Hello, everyone. My name is Professor Vanille Urandall. I'm a professor emeritus of law from the University of Dayton School of Law. And I wanted to do a short video. There was a, I woke up about two days ago to a video from my sister asking me if the video was correct. And it was so wrong that I felt moved to have to do something because I think one of the things we really need to be careful about is really making our arguments based on facts and making sure that we communicate those facts in a way that other people won't misunderstand what we're trying to say. And I felt like the video that I had seen really had misconstrued the law. So here's what I want to do. I'm going to show the video, just a small part of it. It's a three minute video, but I only plan to show the first 30 seconds because most of it is just the person making her arguments as to the condition of black Americans. The second thing I'm going to do is talk about Dred Scott's because I know that everybody doesn't. Everybody kind of knows about Dred Scott. And some people know the name. Some people know the law. Some people have a really good understanding. So what I want to do is give an overview of Dred Scott. Then I want to talk about the structure of law and the role of law. And then I want to put the anti-black racism in the context of this structure. I feel like a lot probably will be more than 15 minutes. And then we can have a discussion about what this means and where to go from there. And so I'm going to share my screen with you and start the slide presentation. Everybody's been muted. Once I get through the slide presentation, I encourage people, let's just have a discussion. Okay, so I'm going to go from here. Okay. So the basic thesis of the video that I want to show you is that the reason we are in such horrible trouble is because this case, Dred Scott says that we're not citizens. And so because we're not citizens, we don't have to be treated as citizens. So I'm going to play a small part of the video right now. Okay, my beautiful black people. I want to show you something. This is how the lawyers are getting these white people off on charges after they kill us. Okay. This is from the Supreme Court of the United States. And basically this is from the Dred Scott case versus John F.A. Sanford.  Persons of African descent cannot be nor were ever intended to be citizens of the United States. This is in the Constitution. Now I've been trying to teach people this for the longest time. So first thing, it is not in the Constitution. It's a case that presents that interprets the Constitution. And what she read from was the interpretation of the case by the Supreme Court in 19, excuse me, 1857. Okay, so I'm going to move on. I don't really want to go further into that. I don't know who I don't know the person who present this I don't know who put it out who gave the person it was sent to me sort of just kind of here is this right. Before I discuss why it's not right, I really want us to make sure that everybody understand what Dred Scott was about the decision. And this is in fact a picture of Dred Scott. The black race has for more than a century been regarded as beings of an inferior order, and they have no rights which the white man is bound to respect. Dred Scott's image was that individual who was denied his freedom, that individual who was treated poorly by the courts, that individual whose case the nation had lost. This is a case that split the United States into it could never really be healed through conventional means. Dred Scott was born into slavery in Virginia. His long struggle for freedom was one link in a chain of events that would eventually free more than 4 million enslaved people. Purchased in a Missouri slave market by Army Dr. John Emerson, Scott was brought to Fort Snelling in 1836 by way of Fort Armstrong in Illinois. When the frontier moved west, Fort Armstrong was no longer needed, so the entire infantry, including Dr. Emerson, was transferred to Fort Snelling. The slaves in Minnesota were different than the slaves in the south. They made the beds, they made the food, and did the things that the people who were officers couldn't do for themselves. I think we see Dred Scott more as a personal manservant or like a butler or steward. Anything that Dr. Emerson needed, Dred is going to be taking care of that. But it is a very different culture than Virginia. He may have seen this as the less of two evils. And when he came to Fort Snelling, there was already a young girl slave, Harriet, owned, if she could be owned, in free territory by Major Lawrence Tolliver. Major Tolliver was leaving for the winter and he wasn't going to take Harriet with him. And the way to leave her there was to leave her married to somebody who was going to be within the protection of the Fort's walls. Scott and his wife Harriet remained at Fort Snelling until 1840. They first sued for their freedom six years later. There were one of at least 300 slaves who had sued for freedom in the St. Louis courts before. The majority of them won because they, like the Scots, had lived in free territory. In the midst of dramatic national events, the Missouri State Supreme Court reversed an earlier decision granting Dred and Harriet their freedom. The case came to the United States Supreme Court after 11 years of litigation. 11 years, the Scots were in limbo. The Scots based their United States Supreme Court case on their residence in lands that were part of the Old Northwest Territory and the 1820 Missouri Compromise, territory where slavery was prohibited. In their landmark 1857 decision, the court declared that Congress had acted unconstitutionally in passing those enactments. Consider the extent of that. The United States Supreme Court declared that the freedom provision under the Northwest Ordinance was unconstitutional. The Scots would have no basis to claim their freedom under that. Further, on a technical matter, in order to get a case into federal court, you had to be a citizen of one of the states. The court, in a 7-to-2 decision, declared that the Scots were not citizens of any state. Not only did Dred and Harriet lose their slavery being maintained, the secondary dimension of this was that no persons of color, free persons of color as well, were deemed to have any rights that white men were deemed to respect. We have watched with increasing anxiety the progress of the opinions of the United States Court on the Dred Scott case, till it has finally reached a conclusion, literally making slave holding legal throughout all the northern states. The antipathy that was directed at the United States Supreme Court by newspapers was extraordinarily strong. The self-satisfaction that Southern newspapers reported was equally strong. It is one of the most atrocious law opinions that has ever disgraced the history of the country. At a single blow, it shatters and destroys the platform of the Republican Party. Five of the Supreme Court's nine silk gowns are worn by slaveholders. Dred Scott decision will bring the enemies of the South face-to-face with the constitution of their country. We can but foresee that this decision will create everywhere a profound sensation. This very attempt to blot out forever the hopes of an enslaved people may be one necessary link in the chain of events, preparatory to the downfall and complete overthrow of the whole slave system. After the court case, they were still illegally considered slaves. Dred and Harriet eventually did acquire their freedom. Dred died as a free man. I'm not sure that the Dred Scott case itself would have caused the Civil War if South Carolina hadn't been primed to secede. Their decision was in part based on Northern reaction to Dred Scott. It couldn't be a legislative compromise because the Supreme Court decision took away congressional power to eliminate slavery. There was no political future short of Civil War. Today, Minnesotans can get a glimpse of Fort Snelling as Dred and Harriet Scott experienced it more than 150 years ago.  Dred's role is one of an agent of change. He didn't accept his circumstance nor did his wife. They sought change not only for themselves but for their future generations. Okay, so basically I mean I really like this film and I used it because it gives a good short overview. Dred Scott had two daughters. They got their freedom because the person who owned them at the time was married a man who didn't believe in slavery. And so she ended up giving them back to their first owner and the first owner ended up buying their freedom and giving them their freedom. So their whole family ended up free. But the question becomes, are Americans citizens because clearly the Supreme Court case says the 1857 Supreme Court says that black people have no rights with white people, which white people have to respect. In order to put this into context, I want to show you an overview of the authority is what we called it of the law. That is the higher up the law, the more authority it has and it governs everything. And we have two tracks. We have the federal track and we have the state track. Not withstanding statues or laws. Regulations are law. And so are cases. And people often argue, oh, well, courts shouldn't make law, but absolutely courts make law. They make law through interpretation, because no law is ever spelled out and enough detail. So the Court of Appeals and the District Court holds cases, but they report to the Supreme Court of the United States and the Supreme Court of the United States, interprets the law in light of the United States Constitution. So if there's not a United States constitutional issue, the state Supreme Court ends up interpreting the state law through the state constitution. And I put treaties out to the side. Because while the Supreme Court can interpret it treaties under the Constitution, treaties have the force of law that is supposed to be over statues and regulations and cases so that you have Constitution and then treaties that the state enters into. So then the question becomes, so why isn't this good law if the Supreme Court of the United States said it? And the answer is it was overturned. It was overturned by constitutional amendments. And I'm going to go into those constitutional amendments. But I just quickly want to show you that I went into Westlaw and I found 29 cases that site red Scott negatively, plenty of them noting that the case was superseded by the constitutional amendment and of course that's based on my other slide. The Constitution supersedes any case. Okay, even a Supreme Court case. So, so if you make a constitutional amendment, no matter what the Supreme Court has said in the past, it is no longer true. Okay, and the second and going forward, the Supreme Court has to interpret the law in the context of the Constitution that was made. So, the two constitutional amendments that came about the 13th amendment, which we all know said neither slavly nor involuntary civil to accept this punishment for crimes for a party that has been convicted shall exist within the United States or any place subject to their jurisdiction. I think I'm not going to get into this if people want me to I can get into it later but there's a whole issue of whether prison labor and that's why I put up all these pictures is current prison labors is a form of slavery. But the 13th amendment by itself did not provide citizenship. The third, all the 13th amendment did is said that people wouldn't be enslaved. And that's why the 14th amendment had to be in that the 14th amendment says and and all persons born are naturalized in the United States and subject to the jurisdiction are citizens of the United States. That is as clear as you can get if you were born in this country.  