02 Alcohol

Okay, alcohol is in phase 4, alcohol is in phase 4. We're going into some psychics and meds are going to be visible. I'm going to talk about the psychological aspects of alcoholism, psychological dynamics. The number one problem in alcoholism, psychological, is the same as the number one problem in any and all abusive situations. The number one problem in abuse is denial, denial of users have an infinite capacity to deny, in fact, an abuser has to deny in order to continue the bay because what does denial allow that abuser to do? Keep doing it without having to answer for it, because they just deny they have a problem with it. Now, I want you to understand the title of this lecture is what? Alcoholism, but this first part is you can use the alcohol rules for any abuse, so what's the number one psychological problem in child abuse? What's the number one psychological problem in gambling? What's the number one psychological problem in cocaine abuse? What's the number one psychological problem in spousa abuse? Elder abuse, denial is the number one problem in all abusive situations. Why is it number one? How can you treat someone that's denied they have a problem, right? So until they admit they have a problem, you've got a problem. Okay, definition A, definition, what's the definition of denial? It is refusal that goes into first blank, refusal to accept the reality of a problem. They refuse to accept the reality of it. They say, I'm not an alcoholic, I can quit anytime I want, I'm not a spousa abuser, we just have a really physical relationship. I'm not a child abuser, I'm just a really strict parent and my kids aren't spoiled. So I'm saying, I'm not a gambler, I like games of chance, I'm not a food abuser, I'm a groomer, you know, they have all these denials about their problem. So how do you treat denial? Let it be, you treat denial by confronting it, you confront it, confront it, confront. You confront it by pointing out to the person the difference between what they say and what they do. So how you confront someone is this, you say, okay, you say you're not an alcoholic, it's 10 o'clock in the morning, you already drank a six pack, you know what I'm saying, you just can put them, what did I point out? The difference between what she said, which was what, I'm not an alcoholic and what she did which was, drink a six pack before 12 o'clock in the morning. You say you're not a spousa abuser but she has a restraining order against you. You see the confrontation, you say you're not a child abuser but protective services has your children. You say you're not a food abuser but you're 400 pounds in your five but one. Do you see what I'm saying? It's my thyroid. Okay, it's your thyroid. But the point is that they will deny what they have and you can run it by pointing out the difference between what they and what they do. That's confrontation. Now, don't get thinking that confrontation is the same as aggression. Don't get those two things mixed up because aggression attacks the person and aggression says you are too an alcoholic, you jerk, you have to admit it, you see what did I attack? What did I attack? Or you jerk, admit it, when I confronted, did I attack her, you what? Say you're not an alcoholic, that's sorry, okay, you say you're not an alcoholic, did I attack you? Yeah, I just said you say you're not an alcoholic but it's six pack gone by 10. I mean, did you, you know you're just saying, you're just saying, hey, you're not saying right, wrong, good, bad, horrible, wonderful, you're just saying, hey, this is what it is. This is what I see. You confront, so don't get confrontation mixed up with aggression, aggression attacks the person, confrontation attacks the problem. On boards, never attack a person. Just another little note, they have these questions where you're interacting with staff and they'll say something like you're dealing with a staff nurse that has more seniority than you on your first job and they just find fault with everything you do. You understand the scenario? Well how do you handle that? What do you say? Does anybody know what you say? What's bad to say? And think about pronouns. What would bad, what pronouns would bad interest have and what pronouns would good answers had in that scenario? You versus I, so explain that to me, what do you mean? What's the good, what's the bad? The good answer has what in it. I, bad answer has you. So what don't you say there? Why don't you like me? Why are you so mean? The right answer is I seem to be having a, I seem to be frustrating. I seem to be having a problem or we have, or seeming to not get along well. You just have to say always when you're dealing with psychodynamic problems with staff, say to use the I, I'm, I'm, I'm not you, you, you, you, you understand that? That's a real big thing they are testing a lot now. Okay, standing with physicians, physicians, when you question them on the phone, don't say you wrote the order incorrectly, you say I'm having a difficult time interpreting exactly what you want. Do you see the difference? Okay. So when you, when they are in denial, what do you do? Confront. Deny, confront. Deny when you link that in your mind, deny, they deny you confront, they deny you confront. However, be careful because there's another place where denial is operative and that is loss and grief. Don't people go through denial and loss and grief? Have you heard of those stages of death and dying loss and grief? What are they? Debdub. Debdub. D-A-B-D-A. D-A-B-D-A. Denial, anger, bargaining, acceptance, I mean, depression, acceptance. Denial, anger, bargaining, there's your dad and depression, acceptance, there's your dad. D-A-B-D-A. So denial is an accepted, healthy, normal first reaction to grief and loss. So what do you do for the denial of loss and grief? Do you confront it? What do you do? Support it. The