Don't hear anything? Which, oh, yes. So if you want to make eye contact with the numbers right now, there's a yes to it. It's your phone off. I can call you. Good afternoon. I am delighted to welcome you to the first of our lectures. This academic year on COVID-19. The COVID-19 pandemic is an unprecedented event in our lifetime. And the extent to which it is, it has permeated our everyday lives forces us to experience the everyday ethics of contagion with 7 million cases and over 200,000 deaths in the United States. As of now, the COVID-19 pandemic has been the worst pandemic since the 1918 flu. The pervasive and disruptive nature of this pandemic has forced us both as individuals and as a country to reconsider our social interactions and behaviors. The limits of our medical response and that of the healthcare system. And even our relationships with each other as well as with our local and global communities. In many ways, the pandemic has been a real world stress test of basic principles and practices of clinical and public health ethics, compelling all of us to reexamine how these ethical fields can and should inform policies that guide clinical practice and social behaviors. This lecture series will examine a broad range of important ethical topics that have far reaching impact for the medical, social and political aspects of the COVID-19 pandemic. The lecture series consists of 27 lectures on Wednesdays beginning today, October 7 and concluding on Wednesday, May 12 of 2021 with about three weeks off around Christmas and New Year's time. As this lecture series unfolds, within the context of the ongoing pandemic, we hope to address critical questions and concerns of the current moment by drawing upon the past and looking ahead to an uncertain future. Some of the issues that we'll focus on closely in these lectures include COVID-19's association with healthcare disparities, COVID-19's impact on ethically appropriate allocation and triage in the face of scarce resources, the focus on the challenges of developing a COVID-19 safe and effective vaccine, and even the work of the World Health Organization in dealing with COVID-19 as an international pandemic. The McLean Center for Clinical Medical Ethics and the Bucksbaum Institute for Clinical Excellence have organized this lecture series, and the principal developers of the series are Brian Callender, Marshall Chin, Laney Ross, myself, along with Peter Angelos, Elbert Wang, Emily Landon, Will Parker, and Monica Peake. I'm now honored to introduce our speaker today, the opening speaker of the 27 lecture series, Dr. Emily Landon, who's been a major leader in addressing the management and ethics of the COVID-19 pandemic. Emily Landon is an MD, is Associate Professor of Medicine in the sections of Infectious Diseases and Global Health, and is a faculty member at the McLean Center here at the University. Dr. Landon is also the University of Chicago's Hospital Epidemiologist and serves as the medical director of the Infection Control Program and the Antimicrobial Stewardship Program. Dr. Landon completed her medical residency, chief residency, and fellowship in infectious diseases here at the University of Chicago. Her research has focused on improving care, specifically reducing the risk of healthcare associated infections and optimizing antimicrobial utilization. She has studied novel electronic hand hygiene monitoring techniques and has evaluated the impact of direct individual level feedback to encourage provider actions that prevent infections. Dr. Landon has been a clear leader during this pandemic, including the speech she gave at the Illinois Governor's COVID-19 press conference earlier this year. Dr. Landon has also appeared and spoken both in local and national outlets, such as the Hyde Park Herald and the Chicago Tribune, the Washington Post, the WTTW Association, CNN, ABC, CBS, NBC, and I could go on for quite a while. I am delighted to welcome Dr. Emily Landon to present her speech today, the title of which, bear with me, is COVID-19 Ethics.  Dr. Landon. Hi, Mark. Hi, everyone. Thank you, Mark. That was a very kind introduction. I'm going to share my screen now so that we can all see my slides. I don't usually use slides when I'm talking about COVID because I realized in January that I had to change them every single day because things were changing so quickly and I got used to not using slides, but I did think that there were some important things that I wanted to illustrate today as part of this talk, which I see as a little bit of sort of a step away from sort of the media and the instruction than the sort of most recent thing that came out that needs to be explained and instead an opportunity to reflect a little bit on how this pandemic has shaped who we are and what it means to talk about how this whole year's worth of a series of lectures will be important. I have no disclosures related to this talk. And everyone knows the world is not the same as it was before. We are all different. We don't really know what that says about us or what it means for us, nor do we know exactly how the world is going to be tomorrow or next week or next month and comparing it to how it was last month doesn't make any sense. A lot of the questions that we've been asking ourselves are not new. Questions about the ethics about how to distribute scarce resources and the other things that Mark was talking about, but they are in a very different context here, a much more quick moving context that has changed the way we do things. We talk a lot about the beneficence autonomy, non-maleficence injustice or the four box method, Mark's square box method, when we're talking about ethics in medicine. And in that job, we often strive to try and minimize the contextual features of the situation or the community effects. We try to focus mostly on the patient in front of us, but in a pandemic, everything changes and justice or the surrounding situation or the community or the effect on other individuals becomes central to everything that we choose to do or choose not to do. And in this world of self-preservation, personalized medicine and individuality, it's quite a shock when we need to sacrifice and change everything from our leisure activities to our professional practice in order to reorient ourselves around the demands made by an invisible, transmissible illness. It's not an experience that I've ever had in my lifetime, and it's not one that many of us have had, but it's one that we're in and one that we need to face together. In this series, we're going to delve into the ethical questions that come along with having public health rules about masks and protective equipment, and if they're where they need to be and who needs to have what, about distributing scarce resources, like the new therapeutics that are being developed on the fly and tested in a very high pressure situation with a lot of political influence. The disparities aspect of this pandemic is so huge. It can't possibly be contained in a lecture series, in a year's course, in anything. It is literally shows us what the foundation of our medical care system had, all of the cracks show with this disease. The testing and contact tracing and the subsequent quarantines and isolations and whether or not we have to follow them or should follow them or must test or must allow people the decision about whether or not they should get a test. These are questions that we ask every day about things like cancer treatment, but they often don't have any impact on others around them, whereas with testing and contact tracing with quarantine and isolation, they definitely do. This is very evident any time you turn on the news today. We are going to talk about how we are going to distribute the vaccine. How we are going to, whether or not we should stop trials early, whether the cutoffs for trials are appropriate, or whether they are not careful enough. There are reasons to cut corners in vaccine development when you are in the middle of a pandemic, but how much do you cut? How many are the health benefits and how many are the health benefits? There is also a strong issue with education and children. I would go on to say economics and public health and whether or not it is fair or right that people who are often lower income and maybe more often black or brown are more often in our essential communities. We are going to talk about how we are going to put ourselves in harm's way for the rest of us. There are so many things to talk about. Many of them will be covered in this lecture series. But today, I think that our knowledge about the disease itself has grown as exponentially as the spread of the disease. And it is hard for the general public to think about it. And it is hard for the general public to think about it. And then ultimately influence their daily behavior. Needless to say, the embrace of this life or death level threat that surrounded by uncertainty has made some people's mental health crisis worse. Has created new mental health crises and we are going to talk more about that later. But first, I think it is important and what I want to accomplish today is to give you the basics of the fact. Some information about what has happened, about what we know, and some notes that will