what I do in my person. I actually... So, I give it a my person because we have a partner flow. We have a normal flow. We have a free trial. We have Shopify. So, we go through and in that resolver, it hands me the order. It says, tell me what checkout flow can pick and need to return. Do whatever you want. In A to B tests, it's like, hey PHP, give me a random number. It's less than 10. It's greater than D, A. That's how I would do that in the last session we talked about where if you had digital and physical or mixed order, I would do that. I would say by default. Yeah, I would look at the products and say, okay, it's all digital, bam. Oh, it's a mix. Right down in the middle to that kind of space. On the idea point about checkout or skipping the cart, I did buy a contract module for it. So, having the name of it on that demo, it adds an event subscriber and basically says if the bundle of the order is checkout of X, skip the checkout, remove any extra quantities, just checkout that one. So, it's valid as a contract module, but it probably should be in code. I use it. I have it implemented too. We need a direct checkout of the box. Yeah, but you need to put it in the checkout file. Detail. Because of the same order, and then we order... Not out of the box, but should be doable. You get an order history in your profile. So... You just make a button up there. So... You can spin it out. We have a re-order one for the B2B to be able to easily do that. A duplicate. So, I'll see if we can spin it out. I don't know if we'll put it in core because you might want to do a little more. You don't need to create a full recipe on the box, or are you serious? So, in commerce crates, you have orders that you could add the bundle into that. I think we're almost done. Do you want to collect extra information when someone adds a product to the cart? So, a little t-shirt? The same principle of in commerce 1. You can create new pain, create a field. When you select an attribute, you're capturing information, and that's just a select list. You can have a text field, to capture a t-shirt, by swiker. It should really come in. Here, should we show how to do it? Do you want to show how to do it?   Here. Yep, and that's what I'm doing right here. So, I'm going to add a new field type to here. No, I want to make it even image because this is a bakery, and we're going to order a Drupalcon cake, and we want to upload a picture to put on the cake. I literally had to do this in 1.x. They want people to be able to send it. Let's be really careful when we demo the images. I won't upload. So, I've edited the order item type. Oh, here's a key difference in 1.x. They were called line items. Now they're called order items because we made them more cohesive, and we kind of normalized about the terminology. I feel my laughter. So, what you need to do is you go to the managed form display, and then you would just take, oh, go to the added card. I always screw this part up. And then go to picture, and why does it actually, why doesn't it say hidden? Did they change it? It works? I don't know. So, drag it up, save it, and then... I didn't know what it was. Do you have a page open with it? It was history. So here, so now that field is there. So that's how you would take input. Oh, I see. So you mean like expanding that right there? Or like in this area, do you mean? So that's where, unfortunately you have to duplicate. I always recommend duplicate the view so that way you don't override what's shipped so you can get the updates. So then, so if you look at the order type, I'll just open a few. So, that's... So if you edit in here, there's the cart settings. So cart form, I would duplicate the core one. Yeah. It's still not showing up. Open an issue. We'll look at it. But yes, everything is customizable with the cart block, those cart forms. So you can take the view right here. And that's for each order type. So if you have a digital one, you can show like whatever you want. It doesn't grudge me because they're going across the point to share so it can come flatness down. So it's on the order... So it's on the order... We're out of time. Do you want to talk? Thanks guys.


Hello, my name is David Mast. I'm the Chief of Perfusion Services at the Ohio State University Wexner Medical Center. And I want to welcome attendees to my lecture, Becoming a Smart ECMO Program, a Single Center Experience. If you had spoken to the perfusionists at Ohio State prior to 2009, we would use the four letter word we're referring to ECMO. In our opinion, ECMO did not work for adults. And the primary reason for that was that we had little experience using ECMO and we didn't have the equipment that we needed. And as a result, we had poor outcomes. And so really we had no interest in doing it at all. And in fact, if you had mentioned ECMO, this is probably a response you would have gotten from the perfusion crew back in the day. So what was that four letter word that we would use when referring to ECMO or when ECMO came up? It was no, we wanted nothing to do with it. However, as everyone knows, in 2009, things changed. H1N1 led to a paradigm shift, not just at our center, but across the country. What we saw was patients were being successfully supported that were at H1N1 with ECMO. And so people across the country, our center included, were scrambling