word is support. You want to support it. So my point is this, when you get a patient in denial, what do you have to pay attention to to get the question correct? Is it loss or abuse? Is it loss or abuse? Will abuse you what? Confront with loss to you, support. I have a missceder, college of 3,000 in a town of 3,000, so there's one student for every person in the town, but we are basically a farming community with a college, and we have a lot of one-handed men in our town, why, Baylor actions, the Baylor's amputate their hand. So we have a lot of farm machinery, one-handed Baylor get accident, guys. Can you imagine a guy, a farmer comes in his hand, gets amputated, and it's all wrapped in a bandage the next morning, you're taking care of him, and he says, "I can't wait to go home and play piano." Problem. He only has one hand, right? So he's in what, what is he refusing to accept? The reality. Is that denial refusing to accept the reality? Yes. So he's in. I don't know, what would you never say to him? You say you're going to play piano, but you only have one hand, that's called con-bron-tation. Now it's conversation okay for denial. Yes, as long as it's abuse, but not if it's loss, and this guy is loss, so what do you do? You say, "Oh, well, how long have you played piano, what's your favorite kind of music? Did you take lessons? What are you allowing? That denial to continue, you're supporting it, because it serves a function." Is everybody getting the difference? But if you got an alcoholic, an alcoholic says, "Oh, I've got an alcoholic, I can put any time, I want. He's in what? What's the strategy?" In front, what would be really horrible to do? Support. You would say, "Oh, how long have you been drinking? What's your favorite beverage? Did you take like it?" You know? You never got to have that hurricane over there, but Giver's bar, you know, you don't support it. So you see where you have two totally different answers for denial, just pay attention to that. Okay, let's talk about the number two psychological problem that abusers have, and that is dependency, codependency. Dependency is when the abuser gets the significant other to do things for them or make decisions for them. In other words, abusers says, "Oh, would you call my boss? Would you go do this? Would you do that?" And they do it. So who is dependent? The significant other or the abuser? The abuser is dependent. Now, codependency, on the other hand, is when the significant other derives positive self-esteem from making decisions for or doing things for whom? The abuser. So the abuser says, "Call my boss, tell him I'm sick." That's an example of what? Dependency. Dependency. The significant other calls the boss, says, "He's sick. He can't come to work." Hands up, says, "Oh, aren't I a wonderful spouse because I did that because I don't know anybody else would do it for that jerk." What are they? How do you know they're codependent? Did they get positive self-esteem? Yeah, what did they say? Or an IA wonderful spouse because I did that. See, they have this rather pathologic yet symbiotic relationship. You know, one is dependent, the other gets positive self-esteem, permitting those dependency need, and they just feed off the other. What does the abuser get out of the relationship? What's that? It's keeping doing. Yeah, unlike without responsibilities, he gets to keep doing whatever he wants, abusing. What does the significant other get out of it? Positive self-esteem out of it, and then we sit there and we say, "What's the significant other?" Leave it. What are you doing in that relationship? Get out of it. Get out of it. But they can't get out of it because they're what's tied up in that whole thing, their self-esteem. So, you know, I mean, it's really kind of tough to treat. Well, then how do you treat it? How do you treat it? Well, number one, you set limits and enforce it. You set limits and enforce them. That goes still in the blank. Set limits and enforce them. In other words, you start teaching the significant other to say the two-letter word, "No." And then they have to keep doing it. Will you call my boss? No. Would you go buy me some? No. Would you drop me off with the track? No. Would you give me a half sandwich other refrigerator? Well, see, that would be okay. You know, I'm not saying saying no to everything. I'm saying, saying no to those things where you're feeding into everything, all right? But that's not good enough, that alone will not work because you must work on the self-esteem of the co-dependent person or it will never work. Because as soon as the co-dependent starts saying no, what will the, what will the dependent abuser start saying? You don't love me anymore. You're at mean, nasty old, whatever, because you are just horrible, you're horrible. And what is, what's that, what's that person playing right at? Self-seem. They know where the, what side the bread's buttered on. And they, they go right at that person's self-esteem and within 10 minutes, they got them emotionally manipulated right back into the whole system. So in order for this to work, what does the co-dependent person have to say? I'm saying no and I'm a good, sick into it because I'm a good person because I'm saying no. Oh, you're nasty. Okay, what you say, I'm a good person. And that's, that's how you have to work on it. The thing is, I want to lock you at clinic in Detroit, Michigan for a couple of years and it's mostly alcohol rehab and seizure. And we found that when we treated co-dependency, dependency, successfully when we treated this problem, guess what we lost? The relationship, you know, the co-dependent person got, I'm a good person, I don't need you and why am I here at the head leave. So you know, we'd solve the problem but lose the relationship, real common. Okay, turn the page, let's talk about manipulation. What's the definition of