help you to understand where we go from here. And then I will leave plenty of time for questions because I know there will be many questions in the future. I will leave them to you. I will leave them to you on January 23. For our very first episode with, or our very first meeting with the Hicks team. And this was the basic information that I could put together. I added a bit at the end. The coronavirus is a known virus. It is named for the crown that is seen on electron microscopy. We have a partnership with Wuhan Medical School. I have been to Wuhan many times and worked in these hospitals alongside some of these providers and friends with many of them who cared for some of these patients. In our discussions with them since then, some of these dates have been while not officially revised by the Chinese government acknowledged that perhaps the COVID-19 pandemic is a new virus. We found a new beta coronavirus that is related to a bat coronavirus and the SARS coronavirus. Most coronaviruses that cause the normal everyday common cold are not beta coronaviruses. This is a separate family that includes some bat things, some regular SARS and some MERS and SARS-CoV-2 which is now dominating that entire class. And the case fatality rate was already around 1% or less than 1%, meaning it was less deadly than SARS or MERS and remains to be the same but is much more transmissible as we have all seen. The infection timeline hasn't changed much. It takes about two to 12 days of an incubation period although the majority of people get sick on day five or six or seven after an exposure. Severely ill patients who need to be in the hospital before they come to the hospital before they come to the hospital which means it can be two weeks from the exposure to the time that patient is registered in the hospital. And then what we know now is that it can take another couple of weeks before that person succumbs to their illness. But far and away most patients don't. Most patients are able to be supported through their illness and are able to be supported. Some people have long-term consequences of the illness. Some people with mild symptoms seem to have long-term consequences of their illness and the actual longevity of these concerns and the severity of them over time is unknown because we haven't had enough time. I used to say in March and April that at that point this disease wasn't old enough for us to know what would even happen with their babies. We're now past that place and we now know much more that most people are actually not going to get very ill from coronavirus including many pregnant women. But older individuals, those with cardiovascular disease, lung disease or kidney disease and men are at higher risk. It seems that those with vitamin D deficiencies or lower vitamin D often are also at greater risk and there is more to be learned about this disease.  Fever and cough are often the common symptoms that we now acknowledge that there are different sort of constellations of symptoms that some patients arrive with. Some have viral pneumonia and look exactly like they did when I made this slide. The disease is now transmitted by droplets and sometimes aerosols and we'll talk more about that because I know it makes a big difference. We also know now that pre-symptomatic and asymptomatic spread are common and that they dominate the problems that we see with this virus. On this slide are everything that you need to know to know that this is going to be a pandemic.   That's what makes anything dangerous and difficult to manage. The symptoms of coronavirus have grown and we know more about it than we did with COVID-19. We know more about it than we did with COVID-19. Some people have chills, muscle pain and fever. Some people have GI symptoms which aren't even listed on this sheet. But this new loss of taste or smell is the most interesting one and one that we're often seeing. Interestingly enough, the main reason why we have people come to work sick with COVID is that they think it's probably their allergies. Which means that congestion, which seems to be one of the main reasons. Unlike influenza, which seems to sort of hit you like a truck as they say, COVID comes on slowly without having very much or any really warning. Sort of insidious in its onset. And that asymptomatic and pre-symptomatic transmission is important. For every person we diagnose with COVID who has symptoms of COVID and who's tested positive, there's at least one person who is contagious with COVID who thinks that they are completely fine. They may have such minor symptoms that they think it's just their allergies. Or they may be not sick at all. Making control of the virus. Even more universal. So what's the difference between this airborne and this droplet precaution? Well, we use different signs for them in the hospital. And I think about this sort of thing. One means you wear a surgical mask and one means you're wearing N95. The reality is that there is actually a continuum between the two. And many diseases can behave more airborne or more droplet at different times. In fact, influenza is a good example. It often aerosolizes itself when patients undergo aerosol generating procedures. And while you may not know this, there certainly are times when you're sick. But you may not have read the fine print on the signs. Right now, we know a lot more about COVID. And it is really a much bigger problem with COVID than it is with influenza. In certain circumstances where there's more heavy breathing, where there's singing, especially the vibration makes the droplet smaller, which allows them to hang on in the air, travel longer and stay aloft and in the room lingering longer. And this is a very common problem with aerosol transmission. This is distinct from full-on airborne transmission like measles where it can stay in a room for hours after you walk out of it. It's not very common with COVID. We're not seeing that very often. But obviously if the concentration of respiratory droplets, even the tiny ones are high enough in a room, it could linger after someone leaves. And so you can see how the continuum means that we sometimes use high-flown nasal cannula and nebulizer treatments often don't do that. We need to have a crowded room. That means higher humidity and maybe warmer. And not very much ventilation, which none of the rooms in our hospital have. We all have very high-flown nebulizer treatments. And we need to have high-flown nasal cannula and nebulizer treatments often don't do that. We need to have a crowded room. That means higher humidity and nebulizer treatments often don't do that. We all have very high-flown ventilation rates in our hospital. And then we need to have someone who is making lots and lots of droplets that are infected without having a mask on. We ask people to wear N95s when they get close to that situation, but at home, the best way to stop these things from happening is by wearing a mask because source control holds in 95% of the droplets, making it much less likely that they'll ever be enough to create a mask. And then we need to have people wear N95s when they get close to that situation. What about surfaces? I'm asked this a lot. Viral particles from COVID can sustain life on some surfaces for up to 72 hours. But it turns out that in real life, we're not seeing very many people get infected from that. In other words, you have to get more, even if you touch a surface that's contaminated, there's not enough of it there or not enough of it transferring to the surface. So, I think we need to keep surfaces clean and wash our hands, of course, but this is not the main way that COVID is transmitted. And we shouldn't be too, too overly concerned and focus too much of our efforts on preventing transmission by cleaning things instead of doing what's really necessary, which is putting masks on everyone and improving our ventilation. I'd like to talk for a moment about the current epidemiology. Now that we've covered some of the transmission, in the United States, we have not done well. We have failed to address things on a national level. The state of Illinois is doing much better and I'll show you that in a moment, but this is the graph from the New York Times of the sort of new cases. And you can see that we never get back anywhere near where we were in the beginning of March, when we honestly didn't have any cases because we weren't testing. Now that we're testing more frequently, we're identifying more cases, which is common happens in every pandemic and epidemic. But you can see that the baseline is ever increasing and that means there's more and more transmission with increasing transmission happening over as we're moving into a time when these super spreader like events where we have the trifecta of unmasked individuals crowded into a space with poor ventilation is going to happen much more frequently. This is another look at the map version where the cases are right now in the United States. I pulled this actually at about 11 o'clock this morning. So I think it is pretty accurate for right now from the New York Times website. Wisconsin is battling the pandemic in a significant way right now and everyone is taking their turns having a really rough time of it. How does this happen? Why