The topic that we will be looking into today is inhalation sedation also known as conscious sedation or moderate sedation. This will be the contents we will be covering it under. Now as we all know sedation is one of the most commonly used pharmacological behavior management techniques which comes under extremely handy for dental procedures, extremely handy especially for pediatric behavior management. Now on the screen what you can see is the spectrum of pain and anxiety control because all the agents that we use for sedation do not produce the same level of pain and anxiety control. Different agents produce different depths of sedation. Now as you can see in an increasing order on this side of the spectrum comes the conscious sedation agents that is Ayurvedic sedation, hypnosis, local anesthesia, oral or rectal sedation, nitrous oxide etc. Whereas methods such as general anesthesia, tracheal intubation etc. They come under the unconscious side of the spectrum. Now the AAPD has defined certain goals of sedation in the pediatric patient for diagnostic and therapeutic procedures. So any form of sedation used should ensure that you are used to guard the patient's safety and welfare, to minimize physical discomfort and pain, to control anxiety, minimize psychological trauma and maximize the potential for amnesia, amnesia in the sense that the memory of the procedure that is any memory that the child retains during the procedure is not significant and the child is able to forget it to prevent the trauma from it. Control behavior and or movement to allow the safe completion of the procedure, return the patient to a state in which safe discharge from medical supervision as determined by recognized criteria can be done once the procedure is completed. Now moderate sedation or conscious sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands or light tactile stimulation. Now nitrous oxide is one of the most commonly used agents for inhalation sedation to produce conscious sedation. Let's have a look into the history of nitrous oxide. This was, nitrous oxide was first synthesized in as early as 1722 by John Priestley who described it as deflogisticated nitrous air. In 1794 what was hired by Beddow's to invent a machine which was capable of producing this nitrous oxide and they called it fictitious airs. In 1790 Humphrey Davy was the first one to refer to nitrous oxide as laughing gas. So owing to the effect of euphoria that nitrous oxide gas tended to produce, during the 1820s laughing gas was majorly used as a source of entertainment during parties or celebratory gatherings. In one such party Dr. Horace Wells saw that a man who was under the influence of nitrous oxide though he hurt a store did not feel any pain and this got him interested in the effect of nitrous oxide that it may lead to pain control and this effect can be used in dental procedures as well and hence Dr. Horace Wells used it, tested the effect of nitrous oxide in a procedure of molar extraction. Similar to nitrous oxide other agents, anesthetic agents have been considered for the conscious sedation which include either and a volatile agent named chloroform however in 1864 the American Dental Association officially recognized Dr. Wells as the discoverer of nitrous oxide and they confirmed that nitrous oxide can be used as an analgesic or anesthetic. So what are the ideal requirements of an inhalation agent? The agent should be rapid and have a rapid and pleasant induction and also the emergence from anesthesia should be very quick. It should have rapid and easily identified changes in the depth of anesthesia so that the safety margin can be maintained. It should lead to adequate relaxation of skeletal muscles, there should be a wide margin of safety, there should be absence of toxic or any other adverse effects at normal doses, high degree of specificity of action should be there. It should be easy to administer and it should be useful for all age groups. Objectives include as we saw under the gold sedation earlier to reduce or eliminate anxiety, to reduce untoward movement and reaction to dental treatment, to enhance communication and patient cooperation, to raise the pain reaction threshold, to increase tolerance for longer appointments, to aid in treatment of the mentally or physically disabled or medically compromised patient, to reduce any possible gag reflexes and to potentiate the effects of sedatives. Now in what kind of patients is inhalation sedation or conscious sedation indicated? It is indicated in fearful and anxious patients. In certain patients with special healthcare needs where you cannot carry on a procedure normally because of any untoward movement that can cause disruption of the procedure and can lead to injuries in the child. It can also be used even if the child is cooperative but however the procedure is going to be extremely lengthy where the child can turn potentially uncooperative. It can be used if a patient tends to have a lot of gag reflex which can interfere with dental treatment. Can be used in a patient for whom profound local anesthesia cannot be obtained. There are some relative contraindications for the use of nitrous oxide sedation. It is contraindicated if there are some chronic obstructive pulmonary diseases. Severe emotional disturbances or drug related dependencies if you see any such potential trends in the patient then of drug dependency or emotional disturbances then it is such sedation inducing agents are best avoided. It is also best avoided during the first trimester of pregnancy or also in methylene tetrahydrofolate reductase deficiency. This is because of the pharmacodynamics of nitrous oxide then or if the patient has had any recent illnesses such as cold or congestion that may compromise the airway it is best to postpone the procedure till the airway is completely clear. Now this is how nitrous oxide is synthesized this is the reaction when ammonium nitrate is heated at the temperature of 240 degree Celsius it disintegrates to nitrous oxide. So some of the common impurities that can be found in the agent is nitrogen, nitric oxide, ammonia, water and carbon monoxide. So nitrous oxide is compressed in stages so that the less liquefied gases are separated and then it is compressed and stored in metal cylinders. So once it is stored in the cylinder 30% of the nitrous oxide in the cylinder is present in a liquefied form. The physical properties of nitrous oxide include that it is non-irritating and sweet smelling colorless gas it gets converted to a clear colorless liquid at 28 degrees. It is stable under pressure and it is marketed in cylinders as liquid under pressure. It is relatively insoluble. Now this is a comparison of nitrous oxide that is inhalation sedation. As you can see here compared to other agents. You can see that the onset of action is much lower, the peak action sets in much earlier when compared to other agents such as oral rectal IM or IV. Duration of action is fixed in all the other agents the duration of action is fixed whereas the advantage of inhalation sedation is that the duration is variable and it can be controlled depending on the amount of sedation that the dentist is using. The recovery time is also extremely low so the effect of the sedative can be reversed almost as soon as the procedure is completed. And one of the main advantages of inhalation sedation is that titration is possible. Titration is possible in the sense that we can control the amount of the agent that we are introducing into the body of the patient. This cannot be done in oral rectal or IM form sedation. Other advantages include that the patient can be discharged from office following procedure with no prohibition on any activities. They will be completely normal once the effects are reversed. There is no injection required because it is given through a nasal hood through inhalational means. There are no adverse effects of drugs on liver, kidneys, brain or CVS. There are no effects. It is completely reversible. Nitrous oxide can produce analgesia when given in sedative concentrations and nitrous oxide is eliminated from the body within 5 to 10 minutes after discontinuation of use. This summarizes the advantages and advantages of nitrous oxide. Rapid onset of action, titration is possible, depth of sedation can be altered, duration of sedation can be altered, rapid recovery rate once the procedure is done, no injection required. It is extremely safe and has very few, if any, side effects and it can be used instead of local anesthesia though it is not completely recommended. However, the disadvantages include weak potency. The angiolices and analgesia produced by nitrous oxide is definitely not comparable to some other agents like IVIM or general anesthesia for that matter. Significant dependence on psychological reassurance, interference of the nasal hood with injection to anterior maxillary region because the nitrous oxide will be supplied using a nasal hood which will be sitting on the nose. If there are any procedures that have to be done in the maxillary anterior teeth, it may make it a little tricky. Patient must be able to breathe through the nose and cooperation is required. Nitrous oxide pollution and potential occupational exposure, health hazards are possible and initial cost of equipment is high and the equipment which we will be looking at also occupies considerable space. Nitrous oxide is said to have analgesic properties, angiolytic properties and also amnestic properties. Now these are some of the properties of characteristic features of nitrous oxide. First is the concentration effect. This occurs when high concentration of a gas is administered, higher the concentration of the gas inhaled, more rapidly the arterial tension of the gas increases that is known as the concentration effect or the and next is the second gas effect. This refers to the rapid uptake of the second inhalation agent administered following nitrous oxide so if at all nitrous oxide is used for induction of sedation, the second gas effect should be kept in mind because this influences the rapid uptake of the second inhalation agent that is introduced after this. Now one of the most important features this is called as diffusion hypoxia very important. So on the termination of procedure what happens is the nitrous oxide that has entered the lungs once the procedure is terminated and you switch off the supply turn off the supply of nitrous oxide it diffuses out of the blood very rapidly and gets eliminated. So nitrous oxide now escapes in alveoli which from the alveoli in such rapidity that oxygen becomes very