to buy up ECMO equipment. And this is what we bought up at the time. And it worked. We were able to support patients with H1N1 and they actually did very well. And so for us, things changed. We saw ECMO differently. In this instance, this is a patient who came to us from an outside hospital. He was a young man on scholarship for rowing to a major institution in America. And what happened was, is he had a small little scratch that led to an infection and it kind of escalated and cascaded from there. They ended up having to bring in a cardiopulmonary bypass machine to support him in a non-cardiac OR because he was so sick and they were losing him. From there, they transitioned him to an ECMO system that they piecemeal together and then they supported him for a day or so while they were reaching out to find someone to take him. And so they did reach out to us knowing that we had recently started an ECMO program and we happily took him at our center. When he came in, he was this very athletic big young man and he had, like I said, he had this whole rowing scholarship ahead of him that he was planning on going to but because he was so big and so muscular, the canyons that they had to use to support him were very large. And as a result, he suffered from distalemischemia and he lost one of his legs as a result. He ended up losing a second leg due to a necrotizing fasciata and so he lost his second leg as well. And so you can imagine the impact that that would have on a young man with a rowing scholarship. It'd be very easy to look at this as a negative. However, this young man completely turned it around. He went back to rowing. He worked really hard. He made the US Paralympic rowing team. He ended up getting named the US rowing male athlete of the year and he went to the Rio Paralympics in 2016. And as a result, ended up going to the White House and meeting the president. So it's very easy in the day-to-day things to get caught up in this and look at it and say, you know, this was a negative, but then you look at what this young man has done with his life since then and it's actually pretty amazing story. So profusion posed 2009. The four letter word, it actually started changing to hope we actually had a belief that we could use ECMO to support patients and get them through whatever illness they might be dealing with. Yeah, there were some bumps along the road that we were on, but we were seeing some success stories and it did give us that hope. So for the early days of ECLS at OSU, we wanted to focus on building the program. That involved the criteria, education, quality, staffing and then expanding the team and expanding our footprint. So as far as building the program, we started with creating the criteria. Early on, it was pretty much a, you know, take all cumbers type mentality and we learned from that. You know, obviously we had some bad outcomes of result and so what we wanted to do is we wanted to create some criteria, which is what we did. Our criteria was pretty basic at the beginning and then we kept evolving it over time. We'd go back and we'd look at what happened on patients that we decided to accept and place on ECMO and how they did. And we just kept making changes. So about every six months to a year, we review it internally and it gets updated every year or two. And then also you need to have an education program for your team. So we started an ECLS class back in the day and we would actually have our bedside providers come in. So all the bedside nurses initially went through this program and they got to go over things like pathophysiology for patients that we would support on ECMO, pharmacology from the pharmacist team that respiratory therapy came in and gave a talk on ventilator management. And then the bedside nursing component of it and then of course the perfusionist would talk about the ECLS circuit itself and the interactions with the patient. And then at the end, we did have an evaluation for them and an evaluation that they would fill out for us. And as a result, we grew from that and we were able to fine tune it and make it better each step of the way. The next step was to create a simulation program. The classes were good, but what could we do to make it better? So we ended up buying the Caliphia 3.0 ECMO simulator and put it to use. And we wanna make these scenarios that we put them through as realistic as we can. So we do simulate a ruptured circuit, de-cannulation, things like this. And they have to react to that and talk about how would they deal with this situation? What would they do? Where would you place a clamp like you see in the picture here? Or how would you treat the patient while somebody else is taking care of the circuit? We feel like having this type of program really helps to build confidence, not just in emergencies, but also in treating patients on a day-to-day basis because if you're worried about how you're reacting in an emergency situation as you're treating these patients and you have that in the back of your mind, I think it can impact you. But if you have that confidence that you know how to handle the situation, I think that goes a long way. And our goal then is to make this a multidisciplinary approach. So we'll have teams in another room and as somebody is going through a scenario and they're presented with something, they