is it that it doesn't go everywhere all the time? Why is it that things have been so spotty? Why does one city get sick while another city doesn't? That's a great question. Many of us believe that this is because there are sufficient number of these kind of super spreader cluster events that begin to sort of trip off a cascade of additional clustering events and the things that make those things happen is that we have more opportunities for large-scale spread. One is only spreading to one maybe two other people. It's unlikely to be this kind of a problem but when you have a few people that spread to 20 or 30 it can easily become a large cluster and then the ones and twos really matter as much. Just as much. Illinois has been aggressive about this from the start and I have to say as much as I have been critical of our federal government's response of getting the appropriate PPE to the right places of getting working hard to distribute the therapeutics correctly to develop new therapeutics I think that and to get testing into the places where we need to see more testing we certainly are doing better in Illinois than many other places. That's because we've been aggressive about closing down places that are high risk for these clustering events and that we've been very aggressive about putting masks into place early on May 1st actually before much of the country. Nonetheless, we're still seeing a transmission rate in Chicago and in Illinois that is higher than what we want it to be going into the fall. The daily tests on a 7-day average the daily cases on a 7-day average are still in the 300s in Chicago which is more than what we want. I'd like to see those in the 100s in the fall. If you look at the in the fall, you can see that the positivity rate is hovering just under 5%. We were up at 5% a few weeks ago now we're down at 4.3 but we seem to ping-pong back and forth in that place which is still far more than most European countries consider to be a serious situation. Chicago has done a lot about keeping bars closed I know they've most recently opened a bar and we've been doing better and we've been holding steady and especially in high park. I want to talk now about the numbers behind the epidemiology. I'm not a big fan of complex math but I do think that we should be very simply discussing what an SIR model is and how we make predictions and why does this disease behave the way that it behaves. So an SIR model is a model of infectious individuals and recovered or removed individuals so people who are not in the model or are not susceptible and they are not infectious or they are not able to spread to other people. And you can see a very, very simple model of what COVID would look like. You have a lot of susceptible people in the beginning of the pandemic you have a lot of people get sick some people don't have clinical infection and everyone catches it and you end up with having a lot of recovered or removed individuals they no longer matter they can't be contagious or catch the disease and so they are out of the model and then the disease dies out because you no longer have susceptible individuals. This is how most people think about a respiratory virus pandemic and how it moves through a community. COVID isn't doing this exactly for a lot of reasons. The pandemic spike would be much, much higher there would be so many people sick that we've taken a lot of efforts to try and control the spread of the disease and we're not entirely sure about how many recovered people are actually no longer susceptible to the disease which makes it all much, much more confusing. Looking at it another way these are the boxes you can see that there is more to the equation than just one piece here, one piece there. In fact what needs to happen is in order to understand the model you need to have a good understanding of how many infectious people there are how many susceptible people there are how often the infectious people actually turn up infecting the susceptible people so the rate at which susceptible people become infectious and the rate at which infectious people recover or develop immunity you can imagine how this graphic the previous graphic would change over time so I want you to think of this and talk about now like testing, contact tracing and therapeutics and vaccines vaccines work to make more people immune by bypassing infection. They are a fast track to the ending state on the previous graph there's also the possibility you hear people talk about herd immunity that is actually a term that's associated with the vaccines to create a herd immunity it's not actually used for natural infection going through a community and I don't recommend that because in order to get there we probably need a lot of people to die or become very very sick and that would create a lot of different problems than what we have right now the same problems we're having right now but even bigger. So I think we have to take the idea of removing people from the model by just getting them through the model by getting them sicker faster by getting the vaccine it's important to remember even when we do that a vaccine may not be 100% effective and so some of the people who receive the vaccine will not actually be sort of shot put through the model over into immune some people will not be immune and you will not know which individuals are not immune. We also don't know how long the vaccines will last and how long immunity lasts and so there's a lot of confusion about that and that is another way. I mentioned earlier that removing people from the model doesn't happen only by them being immune you can also physically remove them from the model by putting them into isolation or quarantine and just to note sick people go into isolation and expose people who are still well are in quarantine this is a terminology that is one of my pet peeves anyway you find people who are sick and you remove them from the model by taking them out and they can't have contact with susceptible individuals meaning that you have essentially removed them from the model to reduce the likelihood that there are contacts or reducing the rate at which susceptible people become infectious so contact tracing and isolation is one way of getting people out of this model once they become infectious reducing the number of people in the green box is one important way of reducing the spread of infection another way that we can do that is by quarantining which is technically taking susceptible people that are very high risk of becoming infectious in the very near future and removing them from the model as well that's quarantining it says I think these people are the highest risk of becoming infectious I'm going to take them out of the model before they ever are but there's another way that's really important and that is acknowledging that we'll never ever get all of the people we'll never be able to identify all the people who are infectious which is a big problem we can't test our way out of that you never know exactly who's infectious and you can't know exactly who is susceptible and so reducing the likelihood that an infectious person will infect a susceptible person is another very good way of reducing the stress of this model on humanity that means masks distance hand hygiene staying home when you're sick that sort of thing so now you understand why everyone harps on these things and why they make things look better or not better based on whether or not they're done but it's really important to remember that each of these things is imperfect in and of itself not everyone who gets sick will be immune not everyone who gets a vaccine will be immune not everyone who is infectious will be identified and taken out of the model not everyone who's high risk for becoming an infected person is going to be quarantined not every time that a mask is worn will it be successful not every ventilation system is going to be perfect not every your hands can't be perfectly clean all of the time I know it's odd that I'm acknowledging that but it's true your hands cannot be perfectly clean all of the time and there are so many more you may not know that you're sick to stay home when you're sick doesn't actually work if people are asymptomatic and so there are always going to be holes in every single step that we might put into place but just like other safety interventions if we layer them up and we do all of them at the same time we have the best chance of preventing any harm from happening in the model in other words trying to keep the number of people who die the proportion of those infected individuals will die and we want to keep that number low we also want to keep the number that are in the hospital low because that would be too much of a strain on our health care system and so it is essential that we wear masks even though they're not perfect it is essential that we wash our hands even though our hands may not be clean all of the time it is essential that we stay home when we are sick even if we may end up coming to work with asymptomatic COVID all of those things together are the imperfections of the other things so what actually is going to protect you the most important things are physical distancing face masks and eye protection those of you