diluted and oxygen carbon dioxide exchange is disrupted creating hypoxia. Because of this rapid elimination there is a disruption in the normal oxygen carbon dioxide exchange that takes place during the within the alveoli and this leads to lower levels of oxygen causing diffusion hypoxia. So what do we do to avoid this usually once the procedure is done the patient should be flushed with 100% oxygen for the first few minutes following discontinuation and this can lead to avoiding diffusion hypoxia. Now coming to the pharmacodynamics of nitrous oxide, nitrous oxide is very less potent anesthetic. So the drug potency is usually determined by minimum alveolar concentration. So minimum alveolar concentration is defined as the alveolar concentration of an anesthetic at which 50% of patients fail to respond to a standard surgical stimulus. Now the MAC for nitrous oxide is 104 to 105%. This shows that the potency is very less and hence the safety margin for the use of this drug as an anesthetic is extremely high. However, nitrous oxide alone is not able to produce very profound anesthesia. Now what are the effects of nitrous oxide on different organ systems? On the central nervous system it increases cerebral blood flow, cerebral metabolism and intracranial pressure. When administered in conjunction with physiological levels of oxygen, nitrous oxide produces very mild depression of CNS. On the CVS, nitrous oxide causes direct myocardial depression but increases central sympathetic outflow but no significant changes in heart rate or cardiac output are seen. Respiratory system, nitrous oxide causes a decrease in the tidal volume and an increase in the respiratory rate. Now coming to the preparation and setup for sedation procedures. Now any sedation procedure for that matter and we are here talking about the inhalation sedation procedure. These are the main important things that you need to remember. So this can be remembered using the acronym SOAPME, S stands for Suction, O stands for Oxygen, A stands for Airway, P stands for Pharmacy, M stands for Monitors and E stands for Equipment. So one needs to make sure that this checklist is thoroughly ensured before beginning any sedation procedure. Now coming to the armamentarian, the two kinds of units are available for the supply of nitrous oxide for sedation. One is the continuous flow unit and another is the intermittent flow unit. The continuous flow unit delivers continuous flow of the gas regardless of the respiratory pattern of the patient and the intermittent flow unit does not deliver gas continuously but varies the rate and volume according to the patient's respiratory demands. So if the patient's respiratory rate is changing, the intermittent flow unit varies the supply in accordance whereas continuous flow unit constantly supplies the same amount. There is a larger margin of errors in the intermittent flow unit when compared to the continuous flow unit. These are the portable unit and portable unit which can be moved across the clinical area and the central storage unit. Now coming to the compressed gas cylinders, gases are dispensed at a pressure greater than 25 pounds per square inch at 25 degree Celsius. It is very important to keep grease and oil away from the cylinder and the cylinders can be manufactured in various variety of sizes and then the one important thing to remember is the color coding of the compressed gases. So this color coding is international and it is standardized so that there is no mistake in the gas that is supplied. For example, oxygen, the color coding for oxygen is, the international color coding of oxygen is white, it is green only in the US. Nitrous oxide is light blue, nitrogen, gray bottom or in shoulder, carbon dioxide is gray whereas helium is brown. So this color coding ensures the, is one of the safety measures. Then coming to regulators or reducing valves, this is located in between the compressed gas cylinder and the flow meter. So this regulator helps us in regulating the pressure of the gas that is coming out of the cylinder before it is supplied to the patient. So it reduces the high pressure of gas coming out of the cylinder to one that is safe for the patient and the sedation unit. Then comes a yoke assembly. This yoke assembly holds the compressed gas cylinders tightly in contact with the portable sedation units. The metal pins located on the yoke assembly constitutes the pin index system. We will be looking at this a little later. Now coming to flow meters, this permits the administrator to deliver a precise volume of gas to the patient. The calibration of the gas, of the nitrous oxide and oxygen gas that is supplied can be seen on the calibrated flow meters. It is either digital or analog. So you can control the concentrations that can be used. Now this is the reservoir bag. This is made of rubber or silicone and the capacity of the reservoir bag that is commonly used in dentistry is a 3-liter bag. Its function is that it acts as a reservoir from which additional gas can be drawn. And if at all the patient's respiratory demand exceeds the delivered gas flow, there is a buffer of gas that is maintained within the bag. It monitors the device for respiration, means of providing oxygen during assisted ventilation. Then the conducting tubes. These are the conducting tubes. So it connects the reservoir bag to the nasal hood, a variable in length. It can either have a large diameter or it can be corrugated. That is the inner tube can be corrugated which prevents the occlusion of the lumen. It is attached through non corrugated tubes to the nasal hood. Now this is the nasal hood through which the gases introduced to the patient's respiratory system. It is designed to fit comfortably and securely over the nose. There are two types, the scavenging hood or the traditional hood. Scavenging hood has a smaller inner mask and a larger outer mask. The outer mask is connected to the suction device. This minimizes nitrous oxide contamination. This is a schematic diagram that shows the structure of the nasal hoods. Now this whole unit, this whole sedation unit, nitrous oxide sedation unit has certain safety features that ensure that there is no margin of error that can lead to any disruptions. These are the safety features that are important to remember. One, it is the pin index safety system. This consists of a series of pin configuration for each gas on the yoke and matching series of holes on the gas cylinders. So now for example if you attach a different cylinder for a different cause that would be extremely dangerous. To ensure that this interchange of cylinder does not happen, each particular yoke assembly has an index system that is unique to that particular gas alone. And so only that gas cylinder can be attached to this pin. For example, the pinhole system in oxygen will be completely unique to oxygen alone when compared to nitrous oxide. So you cannot by mistake attach a nitrous oxide cylinder in place of a oxygen cylinder. This is how the pin index safety system is designed. Next comes the diameter index safety system. This is with respect to the diameter. That is the diameter of the coupling differs. Nitrous oxide coupling is larger than the oxygen one. Hence again the interchanging of cylinders is not possible. Minimum oxygen liter flow. In most units a preset minimum liter flow of oxygen through the flow meter. 2.5 or 3 liter per minute is ensured. So nitrous oxide flow cannot start until a flow of oxygen has been established. Without oxygen, without a minimum amount of oxygen being introduced, nitrous oxide sedation cannot start. So this is a minimum oxygen liter flow safety feature. Then again is the minimum oxygen percentage. So minimum oxygen percentage that is required to be delivered along with nitrous oxide is 30%. So 70% is the highest amount of nitrous oxide that can be supplied because without 30% the oxygen level cannot go below 30%. And the insurance of this it allows for error in calibration of flow meters. Then the oxygen fail safe. This is if it prevents administration of 100% nitrous oxide. So if the oxygen cylinder becomes empty by any chance, this oxygen fail safe mechanism ensures that the nitrous oxide supply is immediately terminated. It does not continue. If the oxygen is empty. Then comes the emergency air inlet. It is located above the reservoir bag. If flow of gas ceases or when oxygen fail safe is activated, this inlet opens allowing the patient to breathe comfortably. Next is the alarm. It is attached to the oxygen fail safe system. If any disturbance is there in the gas flow, this alarm goes off and alerts the operator that the gas flow is disturbed. Next is the oxygen flush button. Permits delivery of high flow of oxygen delivery to the patient. It is very advantageous during emergency situation. It automatically stops the nitrous oxide delivery and delivers 100% oxygen flush. Then the reservoir bag as we saw before reservoir bag acts as a buffer and it also ensures that the respiratory rate of the patient is fine. Colour coating. This also we saw before different gases have different colour coded cylinders. Quick connect delivers positive pressure of oxygen and the lock. This is included on protective caps of cylinders. So this lock cannot be opened in any simple ways. This prevents the misuse of nitrous oxide. Coming to the pretreatment instructions. Introduce the patient to inhalation sedation by giving proper instructions to instructions and explanations to the patient and parents. Discuss benefits gained by the patient and operator. Familiarize the patient with the procedure to relieve any fear and anxiety. Use open-ended statements. Pre-operative antibiotics and anti-anxiety drugs can be used if necessary. Heavy meals should be avoided before the procedure. Technique of administration. Position the patient in a comfortable recline position. Sedation unit should be positioned behind the patient out of the line of sight of the patient. Select and place the appropriate sized nasal hood over the nose. It shouldn't be too big or too small. It shouldn't be uncomfortable. And also very important to remind the patient to breathe through his nose. Secure the nasal hood by adjusting the slip ring behind the headrest. Determine the flow rate for the individual by asking the patient if he is able to breathe comfortably. Then observe the reservoir bag to observe the respiratory rate of the patient. Then begin titration of nitrous oxide. To begin with, administer 20% nitrous oxide for 60 to 90 seconds and look for signs and symptoms of the sedation. Observe the patient. If initial concentration