And it was done this way for a very specific reason. It was the only way to give citizenship to the formerly enslaved people, because the Supreme Court of the United States had already determined that they want citizens. And so it on once the Supreme Court makes a determination of something, unless you can find a way to an end and that's the law that correct whatever the problem is. The only other way to fix the problem is by giving a constitutional amendment and that is what's happened. The 14th amendment says all persons born and nationalized are citizens. If others than that it says that states cannot make or enforce the law that gets in the right that abridges the privileges or immunities of citizens. So, the states cannot make a law that gets in the way of the citizens exercising their rights. And then the other part of the causes we've come to know as due process clause and equal protection clause. Now, United States legal system out and I'm going to get into this. So, so, so what we have here is dread Scott the case. Yes, said that in 1857.  But the 14th amendment 1868 said all persons born in this country are naturalized in this country is citizens, and that no large shall be enforced that gets in the way of them exercising your citizenship right. Oh, then this comes down to the distinction that I think the young lady didn't make. There is no doubt that anti black racism, starting since before this country was formed is embedded deep into the social norms and the cultural norms. And because it's been deep into the social norms and cultural norms, it gets interpreted laws and things get interpreted in a way in that doesn't provide us the fullest legal protection. But it is not correct to say we are not citizens. We are in fact citizens. The problem is that racial discrimination in this country has been so narrowly defined. And that's that's the problem that only intentional discrimination is illegal. So if you want to say that it is legal to discriminate in this country that would be a correct statement. It is legal to discriminate in this country based on race. So long as you don't do it intentionally. So if you do it recklessly or negligently. That's fine. But the legal norms, but the citizenship norm we, I think we have to make a distinction between social norms and cultural norms, and how they impact legal norms. And to say something is the law. Then we have to look to the law as it stated and are citizens of the United States. We don't get the citizenship rights are not fully it's exercise in our favor and have never been. But that's another discussion. That's part of the discussion we can have now. I just want to end quickly by saying that if you have a question about race and racism and the law that you'd like me to do a short video on please post it on Patreon or on Facebook. The slides from this presentation will be available on my Patreon site. The video I'm not I haven't decided where I'm going to place the video. I'm going to stop now and talk.


gut flora, which is a variant of lactobacillus roteri. Upon consumption of foodstuffs contaminated by SCP-2001-J, a mammal's native population of lactobacillus roteri will be replaced by SCP-2001-J. This process occurs over a period of two to three days and typically goes unnoticed by the host organism. When a coherent population of SCP-2001-J is agitated, as may occur due to gastrointestinal stresses, they adhere to one another, a process which facilitated by rapid generation, a cobalamine SCP-2001-J material will align with the common axis, a cobalt lineman generation. This process causes a thin, unicellular sheet of 2001-J to form. When agitation ceases, SCP-2001-J will coherently biolubinescence along the axial perpendicular to the sheet. The degree of luminescence involved in this is in the order of 3 watts per SCP-2001-J bacterium. However, the luminescence will typically cease after approximately 50 milliseconds. This results in a directed, coherent light source similar to that of a multiple kilowatt laser projected from the posterior of the infectee. Addendum 1 – Research into weaponizing SCP-2001-J's ongoing Addendum – The first Mobile Task Force Team equipped exclusively with SCP-2001-J infections. Laser butt squad has been created to combat the spread of SCP-789-J, also known as the butt ghost.


Let's see that thing right there. This one, I don't know. Jesus, that's scary. Anyway, extinction, respondent extinction this time, is where you break the connection between the CS and the CR. You do that by presenting the CS over and over and over and over and over and over. And you do that and again and again and again. You do it constantly until that connection between the CS and the CR breaks, right? Remember that the condition stimulus, right, elicits a conditioned response or a conditioned reflex. What we wanna do is make it to where that condition stimulus no longer elicits the condition reflex. How do you do that? By never giving the unconditioned stimulus in the presence of the conditioned stimulus. Ever, never, uh-uh, not gonna happen. CS, CS, CS, CS, CS, CS, CS, CS, CS, CS, CS, CS, CS, CS. That's how it works, right? We're just gonna keep giving that CS until the CR does not happen or the intensity is decreased to a level that is acceptable for experimental or biological goals. Ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha.


2. Ways to teach vocabulary effectively Vocabulary, as one of the three main elements, the other two are pronunciation and grammar, of a language, is essential in language acquisition. Teaching vocabulary is always being a great concern for any English language course. Quite a lot of teachers are really focused on how to make a vocabulary lesson more interesting and memorable for students. New vocabulary has to be introduced in such a way as to capture the student's attention and place the words in a practical way. How to Teach Vocabulary Interesting and Memorable Vocabulary learning can be often seen as a laborious process of memorizing lists of unrelated terms. However, there are many much more successful and interesting ways to learn and teach vocabulary. Using teaching tools is a good way to increase entertaining in this process. Such as, flashcards, short videos, letter box or posters, etc., it not only can make the lesson more interesting and also provides visual contents for students. The method can be easier to input visual memories to the student's head. And also review is very important for memorizing vocabulary. Some vocabulary game can make the memory process very solid for the future. For example, choose one student to act the words without speaking it and makes the others to guess, that is one fun way to interact with the class. How to Enlarge Students Vocabulary For students, vocabulary lays the foundation for further study. There are several methods of enlarging vocabulary. For example, prefixes, root words, and suffixes. Prefixes can make a word negative or change the word formation, like having an undisturbed in front of a new word. These infections are vital for students' understanding of words and will increase their vocabulary substantially simply by inflecting words they already know. And suffixes work in this same vocabulary-enhancing way, by adding endings such as immensless and like etc. Teaching prefixes and suffixes can be a good way to illustrate and enlarge the new word. And learning synonyms and ansonyms is also a useful way to enhance vocabulary learning. Synonyms can consolidate the memory of new words, so can antonyms. There are many ways to enlarge vocabulary, these methods above are just a few examples. Practice Makes Perfect We all say Practice Makes Perfect. After learning new vocabulary practice in an actual way is very important. Usually, we ask the students to fill in some words blanks to check the writing, some choose definition questions to make sure that students understand the meaning, and some vocabulary puzzle practices are also good to work on vocabulary knowledge. Plus using new vocabulary to create an imaginative story can also practice sentence making and memorize it. The most advanced way is to write an essay or sentences to check students' utilization of spellings and grammar uses. These usually require the one as an intermediate level student or up. Are you ready to teach English to ESL students all over the world? Above all, there are several methods for teaching vocabulary. As a teacher for ESL students, we do not only need skills to teach vocabulary, and also requires patient, understanding and precise to design a lesson. Speak with an ITTT advisor today to put together your personal plan for teaching English abroad. Send us an email or call us toll free at 1-800-490-0531 to speak with an ITTT advisor today.