working in the hospital know this because we put it everywhere and there is good data this is a meta-analysis from the Lancet which is a landmark study now for COVID that shows that without an intervention without using physical distancing and they're only looking at 3 meters or not 2 meters that's 3 feet not 6 feet that means that there's less than 1 meter of social distancing 12.8% of people would get infected but if you had at least 3 feet of distancing only 2.6% of the individuals who are exposed will get infected that's a big difference if you wear a face mask if you don't have one on that's not even including a respirator this is any mask at all all comers will be infected whereas only 3.1% will be infected if the mask is worn by the individual who is protecting themselves there's a whole other issue with the source control aspect of masking and that is very important independent of this study there have been a number of other studies that have shown that even a 2-ply cotton mask that isn't super filtering can contain 95% of the particles of even a very contagious individual including the aerosolized particles and that means that everyone else is getting much less of an exposure and that's really the main reason why people need to wear masks all the time it is for source control more so than it is for protection when you're caring for patients it's for protection when you are wearing it out and about it's for source control eye protection is also really important 16% of people do get infected but only 5% get infected when there is eye protection which leads me to believe this is independent from the mask eye protection is very important when there is no source control distance face mask and eye protection is the way to go and that leads me to say whenever you're around someone who does not have a mask on we need distance masks and eye protection as healthcare workers instead of distance and we put a face mask and eye protection on in real life you can't like sort of you could try and treat the train like in a contaminated environment and put on a sort of suit while you're on the train and dispose of it when you get off but in reality physical distancing is a little bit easier to practice I want to make some notes about testing so we have three different kinds and they're kind of big categories this is going to be important background understanding for you as you go forward in your daily lives and in this lecture series PCR tests are the current goal standard but they come in many different flavors nasal swabs are definitely the best NP aspirates and mid-turbidate nasal swabs are very good oral swabs not nearly as good saliva tests the best we've seen is about 80% sensitive so we need to consider that that's why we don't offer saliva tests for you when you're sick or why we don't offer it for our patients we need something better when someone is sick these take a little bit longer than rapid tests but as many of you know some of the platforms turn around very quickly including our Cepheid test which can turn around in a couple of hours then we have the so-called rapid tests which may take longer than the Cepheid test does which is a PCR test but just for argument's sake let's put these rapid tests together these rapid tests often detect antigen they may be partnered with something that's sort of PCR like they may use different wavelengths of light to try and identify particles that are associated with coronavirus it's complicated the point being that these are quick often point of care tests they are usually in this situation less sensitive which is not what you would think of so in many cases we do rapid tests and they're more sensitive and then we have to confirm only the positives because we want to over select for example mammograms they're a screening test we want to catch anything that's abnormal in a breast and then go on to have a more detailed examination using one of any number of more specific tests however when it comes to COVID the best we can do right now are these less sensitive rapid tests they use them not great at identifying who has COVID many of them are 60 to 70 maybe 80% effective at identifying who has COVID these are the tests that were used in the White House in order to identify individuals as being COVID positive or negative before they met with the president or came to work that day I think you're beginning to see how every single day in the White House was a big gamble these tests are less sensitive and confirm all the negatives which is not really very reasonable these tests are actually useful in sort of detecting clusters if you test a lot of people and there's been a large scale cluster or super spreader event you'll usually pick up some of the individuals then you can figure out from them where they might have picked up COVID and then you can go back and test all of the people that had that exposure using a PCR test unfortunately that process often takes so long for people being infected and so there are definitely pros and cons of each of these strategies and when you start to look at different university testing platforms and university testing priorities I have thought about this a lot you can see that there's no one standard way of doing things there's no easy way to screen whole populations on a regular basis serology is useful for late complications like the MISC and children many of them won't still have a positive COVID test or it's unreliable to expect them to have a positive PCR test but they do have these positive serologies in that time frame now what we are seeing is that antibodies do deteriorate over time or the antibody titers go down it's not clear whether or not that has anything to do with immunity and I'll get to that when I give you a little bit more information about immunity in general I've misspelled immunity I apologize therapeutics there are four main therapeutics for COVID right now Remdesivir you've heard of it's a small molecule similar to other antiretroviral drugs this is just one that helps bind to it and keeps it from replicating inside of cells it was originally proposed as a drug for Ebola it was then repurposed as a drug for COVID it's not awesome but it's okay to reduce the length of stay it's not pulling people back from the brink of death with a single dose but it is certainly helping and it's now pretty widely available I'm sure that there will be shortages if we do see the peaks that we expect to see over the winter dexamethasone widely available easily used for many other things a note is that in SARS and MERS steroids are thought to decrease or increase the likelihood that a person will continue to carry the virus it's not thought to be proven to increase the time to clear viral clearance they may make the course longer but they may actually help people feel a little bit better in the beginning there is some evidence of at least improving mortality in these patients with COVID and so it is used widely widely in people who are hypoxic but because it does have this potential it's never great to give steroids to people with infections and so no one wants to give it to people who are getting over COVID on their own period then we have convalescent plasma which is sort of a blanket attempt at passive immunization we're taking antibodies from individuals who've had COVID but it's all their antibodies it's nothing specific it's just the whole IVIG from the person that got over COVID and we're just giving it to people that have COVID hoping that there are some antibodies in there that will neutralize the virus and help tide the patient over until they can make their own immune response iffy sometimes it seems to help sometimes it doesn't these poly and monoclonal antibody cocktails which are all still in phase 3 clinical trials are not even available as an emergency use use authorization but are available for compassionate use apparently you didn't know that until last week but apparently they are because our president got some on compassionate use these are more specifically engineered antibodies you can imagine them as taking the good antibodies from plasma the ones that we think neutralize the virus in different ways or prevent it from entering cells and then creating lots and lots of them in the same way that they create humera or ed brol or any one of those drugs they're all slightly different and there are some that have multiple antibodies in them some have only one monoclonal antibody but the concept is the same they are passive antibody passive immunization and they seem to last their pharmacokinetics last about a month which should be enough time for the person to develop their own immune response we have trials of them here and from what my colleagues say they're doing very well so that leads me to talk a bit about immunity and reinfection so reinfection happens we know it does it's been proven but it was really hard to prove the way to prove that reinfections happen is you have to have a sequenced virus from the original infection and then a new clinical syndrome a positive test and a sequenced virus from that infection in that case we can see that someone has a different coronavirus or COVID we've only had a few reported cases that are confirmed but there are others that