manipulation is when the abuser gets a significant other to do things for him or her that are not in the best interest of the significant other? The nature of the act is dangerous or harmful. What goes in the blanks is interest and harmful, interest and harmful. So how is this life dependency? How is manipulation like dependency? Yeah, in both situations, the abuser is getting the other person to do something for that. Then how in the world do you tell the difference between those two things? What's that? Well, neutral versus negative, look at what they're being asked to do, if what the significant other is being asked to do is neutral, no big deal, no harm down to, no harm, no foul. It's simply dependency, co-dependency. If what the significant other is being asked to do is inherently harmful or dangerous to the significant other, that person is being manipulated. So let me give you two examples, and you tell me which one is denial, which, I mean which one is dependency in which one is manipulation. A 49-year-old alcoholic gets her 17-year-old daughter to go to the store and buy alcohol for her. That is what. Well, because a 17-year-old gone and buy an alcohol is illegal in the state of, you know, Ohio. So it is illegal. So she's being asked to do something illegal. Now what about this? A 49-year-old alcoholic asks her 50-year-old husband to go to the store and buy alcohol for her. Of what is that an example? Why is it dependent to the same thing, buy an alcohol? She's normal. She knows she has a problem. How harmful is it for a 50-year-old man to go to a store and buy alcohol? Any harm? No. So that's simply dependency. But when the 17-year-old goes to buy alcohol, that's illegal. There's harm. That's manipulation. Let me give you an example, Tuesday evening or last Friday evening. Remember Tuesday, last Friday around here, okay? Your neighbor calls you, no, your brother calls sister-in-law, calls you and says, "Would you pick up little Billy from basketball practice at school?" So he could spend the night at your house because of the snow. Now you have a -- what's -- what's -- what's -- what's -- what's -- what's -- what's -- a four-wheel-drive lot? Hummer, cheap. What's best in the snow? Not ice to snow. What? Four-wheel-drive. Some big -- okay. You got a big Earth mover, four-wheel-drive, Earth mover, okay? You live three blocks from the school and you say, "Okay, sister-in-law, I'll do that." You are being what? She is being dependent on you. You're being -- come and depend on us because you'll say, "Oh, aren't I a wonderful brother in law for doing this, right? What if your sister-in-law calls you? She's got -- before-wheel-drive, altering vehicle. She lives three blocks from the school. She asks you to pick up her son and take him to your house. You have a -- a key -- a -- a -- a -- a key up with ball tires and it starts every other time. You leave soil, got no heat, you show's name, and you live 20 miles from the school. And you get -- what's happening here? You're being what? Manipulate. Because it is inherently dangerous for you to get in that car and go that distance when she could do it easily, safer, better, herself, whereas in the first one, it was safer and better for you to do it than -- do you so say -- dependency and manipulation are similar. It's just the only way you tell the difference is is one, you're being asked to do something which is bad for you. That's manipulation versus something that's neutral, that's dependency code, dependency. Can you tell the difference now? Okay. Go. All right. Having treated manipulation, you set limits and enforce them. So you start saying what's to let a word, no, number two, it is easier to treat than dependency code dependency because nobody likes being manipulated. I have never heard a person say, oh, I must be a wonderful person for being manipulated. Do you know what they all say? I must be an idiot for following for that. Do you hear any positive self-esteem going on? No. No positive self-esteem issue going on with manipulation like there is with dependency code dependency. You see why it's easier to treat? Okay. Let's just summer us. How many patients do you have with denial? If you have a -- if Bob is in denial, how many patients do you have? One, two, or three, or four? Bob is in denial. How many patients do you have? One, two, or three or four? Bob is dependent. One or two, two, because you got to get the code dependent. Bob is a manipulator. One or two? One. Just out saying, because you don't have to do anything with the person who is being manipulated because there's no self-esteem issues. So with denial, you got one patient with dependency, you have two patients with manipulation. You have one patient. Does that make sense? Let's talk now about things specific to alcoholism. Let's talk about the Wernickees or Corsicaus. Wernickees and Corsicaus. Typically, they are separate, but force often mumps them together. Wernickees is an encephalopathy and Corsicaus is a psychosis, but they tend to go together. You find them in the same patient. So Wernicke Corsicaus is number one psychosis induced by vitamin B1 or thiamine deficiency. This is a scenario where you lose touch with reality. You go insane because you don't have B1. What's it do? Psychosis. Psychosis, which means insanity or loss of touch with reality. These are psychotic people. Not just a little bit emotionally disturbed. These are psychotics. The primary symptom number two is amnesia with confabulation, amnesia with confabulation. Amnesia means memory loss, confabulation means making up stories. Why do they make up stories? Because they forgot. Well, in that case, then I'm psychotic, because I often make up details that I have forgotten. Right? So then why are they psychotic and me not? Fair question, why? So everybody that forgets something and makes up a story to fill in