might have to call in the perfusionist, they might have to call in the intensivist, they might have to call the cardiac surgery team in. And we wanna make that as realistic as we can then in that regard. The other thing to consider is, can you offer this type of training for those centers that you partner with? It's one thing to have this for your team and run your teams through it and that's great and you should do that. But can you also offer this for these outside centers that you partner with? I really strongly believe that by doing that, you're gonna improve patient care starting from the very beginning at that outside center instead of waiting to have that higher level of care when they get to you, you can start providing that same level of experience and you can take your experience and level of care that you know and you can put it into these centers and help them to do a better job from the very beginning. And so it's a true partnership with them. The other thing we wanna do is focus on quality. So we did pretty early on, we started a quality assurance and process improvement meeting and we would actually review every single patient that we had and we would look at what we did right, what we did wrong and how can we do it better? And having the fewer numbers at the beginning allowed us to do that. As our volume has grown, we can no longer review every single patient, we just don't have enough time. However, what we've done is we assigned the cardiac surgery fellows the task of reviewing those patients and then picking out patients now that had a special circumstance around them, maybe a moral dilemma associated with it. You know, maybe something as simple as, you know, what cane that were selected that made a difference in the outcome. And so they select these patients and then we review those few patients and try to improve our process from that. The other thing that we have done is with our staffing model is we've gone with a hybrid approach from the very beginning. We do have a perfidious in-house 24-7 for coverage. We handle the setup, the priming, initiating support. We round on the patients once per shift at least and then we're also there for any kind of emergency circuit response, transports to CT to procedure areas, things like that. The bedside nurses, after they meet minimum qualifications, they go through a four to five hour class and then they can become a level three ECMO nurse. Once they go through that program, then they are shadowed by an experienced ECMO nurse for four weeks. And then every year they have to go through annual competencies as far as the ECMO program itself goes along with the normal competencies that they have. The other thing that happened kind of just a natural evolution was the circle of caregivers that we interact with. Early on it was pretty small. You know, your typical, you know, ones that would work with an ECMO patient or any kind of extracorporeal circuit, cardiac surgeons, perfusions, the nurses, respiratory therapy, and of course the anesthesia critical care who we only had a couple at the beginning, but as our program grow, so did our circle. And so now the team that we regularly interact with is much larger as you can see here. And as a result that care just continually evolves and improves that we're providing those patients, the more of these specialties you can get involved, the better the outcome for the patient. The other thing you wanna look at is just improved equipment. You know, one of the things we did was we went from a large bulky ECMO cart like you saw from the very beginning slides to a more narrow cart. And that's just a simple thing that we did. One of the larger things we did is a nursing team and a nurse educator. They went out and decided to bring in these tilting beds so that we can place a patient on a tilting bed. And we do it pretty early on. And so those patients, even if they're primarily candulated, we can stand them up and interact with them as you could see in this video. And it's really made a big difference in these patients. You know, getting them into these different positions not just helps with, you know, the weight bearing, but also as you can imagine the anatomy and what you're dealing with, you know, with the lungs and processes are going through, you know, staying flat and prone in one position is not good for you. So getting them up and changing that position is beneficial as well. So just a simple act of standing them up like this is a big change for them and it can help with their care and improvement. But then it just also allows for different levels of interaction. It's helping them with building up their strength in their legs to be able to handle the next step and things as far as ambulation and movement through the hallways and whatnot. And then the next step for us was community outreach. We did some site visits from the very beginning but we wanted to add to that. We wanted to have education centers, consultation and transport center hotlines that we added an ECMO symposium. As I mentioned, high fidelity simulation training that we do and that we also want to offer to our community partners. And then recently we started an ECMO retrieval program. So again, you have to ask yourself, why are you partnering with outside centers? Is it just to accept patients or is it truly