of nitrous oxide is inadequate, increase the nitrous oxide levels in 10% increments only. You administer 20% first, then you test the signs and symptoms of the patient whether any appropriate level of sedation is achieved. If not, increase it in 10% increments only. Then what are the signs and symptoms that you test for in the patient? Ask for signs and symptoms like lightheadedness, a tingling sensation, warmth or heaviness. Sensations of warmth or heaviness indicate that the patient is approaching the desired level of sedation. Now this table summarizes some of the symptoms and signs that you see depending on the level of sedation that is achieved by nitrous oxide. In early to ideal sedation, you see lightheadedness, tingling, wave of warmth, feeling of vibrations throughout body, numbness of hands and feet, numbness of soft tissues, euphoria, lightness, etc. Heavier sedation, it can cause hearing, especially if distant sound becomes more acute. You get a very acute sense of hearing, sleepiness, sweating increases, laughing or crying, dreaming or nausea. And over sedation causes nausea or loss of consciousness. In the beginning of dental treatment, patient appears relaxed, continued titration till optimal sedation is achieved, continue to observe the patient and inhalation unit during the procedure. After completion of treatment, nitrous oxide flow should be terminated and oxygen should be returned to flow rate determined. And 100% oxygen is flushed for three to five minutes to avoid diffusion hypoxia. Then coming to the discharge of the patient, vital signs are recorded, patients' response to verbal commands are observed, modify neurological tests such as the trigger test for motor coordination. I use, the child can be given this and asked to connect the dots on the figure outlined immediately. This will help us in understanding if the child has achieved the desired level of motor coordination. Then once the discharge is done, cleanse the equipment, sterilize it appropriately. Now, coming to safety of pediatric patients, not advised to let child fall asleep under sedation. Make sure that the child is awake. Silent regurgitation is most engaging concern in this situation. So any form of regurgitation should be avoided. Maintaining conversation with child ensures protective laryngeal and pharyngeal reflexes are intact. It should be ensured that the protective reflexes in the child is intact. Parents are generally dismissed before procedure starts if child is three years or older. Some of the possible complications of this include inadequate or incomplete sedation, poor patient experience, equipment performance can be hampered. This can be prevented by routine inspection of the equipment. And in some cases, approximately 0.5% of cases it can cause nausea and vomiting, which is commonly due to over sedation or hypoxia or presence of food in stomach if the patient has had a very heavy meal just before the procedure. In some cases, nitrous oxide can displace air from the sinus. And this can cause tooth pain associated with sinus procedure. It can also be called vertigo because of prolonged exposure of the vestibular cochlear complex to differential air pressure. And in some cases can also cause Burwell discomfort. One main disadvantage of nitrous oxide is the potential occupational hazards that can be caused. There is a higher incidence of hepatic renal and urological disorders among the exposed personnel. Increased spontaneous abortions in chair side assistance and congenital abnormalities in their children have been reported. And inactivation of the methionine synthase enzyme, which is linked to vitamin B12 metabolism, has also been reported on prolonged and continuous exposure to extremely high levels of nitrous oxide. This summarizes the American Academy of Pediatric Dentistry guidelines that is specifically given for inhalation sedation or analgesia equipment that delivers nitrous oxide must have the capacity of delivering 100% and never less than 25% oxygen concentration. Equipment that delivers variable ratios of nitrous oxide to oxygen and that has a delivery system that covers the mouth and nose must be used in conjunction with a calibrated and functional oxygen analyzer. All nitrous oxide to oxygen inhalation divisor should be calibrated in accordance with appropriate state and local requirements. Concentration should be given to the National Institute of Occupational Safety and Health Hazards for the scavenging of waste gases. And newly constructed or reconstructed treatment facilities, especially those with piped in nitrous oxide and oxygen, must have appropriate state or local inspections for proper certification. Nitrous oxide in oxygen with varying concentration has been successfully used for many years to provide analgesia. The use of nitrous oxide for minimal sedation is defined as administration of nitrous oxide with the balance as oxygen without any other sedative, narcotic, or other depressive drug, or concurrent with the nitrous oxide to an otherwise healthy patient, that is, in ASA class 1 or 2. And the patient should be able to maintain verbal communication throughout the procedure. If nitrous oxide in oxygen is combined with other sedative medications, such as chloral hydrate, merazolam, or an opioid, or if nitrous oxide is used in concentrations more than 50% percent, the likelihood for moderate or deep sedation increases. In this situation, the clinician must be prepared to institute the guidelines for moderate or deep sedation, as indicated by the patient's response. The recommended discharge criteria are as follows. CVS function and airway patency are satisfactory and stable. The patient should be easily arousable and protective reflections should be intact. The patient should be able to talk. The patient can sit up unaided. For a very young or handicapped patient, a child incapable of usually expected responses, the pre-sedation level of responsiveness should be achieved. The state of hydration should be adequate. Some of the other agents that can be used for sedation are halothane, sevofluorine, and desferine. So inhalation sedation utilizing nitrous oxide oxygen has been a primary technique in the management of dental fears and anxieties for more than 150 years and remains so today. I minister properly with well-maintained equipment. The technique has an extremely high success rate coupled with a very low rate of adverse effects and complication. Its main advantage is it is tight-ribble. You can control the concentration of nitrous oxide that you are supplying. It is easily reversible and the patient can be discharged almost immediately with no complications. Thank you.


Because each patient is different, physicians make a careful evaluation before writing a prescription for hemodialysis. Selection of the dialyzer, blood flow, actual time delivered, dialysate composition, heparin monitoring, fluid management. These are all components of the dialysis prescription that have to be considered. The provision of an adequate dialysis is the major task of the entire dialysis team. Patient survival is dependent on this. The amount of dialysis given is measured by the urea clearance of the dialyzer delivered over a specific time in a patient with a specific volume. This is expressed as KT over V, which is measured regularly. An alternative to the use of KT over V is the urea reduction ratio, or URR, which is calculated by pre-dialysis BUN minus post-dialysis BUN over pre-dialysis BUN times 100. As the patient care provider, you must always supply a certain quantity of dialysis. The physician has carefully determined what that quantity of dialysis should be. The delivery of that prescription is your responsibility. The dialyzer used can reflect the patient's size to a certain extent, and the other option obviously is whether to use a conventional dialyzer or a high-flux dialyzer. The first important element of the hemodialysis prescription is the selection of the dialyzer. The dialyzer has two primary functions. The first is to remove toxins from the patient's blood. This is known as clearance. Clearance is defined as the amount of blood that is completely cleared of a particular solute in a given period of time. It is expressed in milliliters per minute. Usually the clearance of urea is used as the measure of the efficacy of a dialyzer. The dialyzer's second function is to remove water from the patient, a process called ultrafiltration. Ultrafiltration is the transfer of fluid between the blood and dialysate through the dialysis membrane due to a pressure gradient existing between the blood and dialysate compartments. The physician has taken a number of factors into account when prescribing a particular dialyzer, whether high-flux or conventional. These include membrane type, biocompatibility, surface area, clearance of various solutes, ultrafiltration coefficient, priming volume, reusability and cost. If dialysers are reprocessed, you must ensure that patients receive their own dialysers. The decision of the medical director to reprocess dialysers carries with it additional responsibilities for monitoring the delivery of the prescription. Every dialyzer must be properly primed according to the manufacturer's instructions and your facility's protocol to assure that all air, residual disinfectants or manufacturing residues are removed. Another important factor is assuring that the dialyzer has been connected properly to the blood and dialysate lines. To maximize solute clearance, the dialysate flow must be countercurrent to the blood flow. The dialysate flow through the dialyzer is directed upward during dialysis to prevent the accumulation of air bubbles on the dialysate side. When air bubbles are present, the membrane does not come in contact with the dialysate. Diffusion cannot take place and the efficiency of the treatment is decreased. Blood flow and dialysate flow must be set according to the physician's prescription to achieve the expected dialyzer clearances. All machines have a preset dialysate flow rate that cannot be adjusted. Your facility's quality assurance must make certain that the prescribed dialysers are being used, that the blood and dialysate flows are accurate, and that reprocessing is performed according to the AMI recommended practices, federal regulations, and your facility's established procedures. Blood flow is critical. With the kind of dialyses that are being prescribed in the United States in this era, the blood flow that is prescribed must be achieved. Blood flow is an essential component of the prescription since the dialyzer's solute clearance