have been suspected in other patients and those are all over the map anywhere from 45 days to 150 days 200 days after the original infection we also know that patients who have COVID have a long tail or remote positive test after infection but that we can't isolate transmissible virus after about 8 days of the patient being sick and so we aren't sure what this represents probably just dead bits of RNA from the virus but how important are they to whether or not the patient is going to get sick again whether or not they keep making an immune response it's not clear what we can do with those there's a lot more to know about that particular situation we know some antibodies are short-lived in fact what we consider to be the best neutralizing antibodies go away very quickly in individuals that have very mild infection but there are also some studies that suggest that there's longer term T-cell related immunity in those individuals and maybe even in some individuals who had other coronaviruses in the past that may make them susceptible we are still learning a lot about this and many of the things that we tell people to do regarding re-infection and long-tail positives is extrapolated from data that's very minimal and so clinical suspicion is still really important in that aspect of things but there will be a lot more to learn and as we get further and further away from people's infections this is going to become more and more important I'd like to make a note on vaccines which I think will feature prominently in the lectures this year there are at least 4 vaccines currently available in phase 3 clinical trials that have different mechanisms one is an RNA and messenger RNA vaccine which has never been successful before that's the Moderna vaccine there's an adenovirus vector vaccine that's the AstraZeneca vaccine which that trial was stopped briefly for neurologic side effects it's been restarted in the UK but not in some other countries there are different protocols for these vaccines and one of the pieces that it's important to remember from an ethics standpoint as you think about vaccine trials these safety of these vaccines are different than medications because they need to be given widely to a large population of healthy individuals the standards for safety are always higher to something that's given widely to all individuals whether or not they're sick so tell the individuals however in a situation where you have 200,000 Americans dead in just a few months that safety it may not be as important to prevent a few cases of Guillain-Barre because if people get over those cases of Guillain-Barre and they're only going to be a few if they're going to be 100,000 that's not great if they're going to be five that's probably okay because of the number of people we can save by using the vaccine this is why there's an actual debate about whether or not we should cut trials short I think that the current recommendations for at least two months of looking for for looking at side effects is reasonable as most side effects happen earlier than that with all the other vaccines that happened in the past the population or sample size is also important and many of these trials have not enrolled to their appropriate or estimated size that they proposed and there are a lot of questions about this I was pleased to see over the last 24 hours that the government the White House wanted to overrule the FDA and the FDA said no we're just not going to submit any vaccines until we know for sure that everything's good the timeline for this is uncertain as you know because clinical enrollment in trials and clinically how patients are doing and how long it takes for them to develop immunity is different for different people and so we can't set a timeline in advance you have to see how the trial unfolds which is kind of lost on some of our political friends I also want to say a big shout out to our data safety monitoring board members across the world who are sitting on these trials and they are the stop gaps right now and they are the ones who will not let trials go forward and many of them are ethicists like you all in the audience and so thank you for sitting on DSMB's I've sat on DSMB's before and sometimes it's annoying because you feel like everything's completely fine and why do you have to do this but the reality is that job is more important than ever and this is a really good example of that so please be altruistic and support being on DSMB's and being part of IRPs and things like that and I think I've already mentioned plenty of politics about vaccines oh a last piece the distribution of vaccines is going to be the biggest issue of all many of these vaccines need minus 80 freezing and all sorts of other things and most people will need two doses making the logistics of distribution really complicated the last thing that I want to talk about today is a piece that I think actually describes why we're having so much trouble addressing and sort of accepting that what's been happening to us over the past six or seven months now in the United States and in the world it's normal as all of you especially the fellows know Elizabeth Kubler-Ross described the stages of grief many years ago now you see them here these are commonly also applied to change and this virus and this pandemic situation represents a serious loss for humans everyone has lost something some of us have lost loved ones some of us have lost patients many of us have lost out on opportunities things we wanted to do seeing family being there for things we wanted to be there for many of us have losses even if you are living on an island alone you still have lost out on things that you wanted to do and that loss is hard for people and everyone experiences loss differently but we all go through these similar stages now it's not that you first have denial then it's followed by anger then bargaining then of course not you bounce back and forth between these until you finally get to a place where acceptance is happening more frequently and more often than the denial anger bargaining and depression and one of the things that really matters here is our leadership and who helps you through your grief process if you are in a grief process and someone you love has died and everyone around you tells you that you should just stay angry because it's not fair and the only thing you have to you know if you just keep staying angry you'll be better you're probably likely to stay angry for a very long time and it will be harder for you to get to acceptance it's important to experience the anger the denial the bargaining and the depression but it's just as important to recognize them for what they are and acknowledge that we need to get to acceptance we've been missing that in our national discourse there is not a clear message that it's normal to feel like you don't want to pay attention to coronavirus anymore I am sick to death of COVID I don't want to hear about it ever again I could I have so tired of listening to contact tracing on TV I am so tired of all of it but the reality is that I can't ignore I can't just pretend it's not there and I'm angry about a lot of things that have happened but that doesn't mean and that I need to be angry forever but if we tell people regularly if leaders tell people that trust them regularly the denial and anger are the place to be that bargaining about when we need to wear a mask when we have to wear a mask if we tell people that those are the only options that that's the right answer to this catastrophe they're likely to stay there for as long as they can but if we help them see a way to get from their denial their anger their bargaining and get them through the depression that is definitely part of all of this we're more likely to get people to a place of acceptance where we can begin to incorporate the things that we need to do to live with COVID fighting against COVID we will not win but we can live with it if we continue to work together there are lots of ethical questions long way many of them stem from the facts and information that I've given you today but I'm hoping that you can see a little bit more about how we got to where we are and about well you can do at least as good a job as anybody in terms of crystal balling what's going to happen in the future bottom line is we have a lot of knowledge now but it's hard to accept that it's hard to accept that everything is changed but that's something that we need to do together and I hope that through this lecture series that you all will get become more familiar with how these things work in pandemics and how infectious diseases and ethics come together in a way that is super interesting to me or I wouldn't be here today so that is all I wanted to say today except I do want to take a moment I have talked to a ton of media and I have spoken out on COVID I spend the majority of my day now giving talks about and talking about COVID I never have had the chance to say thank you so I do want to say thank you to all the people that have helped me and that have helped us as a hospital get through and get to where we are today there are so many people that have been everybody's been working on this and it's affected every single one of us but there certainly