to improve patient care? Not just at your center, but at their center as well. So for us, we started with site visits and education centers with these outside hospitals. One of the early ones was Fairfield Medical Center that we have partnered with. We would start off by having them come in. We'd have the welcome and greeting that we would normally do and provide them with some food. It's always a good way to start. And then we do like an ECMO overview. Early on, it would be like an hour long talk that somebody would give. And what we found it's more effective to break that up into like three smaller sessions. You hit a key typical ECMO points that you need to those topics, but then also hit on something that's more of a topic of the day. Like right now would be COVID. And then from there, we would go up and we do a mock ECMO insertion along with transport to the ICU and a handoff. After that was completed, we would then break up into our peer groups and we would round on the patients since we're already in the ICU. It worked very well. And breaking up into those peer groups, I allow you to have that more intimate one-on-one conversations with your peers about how you personally handle things and how your team personally handles things versus how you handle things as a overall team. And then at the end, we come back together and we have a debrief and we have a question and answer session. We found these to be very effective. The other thing we did is we've always had a transfer hotline for centers to call, but what we wanted to add was a consultation line for ECMO. And so we created the ECMO patient consultation with just 293 ECMO. Very easy for people to remember. And the thing I really like about this is from the beginning, it wasn't simply about them calling us about taking their ECMO patients. It was about calling us to help them improve care at their site. So when they call us, it's not just, yep, use these cannulas in this circuit and get them on ECMO. Have you tried this treatment method? Have you tried this one? You might go to avoid placing this patient on ECMO or they might just simply say, we really don't think that this patient needs ECMO. And so it's really helped these outside centers in refining their process at their site on whether or not to place patients on ECMO. And then, of course, there is that call that they'll come and they've placed a patient on ECMO. How can we manage that patient better? What should we be looking for until we can arrange transportation to our center? So it's been a very beneficial tool that a lot of the community partners have given us good feedback on. Another thing that we wanted to do was host an ECMO symposium. We put this together pretty quick. The lady picture with me on the left is Ellen Yokohama and she was so instrumental in putting this together. She helps a lot of the different groups in doing this. And so we could have never done it without her. And the other picture is Venus Atapria and Brian Whitson who are ECMO directors at the time. And so we had this vision with this symposium that we were hoping to reach about 50 participants from maybe six or 10 centers. And we thought that that would have a meaningful impact in the community by getting some of the experiences that we've had and some of the knowledge that we've gained and putting that out into community, like I said before. When it actually came time as we got closer to the symposium, what we actually found was that we ended up with 165 people registered from 22 different centers and everybody attended. And I don't say this to talk about, what a great symposium we put on and how popular it was. Instead, it's to highlight the fact that there was a real thirst for this type of knowledge in the community. And so we saw a role that we needed to step into in this regard. The latest thing that we've done is we've launched an ECMO retrieval program. We actually went through the first 10 years with people delivering ECMO to us, but especially with COVID, what we found was, these resources at these smaller centers was strained in doing that. And so we wanted to answer that need in the community. And so we started our ECMO retrieval program. I'm proud to say we partnered with MedFlight who's just an amazing and professional team. And so from the beginning, what we did is we had classes and we had sessions where we got together with them and we would bring up a gurney from the mobile ICU, have a dummy in the unit that we would go to retrieve. And so we'd go through the process of all the steps that's involved in retrieving this patient and what you have to watch for in moving them over onto the gurney and then the checklist that you go through before departing and then transport them back downstairs to the mobile ICU and load them up to head back to OSU for the training. And I'm proud to say that after launching the program on February 1st, we actually had our first activation on February 3rd. The young man you see in this picture in scrubs is Greg Davis. He was day three on the job. And we did not just throw him to the wolves and send him out on the ECMO retrieval on day three. He actually went with Jim Ralston, who's been at Ohio State for 33 years. And so he had this great pairing of a young eager guy that came from the center of the ECMO transports going along with the