Welcome back. In the last lecture, we looked at the mechanism of mass transfer from a gas to an agitated liquid and we considered two theories which seek to explain this phenomenon. The two theories, the first of which was the film theory and the second the surface renewal theories. These two theories start from very different standpoints and the mechanisms that are postulated for the mass transfer process are also quite different and not surprisingly the mathematics also works out quite differently and we end up with two different expressions for the mass transfer coefficient from a gas to a liquid. Now, in the ultimate analysis neither of these theories is able to predict the mass transfer coefficient from first principles, but as we shall see the main utility of the theories is in their ability to predict the effect of mass transfer, effect of chemical reaction on mass transfer. So, this is what we are going to concentrate on in the present lecture as well as in some of the lectures to follow. So, the situation is something like this. There is a gaseous solute A which is getting absorbed into a liquid B, liquid solution and liquid contains a component B with which A can react. So, we write the stoichiometry of the reaction as A from the gas phase reacting with B from the liquid phase giving rise to C and although it does not really matter all that much we will assume that the C remains dissolved in the liquid phase and B and C are stoichiometric coefficients and we shall assume that this reaction has an intrinsic rate which is first order in A and first order in B. As usual as we did in the case of the physical mass transfer we will assume that there is no gas phase resistance the entire resistance to the mass transfer is concentrated on the liquid side. So, we shall loosen these assumptions towards the later stages of this topic both the assumption with respect to the orders of the reaction as well as with respect to the non-existence of gas phase resistance and we will see the consequences of those at that point, but at this point we will make this make these assumptions in order to keep the focus on the essential aspects and keep the other details simple. We will further assume that the film theory is good enough to explain this process of mass transfer with chemical reaction and while we have said earlier that in view of the available evidence the surface renewal theories are to be trusted more than the film theory. In view of the simplicity of the film theory we will do the development first in the framework of the film theory and later on we will see what differences come about if it is the film if it is the surface renewal theories that we invoke and we shall also give a justification for why film theory is still useful in spite of the fact that the prediction it makes about the way the mass transfer coefficient depends on diffusivity is not borne out by the available experimental data ok. So, we shall proceed with the analysis of this process. So, A is getting transferred from the gas phase to the liquid and on the liquid side when it diffuses into the liquid side it reacts with one of the components of the liquid phase which we have called as B. The concentration of this B in the bulk liquid we take it as C B B and C B B is the concentration of B in liquid bulk that is to say outside the film and C A star is the concentration of A in equilibrium with the prevailing partial pressure and within the film theory parlance therefore, this is also the concentration of A at the interface. So, with those notations having been agreed upon we can write the diffusion reaction equations that govern the diffusion of A into B A into the liquid rather in the following manner D A D squared C A by D x squared equals K C A C B which is the same equation as we had worked with before except for the presence of this reaction rate term. So, what this is saying is that if you look at the film with this is the gas liquid interface that is the gas side and this is the liquid side and that is the film. So, in any differential slice of the film there is a rate at which the solute is entering by diffusion there is a rate at which the solution is leaving by diffusion the difference between these two rates is consumed by chemical reaction within this slice. So, we had a 0 here when there was no reaction. So, whatever was entering was equal to the rate at which it was leaving, but now there is a rate at which the material enters at x and there is a lower rate at which the material leaves at x plus delta x and this difference is consumed by reaction. That is all that is happening because this is a steady state theory and there is no accumulation. So, input minus output equals consumption. So, that is what this reaction is this equation is saying. Now, this equation cannot be solved by itself because it contains the concentration of B and it is possible that the concentration of B also has a profile within the film. In order to describe that profile we have to write a very similar equation for B. It is almost identical except for the fact that we use the diffusivity of B instead of the diffusivity of A in this equation. So, this is input minus output of B into the differential slice and the reaction rate term contains the stoichiometric factor in addition to the rate term that was present in the equation for A. That is because the rate of consumption of B is lower case B times the rate of consumption of A. Consistent with the postulates of the film theory, the boundary conditions can be written in the following manner. At x is equal to 0, we have C A being given by C A star and at x is equal to delta. This is delta C A is given by C A bulk and when it comes to the boundary conditions for B, at x is equal to delta the concentration of B is C B B as we have already assumed. At x is equal to 0, we make the assumption of non volatility that is to say we assume that B has no tendency to pass over onto the gas side by vaporization. What this means is that the flux of B at the gas liquid interface is 0 and if you invoke a fixed law for the flux, what this means is that we are saying D C B by D x is equal to 0 because it is a product of this with the diffusivity that determines the flux and since we are saying that the flux is 0, this gradient must be 0 at the gas liquid interface. So, this is the formulation of the problem that is the diffusion equation that governs the transport of A. This is the diffusion equation that governs the transport of B and these are the relevant boundary conditions with which these equations have to be solved. Now, if you look at these equations, there are concentrations, there are distances, there are concentrations and there are distances and these are in different units and they have different magnitudes and therefore, in order to analyze the effect of this chemical reaction on the mass transfer and particularly in order to understand the effect of chemical reaction as the chemical reaction rate is varied relative to the diffusion rate, it is far more useful to treat these equations in a dimensionless form. Let us do that by defining the following non-dimensional variables. Let us call lower case A as the non-dimensional concentration of A which is obtained by dividing the concentration of A divided by the concentration of A at the interface. Similarly, small B is concentration of B divided by concentration of B in the bulk, maybe what we should do is in order to avoid confusion between this B and the stoichiometric factor B, we will conserve the stoichiometric factor as nu. In other words, we will go back and change this stoichiometric coefficient to nu, the Greek letter nu so that there is no confusion between the two sets of symbols that we are using and we are left with the independent variable that is distance and we shall let zeta, the Greek letter zeta stand for non-dimensional distance which we obtain by dividing the value of x by the maximum value that x can take namely delta. So, what we see in this scheme of non-dimensionalization is that each variable is being divided by the maximum value it can take and therefore, the non-dimensional variables will have a value between 0 and 1. So, they are all comparable. So, earlier in the dimensional form they need not have been comparable, right now they are and substituting these into the differential equations, we can do the non-dimensionalization as follows, d A we have got d C A that is d A multiplied by C A star, this is the second derivative and we have got the second derivative of x which becomes delta squared times d squared zeta equals K C A is C A star times A and C B is C B bulk times B. So, the C A star will get cancelled and we can rearrange this equation to read as follows delta squared K C B B divided by d A multiplied by A B. So, I shall call this group as m and write this equation as d squared A upon d zeta squared equals m A B. So, what is the let us stop for a moment and consider the meaning of this dimensionless group that we have defined here m which is delta squared divided by d A multiplied by K C B B and if you look at this K C B B is a pseudo first order rate constant for the reaction and the reciprocal of the first order rate constant has the significance of a characteristic time for reaction that is the time that is required by the reaction to proceed to a significant extent. So, 1 over K C B B is the characteristic time for reaction and delta squared by d A is the characteristic time for diffusion because delta squared is the square of the distance over which the diffusion is occurring and d A is the diffusivity which has units of centimeter square per second or meter square per second and therefore, this is the characteristic time for diffusion. In other words, this parameter m compares the characteristic time for diffusion with the characteristic time for reaction or it is comparing the reaction rate with the diffusion rate. So, if m is large it means that the characteristic time for diffusion is much larger than the characteristic time for reaction or reaction is much faster than diffusion. If m is small it means that the characteristic time of diffusion is much smaller than the characteristic time for reaction which means that diffusion is a much faster process than reaction. So, by varying m we can look at reactions of varying grades relative to the rate of diffusion. In the literature square root of M has come to be called as Hata number and in some books you will see this being referred to as H A and we shall use the nomenclature M because much of the literature continues to use that kind of nomenclature. So, we have got the non dimensional form of the diffusion equation for A in that manner. We can do the same thing for the diffusion equation for B and here we get D squared B divided by delta squared here and D squared zeta D zeta squared equals nu k C A star A C B B B. So, this is the concentration of A and this is the concentration of B and that is the rate. So, in order to express this equation also in terms of this dimensionless number that we have defined we will group these various quantities that we have obtained here in the following manner multiplied by nu D A C A star divided by C B B into A times B. So, we see that in the equation for B this familiar quantity has made its appearance there is an additional dimensionless group that has arise. Let us see what is the meaning of this additional group that has made its appearance now.  