directly correlates with it. Adequate blood flow is dependent on the patient's blood pressure, condition of the access, needle selection, and needle placement. Check the vascular access, visually inspect, palpate for thrill and contour, listen for brewery, and observe for aneurysms. Look for areas of redness or drainage. Evaluate the access for direction of flow and clean and disinfect the access before placing the needle. Make sure that the needle gauge and length are appropriate for the blood flow that you're trying to achieve. Shorter needles with large internal diameters are usually preferable because they minimize resistance. Be sure you have achieved optimal placement of the needle by verifying a flashback of blood in the fistula needle tubing. Tape the needle immediately and check again for blood flow before attaching the blood lines to the corresponding needle. The prescription is based on the assumption that the blood flow is constant throughout dialysis. Try to achieve a constant, steady flow of blood through the dialyzer as quickly as possible. If the prescribed blood flow cannot be maintained throughout the treatment, the dialysis time may need to be extended. When blood flow from the vascular access is inadequate, there may be several causes. The most likely reason may be as simple as poor needle positioning, which may allow the bevel of the needle to rest against the blood vessel wall, restricting blood flow. Sometimes, personal items may obstruct the blood flow, or the patient may have shifted position. At times, even the tubing itself may kink, which could reduce blood flow to a significant degree. Blood pressure should be monitored frequently to assess the patient's condition. A drop in your patient's blood pressure could decrease the flow rate in the access, reducing the blood flow available to the extracorporeal circuit. If there is a pre-pump arterial drip chamber, observe the flow into the chamber at the initiation of dialysis, and again with each monitoring check of the patient and the equipment. This can be used as a good indicator of blood flow. Some facilities monitor the pressure with a pre- or post-pump arterial drip chamber. Other facilities may use a pressure pillow, and still other facilities may not measure the arterial pressure at all. When the pressure pillow collapses, or a high pre-pump negative pressure is measured, the patient's access is not providing the blood flow rate indicated by the blood pump setting. Patients should not be dialized at pre-pump negative pressures greater than minus 250 millimeters of mercury. High negative arterial pressures are associated with recirculation, blood cell damage, access damage, reduced blood flow, and small air bubbles in the extracorporeal circuit. High negative pre-pump arterial pressures that are not typical for a particular patient at the prescribed blood flow rates should be investigated. Whenever the blood flow from the patient to the dialyzer is reduced, the staff must take immediate action to determine the cause of the problem and do whatever is necessary to correct it. If the negative arterial pressure is not correctable by repositioning the patient's limb or the blood lines, the blood flow rate may have to be turned down or turned off if necessary in order to reposition the fistula needle or recanulate the access. If it is not possible to restore the blood flow to the prescribed level, the physician should be notified and a decision made whether to extend the patient's treatment time. Potential failure of the patient's vascular access can be indicated by greater difficulty in achieving prescribed blood flows, greater negative pre-pump arterial pressures, or gradually increasing venous pressure. Since these signs of impending access failure progress slowly over time, you should review your patient's previous treatment records to evaluate trends which indicate the possibility of access problems. If there are repeated problems achieving the patient's prescribed blood flow rates, it should be brought to the attention of the physician. Another frequent problem is recirculation of blood through the patient's access. Recirculation causes the effective clearances to be reduced. Recirculation may be caused by a partially occluded access or by improperly placed needles. This could include being placed too close together, pointing in the wrong direction, or actually reversing the arterial and venous connections. Recirculation studies should be performed to evaluate whether or not an access is failing. Some small amount of recirculation may be unavoidable and acceptable as long as the prescription takes this into account. In patients with fistulas or grafts, the patient's blood occasionally may appear darker than usual when recirculation is present. Blood routinely appears darker in patients with femoral or subclavian catheters because the catheters are inserted in veins, so the color of the blood is not always a good indicator of recirculation. Remember that dual lumen venous catheters are particularly susceptible to recirculation because the arterial and venous openings are so close together. It is not good practice to reverse the bloodlines to improve blood flow. This can greatly increase recirculation and could affect the dialysis prescription. Recirculation is far more common than many clinicians realize and should be suspected whenever the KT over V or URR results are lower than expected for the prescribed dialysis. Your facility's quality assurance must see to it that prescribed blood flows are being maintained throughout the treatment. It is important to monitor routine calibration of blood pumps and machine pressure gauges. It should also include observation of staff for compliance with facility procedures and in-servicing as needed. Even in the hospital environment, we would tend to concentrate on the time of treatment as being the critical factor. This is a little old-fashioned, but results in Europe have often shown this to be justified. The actual time delivered is a critical component of the dialysis prescription. This involves both the frequency of the dialysis treatments, how many times per week the patient comes in for treatment, and the length of time prescribed for each treatment. Simply noting the elapsed time from the start of dialysis to its conclusion may not be sufficient. If you analyze a patient's prescribed time compared to the actual treatment time, you may find that a significant number of treatments were shorter than prescribed. This raises concerns that the high mortality rate and morbidity of dialysis patients may be due to less than adequate dialysis prescriptions or treatment delivery. The most effective way to determine actual dialysis time is with the use of a machine clock that runs only when dialysis is taking place. Some machines visually display this number. The clock will not run when there are machine alarm conditions that cause an interruption in blood or dialysate flow. If machine clocks are not available, you should note the amount of time that the dialysis is not being delivered. Additional time should be added to the treatment to compensate for the interruptions. The shorter the prescribed treatment time, the more critical this becomes. There are many reasons for the dialysis treatment to be interrupted and you may have little or no control over these conditions. For example, if the patient moves and kinks the lines, this may result in an alarm condition that stops dialysis. Dialysis will also be interrupted if the temperature of the dialysate is out of limits, if there is a blood leak, if there is a pressure excursion beyond the set limits, or if the conductivity of the dialysate is either too high or too low. Any of these interruptions will decrease the actual time that the patient is dialysed. Richard, you have a taxi cab waiting for you downstairs. Occasionally, dialysis may have to be interrupted or terminated for medical, personal or other reasons. If this occurs, you must document these situations and when or if treatment resumed. You should remind your patients that they have a responsibility to arrive on time and to remain for the specified length of treatment. It's never acceptable to deliberately shorten the actual time of a patient's dialysis, either for your own or the staff's convenience. Surveys have shown that treatments are sometimes shortened at the end of the day or when facilities are closing for the weekend. There may be a tendency to take shortcuts knowing that your patient will return in a couple of days and that you can make up the lost time. However, making up lost time is not always possible. If treatment time is shorter than prescribed, the patient could develop serious complications. Therefore, a careful study of the actual dialysis treatment times should be a part of your facility's quality assurance process. A study of dialysis treatment times would include observing staff practices, auditing records to assure compliance, assuring the time is being measured and recorded accurately, and that interruptions of blood flow and or dialysate flow are noted and factored into the total time of dialysis. The outcome of a quality assurance process should be to consider these actions. Educating your facility's staff on the importance of dialysis treatment time, educating your patients in regard to their role, and when necessary, having the physician reevaluate the dialysis prescription. All patients expect and deserve the treatment specified in the prescription. It must be delivered consistently, accurately, and for the time required. When we decide the dialysis fluid composition, the purpose is of course to purify the uremic blood and to normalize the composition of blood, and we select the composition to do the job properly. Another important component of the dialysis prescription is the dialysate composition. The function of the dialysate is to balance the chemical composition of the body fluids. Failing to provide the prescribed dialysate can have serious adverse effects for the patient. First you must assure that the prescribed formula and type of concentrate are used. It is essential that the acid component of bicarbonate dialysate concentrate not be confused with the acetate concentrate or with the bicarbonate concentrate. It is critical that you take the time to read the labels on these containers. Use water that meets the AMI standard when mixing the powdered sodium bicarbonate into a liquid. The water should be at room temperature for the best mix with the sodium bicarbonate. Never shake the container as this releases the carbon dioxide. Remember the