experienced guide OSU who hadn't. And so it was a really nice pairing and it worked really well. And I was proud to say that after bringing this gentleman back that we were able to provide him with that next level of support that he needed. And so our growth over the years, after the ECMO symposium, we did see an increase in partnerships and relationships formed. Some of them was just conversations. Some of them were true partnerships where people wanted to start a program or they had recently started a program. Early on it was Mount Carmel and Fairfield were the ones that we primarily received patients from. We started partnering with these other centers that you see here on the slide. And then of course our growth, our program growth occurred along with that. So in 2015, you can see with this outreach program that our growth didn't improve and grow. Got a little bit of a drop in 2016, but then from 2017 on, we've been right at about 100 patients per year. So far in 2021, we've already done 51 ECMOs in the first 90 days. The other really neat thing that just kind of happened and evolved as a result of a program where you're investing into your partnerships is that people talk about it. And so early on, it was pretty much just in Ohio. And honestly, it was inside the outer belt of 270 in Columbus, Ohio. But that started to grow and we started to partner with people outside of the outer belt and in different areas in Ohio. And then from there, it just continued to grow where people were reaching out to us from the Midwest region and from there it just grew and it continued to grow until finally we had this national footprint where people had called to us and asked about how we run a program, different ways that we staff things and such. And so it's been a really neat experience. Like I said, in the one slide, that our circle within Ohio State had grown from that small little group to a much larger group. And now what we've seen is we've started to have these interactions with different centers across the country. And it's just been a great thing to see evolve. And then of course, everybody's been dealing with the COVID pandemic. And so I did wanna touch a little bit about how we managed our team during the pandemic and what we went through during that. So we have a team of 14 full-time and two part-time staff. And one of the things that we were looking at in terms of staffing was how do we reduce the impact of a team member to test positive? So we split them up into two teams.  And the idea behind that was that it would allow for time for symptoms to develop, right? So if somebody got exposed, then during their time off, then they would have that two-week period to develop those symptoms. And then hopefully we could avoid them coming back in and exposing somebody else. Our leadership team actually ended up reducing that to one week on and one week off. And it was the right call. What we found out was that most symptoms develop within five to seven days. So the chance of that, somebody getting exposed as a result was pretty low. And then the nice thing about the one week on, one week off is it actually reduced the strain on the teams. As you can imagine, anybody that worked in a COVID unit two weeks on, two weeks off is a long way to go. There were other teams that certainly went longer than that. But this one week on, one week off model really worked well for us. They called it the bullpen model. And so for us, all of our cardiac related COVID patients and some others even went to one unit in the Ross Hart hospital where we work. And so that unit, it was really interesting to see because what happened was we have a partnership with the prison system in Ohio. And so as those patients came in to our floor, we had a lot of prisoners and a lot of guards on the same floor together. And there was a lot of concern about that. And so they actually ended up bringing in a national guard and they had a national guard, national guardsman stationed in our unit and around the area just because of how many prisoners and guards we had on one unit together. And so it just added this whole another layer of surrealness. So when you walk down onto the floor and everybody's in their COVID gear and all the PPE, and then you have these armed guards and their PPE there. And as well as prison guards sitting outside of some of the patient rooms, it just was a surreal experience to go through. But the team rallied together really well and did a great job supporting the patients. So for us during our first wave, we had about 150 patients in house at one time. I think we went just over 150. We had about six to eight patients on ECMO at any given time and the majority of these were COVID positive patients. However, during the second wave, it was a little bit different. We actually had more patients in house over 200. But we'd see about the same number of six to eight patients on ECMO at any one time. And the reason for this was that our teams had really learned how to treat these patients in a better way than what that first wave when really nobody knew how to treat these patients and what was the best path to take for them. And so as we got better and caring for these patients then we were able to avoid ECMO. Again, it's not always about just getting a patient on ECMO. So we're able to avoid ECMO on some of