So, by Q let us denote this quantity D B C B B divided by nu D A C A star. So, what does this represent? D B C B B divided by D A C A star is the relative rate of supply of B to the rate of supply of A that is because you know the maximum supply of A can be written in that manner which is nothing but the mass transfer coefficient of A multiplied by the maximum driving force that is possible. And the similarly the maximum rate of supply of B would be D B C B B divided by delta. And so it is the ratio of these quantities that going to the numerator and this coming to the denominator that is appearing here that is being divided by the stoichiometric factor B which is the number of moles of B that is required by the reaction per mole of A. So, we can regard this as the relative rate of supply B to A divided by relative requirement B to A. So, because of this definition we can associate the significance of relative abundance to the parameter Q and we will continue to denote by this letter Q. So, with that definition we can now write the equation for B as D squared B upon D zeta squared equals M divided by Q multiplied by A times B. So, we have the equation for A we have the equation for B it is a simple matter to write the non-dimensional boundary conditions x equal to 0 corresponds to x equal to 0 corresponds to zeta equal to 0. And at that point small a equals 1 and the equation for B is D B by D zeta equal to 0 and at zeta equal to 1 which is the end of the film small a is A B which is nothing but the concentration of A in the bulk divided by the concentration at the interface and the concentration of B in non-dimensional terms is 1. So, we have got the equation for we have got the equation for A we have got the equation for B and we have the initial and boundary conditions and now we are ready to look at the implications of these equations on the rate of mass transfer. So, in order to understand the various things that can happen when reactions of various velocities take place in conjunction with mass transfer instead of directly going ahead and solving these equations by brute force method let us do some analysis and see what happens. So, we first note one thing that the value of Q is almost always much greater than 1. This is because if you look at the definition of Q it has D B and D A which are similar in magnitude it has the concentration of B which is rather large B could be if you take an example such as the absorption of carbon dioxide in a solution of monoethanol amine B would be the concentration of monoethanol amine in the aqueous solution that can be very very large and C A star is the equilibrium concentration of carbon dioxide in water and this is usually much smaller than the concentration of B in the bulk. So, this is the case for most gas liquid systems whether you take oxidation reactions in which oxygen is the gas or hydrogenation reactions in which hydrogen is the gas or gases like carbon dioxide or H 2 S or whatever. Usually the concentration of the gaseous species on the liquid side at equilibrium is a much smaller number as compared to the concentration of the liquid phase reactant. There that is to say this in this expression the C B B is almost 100 times or more as compared to C A star and nu. Once again is a stoichiometric factor which is a small number like 1 or 2 or 3 etcetera. Therefore, the net result is that the value of Q is governed by the ratio of C B B to C A star which is usually very large. So, this can be of the order of 100 or even higher and therefore, we make the point that this is usually the case that is Q is much smaller than much greater than 1. So, let us look at reactions in the increasing order of the values of m. In other words in the increasing order of the relative rate relative to diffusion. Let us first take the case of m being small in particular we will take the case where m is much smaller than Q. Q is a number that is much higher than 1. So, it is not very difficult to find values of m which are much less than Q. So, if you if this is the case looking at the equation for B looking at the equation for B where we have the ratio of m to Q and we are saying that m is much less than Q. We can make the approximation that D squared B upon D zeta squared is approximately equal to 0. Now, if this is the case then it means that D B by D zeta is a constant at all values of zeta. We know that at zeta is equal to 0 D B by D zeta equal to 0 because of the non volatility condition and therefore, this is equal to 0 everywhere which means that B is equal to 1 everywhere that is all values of zeta. What we are saying here is that under these conditions where the value of m is much less than Q what happens is that the concentration of B is uniform throughout the film and the bulk concentration prevails right up to the interface. So, if that is the case looking at the equation for A we immediately have D squared A upon D zeta squared. This is the equation that we are looking at and because B is equal to 1 we can write this equation as D squared A upon D zeta squared equals m A. In other words now this equation has become independent of B and this can be solved by itself and what we see is that the reaction is really behaving like a first order reaction because the dependence of B does not matter B concentration being constant everywhere. So, this not surprisingly therefore, this condition that we are considering that is m being much less than Q is called as the case of pseudo first order. So, we are going to be considering first the reactions for which m is far less than Q and these are called the pseudo first order reactions. Under this once again we will further make the assumption that the reaction is slow enough we will call these as slow reactions for which the value of m is not only much less than Q it is much less than 1. So, this is a more stricter condition because Q as we have already remarked is much larger than 1. So, we are now demanding that m be not just less than Q it must be far less than 1. So, in the equation that we had earlier we had D squared A upon D zeta squared equals m A for the general pseudo first order regime. So, this is very very small in this case. So, what are we left with we are left with an equation that is saying D squared A by D zeta squared equal to 0 with the conditions at zeta equal to 0 A is 1 and zeta equal to 1 A is A bulk. If you look at this this is no different from the equation that we had written in the physical mass transfer case except that in the last lecture we did not non dimensionalized equations here we are talking about non dimensional equations. But this is exactly the same equation as obtains for the case of physical mass transfer. So, what we are saying is when the reaction is slow enough that the value of m is far less than 1 the reaction really has no effect on the mass transfer process. It is unable to influence the concentration profiles in the diffusion film and the concentration profiles in the diffusion film are governed by the same equation as if there were no reaction which means that the concentration profile will remain linear. If the concentration profile remains linear then the mass transfer coefficient is given by D A divided by delta as in the case of physical mass transfer and the rate of absorption is exactly same as the rate of absorption in physical absorption case for the same driving force. So, what is it that the reaction is doing in this case as we shall see the reaction has the important task of actually setting the driving force in this case. So, how do we show this in order to see this we make a balance on the bulk. So, what we are going to consider is the role of reaction in slow reaction regime these are called as reaction regimes. So, we shall adopt the same nomenclature the role of reaction in the slow reaction regime is certainly not to influence the processes in the diffusion film rather it is to influence the magnitude of the driving force. How does it do this we have seen that the reaction is slow enough not to take place to any significant extent within the diffusion film. So, where is the reaction taking place the reaction is now taking place outside the film in the bulk of the liquid. So, if we were to understand the role of reaction we have to draw a balance of the bulk of the liquid and say that the rate at which a is being transported into the bulk is equal to the rate at which a is being consumed by chemical reaction there and it is this balance that sets the value of the value the concentration of a in the bulk. Now, before we do that let us take a value of the let us take a look at the typical values of the numbers that we are talking about here. So, we have invoked the diffusivities and these diffusivities usually have the order of magnitude of about 10 to the power minus 9 meter square per second in SI units. We have talked about the mass transfer coefficient K L and this usually in process equipment has magnitudes of the order of 10 to the power minus 4 meter per second which means that the value of delta which is nothing but d a divided by K L in the film theory is of the order of 10 to the power minus 9 divided by 10 to the power minus 4 that is to say order of 10 to the power minus 5 meters that is approximately the thickness of the film. We will also need the to define another quantity this is we call it as a hat and we shall call this as the interfacial area per unit volume of liquid this in process equipment usually is of the order of a few hundred square meters per meter cube of liquid. So, let us say this is of the order of 10 square meter square per meter cube. Now, if you look at the this quantity film volume per unit volume of liquid the volume of liquid that is inside the film as a fraction of the total volume of the liquid then this is nothing but a is the interfacial area per unit volume multiplied by delta is the thickness of the film. So, that it is this and this is of the order of 10 to the power minus 5 multiplied by 10 square. So, this is of the order of 10 to the minus 3 which means that the film volume the volume of liquid within the film is only about 0.1 percent of the total volume of liquid there is. So, when counting the volume of liquid there is in the tank you will be making no significant mistake if you neglect the volume of liquid in the film altogether because that is only about 0.1 percent having made that point now let us draw a balance for a in the bulk. We will assume that the bulk liquid is in a state of quasi steady state. In other words if concentrations and other conditions are changing in the bulk at all they are changing sufficiently slowly with respect to the mass transfer time scales that as far as the mass transfer process is concerned the conditions in the bulk may be considered to be stationary. Under these conditions the bulk is receiving some amount of a from the film and that amount of a must be being consumed by reaction because we are not allowing for any accumulation. And therefore, it is K L multiplied by C A star minus C A B this is the rate of mass transfer into the liquid this is multiplied this is per unit area multiplied by a hat V L. So, this is the total amount of area that is present. So, this is the number of moles per second of a that are being transferred from the gas to the liquid gas to the liquid at the interface and since there is no reaction in the film itself all of this gas is being passed into the bulk as well. So, this must equal the rate at which reaction is taking place in the bulk which is K times C A B divided by C B B per unit volume multiplied by V L. So, this is the equation that governs the state of affairs in the liquid bulk. So, V L can be cancelled and if you rearrange this equation we have C A B divided by C A star the quantity that we have called as A B this is equal to 1 divided by 1 plus K C B B divided by K L A. So, now we see that there is an additional dimensionless group in the works and that is this quantity here. So, as usual we will stop and consider what that means we will call this quantity as P and this is K C B B divided by K L A. Notice that both the numerator and denominator have units of reciprocal time and therefore, P is once again dimensionless K C B B is the reaction rate constant is a first order reaction rate constant for the you know second order reaction considered in pseudo first order terms and K L A is the mass transfer rate constant if you like. So, what this is comparing is the reciprocal rate constant is the characteristic time of reaction time of reaction and reciprocal mass transfer coefficient is the characteristic time for mass transfer. So, this quantity P is comparing the rate of mass transfer with the rate of reaction if the reaction is much faster than the mass transfer process then P has a large value if reaction is much slower than mass transfer P has a much smaller value. So, this is P and therefore, we can write this earlier equation as 1 over 1 plus P. Now, this is where the role of the reaction comes in because the role of the rate of the reaction determines the value of P and we can imagine two extreme situations one in which P is much less than 1 that is the value of reaction rate is much smaller than the value of the mass transfer rate. In this case what this equation says is that P can be dropped from the denominator and this implies A B is almost equal to 1 which means that under these conditions if P is so small then the concentration of A almost attains