what they forgot is insane psychotic. True false. False. People that explain to me the difference, why? Why are these poor people called in psychotic and we're not? Because they believe it. See, when I fill in details, because I forgot, I know it's not really true, but they really believe it. The lie is just as real as reality. And their memory loss is not, oh, I forgot what I did last night when I was drunk, no, it is, what happened to the 90s? They don't remember anything in the whole 1990s. They'll lose entire decades of their memory. So what will they do? Make up stories as to what they were doing during the 90s. I had a guy that, with mortgages, all he was Ronald Reagan's National Security Advisor during the 90s. The guy had never made it past 3rd grade. Now, whatever you thought of Reagan, he wasn't that bad that he would have had a 3rd grade or run in the national security, you know what I'm saying? So he definitely was never Reagan's National Security Advisor. He thought he was. He could tell you meetings, dates, times, people, he had this whole psychotic reality built around Ronald Reagan's terms in office. He believed it. He literally believed it. He believed it as, that was as real as anything that was happening right then and right there. So how do you deal with that? How do you think you deal with that? You've got a Wernicke's Corsica guy who thinks he is Obama's Secretary of Defense. And so he's got to get up there and go to a cabinet meeting right now. How do you deal with that? What would probably be a bad way to deal with that? What's that? Okay, we don't usually agree or disagree. We don't confront why. Why? Because you're telling me that what they're saying is true and they believe it. Right. And it's due to brain damage. So are they ever going to learn what's true and what's real? Yeah. So is this proven or not? Typically proven. So you don't present reality because they can't learn it. So what do you do? See, this is a question they ask you. They give you a person with Wernicke's and they say the Wernicke's says he's going to a presidential cabinet meeting at 8 o'clock this morning. Okay, distract is not as good a word as redirect. Redirect is a really good word and that means to take what he's all about that you can't do and re-channel it into something he can do. So can he go to a Barack Obama's cabinet meeting this morning? No. So what you do is you say something like this. Well, why don't we go once you then get a shower when you're done, we'll go watch CNN to see what the news of the day is in Washington, DC. Do you see that? Is he going to do that? No, I don't believe because he, you see what I'm saying, and you don't get into a fight with him about, no, you're Joe, the milkman, you're not, Ronald Reagan's national security advisor. You see what I'm saying? Because that's fruitless and pointless. So when somebody has Wernicke's in course of course and they talk crazy, what do you do? Redirect, you don't present what? Reality. Because presenting reality is for those people that you think that can learn it and these people can't learn it. So redirecting them is the way. Now let's talk about characteristics. Number one, it is preventable. You never have to get this in the first place. How can you prevent getting this in the first place? Take vitamin B1. By the way, vitamin B1 is a co-enzyme, necessary for the metabolism of alcohol. It's necessary for the metabolism of alcohol. So if you don't have B1, you won't metabolize alcohol. It won't go into crev cycle, that's not familiar. It won't get burned up for energy, so what will it do? Accumulate and where will it go? Brain and it will destroy brain, so that's how this happens. So all they need to protect the brain is to take vitamin B1 and then any alcohol they drink will be what? Metabolized. So they don't have to stop drinking. All they have to do is take their one a day with their vodka in the morning and they'll be fine. They will be perfect in the morning. You get a lot of good complies with this. B, it is arrestable, which means you can stop it from getting worse. How can you stop it from getting worse? Take vitamin B1. Stop drinking is stop drinking necessary, no. See it is irreversible, now not everybody has irreversible, but it's about 70% irreversible, so you always say irreversible. Do you understand on boards you always answer with the majority? If something is majority of the time fatal, you say it's what, you don't say what you say. No, 5% of the time it's not fatal, so I'm saying it's not fatal, no, go to that. Go with the majority. So it is irreversible, so it's preventable, it's arrestable and it's irreversible. Two good news, one bad news. All right, let's turn the page and talk about some drugs that have to do with alcohol. This is orevia, antivirus, orevia, everybody knows that generic name for this, these drugs die salt for ran, die salt for ran, number one, it is a version therapy, a version therapy, it's a form of a version therapy, now what a version therapy is, is this, the word a version means a really strong hatred for something, a gut hatred for something. What we want alcoholics to develop is a gut hatred for alcohol. That's what we're trying to do here, well how do we do it? Well we give them this drug, now just you have to write this down, but just sort of listen for a second. When you take this drug and it gets to a blood level in your blood, if you drink alcohol it will interact with that chemical in your blood and make you super sick to your stomach. Not like, I mean really super sick, horribly ill. Let me ask you, have you guys ever been to a restaurant and gotten sick afterward from eating at that restaurant, anybody? Will you eat at that restaurant anymore? Now if you go, you probably won't order, you may order something else, but you're not going to order what made you sick because you have