are a lot of us who are still living literally COVID from dawn to past dusk every single day and have been since January and I really appreciate all the support that it's given me to have all these people on my team and I'm sure I've forgotten a lot of people but I wanted to say thank you because without them I could never do anything that I've done we would never be where we are as an institution and these are the people that have really done a lot of work are there any questions and I'll take away the slides now and share my screen great so Emily this is Laney Ross I'm helping Mark with following up on the chat line so first we want to say thank you to you for all you've done for all of us as well as for opening this session with a fabulous talk the first question comes from one of our attendees who said you mentioned that many pregnant women will not get very sick from COVID what's the impact of COVID on pregnant women when compared to the general population and are they considered a high risk group early on we found that pregnant women were much more likely to be positive than we thought they were they didn't seem to be very sick in New York there was a study that said 14% of asymptomatic pregnant women were positive for COVID and most hospitals started screening every woman that came in in labor when it came time to have their baby and we found that a lot of them were positive now certainly we know that COVID is common in pregnant women so while they it's also true that we were missing a lot of asymptomatic cases and non-pregnant people and so it's not clear that they are getting it any more frequently than anyone else is but they definitely have less sort of less complications than we think that they would given that they are oftentimes a very high risk population now that said they have actually been downgraded and they will sort of how risky they are according to the CDC they used to be in a tier 1 they're down in tier 2 there doesn't appear to be any effect on the fetus even if you get COVID early on in pregnancy but I think that everybody wants to see more data to know that for sure and there's also it appears to maybe be associated with preterm delivery but not not a ton of pre not really really little preemies like maybe a couple weeks if you get it a couple weeks early it's not too bad that said no one wants anyone to get COVID even pregnant women and we don't want their babies to get COVID but just because it's not so bad most of the time does not mean that we are going to just turn a blind eye thank you the next question is is it truly safe to be around people outside do you have any suggestions for being social in the winter time yeah so outside it's masks or distance right so if you're going to be up close with people outside you want to wear a mask and they should wear a mask too inside it's masks and distance now that doesn't actually mean that you can't be near each other in a room and this is something that I know goes against a lot of what I'm saying you need to have that much room for the people in the room because you need that volume of air to dissolve and dilute out their droplets now I don't want you sitting up close with people wearing masks or falling down under their nose or they're not really doing the right thing or they're taking drinks from their water bottle so you should in break rooms and work rooms stay far apart but if you're meeting up with friends and family friends that you want to keep you're not ready you don't want them to be part of your unmasked group but you're going to meet up with them somewhere and sit and talk or play a game that would be a time to wear your mask and you don't need to be too insistent about that six feet space in the room for everybody's air to be diluted and keep as much space as you can and then how do you keep safe that is my advice for how to keep safe in the winter we're going to need to that SIR model is all driven by how many contacts there are between susceptibles and infected and you can't tell who's infected and so what you have to do is keep all there are safe contacts and then they're unsafe so safe contact is when you're wearing a mask or you're keeping some distance you're outside you know that sort of thing so it's going to be not too many people at a time if you're going to be indoors wearing your mask playing I don't know a board game or something but trying to avoid things where you're breathing heavily no singing which to those of you who know me know is very very sad for me I love to sing and so that's sort of the thing that you're going to have to look for and I guess I'm going to be playing a lot of board games or watching Netflix thank you the next question is in medicine we talk a lot about professionalism and communicating truth yet in certain conditions such as COVID-19 a major part of information is conveyed through news by journalists can you say what is the moral responsibility of journalists in communicating in such conditions do they have any less or even more responsibility to communicate truthfully I think they have they always have a responsibility to I mean I'm not a journalism ethics person but I think that they need to I think that their goal and they should be always attempting to present the truth unfortunately I think that one thing I talk to a lot of journalists and I've realized come to realize that they feel like at least the ones that are writing about the science aspects of this they want to get the message across and they feel that the more that the end justifies the means a little bit in terms of their salacious headlines that if it gets people to read it and then believe some of what's the truth they don't want to lie but they want to make it as click worthy as possible so that people will read the truth about it and feel and maybe that will drown out some of the disinformation that is actively coming from other people and don't no doubt about it there are some doctors out there that have a lot of disinformation and I anybody who wants to search for me on twitter see a few doctor twitter trolls and a lot of other twitter trolls and that will give you a very good idea about the disinformation that's going around so on that note how do you recommend that we respond to misinformation, conspiracies and things of that sort I think that this is that whole business about the mass stages of grief these people are in denial they're angry, they're bargaining with you about whether or not they need to wear masks in certain circumstances or whatever or it says that masks aren't perfect so we shouldn't have to wear them at all this kind of thing they're experiencing a loss and they can't figure out how to deal with it I don't really respond to them I don't think that shaming people or pushing people is really going to make a difference there's some evidence that they wear a mask even more they kind of dig their heels in so I try and be as friendly as possible and treat it kind of the same way that I tell people to treat hand hygiene oh hey I think you forgot to pull your mask up not anything pushy or mean but just I didn't want you to be unsafe or be unlucky that kind of thing and then just keep your distance keep your distance from people who are behaving badly in public people are behaving badly online I don't know how to handle that other than to just ignore them we can't stop social media from being social media and I think the best way the best way of all and this is like not a thing I never thought I would be giving talks about this but now I'm saying almost every talk the best thing we can do to combat disinformation is to vote thank you I have an economics question and basically like how did we pick opening bars before we picked opening schools because no one was thinking because there's a lot of lobbyists for bars and restaurants and restaurant associations and because it was summertime and that is true we had to choose we needed to make a societal decision about what was the best thing to open and the problem is that there isn't a clear guidance from all of that disinformation about it's perfectly safe to open schools with whatever is going on no matter what everybody knows that's not true there are certainly things that have to happen in schools we've got to mask kids we need to do something about ventilation or at least thin out the classrooms you can't put that many kids into crowd them into a classroom and we know that kids are getting COVID they may not be dying of COVID but they're going home to grandparents and so we've got to and there are teachers in those classrooms so there needs to be safety parameters around school but instead of putting out safety parameters around school they just said open school no matter what and that resulted in a situation where nobody knew what to do and I think bars are something where people are old enough to make a decision for their own safety and their own lives and so people said okay fine there was no no effort to consider the downstream effects of choosing one thing over another and there was no acknowledgement that our contacts are a zero sum game we can only have so many contacts with other people without having COVID spread so much and if you were going to put kids in school they're going to have