saturation. The other extreme is P much greater than 1 and under these conditions P will dominate in the denominator and therefore, A B will tend towards very small values. So, there are these two situations. Now, what happens to the rate of absorption in these two situations? The rate of absorption in units of moles per second is nothing but the mass transfer flux multiplied by the interfacial area or moles per centimeter cube per second is mass transfer flux multiplied by interfacial area per unit volume and this is given by K L A writing this equation again writing this equation again. So, this is K L A C A star minus C A B or under the quasi steady state conditions this is equally equal to K C B B C A B. So, this can be written as R A equals K L A C A star into 1 minus A B or this is also equal to K C A star C B B multiplied by A B. So, if P is much less than 1 that is this condition here then A B is equal to 1 A B is nearly equal to 1. So, this part of the equation will tell you that the mass transfer rate is operating with minimum driving force. So, if you want to calculate the rate using this expression it is not going to be very accurate because the driving force is so close to 0 that it is difficult to estimate. On the other hand it is very convenient to use this part of the equation because A B is close to 1 here and therefore, R A can be written as K into C A star C B B. In other words the rate of absorption is equal to the maximum rate of reaction that you can expect in the system because this is the concentration of B and this is the maximum allowable concentration of A under the circumstances. So, the rate of absorption being completely determined by the kinetic rate here. So, this would be considered as a case of kinetic control. On the other hand the other extreme of P being much greater than 1 this situation that we talked about A B is equal to 0 or A B is nearly equal to 0 which means it is not going to be very realistic to calculate the rate from this expression because the reaction driving force is very inaccurately estimated here. It is so close to 0 that it is not very easy to measure and therefore, on the other hand it is very easy to calculate the rate from this expression here. So, we write R A equal to K L A C A star. Now, if you look at this this is the maximum rate of mass transfer that is possible in the system because under these conditions the driving force takes the maximum value it can. Therefore, the rate of reaction being completely determined by the rate of mass transfer here this can be considered as a situation of mass transfer control. So, let us so what happens in the situation where P is neither much smaller than 1 nor much greater than 1 in that case we can calculate R A in general we can calculate R A as K L A C A star into 1 minus A B that is 1 by 1 plus P as we have derived earlier or this is given by K L A C A star multiplied by P times 1 plus P. So, this is how we can calculate the rate of reaction or rate of absorption in the slow reaction regime. So, let us step back and then summarize what we have seen so far. So, we have seen the following first is we are considering cases of M far less than Q not only that additionally we consider M far less than 1 and this we are calling as the slow reaction regime. Under this there are two extreme situations there is an additional parameter that comes about P which is nothing but K C B B divided by K L A P much less than 1 and P much greater than 1 these are the two extreme situations and this is called as the kinetic control or we will use the term kinetic sub regime and we will use the term diffusional sub regime for the other extreme where P is much greater than 1 and therefore, you have got P is much less than 1 is the case where the liquid get saturated that is the kinetic sub regime P much greater than 1 is where the liquid is starved of the gas and that is the diffusional sub regime. So, we have the pseudo first order regime under that the slow reaction regime and under that two extreme situations kinetic sub regime and diffusional sub regime. Of course, it is possible for the value of P to be somewhere in the middle and in that case we have got no particular rate process controlling and we have got this equation K L A P divided by 1 plus P C A star as giving the rate. Now, before we go to other matters we should examine this case of diffusional sub regime in a little more detail because it is rather interesting. So, we shall call it the interesting case of diffusional sub regime. Why is it interesting because we have on the one hand said that the reaction is slow and we have ensured this by saying that M is far less than 1 on the other hand we are saying that the reaction is fast in some sense because we are saying that the value of P is much greater than 1 and P contains the rate constant recall that it is relative to the mass transfer coefficient the value of the rate. So, is this possible are we talking about two opposite things here can the reaction on the one hand be slow enough to ensure that M is much less than 1 on the other hand at the same time can it be fast to ensure that P is much greater than 1. In order to understand this we examine the definition of P which is this and we can write this in the following manner K C B B divided by K L divided by K L divided by K L multiplied by a delta there and multiplied by a delta here. Now, what is delta divided by K L? So, this is P. So, P is delta K C B B and K L is nothing, but D A divided by delta right a delta. So, looking at this is nothing, but the value of M divided by a delta. We have already made the point that this a delta is order of 10 to the power minus 3 in most process equipment because a delta is so small it is possible for M to be also small and still P to be large. In other words if M is small, but still much greater than 10 to the power minus 3 P will be large and you will always have a diffusional submerged. So, as you consider the reactions in order of ever increasing values of M you have a situation where M is so much less than 1 that in spite of being divided by a quantity of the order of 10 to the power minus 3 P remains much smaller than 1 and then that is when you get the kinetic sub regime. As you go to increasing values of M, M becomes somewhat large that M divided by a delta still is fairly large value. So, you have M less than 1 and therefore low reaction is ensured, but P is much greater than 1. Therefore, the reaction is fast enough compared to the KLA process that the diffusional sub regime results. So, because of the circumstance that in most process equipment a delta has this small value of the order of 0.001 you almost always have a situation of diffusional sub regime before the reaction becomes fast enough to affect the processes in the diffusional film. So, this is a statement of some importance. So, what we have said is that in normal process equipment in cases where a delta is of the order of 10 to the power minus 3 you always have a diffusional sub regime before reaction starts influencing film processes. A corollary of this is that what happens in diffusional sub regime? In diffusional sub regime the concentration of A goes to nearly 0. So, what we are saying in as a corollary of this statement is that in practice as you consider reactions of larger and larger values of M or larger and larger velocities they are always or rather the bulk concentration of A always goes to 0 before reaction in the film becomes important. That is to say so far we have neglected the occurrence of the reaction in the film and remember that we solved the equation D squared A by D zeta squared equal to 0. We can continue to do that as the value of reaction rate increases till the reaction rate is fast enough that the bulk concentration is nearly equal to 0. So, if the reaction rate increases beyond this value only then you need to consider the reaction rate term in the diffusional equation. So, what happens in those cases we will see in the next class.


expected that but not that soon. Hey guys so this is my review for episode three of Supernatural season 12 and they did something that I thought they weren't going to do for at least a few more episodes but I knew it was gonna happen. So this episode is in a sense almost a filler there's no real main story going on well there actually is with Crowley and Cass except that is so small and and not used even though it's super awesome that's not really the main story the whole part is about the three Winchester's going on a hunt together and they fight off this ghost that oh yeah the auto-imit the opening sequence was really badly shot like that weird like cut zoom in cut zoom in cut zoom in on the the baby the fake toys face that was so bad and then the ghost itself wasn't that really interesting it like we saw that the brothers really don't know what to do when their mother is in danger like they're more so afraid worry about her safety which it's exactly what I knew it was gonna happen and then she particularly contemplates that she still needs to figure out her own self and so she goes off at the end and knew that was gonna happen I knew that was gonna happen but not this early I thought they had her for at least a few more episodes but that obviously means that she's not top bill she's not a main cast member she's probably gonna be in and out like Cass and Crowley so kind of expected that with a contract wise but even still I got it I understand what's happening there the whole ghost story was kind of in my opinion a really weak story but the idea that she still needs to figure out who she is and she fears that by working with the brothers at the time that she's gonna be a hindrance to them and they'll all be in danger more so because of it that I understood that was standard I knew it was gonna happen but I got expected it and it was okay except for the ghost story the ghost story was really stupid however the idea of Crowley and Castiel teaming up to find the devil I thought that was like a weird buddy cop movie like when they're trying to get in the car and they're going back and forth that was funny the dialogue between the two when they were Agent Beyonce and Jay-Z but they were like supernatural people because they came in and they knew exactly so like go a cops with super powers are supernatural powers I thought that was really funny so I'm really upset that that wasn't a majority or if not at least half of that episode because though every scene those two were together was hilarious and really funny and honestly a lot more interesting than what was going on with the three so I didn't really enjoy this episode too much I thought that things were predictable certain elements of the story we could have been much more abused or sorry used for the other side story of cast and Crowley that opening sequence was really bad some of the cinematography in this episode too is really strange like really weird edits really weird shots like I don't know shot this but it wasn't really well done anyways that's my review for this one I'm gonna give this episode a three out of seven honestly the only thing that happened that was significant was the fact that the mother left oh and then yeah like I said the idea that cast and Crowley could be supernatural buddy cops I hope that's a lot more of a mainstay in the next few episodes anyways guys that's all from me I'll see you guys next time


There it is. So very, very good impressive picking. However, kind of a neat lock. This is a Slaco lock and as Adrienne points out the actual name of the company Slaymaker is an awesome name for, well any company, particularly a law company. I presume that they changed the name to Slaco prior to going out of business, maybe in an attempt to sound a little less threatening to people. But I thought that was kind of a neat looking lock. I'm just, I don't know, five bucks on eBay. Brass, as you can see, it says brass right there. The key feels like it's made out of tin or aluminum. So I don't know if that dates it. There's no other identifying marks on it. I guess the other cool thing is it's kind of, I don't know what you'd call that soap bar shape, maybe. Just don't drop the soap anyhow. Whether it is locked, and you can see how well the springs work. Keyway. There we go. But it's got like that much free play in it. Just a way for lock. But anyhow, kind of cool. Maybe I'll post that. We'll see. Anyway, this is Alex. Have fun. Stay legal. Cheers.