these. And so we saw a different mix in the next time around where we did have some COVID positive patients but we also had to oppose COVID patients and of course your typical ECMO patients that you normally support. In Ohio, they divided Ohio into four zones. And so any patient in a given zone would go to a tertiary hospital and we were that hospital in zone two in Ohio. And so we did get some transfers as a result that way. And then I wanna talk about operational challenges of just having an ECMO program and what you're utilizing. As you know, any foreign surface presents challenges with clot formation. The question is, does the design of what you're using reduce or increase the likelihood of that happening? We know there has to be a need for external monitoring on some systems with the saturations, pressures, temperatures and such. And I consider that like a necessary evil because it adds clutter to the system. And I'll talk a little bit more about that here in a minute. But for us, we were looking for a solution that reduced the likelihood of thrombus formation. And then hopefully as a result reduce the oxygenary changeouts, staff exposure to the blood, risk to the patients and such that goes along with that. And then we're hoping to find that integrated monitoring for a cleaner circuit. And so when Medtronic and MC3 approached us about this novelist, we jumped at the opportunity. You know the old saying a square peg does not fit in a round hole. Well, having this round design fits with what we see in a patient's vasculature, fits with what we see in our own circuits that we use. And so it's just that natural design that you would expect. It does have the same transverse flow path that we like that has that lower pressure drop. It has a minimal surface contact. But that circular profile I think really makes a difference. And it's not just the circular profile of the membrane itself, but it's the design changes on the inflow and the outflow. As you look at it here, you'll see the inflow is actually lower than the outflow. And that allows the blood as it comes in to pass up across the membrane's face. And it has filling veins that then help with the spread out across the entire face. So you hopefully get that more even crossing of blood across the membrane. And so that reduces the velocity of blood going across right at the lower portion of the oxygenator, maybe leaving some areas of stasis. And those filling veins, again, help it spread out so you get that whole distribution across the face. And then you have the interactive display. That touchscreen is really nice. You see all the different parameters that are monitored here. You got the inlet pressure, the outlet pressure, and the inlet saturation and outlet saturation along with the temperature. And then you got the delta P between the two pressures. All of these, you can touch the parameter that's showing and it will bring up the menu underneath it that has the different parameters that you can set for the alarms. So you determine what your high alarm limit is, what your low alarm limit is. And then in the center of the screen, you have the saturation calibration button that you can hit to store values and then calibrate the saturation and then put in a hematocrit range that it's within. And so it's a really nice and simple system. It's actually very intuitive to use. If I didn't give you a class on this and I just gave this to the average profusers, they would be able to go in here and figure this screen out in no time at all. What I really like about it is along with this interactive touchscreen that's very intuitive to use is you have that same performance predictability. You have that, we have a simplified circuit now which has allowed us to streamline our workflow. And what I mean is that without the extra lines and saturation lines and temperature lines and whatnot is it allows you to streamline that workflow. You don't have to add all these things to it as you're building it. And so the priming process is actually much faster. And then you do have that performance durability. So for us, I really think this picture does a lot. It really speaks a lot to how our circuit has changed in utilizing the smart Nautilus. So we have a cleaner system. When it comes to having a cleaner system, think about transporting a patient to CT through those crowded hallways or ambulating a patient around a unit and going in and out of the different things that are sitting in the unit. Personally, I would rather do it with a cleaner circuit than with a cluttered circuit. And so when you look at it, the one on the left and the equipment that we've been able to get rid of the saturation monitor is gone along with the fiber optic cables which have a mind of their own and like to stick out and grab things. And then the cells that they connect to which reduces a connector in a circuit which is always a good thing. We were able to reduce or I'm sorry, remove our recirculation line that we'd run off the top of the oxygenator and then back pre-pump so that we could help reduce stasis there. And we're able to reduce the pressure monitoring the pressure dome and pressure lines that we had on it as well since all that is now integrated into the oxygenator itself. And so when you look at the one on the right versus one on the left, it's a much cleaner