mixed bicarbonate dialysate should be discarded after 24 hours because of the risk of potential bacteria growth. For patients who need additives, you must verify that the appropriate additive formulation is prepared. It is also important to verify that the amount of additive used is appropriate to the dilution ratio of the concentrate and the volume of the concentrate container. Clearly label the container with the formulation, the date and time of preparation and the initials of the preparer. Make sure that the powder is completely dissolved. You must begin each session with enough concentrate to complete the entire treatment. The machine settings must be verified as correct for the dialysate prescribed for your patient. If the machine is equipped with a variable sodium option, it should be set for the prescribed dialysate sodium level. Also, if the dialysate flow rate can be adjusted on the machine, make sure that it is set as prescribed. It is the physician's role to prescribe the dialysate composition. It is your role to make sure that prescription is carried out. Remember that the dialysate chemical composition is equivalent to a medication with the same potential for harm to the patient. The general rule is to check and double check, then check again. It is essential that your facility have adequate quality assurance procedures to make certain that the dialysate is consistent with the prescription. This is accomplished by ensuring that the proper mixing of concentrate takes place. The necessary machine safety checks are performed prior to treatment. Routine or periodic preventive maintenance is completed and that adequate patient and machine monitoring are performed during treatment. The biggest problem with heparin in a maintenance unit is that individual patients' heparin requirements change from time to time, particularly as the seasons change. So it's necessary to monitor the effects of heparin so that you don't over-heparinize or under-heparinize. Heparin is the most common anticoagulant used in hemodialysis. The use of heparin prevents clotting of the extracorporeal circuit, including the dialyzer. Clotting is a serious problem because it causes a reduction in the available membrane surface area. This reduces the effectiveness of the dialyzer so that the prescribed amount of dialysis cannot be delivered. If partially clotted, the dialyzer clears fewer toxins and this results in reduced KT over V or URR if not recognized and corrected. Careful assessment of your patient's anticoagulation requirements is critical. Ongoing clotting studies should be done according to unit protocol to monitor the adequacy of heparinization. The anticoagulant can be given to your patient in a single systemic dose at the beginning of the dialysis treatment, or it can be given continuously with the use of an infusion pump or intermittently during the treatment following an initial bolus. With syringe pumps, verify that the correct syringe size is being used and that it has been loaded into the infusion pump according to the manufacturer's instructions. Each time you check your patient, you should record the dose of heparin that has been delivered. Choosing the wrong size syringe, failure to prime the heparin line or to turn on the heparin pump may cause an improper dose of heparin to be delivered. If there is concern about the dose delivered to the patient, the calibration of the infusion pump should be checked. If your patient suddenly shows unusual clotting characteristics, you should initiate actions to alleviate the problem. Talk to the patient and determine if there have been any unusual medical problems since the last treatment. Patients with an infection or fever often require an increased heparin dose to prevent dialyzer clotting. Sudden, isolated clotting episodes can occur in patients without acute illness and despite seemingly adequate anticoagulation. Other factors that can affect heparin requirements include drugs such as aspirin and other antiplatelet agents, warfarin and other anticoagulants, nicotine, digitalis, tetracycline and antihistamines, medical conditions including fever, infection, uremia, thrombophlebitis, myocardial infarction, cancer and liver disease. Patient characteristics that affect heparin requirements include differences in sensitivity, metabolic and elimination rates and platelet count and for female patients menstrual cycle. Characteristics of the dialysis system also affect heparin requirements including dialyzer configuration and flow geometry, membrane type, duration of dialysis, blood flow rate and blood administration. Inadequate air removal during priming can slow or stop blood flow in the individual dialyzer fibers. When fluid is ultra filtered from blood trapped by the residual air it causes the blood to thicken and eventually clot. This can occur even when heparinization is adequate. Medications like EPO increase the red blood cell production and therefore increase the hematocrit. Patients on EPO may require increased anticoagulation with heparin to prevent clotting of the dialyzer. Poor rinse back of the dialyzer may indicate that there are clotting problems. It is important that each possible cause of clotting be investigated and corrective action taken wherever possible. Frequent communication among all members of the care planning team is necessary to arrive at the best solution for each patient. Your facility's quality assurance should make certain that infusion pumps are being calibrated routinely but staff are adequately trained in anticoagulation procedures and that the therapy is being delivered as prescribed. Fluid management and fluid control becomes a problem and it's best managed by having the patient educated so that they don't gain so much fluid between dialysis. The final key element of the dialysis prescription is the patient's dry weight sometimes called target or ideal weight. Weight reflects the patient's fluid and nutritional status. For adequate fluid removal you must assure that the pre and post dialysis weight measurements are accurate. This accuracy is influenced by what clothing your patient is wearing at both weighings and the position of the patient on the scale. It is important that the patient is always weighed on the same scale pre and post dialysis. In addition the scale should be regularly calibrated. The dry weight itself needs to be reviewed on a regular basis since changes in body fat or muscle mass may affect this value. Also when malnutrition is present dietary protein needs may change. Careful determination of the amount of fluid to be removed during the treatment is very important. This involves compensating for the amount of fluid taken in by your patient during dialysis, the volume of fluid used for rinse back and or priming of the dialyzer, and IV therapy including medications, IDPN, and blood and blood products to be administered during dialysis. There are a number of patient considerations that influence fluid removal. Your patient should be assessed for his state of hydration including presence of edema, elevated or low blood pressure, jugular venous pressure, shortness of breath, and the nature of the breath sounds. After determining the amount of fluid to be removed or ultra filtered you must consider whether the patient can tolerate having this amount removed in the time period prescribed.  Blood pressure must be monitored closely during dialysis. Staff should respond quickly to changes in vital signs. Fluid is removed during dialysis by means of transmembrane pressure or TMP for short. TMP is calculated using the ultra filtration coefficient provided by the manufacturer of the dialyzer, the dialysis time, and the amount of fluid to be removed. TMP is set on the machine as either TMP or negative pressure. If your machine requires that negative pressure be entered it is calculated as follows. Negative pressure equals transmembrane pressure minus venous pressure. Many machines have automatic control of the UF rate so the TMP is a monitored function. UF control machines will calculate the hourly ultra filtration rate needed only if the total fluid to be removed and dialysis time are entered. In both cases this must be monitored throughout the treatment and adjusted if the patient's condition changes. If there is an interruption of blood or dialysate flow the ultra filtration plan may need to be modified. Routine equipment safety checks should be performed before every treatment according to the manufacturer's instructions. Your facility's quality assurance should make certain that target weight losses are achieved. This includes a determination that the scales are properly calibrated, that TMP or negative pressure are correctly calculated, that ultra filtration controls are functioning, and that the staff receives training in fluid management. This program was designed to give you a better understanding of the components of a dialysis prescription, how the physician determines what prescription is needed, and most importantly that you, the patient care provider, play a key role. The delivery of the hemodialysis prescription is your responsibility. I think it's very important for the nurse or technician delivering the dialysis to understand what we're doing, why we're doing it, and to be aware of the need to follow the prescription accurately. Our nurses must be very good at not only carrying out a prescription written by a physician, but also in using their own judgment in, is this something that will meet the need of my patient. It's very important for the staff to know that every aspect of the prescription, such as blood flow, time, and the things we mentioned earlier are critical to a patient receiving adequate dialysis and there could be no shortcuts in the process. I think that the most important thing is that they all work together. The doctors who wrote the prescription, the nurses will deliver the prescription and the patient that will receive the prescription. The three of them must work together. A very good facility really needs to be doing everything right. From properly treating the water that's coming into the facility, mixing the dialysate, maintaining the machines, having well-trained staff to care for the patients, and of course providing excellent dialysis. This is their life and their help and they're very anxious about it and so we should take them seriously as individuals, deal with their anxieties, deal with their individual characteristics, and remember that this is a social interaction as well as a physical and medical one. There is a lot that we can be proud of in dialysis, in that almost every patient who needs it gets treatment. But I think we have a way to go before we maximize the technology we have available and the information we have to make sure that every patient gets an adequate dialysis and that adequate dialysis is delivered reproducibly.