Good morning. I couldn't write too much on this small piece of paper, but thank you President Berwick for your comments. Over the last 10 years, cybersecurity has risen up as an imprimatur for patient safety across the healthcare ecosystem. In the last few months, days, weeks, minutes, as Mike said, artificial intelligence based on a platform with all the predictive analytics systems that we put in place over time has risen up as almost like cybersecurity is a requirement. But how does it affect us from does it sustain patient safety? Can it improve patient safety? Or how do we mitigate the risks of AI using the predictive analytics data that we get from all of our systems? So with gratitude, we have a great panel membership here to provide a multi dimensional perspective on predictive analytics and AI. And we'll just go through each panel member, you guys riff and give us your perspective. And then we'll take some questions at the end. So let's see. Thank you. Thank you so much. AI and ML has the potential to make a positive impact towards zero harm, if done intentionally. And what do I mean by intentionally in the design of it, making sure that we've got the right diverse stakeholders at the table in the testing that it's tested on the right data and in implementing and making sure that there's continuous monitoring and accountability for the results of it. If not done intentionally, it can be one of the greatest threats that we have towards lack of patient safety. And one of the greatest threats that we are seeing today when it comes to patient safety is in the disparities in healthcare that have been growing and getting exacerbated over the last several decades. So this is what good looks like when we look at a patient safety issue, like being able to provide innovative therapies for everybody equally. And we're actually leveraging AI and ML. We have at Oracle Health, a learning health network that has over 100 healthcare delivery systems with over 100 million patients. Leveraging algorithms were able to identify the patients within this database who could benefit from innovative clinical trials. Whereas before they would be left without any options. As a result of this, we're bringing three times the diversity to clinical trials that we're seeing in national clinical trials. We have King Faisal in the Middle East that leveraged algorithms for sepsis and pediatric patients and was able to reduce mortality in pediatrics from 29% down to 17%. We've got Fort healthcare, which leveraging algorithms was able to reduce the number of prescriptions for opioids down to 53%. Benzodiazepines, another addictive medication by 49%. So algorithms set up with intentionality have tremendous power. We have to take that responsibility and accountability to make sure that we set it up in that way. If I may ask a question. How many of you have gone to chat the GPT and asked it a question? Are any of you confused that a person did or did not write the answer? And the way I pose that question is in preparation for this panel. I thought, well, try and become a modernist. So I asked chat GPT how AI could influence and promote patient safety. Unfortunately, chat GPT came up with in seconds a rather interesting two page dissertation, but it did not provide the insight that I believe is going to be important as we move forward to harness the power of artificial intelligence. I may be the contrarian in the group, but I'm convinced that unless we can integrate chat GPT into the culture of the delivery of healthcare, not only from its technical aspects, but also in the users of artificial intelligence who will be the members of the healthcare community and its patients, unless we can create the environment in which we trust and implement appropriate algorithms of care and truly believe that and I would agree that algorithmic care we've heard we know works. The recent COVID crisis actually has given us a stimulus. Over the time of confusion, hysteria, we ended up practicing more sensible care across this nation, more standardized care. And as clinical trials tried to tell us what drugs would and would not work, we actually ended up with more of a continuous quality improvement movement rather than relying on randomized double-blinded clinical trials. The standard of care became the platform. The deviation from the platform became the experiment. The ability to analyze the results depended upon sharing the information from multiple institutions and enabled us to early on decide on which drugs worked. Within the United Kingdom, dexamethasone became an obvious answer pretty quickly. Within the United States, within the first 100 days, despite its well-understood or at least its theoretical advantage, we understood that hydroxychloroquine was probably not a standard of care. So we have succeeded with the combination of platform, artificial intelligence, rapid interpretation of freely diffusible data, and I think that the future is very bright. But we need to understand that culture of the organizations and commitment of the personnel in those organizations and the partnership with the patients they treat is ultimately going to be continually important. Thank you, Phil. I suppose really I would say what are you trying to get predictive analytics and artificial intelligence to do? Are you trying to get it to help you make a decision? Or are you trying to get it to do your job for you? There's a fundamental difference between the two things. And so we talk about new treatments all the time. But if you look at outcome, if we did the things we already know well, we will improve outcome far more than any new treatment that will come on in the next 10 years. I'll give you an example. Can you imagine a pilot flying a plane that says my altimeter doesn't work in bad weather? But hey, I'll just give it a go. But we have every day people who will use equipment in hospitals, use data that is less than accurate, and based on decisions on that, because they think that's the best thing I can get. I'm an intensivist. I'm a neuroanesthesiologist. And I can tell you less than 10% of people who are undergoing anesthesia or sedation in critical care have the brains monitored. But there's plenty of evidence to show that if you don't monitor the brains, those patients suffer. But we still shrug and go, hey, it's just the way it is. I think what COVID did is COVID created a burning platform for a lot of healthcare systems. It wasn't because it was intentional they wanted to send patients home and look at them remotely because there was no other option. And I think that's a bad way to practice medicine. I think to wait for a disaster to happen before you look at your safety, to wait for a disaster to happen before you implement a safety system is retrograde. So I think what we need to do is get the predictive analytics, artificial intelligence IT system to help us make the right decision ahead of time and not take the decision out of our hand. And I think far too often we expect somebody to make decision on our behalf because we're not quite sure what the right decision is. The slogan says do no harm. It doesn't say do nothing. And that's the bit that we really need to follow. That's great. When I think about the coming prospect of artificial intelligence and what we've learned with machine learning, I wonder how we will apply it. And I would ask, I'll ask a question too, but I'll make it rhetorical. We don't need hands. If you work at a hospital, if you work at a healthcare system, what is your number one patient safety issue? What is your most frequent temporary harm event? What is your most frequent high harm event? And then think about where does that data come from? Is it from voluntary event reporting? Most of our hospitals, that's where we rely, that's where we gather that information. When I think about President Burwick's charge of addressing one in four, and that is accurate, one in four patients have a harm event while they are an inpatient. Does that match the data that you have at your hospital or your hospital system? I bet it doesn't. No. So before we ask AI to tell us how to fix patient safety, we need to measure patient safety. We need to understand what heroes like Ruth Andrell at the OIG have told us for years now that we have a bigger patient safety problem than we even realized today. The research is way ahead of operations in hospitals today. We've got to get our hospitals and again thank you Dr. Burwick for charging us to do that. We've got to get our hospitals to keep up with the research that exposes these patient safety problems so that we can prioritize them, we can understand them, we can craft improvement techniques and teams that will go and help to address those problems. So before we apply all of these novel learning techniques, I hope we will take a deeper understanding of what our actual safety problems are because it's just not exposed today in a common way. So you said earlier that you would be a contrarian. You said you have another contrarian, I believe, but we've got a lot to do. We've got a lot to do and I sure do wish we would hear our current president or current leaders charge us in a way that we heard earlier. I think that would be incredibly beneficial. Building on what has been said, I want to move a little bit towards how can we really get something actionable for patient safety out of the potential that exists in predictive algorithms in AI for we hear rightfully concerns. And as users of AI, many of us came here by plane. None of us would board a plane, I assume at least, if you have the choice between one where the autopilot is broken and the other one where it's working. We trust AI works there. That's an autopilot, heaven's sake. I prefer this one over the other. But in healthcare we are conservative and to put new technologies, even evidence-based practice, into the mainstream of how healthcare is being done and delivered takes us years, sometimes decades. Now AI is knocking at our door, but will we wait 10, 20 years before we possibly reap the benefits? I think that would be a crying shame and for sure not what this movement is about, making it actionable. I think we can learn from other industries besides, by the way, aviation. If we look out in German, I love cars. And I learned to drive a car with a stick shift. My kids learned it with automatic. Going forward, what will be how the automotive industry is moving towards mobility, that's the end game of it. It will be with assisting systems. I don't want to, I still want to drive, by the way, but automated driving will be there sooner than later. And we're being led there by accepting and learning the benefits of smart systems. I would want to lose my smart distance control. I have to speed control. I like very much that I get an indication, don't overtake right now, for there is a car coming behind. I think safety features in automotive will hopefully help us as users of healthcare also start with then predictive systems, Basel, to take up your point, not taking away the decision