contacts with other kids and with teachers and if you're going to have that happen it's going to be a great opportunity for everybody in your community and the only way to get there is for everybody else not to have as many contacts and so you cannot do both it is definitely a zero sum game when it comes to contact and that's the hardest thing for people to understand they just see the gathering limits and they're like oh 10 people on Monday morning 10 people on Monday night 10 people on Tuesday night and different people every time and you would have been good although my whole long games promotional activity has not been taken off I've been working on it since May I have a question about healthcare disparities since we know that COVID has disproportionately affected those of low income and minority folks and the question is how do you hope medicine and science will start addressing this fact when training physicians and allied health professionals in undergraduate years I think it starts way before that I think it's everything our whole society has I think what we've learned from the Black Lives Matter campaign the COVID epidemic with disparities and I've been doing a lot of reading about this which obviously doesn't make me an expert but still I have a much richer understanding than I did before that we've been really messing this up as a country for a long time and that has led to so many like tangled mess I think of it as like the string that my child plays with it just gets like a complete mess and it needs to be untangled in so many places that does not mean that we shouldn't do it in undergraduate education, graduate education medical education, residency training and every day and I think we have to just start everywhere and start setting expectations and I mean we can't just educate gotta educate, set expectations and start making changes we all and as physicians I think there's a big role for us I've always been impressed when I did my pediatrics rotation how much of pediatrics how much they pushed the importance of advocacy for children and I think we all need to take that on and have advocacy for the underserved period going back to your zero sum game one of the attendees asks how safe is it to go on a plane and would you fly on a plane well I'm in a different situation than some of you I have rheumatoid arthritis and take medicines that lower my knee I'm on a TNF inhibitor and methotrexate so my my bar is a little lower than what some people or bars maybe higher or however you put it and for what I'm going to do and take those risks now that said my mom has flown on the plane many of my friends have flown on planes I think planes have the opportunity to be very safe or the opportunity to be really risky and it is a bit of a gamble when you get onto a plane things that make a plane safer are when everybody is wearing masks if you are going to fly on a plane the safest way to fly on a plane is do not fly on a long haul flight if you can avoid it the shorter the flight the better and that may mean taking stops on the way if you need to that is one way you can interpret that advice the other thing is to say that you need to wear the best mask you can and that means if you're fitted to an N95 and you have one you should wear that one then the other option would be a medical mask or I've made a number of fabric masks that people at Argonne did this awesome study and they found that 600 thread count cotton and silk like natural silk are really amazing and they are as filtering as an N95 and so I've made these fabric masks that fit very nicely with a 600 thread count sheet on the inside and silk in the middle and then like a quilter and cotton on the outside and they fit tight and I feel confident in those I would wear those on a plane I sent once my mom to wear on the plane when she was coming home from Florida after she got stuck there for months and months and you've got to protect your eyes so bring an eye shield I think that's true of any public transportation just bring a face shield with you and then if you're around people that don't have their mask on put on your face shield wear it. Great, another question is that facilities are beginning to bring back staff who were detailed to home back as part of the reopening plan and the question is what are your thoughts about clinicians who believe they should be allowed to stay home to continue virtual medicine versus bringing everyone back into face to face visits. I think there's a real benefit some patients need to be seen I think that some patients need to have a person to visit some things need to be done that way some things don't I think this is very individualized I think everybody has to think very unfortunately I don't think most hospitals and medical centers or most you know anything are set up to be very granular about what really is essential in person and what's not essential in person but as much as we can try and be personalized about that and individualized about who needs to be in person and who doesn't need to be in person that's probably the best thing to do and I think they're absolutely it's safe to come to a hospital it's safe to work in a hospital although I will tell you this health care workers are not getting COVID from patients they're getting COVID from each other they're getting COVID in work rooms in break rooms they are seeing their colleagues as their quarantine family and they are not distancing and they are not being careful when they're eating they are having their coffee at their workstation maybe six feet apart in the stuffiest break room ever and they're taking their mask off and sitting there drinking their coffee typing on the computer happy as a clan that they're six feet from the person on the other side of the room who also has their mask off typing and drinking and so I think it's probably generally safe for most people to be in the workplace as long as the work spaces are not overcrowded but if the work space is overcrowded it's dangerous so I want to ask one more question because I think we're going to 115 the last question I wanted was from Mark Lambert especially since you opened with Beechman Children's Four Principles it seems that COVID has exposed the problem with the artificial boundaries between clinical ethics and public health ethics do you think that's true and can you speculate on how COVID will reshape these disciplinary boundaries yes this is okay so I did my ethics fellowship because I kept going to talk to Mark when I began being the hospital epidemiologist I couldn't figure out how to apply medical ethics to things where everybody else is applying only public health ethics and I didn't know how to balance them no one knows how to balance them you're right that's what we're figuring out every day in infection control this is what I talk about with the fellows when I give my talks with them I talk about this all the time they are completely different it's possible you just have to think about balancing the risks and benefits differently and bringing in third parties when you need a third party to make a decision if you are a stakeholder in the outcome you probably need somebody else to be helping you to make that decision in other words as a provider if you are going to be at risk by caring for the patient or you perceive yourself as being at risk even if you're not then you have a stake in the outcome and you probably need advice from somebody else about how to handle the situation you need to have shared decision making that involves additional other people that's the best advice I can give from a sort of sort of a pragmatic standpoint but I think that there's so much to learn about this and I don't have all the answers there aren't a lot of people studying it and I'm too busy doing COVID to study that right now but I mean that's like the long term this is what I think is the most interesting like are we should we really be isolating these patients with MRSA I mean right now actually no hospitals are I've been arguing for that for a while and everybody abandoned their MRSA isolation and like the second week of COVID well I want to thank you Emily and I'm going to pass this back to Mark Laney thank you before I thank Emily I want to ask one question if I might and that is early in your talk that you mentioned something about vitamin D an important consideration could you just say a quick word about that I don't have much more than that there's this there's evidence some of it's from I some of it's from a group here at the University of Chicago David Meltzer's team looked at this and they found that vitamin D levels were associated with low vitamin D levels were associated with poorer outcomes there's other data about that as well and so if there's one thing that you want to add an additional layer to your layers of protection you should carry a face shield with you and use it when people are not wearing their masks that's number one I'll say it one more time and then the other thing you should do is it's a once it gets to be wintertime it may be reasonable to supplement with vitamin D but please be very careful that you follow instructions from a provider or what's on the label and don't overdo it vitamin D can cause problems it's not one of those things that you can do to get all the extra so if you're going to take vitamin D you need to follow some instructions or some guidelines about it thank you thank you I found the talk an extraordinary opening talk of this 27 lecture series and you covered the topic so beautifully so much guidance and help I I'm saying for the group who attended how much how important it was and how thankful we are for this great talk well thanks for having me my pleasure okay thank you very much