developed what, a version to that restaurant. Because if I gave you a $20 go right now and said, go eat at that restaurant and buy that meal, would you do it? No, would you take my $20? Yeah, you'd go somewhere else and buy something else, but you wouldn't go there. So I couldn't even pay you to eat there, could I? So we want the alcoholics to have that same reaction alcohol, in other words, we couldn't even pay him to what? So if you couldn't even pay an alcoholic to drink, I think that's pretty much a cure. Now the only problem with this drug is it works in theory better than it works in reality, or else we'd have had a cure for alcoholism years ago. So it really doesn't work as well as they say it does. But you still need to know how it's supposed to work and what not. So the thing the board wants to know is how long does it take to get into their system and how long does it take to get out of their system? In other words, what's the onset and duration of its effectiveness? And that answer is two weeks, two weeks. So how long does they have to be on the drug before it starts to work? And how long do they have to be off the drug before they can safely drink again two weeks? So using the way it happens is doctor prescribes anabuse, you sort of have to live sort of like a transition, like a recovery, plays, a transition home where for two weeks you are made, they make sure you take the pills, and then you're let out into the community. And it will work. And every time you drink, you'll get definitely ill. So by the beauty side you want to drink at a high school reunion, when you have to stop taking your ambulance, doing before the reunion or you're not going to be able to do it. All right, now, number three, patient teaching. Teach these patients to avoid all forms of alcohol, to avoid nausea, vomiting, and possibly death. Death isn't what we're going for. That would cure the problem, but it's not what we're going for. Now, do you suppose you have to teach an alcoholic, hey, let me tell you what has alcohol in. Whiskey does, wine does, beer does, tequila, they know that. What you have to teach them that they have to avoid is stuff that they wouldn't think that they have to avoid that they do. And number one, mouthwash. They need to avoid mouthwash. Even if they swish and spit, they're still going to get sick. Number two, aftershames. Even if they put it on top of it, they're going to get nauseated. Now, they won't get violently killed from that, but it will make them nauseate. News and clones should not be the same reason. Insect repellents, like mischievous praise, awe, deep woods, cutter, those are all bad. They'll make you sick. Any over the counter that ends in the word elixir, E-L-I-X-I-R, because what do all elixirs have in them alcohol, dimetapilixir, robotusinilixir, dateylilixir, nightylilixir, Tylenol, P-M-L-I-X-I-R, Benadryylilixir, alcohol-based hand sanitizers. In Green County, about six months ago, we had our first case of alcohol, hand sanitizer, poisoning. This alcoholic got into Bob Evans and drank every single bottle of hand sanitizer. He could get his hands on to keep his shakes away, because he knew it had alcohol in it. In fact, I've heard that they've taken out of the prison systems because guys are learning how to distill it and sell it. The other thing they're not allowed to have is uncooked ice-sinks. Remember those uncooked, those no-bake ice-sinks, which you make, because what do no-bake ice-sinks have in it? Vanilla extract, which is powerful. That's Granny's way of getting it. Alright, and remember this, here's the one that everybody gets suckered in on. Do not pick the red wine vinaigrette. They can have the red wine, what are they trying to sucker you in on there? Wine. Oh, wine, they can't have red wine vinaigrette. They just can't have the cupcake with the unbake dicing on it. Okay. Is that all the blanks filled in there, guys? Okay. Now let's talk about overdoses and withdrawals. Bad news. You got to know all your drugs, all the overdoses and all the withdrawals. Good news. You only have to answer two questions to get them all correct. It's an easy way to know them. And here we go, every abused drug, did I say every drug? Every abused drug is either an upper or a downer, would you agree with that? Why are drugs that are not uppers, nor downers, why are they not abused? I don't know anything. Right? Although there is an exception, what is the number one most abused class of drug? That's not an upper or downer, laxatives in the elderly, they elderly abuse laxatives, but that is an upper or downer, that's inner or outer, I guess I don't know. But every abused drug is an upper or downer, correct? If you ever had anybody come up to you on the street saying, "I want to buy some vexium?" Because it's not an upper or a, so no letter A, you see in the box letter A, when you get an overdoser withdrawal question with the very first question out of your mouth, is the drug an upper or a downer, that's the very first thing you must establish, that is the first step you take in getting the question correct. Now, let's talk about uppers versus downers. The names of the uppers are, caffeine, PCP/LSD, what are those? Like idyllic hallucinogens, sounds like up to me. And then, another class are the methamphetamines, M-E-T-H-Mphetamines, methamphetamines. Crystal meth, all that stuff, you buy it that grows, you know, you buy it as a suit and fat on the cot, the decongestants and you cook it down, that's the upper meth. What you do, that you're going to have to know, is Adderall, which is the ADD drug, the attention deficit drug. And a lot of kids with ADD are selling their Adderall to their friends at school rather than taking it. ADD is the first three letters of Adderall, but that's another upper and that's going to be tested probably starting April 1, it's going to be a new