system. One that I feel more comfortable transporting through the hallways in the hospital. The other thing is the indicator bar. It does give you that assurance at a glance. The status bar was not a feature that swayed us when we were looking at it. In fact, I didn't give it a second thought when they talked about it but after we had used it especially during the COVID pandemic during the worst part of it and talking to some of the nurses and intensivists on the floor some of them reflected about how when they would walk by a room and they look in and they see that green glow just gave them that assurance at a glance that this wasn't a patient that they had to worry about right then. Yeah, sure they're gonna come back and they're gonna round on that patient and take care of that patient. But when you were going from one fire to another putting them out going by a room and seeing that green glow knowing that all the parameters are within those that you said was actually reassuring to them. So I actually turned into a nice little extra positive that I didn't expect. And so now that I've told you about the status bar and what that's meant to the team I didn't want to kind of walk you through the slide and some of the things that we've experienced while using the Nautilus. So what you see here is actually the ready screen. We like to use a ready screen when we're getting ready to initiate ECMO with the Nautilus. And what this does is it allows you to see all the parameters underneath the screen that are active at the time but they won't be alarming. So when you're getting ready to initiate you don't want those alarms active and have it going off. And so this is a way that you can still see what's going on with the oxygenator but you don't necessarily have those active alarms. Once we initiate you simply press and hold the play button that you see there for about three seconds and that will activate the screen and then activate all the alarms in their preset mode. This is a typical screen that you would see during normal operation. And one of the nice things is when it comes to these pressures there is no going in and having to zero them. They come pre-zero from the factory and they stay that way. And so this delta P that you're seeing here this has been a very typical delta P that we have seen. In fact, a lot of times at initiation we see it even lower than this. And honestly I can't recall yet seeing a delta P over 30. The other thing you'll notice is in the bottom left hand corner you have the auto rotate screen. So when you press that button it will automatically flip the screen. So depending on which side you're looking at it from you can change that. And then even in the bottom center it's showing that right now that this oxygenator is plugged in to the wall power. However, if you're going to be ambulating transporting the CT to the OR or whatever you might be doing when you unplug it from the wall then you'll see that battery indicator light up and it does alert you if you get down to 25% of battery life and it will have that yellow that status bar will change to a yellow status bar in that situation. And this is an example of an oxygenator with that alert going off. So in this situation the status bar that's yellow will be flashing and then the parameter that's affected will also be lit up and you'll have an audible alarm. And this is a nice bright indicator light. So you can actually see this from across the room even out at the nurse's station if somebody had stepped out for some reason. And this one's really easy to diagnose. You got a low outlet saturation. And as you can see right to the right on the right side of the screen is the oxygen line has been disconnected. So let's say you're ambulating the patient and somehow that gets bumped and disconnected and you're gonna have that alert right away that something's not right here. And it's good that during ambulation with that battery backup that you do maintain the saturations of the pressures of temperatures all the parameters that you're monitoring you don't lose any of that during ambulation or transport. And then finally I just wanted to show you a screen where that one of those parameter windows is opened up and in this situation we are weaning the patient.  And so we also found that very beneficial. And then as far as our experience with the Nautilus so far we have supported 24 patients to date. Our longest duration of support was 21 days. Our shortest duration of support was just four days. And that gives us an average of about 9.75 days or almost 10 days. We have changed out two Nautilus. One was due to a suspected gas transfer by the clinical team. However, the new oxygenator that was changed out to did not improve performance and investigation did determine that the oxygenator was functioning normally. We also did change out one Nautilus for thrombus buildup. Like I said, it doesn't matter what the foreign surfaces eventually you're gonna have thrombus buildup. And in this case, it was a VVECMO patient who was not on Heparin throughout the duration of the support. And after 14 days on support we did have that increasing thrombus formation on the oxygenator. It should be noted when we drew a pre and post gas it was functioning properly. So it did have a PO2 greater than 300 saturation was a hundred percent