All this forgiveness is divine, is a divine gift. God gave it to us not because he needs it, but because we need it. This workshop comes from a lot of different books and comes from a lot of different learnings and a lot of, you know, I study Kasi Dude. And, but online there's something called Radical Forgiveness and he has worksheets there for free and there's a book about it which I like the book because it gives you exercises and online there's also something called The Work by Byron Katie and it's about how to transform judgments and it's also free. B-Y-R-O-N is our first name, believe it or not, Katie, K-A-T-I-E. Those are just two websites that I know. If you almost put anything into Google today, you can find something to help you with almost anything. It's not the same as having a therapist. But you know what, there's a lot of self-help books sucked. It's not the same and I think people are becoming much more aware that you don't have to take a pill to heal because it doesn't really heal but it helps you deal with the symptoms of your overwhelming depression or anxiety but it doesn't heal the underlying cause. I wanna first of all thank Julius and Claire and Jews for Judaism for really helping me be here. I'd like to thank Rahul Marmer for providing the space from Sharj Fila and I would like to dedicate this class to my nephew Rahul's brother Shlomo Ben-Abraham who passed away at a very young age and may his memory be blessed and may he have an early young Shema from this. So and along that line, today the goal is to put Hashem in the picture. And I just wanna share a brief personal story about how putting Hashem in the picture helped me go through a place from moving from the lower self to the higher self. My son passed away 15 years ago and the story isn't important but you can imagine that it's very painful. When there's pain, it's very easy to fall into the lower circle and look to who's to blame. So I could have very easily gone into blaming others, very easy or as easy to blame myself. That would not have helped my pain, my grief or my mourning, all it would have done is added to the pain. So by bringing Hashem into the picture, it helped me go into a place of acceptance and moving on in my life. And you know there are people who lose a child that they're never the same again. They lose light, love, joy. Their life is gone because they end up living from the lower circle. By bringing Hashem into the picture, God into the picture, you can transform anything. You can work on acceptance. Reality is God's will. Nothing can exist out of God's will. When you know it's God's will, who are you arguing with? He created you. He created the world. He created your enemy. He created death. He created every single challenge, every single illness. It doesn't feel good. It doesn't look good. It doesn't smell good. You don't wanna embrace it. You don't say, oh, I'm so happy. I'm never gonna say I'm happy that my son died. But I'm at peace most of the time. Not all the time. Soon as I start counting on where we're just towards this yard side, I struggle. It's pain. But it's not drama. There's clean, pure pain. Like when you're giving birth, it's painful. But it's purposeful. Sometimes we don't know the purpose of the pain. And that's called a muna. Belief. It's a hawn, trust. Because if you knew the purpose of the pain, it wouldn't be a challenge. If it wasn't a challenge, it wouldn't be a growth opportunity. And guess what? You're here to grow. You're here to choose. From present day we're adult, you're here to choose.  That's your choice. That's free choice. And some people are given harder challenges than others. They feel like they're caught in a swamp, sinking more and more. And it feels horrible.  And that you have to trust again that Hashem is giving you. Because if it wasn't a challenge, then it wouldn't be a growth opportunity. You know, if I had a headache, I would ignore it or take a pill. But if I lose a son, I'm challenged. Am I going to still believe in a good God? Am I still going to keep shoving this? Am I still going to be able to move on and find joy? Or am I going to be scared to have a relationship? Am I going to go into fear? Am I going to go into drama? It's my choice. And God taught that He gave me that test. Now the other thing I want to say is, according to Pussy Doot, is that when Hashem decides that our soul is going to come down, that he consults with the soul. This is what you need to develop in yourself. Trust, love, forgiveness. So, therefore you're going to be put with these parents at this time in history, with this amount of wealth, all of that is not your personality choice. So that you're going to have the perfect setting, the perfect environment to develop whatever qualities that you need in this lifetime so that your soul will feel good about itself. It's called the bread of shame.  It was a hard job. It says that the rush is going to see his life as a thin thread or hair that he couldn't pass over and he's going to have that shame, like how come I couldn't manage it? And that Sadiq is going to see what he manages a big mountain that he was able to climb over it and all the angels are going to be clapping for him. God doesn't punish.  We ourselves don't feel worthy of being in God's presence. And then God has a favor come down and do it again. I don't know about you, but I don't want to do it again. I'd like machine up now. So machine up is coming soon. So a lot of us have harder tests because we don't have so many lifetimes left to get to do all our soul development. So putting Hashem in the picture means that we see our lives in a certain concept called the pardes. Pardes, Hebrew letters are Pei, Reish, Deled, Zahmah. And we're taught that the Torah can be learned on four levels, the Pshat, the narrative. We have a narrative in our lives. Reish, the Remus, the Hints, the Deeper Levels. We have, which I would say is for us, our regish, our emotions. Deled is the dust, the learnings that come out of it, the halacha, and we have our, I make the parallel to our beliefs, our thoughts. And so is the secret. So all four levels, our Torah has all four levels. The narrative without Rashi is not the whole story. And that's just on the narrative level. So it is the sohar. So we have a mysterious level, a soul level to our lives. If that is true for Torah, we are living Torah. God created the Torah, God created us. Our lives are on four levels, and they're all intertwined. Most people don't know the soul level of Torah. Most people don't know the soul level of their lives. You just have to know and trust that it's there. Some people go to Makubali to find out what their soul level is, like what's their purpose, what's their mission. But mostly we don't know. We have to kind of take it on a game of trust. Okay, so now the work. This is a workshop. The more you work, the more you'll get out of it. So now get your paper and pen out and think of a person that you want to want to want to forgive and write it down. It is my intention, and intention means your will. Will is rutson, it's very high. God will help you if you have a good intention. God will help you in that good intention. So it is my intention, it's my will, it's my desire. But I want you to start with your truth. If you're not truthful, it won't work either. So if it's I only want to want to want to want to want to forgive, let's start where you are at.  Who would you like to, who would you like not to have so much animosity towards when you think of them? And now, I'd like you to mark when you think of this person, how angry are you with them? From one to seven. Seven days, really enraged. And you wouldn't mind hearing bad news about them. That bad news might even be good news for you, okay? That's real rage. Okay, so how angry are you? And how much pain do you have when you think about the person? And just write it down from one to seven.  And then be curious, do the numbers sort of match up? Do they? If you're angry seven, are you pain seven? If you're pain seven, are you angry seven? If it's one, one? Mostly, is it more or less the same between one or two difference of numbers? Okay, so we talked about that the lack of forgiveness is actually causes your energy to get stuck. The energy doesn't flow because you're caught in the resentments and the grievances and the pains. So by moving towards forgiveness, you're letting go of the stuckness inside of you. You're moving on a feeling stuck in the resentments and the grievances.  It was in the other letter, you wanna honor it. But now we're moving on. Like how long do you wanna hold on and honor it?  I wanna take responsibility for the quality of my life. I don't wanna still be giving the other person power of affecting my life. I don't, you know, they may or may not unplug the mic. That's, you know, that happens to be electrocuting. They may or may not know that I'm being electrocuted. They may not care. Some place we have to stop being so concerned about the other and say, what do I need to be able to let go? So I can move on and I can dance and I can smile or not. So one, when you decide and you recognize the reality and what has happened is God's will. That does not mean that the other person is not accountable for their behavior. But now you leave it up to Hashem to be the judge, the persecutor, the policeman. All this is based on that you believe there's a God and that he is in control of the world. Okay, so you start off by feeling like a victim or feeling angry. That's how we usually, one or the other, feeling very hurt, victimized, not fair. So that process starts with the last process that I gave you with emotional healing. It starts off that way in the spiritual because that's your truth. Otherwise you wouldn't need to forgive. So on your paper right now, pretending that the person's in front of you, I'm not telling you to tell the person this in real life, but now the person's not there so you can say it. You can say, I'm really upset with you because. And because of what you did, I feel about you or I feel about me or I feel about our relationship is and it's all your fault. Okay, this is where we're starting from because of what you did are doing. How I feel about you, how I feel about me, how I feel about our relationship. So one might be more significant than the other. I'm just putting out