one. Now, that's only five drugs, caffeine, cocaine, PCP/LSD, methamphetamines, and Adderall. Those are uppers. So what do you think the signs and symptoms are when you're on an upper? Things go up because you're on an upper, figure that out, you know, uppers make you go up. You know, that's pretty hard to remember. So what are they going to have? Give me some signs and symptoms, principles, you're four of them. Black or cardio, restlessness, irritability, balance, what's the vastest going to be? Borberigme, diarrhea, one of the reflexes is going to be, what numbers, 3 and 4. Spastic, spastic. Are they going to rest, before I lay a rest or see, should you have a suction machine or an amobag? Okay. Are you getting this idea? Uppers make things go up because they are uppers, all right? Downers, what are the names of the downers? Am I going to memorize anything? No, why? Everything that's not an upper is a, because every abused drug is either an upper or there's no system as a tweener, so you can't, you can't get that. Now if they want a tweener effect, what do they take? They don't operand it down together, but there's no one drug that gives you a tweener effect. Now there are, how many uppers? Five. Five. You know how many downers there are? 135. You know the lauded, MS content, morphine, sulfate, codi, demorol, fentanyl, drope, new bang, thoresine, cellosine, pheophenosine, pyparasine, chlopromosine, prolixine, adoban, zannax, valium, librium, phenobarbital, pentobarbital, secondobarbital, heroin, hasheesh, marijuana, alcohol, do you know what I mean? It's all what? Downers, because it's not an upper, so only memorized, I hate lists, right? But if we can memorize a short one and know everything else is a, that's things like some payoff for me. So what if downers make you do, go what direction, because they are downers. So what are you going to see there? Lethargy, everything that we said, just flip it and what's going to be the big danger. Respiratory depression, arrest, depression, and leading to arrest. What do you think about this? Your patient is high on heroin, no, high on cocaine. That's critically important to assess, and one of the answers is B, which says, making sure that the respiratory rate is above 12. What do you think? He's high on cocaine, is a critical measurement making sure that the respiratory rate is about 12? No. No. Why? There's no way he's going to even be exposed to 12. You've got the wrong patient, but they're trying to sucker you in to think, oh, respiratory rate, no. You know what I mean? Yeah, respiratory rate is important, but not in this patient, because this patient wouldn't have a respiratory arrest because they're high on an upper, which makes everything go up. You'd rather check their reflexes. And we'll be, oh, ABCs, did you hear that? Airway, oh, respiratory rate, less of, like ABCs is not a great rule, guys. If you've been living by ABCs, you've been short-changed for a very long time. It's a very core rule. I will show you better rules than ABCs. ABCs is a vast oversimplification. Have you ever, how many have used ABCs to get answers? How many have you used ABCs? How many have gotten about as many right using it as you get wrong using it? How many, you get quite a bit wrong using it? How many get it all right when you use it? I just, how many would say ABCs doesn't really work that well for me? It doesn't, it should, because it doesn't, okay? It's a vast oversimplification. We'll get to that later. All right, B, see where R, B, after you know whether the drug isn't up or down, the second thing you ask yourself is, are they talking about overdose or withdrawal? Because they're opposites, and you gotta know which one you're talking about. You have the pay attention, is the question talking about overdose, which is too much or withdrawal, which is not enough. If you don't pay attention to that, you will miss the question. So what's the first thing you have to pay attention to in a drug overdose question? Is the drug right up or down? What's the second thing you have to pay attention to? Overdose or withdrawal? How much of you do those? You've got your answer. Your answer is so simple, it's pathetic. Let's look how it works. Under letter B, you see where it says overdose or intoxication, do you see that? You have what? Too much. Now, put it together, put the answers to the two questions you ask together, and you get your answer for the question. In other words, if they say overdose on an upper, you have too much what? Or everything goes up. So you're going to pick those up things, because you have too much upper. But what if they say downer and intoxication? In that case, you have too much downer, which makes everything go down, and it's going to go the opposite, what if the other one did? You see the point here? However, what if they talk about withdrawal? In withdrawal? You don't have enough. You have too little. Well, let's put it together. If you have withdrawal, downer, you don't have enough downer. If you don't have enough downer, everything goes, okay, I'm doing it backwards. Yeah, on your page, it says, you don't have enough upper, right? Too little. So too little upper makes everything go down, and then too little downer or not enough downer makes everything go, does everybody see the logic in that? So upper overdose, upper overdose, looks like what other situation, upper overdose, looks like what other downer withdrawal, and downer overdose looks like upper withdrawal. So in what two situations, would respiratory depression and arrest be your highest priority, in which two situations, would respiratory arrest and depression be your highest priority? Downer, overdose, and upper withdrawal, exactly. These two would seizure be your biggest risk, upper overdose, and downer withdrawal. You see what I'm talking about? So what's the first question you ask yourself? Upper