making, but making it easier for you to move into accepting the benefits of clinical practice being improved with AI. And I think we need to do it step by step. Thank you. So a couple of weeks ago, we got together and talked about our different perspectives. Half of us were in Europe and half were on the left coast. You guys get up at six o'clock in the morning. One of the things that we talked about, and I think Mike Ramsey told me this this morning, is that China just came up and asked that we develop standards on AI. And so just like we have the world patients safety movement, I'd ask each of the panelists, what's your take on governance for the use of AI or predictive analytics across the world healthcare ecosystem, and is that possible? We'll start with you, Peter. Honestly, again pointing to Joe, you mentioned this morning that open sharing data is a prerequisite. You said, David, that we need to measure truly quality, else we cannot improve it. I think this is a hygiene factor. We need to get over thinking data is something that is private. Right. Incidents shouldn't be reported. We keep them under the carpet. Now, we need to be very, very transparent first and foremost with the information we have, the good, the bad and the ugly. I think we need to go also to really make artificial intelligence become reality and eventually even move it one level further like into an autopilot, into automation. We need to talk about interoperability, open systems. We need to talk about bi-directional communication. Data is a foundation, but if we want to get into practice of AI, I think we need to really think about how we make systems work seamlessly together to provide the clinical users with the help they really need. And I want to push that just one step forward when we talk about data, which is today when we talk about data, we have an 80% problem, which is only 20% of the data that we collect is what happens in healthcare delivery systems and determines someone's health outcomes. 80% of what determines someone's health outcomes is based on where they live, where they work, their health habits. That data today is not really collected in an effective way. So when we come to ensure safety and make sure that we're caring for people from birth through the transitions at the end of life, we really need that entirety of the data. We need a platform that's to your point, it's open, it's connected, it's intelligent, but it actually needs to have all of that data because outside the four walls of our healthcare delivery systems are a lot of issues with safety and quality that are happening that we are not capturing larger in number than what we get within the four walls of the healthcare delivery system. I wonder if I could... I think one of the things that we're talking about, you're talking about data, you're talking about data. In fact, actually what we're talking about is information because data is just stuff that goes around and gets analyzed by clever people in the lab. What the average person understands is information. So what we need to do is turn this data into useful information that can prevent me from doing something wrong, that can help me get to the right decision. And I think this obsession with data, I mean, all my movement in my car is tracked. Google tells me where the road blockage is. I use my apps to tell me where the airplane is landing, which gate has changed to. So this obsession with data security is really overblown. I mean, I don't think anybody's interested in whether I've had my hernia repaired in Hong Kong or Singapore, but yet there's more security on my healthcare date than there is on my bank account. And I just wonder whether we are emphasizing the wrong things. What we need is information so that the clinicians, that the patients, can make an informed decision as opposed to this data analytics artificial intelligence that words that people repeat, it's almost like laser 20 years ago, everybody wanted to have laser surgery. Didn't understand what it was. But it was laser, it was now moved to robotics and now we're moving into AI and predictive analytics. But genuinely, a lot of people don't understand what it means. We have to turn it into something that's understandable, that's tangible, that can make a difference to you. And that's where it is. And in terms of regulation, I'm sorry, international regulation for predictive analytics and artificial intelligence will be the same as regulating firearms. Every country's got a different way of looking at things and it's impossible to get the regulation to do the things. The way you get it is to make sure that the way you use it is beneficial to you and your patients and then people will adopt it. I think one of the clues may be international. And I would say that if I'm flying from Los Angeles to Mauritius, which I did two weeks ago and I also made the return flight, some of you may not wish that, but LAX and Sarasaraga Ramgulam Airport in Plaisance didn't change their locations and they were specific. An A380-300 aircraft doesn't matter if Emirates or Qantas or anything else is flying it. It is an A380. So the pilots, the standards to land in any international airport are exactly the same. So to say that we cannot have standardization and interoperability with highly reliable AI guided systems, I think is a fallacy. The question is, do we have the courage in health care to have the same rigorous standard as they do in aviation that are translatable around the world? A pandemic has just proven to us that none of us are island. It may be easier to have international standards than it will be to standardize care across Los Angeles. It depends what you mean by standards. So the landing may be standard, but the service may not be standard, the food would not be standard, the way your luggage is handled won't be standard. The Wi-Fi won't be standard. Some Wi-Fi will work, some Wi-Fi will work. So it's not likely to kill you? No, no, but the reality is actually some things are not likely to kill you, but they're likely to damage you for a longer period. So delirium is a real serious issue, but people pay less attention to delirium than they do to mortality. Length of stay is important, infection in hospital is important. So you can regulate, you can standardize, but you have to be able to show people what level is important to you. So infection in hospitals may be important for us in the UK or the US, but if you go to a desert area or an underdeveloped area or a poor area, they may not be the first thing they would think about. They think about water, sanitation may be food. So the question of standardization is important, but regulation is different to standardization. Can I take a step back from the, that I think is a little bit more of a basic concept? And maybe I'm speaking to myself as a patient safety researcher and other patient safety researchers who may be here, but standardization that I hear you all speaking is when this happens in the clinical scenario that the next step is that, evidence-based practice. One of the things that I think in the patient safety research world that needs to happen is we don't use terms the same way. Our vernacular is applied in different ways all across the world. What is an adverse event? There is not one common definition of an adverse event in the United States, certainly. I don't think across the world either. Preventability, same issue. We heard a little bit from Dr. Burwick about the bias of the information that we receive. We know that reported events are biased. We know that disadvantaged groups have higher incidents of safety events. So before we start regulating, before, well, at least concurrently, we need to make sure that we're speaking the same language, that we have a harmonized patient safety language. Right now we don't. So do we take, you know, from we have a reverse Pareto principle that you brought up in the scene and then we have standards and what we define as standards then taxonomy and then utilization, how do you drive a stick versus let your Tesla do the full automatic driving? Probably not right now. But thank you for that dialogue. Can I add a little bit to that because I think, you know, we talked about regulations. We talked about standards. One of the things that we've realized in AI and ML is that just because we have standards, the output that you get isn't always regulated. So you can have a particular output which in a population actually gives you positive results and in a different population actually gives you negative results. I would say in addition to regulation standards, there has to be a continuous feedback loop where in the dynamic environment of healthcare, because these algorithms are dynamic and live, that you are continuing to feedback and continue to improve that. I wanted to add that on. The other pieces outside of regulatory parts, I want to go back to a point that you said when you were talking about data and information, you kept referring back to AI, which is the consumer. In healthcare, we've done a very poor job of engaging the patient and the consumer. And I think as Don pointed out, there's a huge gap in what we need to do to actually be able to engage them. Being able to have information should also have a significant role in how the consumer is engaging with that healthcare to ensure safety. So when I was a hospitalist practicing at a tertiary quaternary academic medical center, and I would look at the labs for my thrombocytopenic patient and it was the platelets were not back and we didn't know if we were going to do a transfusion or not. When I would go into the room and the patient's like, hey, I'm looking at my labs, my platelets are low. How much are you transfusing me today? That enabled us to actually give them their transfusions several hours earlier than what would have happened if I had to wait to the end of my day and give them the transfusion, which prevented spontaneous bleed in the patient. So having algorithms, but that close partnership with the patient to be able to ensure safety is, I think, going to be a critical part of this. I'm going to check the slido to see if we have... I think that's right, but the reason the patient checked the platelets, the system shouldn't need the patient to check the platelets. No. There are multiple paths, right? I understand that. So there's the physician, there's the nurse, there's the automated system, but there's also the patient. They should have the right to do that. Absolutely. But there's a difference between having the right to do that versus having to do that because somebody else hasn't done it. It has to be quite clear that what we're doing is... That's the point. We're not putting the emphasis back on the patient to say, hey, tell me when things aren't right.  