the whole picture there. So if I refer back to our model, this comes from lower self. Lower self is not bad by the way. It's only if you get stuck there and it starts dictating your behavior then it doesn't serve you. And it's not like we just own our feelings. In fact, the next step is that you accept your feelings. They're your feelings. If you don't accept them, you can't work with them. You don't accept your feelings. You can't work with them. You can't heal them. You can't change them. You have to accept your feelings because you've just gone from judging the other person to judging yourself. That's still drama if you judge your feelings. You're making your feelings wrong. All feelings are invited. All behaviors are not acceptable. Big distinction, I can want to eat tray. It can smell great that steak. But I'm not allowed to eat that steak but I can still want to eat that steak. That smells good especially when hungry. Your feelings are actually communicating with something important to you. They're letting you know when you're something, if you're angry about something, that something's unacceptable. If you're hurt, there's an unmet need. Feelings are important. They're not meant to be dismissed. You can be aware of your feelings without being controlled by them. Some people are scared that they know what they're feeling are going to be controlled by them. You can be hungry on your hip or not eat. The present day we're adult makes the decision. How do I take care of these feelings? How do I take care of these needs from a dignified place? Usually if you're feeling out of control, it does not feel very dignified. We actually say I lost it. Whether we lose, we lost being identified in present day we're adult. Okay, now moving on to present day we're adult. Your pain can be a signal that you're in judgment. Now we're kind of looking at, moving from the blamer in the lower circle, you're judging the other person. I'd like you to write down the facts of the vent that happened. Just the bare facts that somebody could video of what happened, what was said. Two lines, the person did this, the person said that, the person didn't show up. Facts, the person didn't call me, person forgot my birthday, person didn't give me a wedding present, the person didn't return my loan, person betrayed me. But you understand those are really, those things, when I say betrayed that's not actually an event, that's the feeling, I made a mistake there. That the person didn't return my money, that's a fact. The person's taking advantage of me is my interpretation. So that's, so what is the fact? And how did you interpret it? What are your judgments about that person? Part of the interpretation reflects your judgment about the other person. Write it down. I'll tell you, what I'm telling you to write it down, and I'm taking the time from talking to give you to write it down, is because a lot of times we have a feeling of we're just kind of like, don't feel good about a person, or we're distant from the person, or we don't like the person, and we're not even sure anymore why. So that's why I want you to write it down. So this next step comes from Byron Cady. Would you take an oath that you're right, that your interpretation and your judgment is 100% certain that you're right to the point that you would take an oath on it? That person doesn't care about me, are you sure? There was a person here who was talking about that he didn't receive a wedding gift from a very wealthy person, family member. And when I said I'm not meant to, he wasn't valued. I think that was his interpretation. He doesn't care about me, he doesn't value me. When I ask him a little bit further, he's, that wealthy relative doesn't give anybody gifts. Might be wealthy in his pocket, but not wealthy in his heart. It wasn't personal. It wasn't that he didn't value him. It's just that he's insecure about letting go of money. Or maybe the other guy feels like people only invite him for his money. Who knows what's going on in the other person's head? Can you really know what's going on in someone else's head? I have trouble knowing what's going on in my own head. Like why I'm motivated to do something or not to do something. Can you really know what's motivating someone or why they're doing something? To the point that you would take an oath. Okay. The other way about judgments, and this comes from Byron Cady, and it also comes from the Balchanteau, that if you spot it, you've got it. I summarized that. If you spot it, you've got it. Not exactly in the same way, but somewhere, somehow. And that person is actually a teacher of holding up a mirror so you can see something easier in the other person. So maybe the other person didn't repay a loan. Have you ever not repaid a loan? Have you ever borrowed something, a book, a cup of sugar, a notebook, a pen, and not returned to it? And maybe that person liked their pen and actually came to a place. I'm never lending my pets to anybody anymore because I never get it back. Then you just closed their heart a little bit. Did you ever make a promise and not keep it with good intentions and full intentions that you would? And then you had a headache or then you forgot? So just think about that possibility that if you spot it, perhaps that person is holding up a mirror and look, maybe there's something inside of yourself that this is an opportunity to grow. So this thing about if you spot it, is also what we call Hashgabah Pratit. But if anybody's in your life, there's a purpose to it. There's a purpose that that purpose can be to grow. So that you realize that your judgments are influencing how you feel.  Can anybody deny that when they're tired, they're more sensitive and other people might irritate them a little bit more than when they're well rested and might have just won the lottery? The same behavior might be a little bit less annoying.  I'm when you're hungry, for sure. Okay, so now we've gone from the drama, from acknowledging feelings and knowing that they have something to say to you, looking at your judgments from present day we're adult. And now we're moving, having this idea of doing all this kind of exploration that there's God in the picture and nothing happens by accident, Hashgabah Pratit. Accident means perchance, which is mikret in Hebrew, which is the same gamatria as a mullik. A mullik is the bad guys that come chasing after us. And they come chasing after us, making us feel cool in our ardor to Hashem. And all that happens here in the lower circle. Okay, when we go into a place of fear and coldness, that's the mullik attacking us. Whatever happens in the Torah happens to us, because remember, we're living Torah. All the stories of the Torah happened to us in microcosm. So what we wanna do is move up into the base of MacDosh, where we feel God's presence and his love and his guidance and understanding and accepting and surrendering. Surrendering is different than resigning or giving up. There's a higher surrender. This is God's will. God, give me the tools to handle this. Show me your way. Give me resources. Challenges need resources. Internal resources, external resources. But you know what the biggest, biggest, hugest resources in the whole wide world and beyond? God. God is a resource. Believing that God is with you in this journey and has tailored a major journey. He's the ultimate principle.  There are no accidents with God. Every single person in your life is being there for a purpose. The biggest lessons have happened to me by the people that were the hardest to deal with. Okay, so we're opening up to a spiritual reframe, right? We're all ready to do that? Turn your page over. Get a fresh slate. This is all about getting a fresh slate. A fresh slate means that you let go of your old pain. If you recognize that Hashem has created these circumstances, put these people into your life so that this would be your challenge, not a challenge of past fail, but a challenge that you could develop qualities. We know in the hardest times, we find out that we have qualities that we never knew that we could do.  Unfortunately, that's the way God created the world. I say unfortunately, because it's hard, but we know Abraham had 10 tests. It wasn't because he was bad and it wasn't because he was being punished. Abraham had 10 challenges but there was 10th being sacrificing his son. Not because he was bad and not because he was being punished. I want you to get that, because often when people feel hard things are happening and they're feeling pain because we had pain when our parents were punching us, then we think God is punching us and he's giving us pain and he's punishing us. And that is an unspiritual way of looking at it. God doesn't punish, God teaches. He's not the principal with the strap in the classroom, but he gives a hard surrogate. Would you want to stay in kindergarten for the rest of your life and keep on getting A's? So even though you can't understand why because you're not as wise as God, you can't. When people say, tell me why, I go, I wish I could, but God hasn't yet brought me up to that level knowing I can mind read some people, I can intuit some people, but I cannot do it with God. I don't have a faintest clue why God is doing what he's doing. None of it, not in my life, not in your life, not in the Jewish people's life, but I trust it's purposeful. Okay, so are you, can you say that? Even though this person has hurt you, can you see this that it gave you an opportunity or you can look for the opportunity, identify the opportunity? Sometimes it's trust, sometimes it's patience, sometimes it's generosity, sometimes it's being able to become more compassionate or understanding, sometimes it's learning not to take things personally. Sometimes it's looking at that there was a previous son bird and that they're touching the story that I gave about a child that was always waiting for their her mother and so now she gets ballistic when she has to wait for her husband. Maybe there's a son bird that's being pointed out to you. Can you look? Is there somewhere you might need to grow up? Is there something you might need to heal? Is this person touching your son bird but it's your son bird? Have you ever been son-burned? And someone goes, hi. You go, oh, don't do that, don't touch me. But if you say you, how dare you? And they go, I didn't know. Well, we have son-burns like that. There's topics that are son-burns. There's issues that are son-burns. Certain questions that are son-burns. There's places that end those son-burns. Sometimes it's because we've experienced or because we feel inadequate. Some son-burns come from core negative beliefs introducing a new topic. If you have this naggy insecure thought that you're inadequate, whether you're not smart enough, quick enough, rich enough, pretty enough, handsome enough, successful enough, any of those summarized not good enough. And someone makes a comment. Well, let's say you don't really, not so secure about your cooking and someone goes, is that all? It was a question from present day where adult, wanting to know should they eat a lot for first course?  