down, second question, overdose, and withdrawal, too much or not enough, put it together, just pick the obvious answer. Let me show you how I want it to work this, squat calls you, and says they're rigging in a patient, they're 10 minutes out, these are overdose on cocaine, what would you expect to see, squat all that apart? First is overdose on cocaine, comment into your ED, what would you expect to see, select to all that apply, what's your first question? Upper down to the answer is upper, second question, overdose withdrawal, in this case you have what, which is, put two and two together, two, much, upper, right, so answer your question. And remember this is a central nervous system drug, not and not, talk to your body, see what you're saying? Okay, so first task, cocaine is in, upper, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower, lower. See, patients with AWS are not a danger to self or others, patients with DTs are dangerous to self and others, the word R goes in there, ARE, they are dangerous. So here are two really big differences, AWS, it won't hurt anybody, it won't hurt you, you're stable, you're fine, DTs, you're unstable, you could die. Second big difference, AWS, they are not going to hurt anybody, they're loud and obnoxious, because they're withdrawing from a downer which makes everything go up, they're going to be loud and obnoxious, yeah, but they don't want to hurt anybody, but in DTs you have to assume is dangerous, because they can, they aren't dangerous, alright, yeah, those differences will translate into differences in care which we will outline in the table below, let's fill in this table about the differences between AWS and malaria tremens, first column, first row, is everybody know what clock time in, first column, first row under AWS, regular diet, next box down, same column, first column, first column, second row, semi-private anywhere, semi-private anywhere, which means they could be in a semi-private room anywhere on the unit, same column, third row down, we're just going down that first column, up add lib, up add lib, which means they can go around anywhere they want to go, and last box in that column, no restraints, you do not restrain these people because they are not a danger to sell for others, now let's compare and contrast that with the DTs flight, delirium tremens, second column, middle column, first box, first row, NPO clear liquids, NPO bore clear liquids, why, why seizure, why out, yeah, is it withdrawing from a downer, everybody is going to go up and the big up is seizure, and with seizure you get aspiration, so you want it NPO clear liquids, yeah, on boards sometimes they'll say NPO, sometimes they'll say clear liquids, they won't have them against each other, at least that would be too tough to pick, but it would be either one, the second box down, private near a nurse's station, private room, near a nurse's station, why, they're dangerous, and they're unstable, so you can, could you put an alcohol withdrawal patient on a pediatric overflow unit, sure, that we know his uncle Wally, but you know, everybody's a best friend, the parents will say, but he won't hurt anyone, but if you tears, you've got to watch these DTs, in fact, DTs probably should be an ICU, why, dangerous and unstable, but no self-respecting head nurse of ICU will allow them through the doors, why, because they're screaming in the out of life, banshees, you know, and they don't want that destabilizing the rest of their population, so they usually get stuck on step down units, but if you're going to, if you, as an LPN, what, as an LPN would you accept the assignment of a DTs client, could, no, because they're unstable, as an RN would you accept the assignment, yes, but what would you have to do with the rest of your assignment if you accept the DTs on med search, decrease your workload, somebody else may have to take seven while you take three, okay, and remember, it's a perfect world on boards, everybody will be fine with that, the other nurse will be fine with that, yeah, I'll take nine, you say two, so what kind of reasoning is really a kiss of death on boards, what minor reasoning, what kind of thought process that you would do in question answers, which would really be bad, saying, oh, I wouldn't do that because what, I don't have enough, staff, I don't have enough, experience, I don't have enough time, I don't have enough money, we don't have enough resources, no, on boards you have, what, a perfect world, you have all the money, all the time, all the staff, everybody's cooperative, everybody's happy, everybody wants to make it happen, they even don't mind their, their assignment being changed every hour, okay, okay, let's talk about the next thing down, they are on restricted bed rest, which means no bathroom privileges, if they have to use the facilities, we have bedpans and uralis for them, whatever, and lastly, they must be restrained, why must they be restrained, because they are dangerous, now, with what would you restrain them, certain types of restraints are futile, and not used, some are appropriate, what would be some, that would be appropriate and some that would not, do you know, what about soft wrists, yes or no, no, they'll get out of that, that's not enough, that's not safe enough, what about four point soft, no, that's not they can get out of that, they need to be in a vest, or two point, two point locked levers, now what does two point mean, two extremities, which two extremities, no, not two arms, an arm in the leg, which arm which leg, opposite, you always lock down one arm and the opposite leg in two point, that's what it means, that's what you're supposed to do, now you rotate ahead of it, two hours, so what do you do, two hours later, you switch it, now what would you do first, they're right arms locked down, they're left legs locked down, what would