still. But what we were seeing was that the lactate was steadily increasing and had gone up several hundred just over the course of a couple of days. So the decision was made to change out that oxygenator in that case. One thing I'd like to add is when you have a major ECMO program especially or really any ECMO program it's really important to recognize the staff. This is a very labor intensive and resource intensive modality that's being offered to these patients. And so taking the time to recognize them is very important. What you see here was a slide that we had that we used during a 10 year recognition lunch and that we did for the team. And we really made it a point to highlight a lot of the different team members and people who have contributed to the program over the years. And we also made sure to highlight those patients that have been really good success stories. Any ECMO program is going to have some rough bumps along the way. Some of those bad outcomes that you don't want to have but they're unavoidable. So it's really important to some of those saves that you really had that were really just amazing saves. It's really important to highlight those and remind people just what it is that you're doing. So before our reaction was kind of like that young child turning around running back out when someone would mention ECMO what would be our reaction now? It's actually more something like this. This isn't to say that we're some sort of superhero program that we're some sort of superhero ECMO institution. It's just that before when we were unsure and uncertain and we didn't want anything to do with ECMO now we actually have that confidence. We actually have that skill set that we know that we can go into any patient situation whether they're getting chest compressions or whether it's just an emergent placement of some sort, we can go in there and we can actually successfully place ECMO in these patients and we have that confidence that we're going to be able to do so with the team that we have around us. And so with that I just want to say thank you and go Bucks.


We know from special relativity that mass can be converted to energy and vice-versa, and we know from quantum mechanics that light comes in energy packets called photons, where the energy of a photon is just planes constant times the frequency of the light. And what that means is that light can be transformed into matter and vice-versa. There are still lots of conservation laws that processes have to follow. For example, momentum still has to be conserved. An energy, even though it can be transformed to and from mass, the total energy still has to be conserved. What's more, the charge still has to be conserved. And in fact, we know about several other conservation laws as well. And so one of the more common ways that light can turn into mass and vice-versa is a very simple process called pair production. It's simple because what you have is you have a photon coming along, a little piece of light, and it turns into two particles. And one of those particles is an electron, and so it's going to go off at some momentum, and the other particle from the conservation of charge has to have the opposite charge, and it's going to therefore be a positron. And it's going to travel off with some momentum. And overall, the total momentum, the total energy, and the total charge has to be conserved. Let's look at the energy. So beforehand, we have the energy of one photon, which happens to have the Planck's constant times its frequency as its total energy, and we know from special relativity the energy of a charged particle. It depends on, so let's do the electron first, it depends on its mass. We'll call that M minus, and in fact, it also depends on momentum. So it'd be E equals MC squared if we had no momentum, but with momentum, it's going to be plus its momentum, squared and C squared in there. And because I've used that in my equation, I better put it on my diagram, so I remember which symbol I'm talking about, and I'm going to have a P plus, different momentum down there. And so the energy for my positron is going to be... Now I can write down the conservation of energy from here, E plus, and I guess this E, we might call it, we'll give it a subscript lambda to make it look a little bit like the energy of the photon. All right, and so we could solve that in various ways. And it turns out, because you need to have at least, even if you have absolutely zero momentum coming out of the end, so even if these are zero, you still have to have an awful lot of energy to make the mass of the particles. So you need a very high energy photon in order to make a pair of particles. And then any excess energy can go into the kinetic energy of the particles, and they can fly off with some momentum. It's common misconception that photons don't carry momentum, they do, and so that photon carries a bunch of momentum, and the momentum of the photon turns into the vector sum of the momentum of the two particles once they're created. And so it's just normal conservation momentum, the way you would do it with vectors. And the energy is, of course, conserved in the way we wrote down there. And all of this process can work backwards, so you can take a pair of particles, and they can come together to make a photon, and that's called pair annihilation.