Or other times you don't eat a lot because you think there's gonna be meat and chow and then there isn't. So you just ask, is there another course? You're asking a question so you know how much to eat. Present day we're adult, looking for information. Ah, but the other person is insecure about hosting or insecure about the food or maybe the chow and the fruit. Okay, there's a little drama going on there. And so you get an overreaction because of the insecurity there. So you can see it that way. What about yourself? We all have insecure or toxic negative beliefs. Just think about it. What is there a core belief, a negative core belief? Core beliefs doesn't mean it's true, but you believe it. That might have got touched by this person's thing.  How many times do I have to tell them to clean up? Why is it such a drama? Because they feel like an inadequate mother. They go, my children don't respect me. They don't listen to me if there's something wrong with me. So some of the negative core beliefs is I don't matter. I'm not good at it. Those are the two basic ones. Nobody likes me. Nobody wants to be my friend. I can't trust anyone. Nobody's trustable. People are always rejecting me. People abandon me. Life is not fair. People are not fair. The world's not safe. I'm never gonna get better. What's your core belief? Because that's gonna be your sensitive sunburn, not from a past experience, but because of your own core belief. People pick on me. I'm alone. I'm always gonna be alone. No one's ever there for me. Nobody can understand me. I'm different. Lovely Ducklin Syndrome. No one values me. Nobody appreciates me. So now somebody forgets your birthday.    Then you'll do problem solving around it, but it doesn't become a big drama. If someone gives me a check and it bounces, I can go, I don't have to go, people rip me off. I can go, huh, don't accept a check next time from that person, expect cash. I can take from my present day where adult, I can take strategies to protect myself without the drama.  There's some place inside of us that likes being self-righteous. It's in the drama circle. It's called the ego. Either way, it's the pharaoh syndrome. Either I'm a pharaoh and I got the power or I'm the slave and I have no power. That comes from ego. Present day where adult is a sort of looking for respectful solutions. You can't do that in a drama. You can't do that if you're buying into your core belief. And unfortunately, there's a tendency that if you believe something, you look for evidence to support your belief. And the way this world works energetically is that if you believe something, you energetically, magnetically draw to you. And so it reinforces your belief. And then you feel even more justified to believe your belief. Think about it. What belief has this person tributed in your life by their behavior? Our interpretations are usually about them. And what I'm asking you is to look inside. Instead of the binoculars, take a mirror. We're often using a magnifying glass for the other. And I'm not asking you to use a magnifying glass in yourself, but just look inside. What's your core belief? What are the patterns in your life? That's another clue. Do you find that you keep on being attracted to alcoholics? Or do you find that you keep on being attracted to a piece of people or people that don't treat you well or people that you can rely on? If you have that pattern, what does it say about you? Maybe you don't feel deserving of something better. Maybe. Maybe you have a hard time being assertive. Maybe. It's always easier to look at what the other person's doing wrong. And it's true. Not arguing. What's your part in it? If there's a pattern, maybe you're contributing to the pattern. Now, going looking at yourself should be done with compassion. What's your role in it? Why do you keep on following yourself in this pattern? Because if you say he has a pattern, and it's happened many times to you, guess what? Probably you were part of that pattern. Somehow.  Okay, so learn something else. Learn a strategy. Your present day where an adult is responsible to learn a dignified, caring, loving, compassionate, respectful strategy. And usually when you're in higher self, it's good for you and it's good for them. They might not know that. Like, if I can't, sorry, I can't do something for someone. I have to trust that if I can't, someone else will or that person is not meant to have it. I have to trust that. You believe in that, there's a win-win. So, what are my lessons? What are my growth opportunities? And once you got that, and once you know that you have a way that's dignified, respectful, and loving to take care of yourself, then you know what happens? You don't need to be in the drama anymore. And sometimes we don't feel safe to let go of our anger or pain because we're scared that we're gonna make ourselves a target again. So, the only way we know how to protect ourselves is by being angry and scared and withdrawn, drawn. But if you know and you've learned the lessons and you see your part and you're willing to take responsibility and you're willing to develop strategies, whatever they are, depending on the situation, would be different strategies. And depending on the person, different strategies. Then you don't need the drama anymore. Then you can let go of the drama and have some peace of mind, be free to move on. Are you willing to be out of the drama? How does the drama serve you? You need to know that so that you can find another way. If the drama serves you in a certain way, you have to identify that so that you can find another way to meet that need. You have to identify the need and then you look for the strategy. Wanting to be safe and wanting to be protected or wanting not to be close to that person or wanting not to depend on an untrustworthy person. But how can you do it from a more empowered, respectful, assertive, responsible, respectful, present-day, aware, adult part? Think of one way. Even if you're not ready to use it. Take a moment. You're paying for workshops, the work. I'd like to invite you to think. If you were to take a higher self-perspective that God created you and He created the other and He put you in this world as a classroom for you to work on yourself and everybody in it that you meet or challenges you is all part of your curriculum, your higher self-circulum that your soul agreed to attend. You're in this classroom because you agreed to be here. In this classroom, in the classroom of life. That's your soul contract.   Then the roles keep on changing but you agree to it. Whether you say it from past lifetime or not past lifetime, it doesn't matter. Your soul agreed to it. God did not impose your life in here. You agree to come down because you both saw that it would be for your potential, like the potential of your soul could grow and develop and expand. So with that appreciation, just taking that on for a moment. Then you can realize that this event that you all wrote down and this person that created that event was here as a teacher, as an opportunity for you to develop, either to develop strengths or to heal a previous pain that they had nothing to do with. They just touched your sunburn and there's a charge. And actually, you wanted them. Your soul wanted them to touch your sunburn. Husbands and wives touch each other's sunburns a lot. Parents and children touch each other's sunburns a lot. Did you ever know it was that? So if you realize that you experience very deeply so that it would get your attention because if it didn't really bother you, you wouldn't pay attention.  Your soul wants the growth opportunity. So if you say that, so you have this event that hurts you in order for you to say, what do I need to heal? What do I need to grow? And now that you've got the lesson, you don't have to hold on to the pain anymore. And you can just do what it was intended to do to get your attention so that you can look at what do you need to heal and what do you need to grow? Can you take that off? Can you see how liberating that would be? So much easier to work on changing oneself truly than it is to try to change the other. People pay me to help them change and it's not so easy. To change the other. You have to change yourself. You have to take responsibility for yourself. You have to see why am I in this dance? Why am I losing this pattern? Why does this hurt me so much? Why do you want to be a victim? Okay, think this, just think this, think this. Can you say this now to yourself that after dealing with this workshop that you can have a better understanding? Just think it. That so-and-so was a messenger from God for your healing and growth. And therefore you're willing to forgive the person. Just think this. Without that does not mean condoning the behavior, separating out the person from the behavior. That person's behavior is gonna be judged by God or in court or based in it. Doesn't matter if for a present day, we're adults you still can hold the person accountable without the drama. Doesn't mean that if a person holds you at $1,000, they say, oh, I forgive you, you don't have to pay me back, I'm not saying that. Allowing us both to feel peace. When you can accept that everyone, me, you, him, her, them, is on a spiritual journey, doing the best they can from their past. Most people have not had the best childhood or the best, easiest, life-serving stances and with the tools that they have that most people, except for those that don't, because they're psychopaths, sociopaths. There are psychopaths and sociopaths. I'm sorry, for our people who aren't narcissistic personalities, and there are people who are abusive, I'm not talking about those people. I'm talking about regular people like you and me who are doing the best they can with the tools that they have. And we can be compassionate for our own journey and for our journey and look at ourselves of how we can move on and be at peace. So the day of atonement is a day that we can be one in the moment with ourselves and with God. So the sheets are there. The opportunity's here. This is the time, L. Tishrey is the time.