This is stock number 11324. We are here at Summit Automotive in Fond du Lac, Wisconsin. You're new and used RAM and heavy-duty truck headquarters. Today we are checking out this super clean 2015 RAM 2500 crew cab short box big horn. This truck has the 6.7 liter Cummins diesel. It has been fully safety and inspected by our service shop. It has a fresh oil and filter change. All the fluids have been checked and topped off and this truck is 100% ready to go. Bright white is the color. We shoot all of our videos in 1080p 60 frames per second. So if you have HD capabilities on your computer tablet or smartphone device turn them on right now because it is definitely your best way to check out the quality and condition of the vehicle before seeing it in person. And if you'd like to check out all the photos on this truck in the upper right hand part of the screen is a link to our website. Click that and check us out there. It comes with the painted or I'm sorry polished aluminum 18 inch rims and it has Firestone Transforce LT27570R18 tires. Little under half the tread left on those tires. Frame and underbody is exceptionally clean for being a 2015. Front fender is in excellent clean condition. No dense or dings on that. Headlight lenses are nice and clear and it does come with factory fog lights. Front bumper is in great condition as well. No dense or dings on there. Has the chrome trimmed grille and a very nice bug shield. Hood is in great condition. Didn't see any dents or dings on that and the passenger side front fender is in nice shape as well. Passenger side rim no scuffs or scrapes on there and as you go down this side of the truck take note of how clean the body is how reflective and mirror like that paint is. We take these HD videos so if you're far away or even if you're close by and just can't make the trip down but you're still interested in purchasing the vehicle you can see the truck hear the truck and have confidence in the vehicle that you're looking at before you even get here so that when you do get here there are absolutely no surprises and that is also why we offer the Summit Auto Fastpass option in the upper right hand part of your screen. A link right to our website where you can apply for financing. Get pre-approved. See a payment quote. Even appraise a trade all from the comfort of your home so when you get here all you got to do is drive the truck love it and you'll be all set to go. Back tires have just about as much tread as the front tires and the frame and underbody on this truck is an exceptionally clean condition for being a 2015 and it is like that all the way underneath has all the remaining factory exhaust and lower rockers all look really good didn't see any corrosion on them and it does come with the nice factory chrome step bars. It does have an MBRP exhaust tip on it but it does have the factory exhaust on it. As we come around to the back rear bumpers in really nice shape. It does have the backup parking sensors. The tailgate is an exceptionally nice condition as well and it comes with a lund soft tonneau cover that is an excellent condition it's like the fabric on there and you do get a linex spraying bed liner, gooseneck and fifth wheel prep package and it does come with these seven pin wiring on there. Tailgate locks and shuts nicely and as you go down the driver's side just as clean as that passenger side no dents or dings on the box and for full disclosure this back rim is in perfect condition as well. Down the rest of the side of the truck looks really good it does have the heated fold-out tow mirrors so they fold up like so they also fold in and they are a power fold-in mirror. I always like showing both sides so that you know that both sides are working good. Inside the big horn package gives you the gray cloth interior this one has the 40-20-40 split bench seating. Both of these front seats are heated power driver seat with lumbar factory floor mats throughout. It does have auto headlamps, audio controls in the back of the steering wheel and power windows power locks and power mirrors. As we hop inside the vehicle here you can see that this one has 25,624 miles. Instrument cluster is very nice and clean comes with the heated leather wrap steering wheel, cruise controls on the right, Bluetooth and information center controls on the left and audio controls on the back of the steering wheel. Comes with the six-speed automatic transmission with the optional tap shift. This one has the 8.4 3C radio which gives you a MFM and Sirius XM radio capabilities. It also can do your heated seats and heated steering wheel buttons from the radio and then your cargo cam shows up right there so it shows you what's going on in the bed and then if you put your backup camera on the backup camera shows up in the rear-view mirror. You do get 911 and assist buttons in that rear-view mirror and the nice thing about this radio is it's nav capable so if you wanted to add nav to it you could do that by at the dealership here it's $595 see your sales professional for more details. Down here you have your turn-dial four-wheel drive, climate controls, more tactile buttons, volume and tune controls as well, factory brake controller, heated seats and heated steering wheel buttons, stability control, tow haul, factory exhaust brake and your parking sensors you can turn those off and on. Comes with the 115 volt 150 watt plug-in. Look how nice and clean that carpeting and floor mat is. Passing your side seat no rips or tears on that this truck's never been smoked in smells very clean inside and the headliner is in excellent condition as well. You do get map lights up there at power side mirror window and your home link buttons for your garage door security systems and lighting systems. Once again that 911 and assist buttons in the mirror. We'll take a quick look at the back seats and then we'll check out under the hood and start it up. Back seats are just as nice as the front seats no rips or tears back here.  Power sliding rear window with the built-in rear defrost. It's just about one of the cleanest 2015s you'll find anywhere. Comes with the load floor which is nice if you got pets you can put both sides down you got a nice flat place to lay or if you got muddy boots or tools put them on there you're not gonna wreck your nice seats and it comes with a receiver hitch reducer which looks like it's hardly ever been used. You also get in floor storage on each side one on each side with removable containers for easy cleaning. You can put ice and drinks in there it's like you have too many coolers wherever you go. Child safety locks on the back doors as well. We'll start it up and take a quick look under the hood. I would personally like to thank you for checking out the video today and hopefully from this HD video you'll have been able to tell just how clean this truck is all the way around. Inside note under the hood we have the 6.7 liter Cummins diesel. Enterbay is very clean runs very smooth. Once again this truck has been fully safe and inspected by our service shop has a fresh oil and filter change all the fluids have been checked and topped off and this truck is 100% ready to go. I would highly recommend it from a quality and condition standpoint and to see more pictures of this truck the one or other 450 new and used cars, trucks, SCVs, minivans, Wranglers, half-tons, three-quarter-tons, one-tons. You name it we got it go to our website right there www.summitauto.com. Full pictures and descriptions of every single vehicle from two locations all at summitauto.com and if you'd like to check out more HD videos you can go to youtube.com slash summit auto number two like subscribe and share on this video and all the videos that you see there. In fact in a second you will see links to subscribe to our YouTube channel on your left. You'll see links more Ram 2500 truck videos like this one on your right. If you have not been to our website on the bottom link to this vehicle on our website click those checks out. We really look forward to helping with this super clean 2015 Ram 2500 crew cab short box big horn in bright white clear coat with the Cummins diesel. Thanks again for checking out the video.


Check this out. We have a one-of-one brand logo rookie of a Jaden Hardy For these spurs boom Brand logo from the cleat or not the cleat the shoe. That's fire. That is fire rookie Jaden Hardy on the brand logo one-of-one For the Mavericks That these sneak peek that is beautiful. What kind of shoe is that where my where my shoe guys at? What kind of shoe we working with here? That is very sick there one-of-one on the brand logo sneak peek There we go maps that is Mr. Hans H Took that man's shoe. That's right Jaden. That's what we do That's a crock. I could I could see it PG's maybe