Which most of them do anyway. But the reality is, is actually you need to be able to arm the patient with your advice and your experience so that they can make the informed decision. Not to say, what would you like to do with your chest x-ray? What would you like to do with your CT scan? That would be unfair, I think. And I think that's what's scaring a lot of the remote monitoring and report patient is that the patient feel that I'm alone, I'm going to have to make decisions. And what we need to do is reassure them, you're not alone. We're looking after you continuously. And particularly in Saudi Arabia, when they introduced remote patient monitoring and patients at home, they found the customer satisfaction went up by 50%. Why? Because they were involved in their care, but they weren't left alone. So instead of saying, you're going home a day early, you're saying, you're going home a day early, but we're going to keep an eye on you for another three or four days because we really care about you. And that changes the narrative. And I think that's what we need to do. Get the patients to be comfortable that we're making the right decisions or helping them make the right decisions. I think that open, transparent data is critical for that partnership to happen. When we end up being the ones who hold all the data and the information, you can't have that two-way conversation. And to your point, there are different levels of patient engagement. But we have to provide open data to patients to be able to engage. This is in the end really the basics. But I think to Bezel's point, it's about starting with the why. Start with the why. That's the same with patient safety. We need to make the business case. And I would really take the approach how you eat an elephant, cutting it into little pieces and going for it one after the other. That's also some of our adverse events are more applicable to be solved and addressed with predictive algorithms than others. And I think we need to really be choiceful and bring examples. Success, success, success, fail fast also if it's not working, adapt the algorithms totally with you and fine tune them in a learning way. But I think that's the way to make it actionable. Not trying to solve world hunger and world peace as much as we'd like to do it, but maybe going after delirium, maybe going after acute kidney injury. Let's focus on a couple of distinct examples and really make the case there. And I think this is what will drive adaptation and change. World hunger and world peace by 2030. Yeah. So we've received some questions from our esteemed audience here. So I'll read the questions and then you can start with the answer first and see. So we failed to use technology in our benefit with the electronic health record. What makes the use of AI a better experience? Oh, that's a great question. That's a great question. So I'm old enough to have both trained on paper and pen and practiced on paper and pen and went through the transitions analog to digital. It's electronic health records. And I remember distinctly when we implemented electronic health records, the promise was all the stuff that we're talking about. It was higher quality. It was safety was open data and transparency. And we have really failed to do that. Our electronic health records have become a for the most part, a static repository of lots of information, much of which we can't access effectively. We're going to need to change that. The two largest electronic health records in around the globe are on four decade old technology. We're working on modernizing one of them so that we can actually be able to leverage the data effectively. We have to be able to modernize the technology across the board so that the data can actually be usable. I think it to me it goes back to intentionality. If we keep that purpose clear in terms of what we're trying to do and transition our electronic health records and we have better data than on that we're going to build better algorithms to be able to be more effective. But we got to we have to keep each other honest. We have to keep coming back to that and continue to iterate on that on that process to really get the results that we want in quality and safety. To add to that I think this is where we also need to align government and healthcare incentives. We were forced into electronic health records before they were ready for primetime use because it became a fundamental benefit for reimbursement to hospitals if you met that standard. And we actually used your 40 year old technology because better stuff was available but we weren't given enough time to implement it appropriately. And I think that when regulation outpaces the ability of technology we lose. I think electronic health records were invented for billing purposes to start with. So they weren't really analytic systems. They weren't designed to have a look at outcomes. They weren't designed to teach people anything. And we have an electronic health medical record that does that. But what you have to remember is also there's a learning curve and what people do is implementing a system like Epic or Cerner takes so much effort that just getting it in everybody's eyes and go great it's done now it's working. People have stopped complaining. So it's moving that and we talk about it's no different again to remote patient monitoring. We have this idea that digital inequality by introducing digital technology you may be disadvantage some people who don't have the ability to use that. And you go well actually we take 80% of the people away and we concentrate on the 20% that can't use it so we give them more care. So the reality is about creating a system that is fit for purpose and electronic health medical records are not analytic systems and they're not artificial intelligence and we need to adapt them to do that. Charlie I might take it in a little bit of a different direction and rather be the patient safety fundamentalists that I've been for my earlier responses. I think we can adapt and we have examples of areas where there's a lot of success with feedback loops. Treating type 1 diabetics with continuous monitoring and continuous and adjustable infusion rates is a great example right. I'm a pediatric intensivist several of us up here are intensivists. I would love to see the day hopefully not very long where our ventilators can keep up with patient improvement once they start to improve. We've got continuous oxygenation. We've got continuous ventilation parameters. Those should be driving our changes. One of the things that happens in both the ICUs that I've worked in is that many times when a child is better we don't keep up with their improvement. Therefore they stay on the ventilator longer and therefore they're at more risk. I think we can apply those types of things and that doesn't seem to me to be insurmountable even today. Those are the kind of things that I think we could do quite readily. David you just emphasized again my plea for open communication between systems and devices. That's absolutely the way to go to make your dream become a reality not years out but hopefully a lot sooner already. But to come back to the original question a bit what failed in the EMR implementation and what will be different around AI. I think we need to early on show the success the why again and then also bring the users along. What's in it for me. What's in it for a nurse or doctor to use an electronic record. I'm not sure we really have successfully answered that question. So I think we need to clearly show here what's in it for the patient for the outcome but also for the user. Some of the questions that we're getting from our colleagues out there align perfectly with what you've all presented. I think I'm just going to one here. The you know how can a health care system improve the quality of the data collected. I think we've talked about that. That's really good. And this is the social one. You know patients need to have full access to their data which the 2080 perspective yet we need to be careful with the do your own research perspective too. So is is physicians what's your perspective on that with having our patients and families you know more empowered with more data or as long as the data is good. How do you balance that out. I'm always so appreciative. I can remember back when the Internet was first coming to be and patients were looking up their own diseases or their children's diseases in my case and at first it was threatening but very quickly I started to feel that we all needed to embrace that to be asked hey Dr. Stockwell I just read about this condition. Is this something that would help me. And as I embraced it more and I've had a child who's also had some serious health illnesses. You think of course that's where we have to go. We have to embrace high level conversations because everyone will benefit from that. Everyone will benefit from that. You know when when Joe started the the movement and the team started the movement you know the data highway and the sharing of data it's improved over the last 10 years but it's still not where it's supposed to be. You know Cerner was one of the first Phillips and GE and a bunch of other companies stepped up to sign the the open data pledge. We're still a long way from that but it has it has gotten better having been on the administrative side looking for you know interoperability with medical devices as well as the sharing of data bringing that forward so it's facing front facing with the patients and their families. It's a move. Where does the where do the algorithms and or some of the AI components is that going to accrete into that world now too. Do you see that from your perspectives. We have a minute and three seconds to answer that. I think these things as you say we have we have to adopt these things it's like we all Google what should I do when my BMW doesn't start or when my iPhone you know what I you know we all do that so so the reality is that people Google but what I say to them is that yeah sure you can Google that but based on my experience of 20 years of critical care that's what I would do but if you want to choose the internet fine we have to remember this isn't this isn't a this isn't karaoke you can't just choose the way I treat you you can choose to be treated or not but ultimately we have to do what we think is right taking the patient's opinion into consideration but I wouldn't do anything wrong just or do a treatment that I don't think is beneficial just because the patient wants it that wouldn't be something I would do and so I'm not scared of people looking up to stuff but I also am I'm entitled to have my own views on things it's always good to have that conversation I think but the conversation helps the example we had from Martha if there would have been the culture of having an open dialogue right that's what prevents these cases and we need to be open as physicians to have that conversation is that why they call it open AI now that's not sure of this open ended yeah so uh we're done so thank you uh team panel members um we have a it says Charlie Charlie throw to a 10 minute break so I'm throwing everybody to a 10 minute break so thank you thank you guys yeah thanks great thank you


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