you do first, lock, they're left arm, then the right leg, then release the, yeah, don't release the first, you'll only make that mistake once on, and then you're gonna, okay, I got it now, you'll remember, now what do they both get, will they both get an anti-hypertensive, a blood pressure pill, why would they get an anti-hypertensive, why, why is everything going up, perfect, yes, excellent, excellent, excellent, you got it, we get it, okay, they're both on a tranquilizer, why do they both get a tranquilizer, because they're up, then why are they up, is there a going from a downer, and they both get a multivitamin containing B1, why, we're the keys, of course it costs to prevent that, I always say no B1, you B1, one of those crazy, no B1, you B1, and then that last box I shaded, and I shaded that so that you have a sense of compulsive, two weeks from now, when you go over this lecture, there was nothing you missed, you don't need to call everybody in the class, and find out what was in that last box, it was in the last box, nothing goes in that last box, okay, all right, let's talk about some drugs, then we'll take another break, drugs, amino glycosides, this is a powerful, powerful class of antibiotics, as far as antibiotics go, they're the big guns, you know what I'm talking about, when nothing else works, pull out your amino glycoside, you know, it's like the, amino glycosides are to infections like that seen in Indiana Jones, when the big Arab die comes out with a cimitar, you know, and it starts like this and Jones pulls out again and shoots them, but they're like the gun, you know, they're gonna blow it away, but you don't use it unless, nothing else works, these are dangerous now, boards love to test things, my boards love to test these drugs, because they're dangerous, and this is a test of safety, and do you know these drugs? They're in the top, in my, from my experience, these show up probably in the top five most commonly tested groups of drugs on boards, but you don't have to know this because I repeat it several times, but probably the most common group of drugs you have to know for boards are your psych drugs, and we'll get that on Sunday. The second most common are the insolence which we'll talk about tomorrow. The third most common are the anticoagulance which we'll talk about tomorrow. The fourth is digitalis which we'll talk about today. The fifth are the amino glycosides. Then you've got to know your steroids, your calcium channel blockers, your beta blockers, your pain meds, and your OB drugs. Those are the big 10 and we hit all of them. So these are real, real important enough. Now, here's the deal. For amino glycosides, think, they'll follow. A mean old micecid. When you see the word amino glycoside from now on, I do not want you to think of amino glycoside. I want you to think of a mean old micecid. Do you hear the similar sound? Amino, amino, amino. Amino, amino. So when you see amino glycoside, think, what? Amino, amino, amino, amino. Okay, now, what does that tell you? Well, here's what that tells you. That matter be, they are antibiotics used to treat what? Well, if they are mean, old drugs, what kinds of infections would they treat? Serious or non-serious? Life-retting or non-life-retting? Resistance or susceptible? Grand positive or grand negative? Grand negative. So you got the resistant, serious, life-retting, grand negative infections are treated by what? A mean old micecid. So you treat a mean old infection with the mean old micecid. Do you hear what I'm saying? So would you use these drugs to treat sinusitis? No. Why? It's not a mean old infection, so don't use a mean old glycoside. What about tuberculosis? That's a mean old infection, I use a mean old micecid. What about septic parotonitis? Is that a mean old infection? Yep, so I use a what? A mean old micecid. What about botitis media? Middle-ear infections. No, do I use a mean old micecid? No. What about bladder infection? No. What about forminating high-alone nephritis? Yeah, septic shock. Infection of third-degree burn wounds over 80% of your body. Yeah. You got it? What about viroles, pharyngeitis, streptop throat? No. So use a mean old micecid when you got a mean old infection and never any other talent. So mean old tells you what it treats, mean old infections. The micecid tells you what they end in. Good news. All a mean of glycosides end in micecid. They all do. Let's let her see. But you know what the bad news is? Not all drugs that end in micecid are the mean of glycosides. We're at it. Wish that would work, but it doesn't. But don't despair because most drugs that end in micecid are mean old micecids. There are three of the micecids which are not these drugs and the three micecids which are not mean old micecids. Not mean old micecids are. Erin, throw micecid, zin, throw micecid and clear in, throw micecid. What do all the micecids that are not mean old micecids have in them? Throw. So I say if it ends in micecid, it's a what? Mean old micecid, but if it ends in what? Micecid, it is a mean old micecid, but if it has throw in it, throw it off a list, it is no longer a what? Mean old micecid. So would you use chlorythro micecid, zythro micecid and erythro micecid for sinusitis? Yes. Would you use it for tuberculosis? No. Would you use streptomycin for good types of media, sinusitis? No. Yes. So the micecids are mean old micecids except the throw micecids which are little and harmless no big deal. So watch out for your throw micecids. They're a little tricky. So if you see throw micecid, do what with it? Throw it off what list? A mean old list, so it's just a little old. Some examples, clindomycin, pleomycin, pleomycin, pleomycin, dachshundomycin, aegriomycin, streptomycin, canomycin, pleomycin, you know, all these micecids. Now, what are the toxic effects, letter e? This is what they really key in on. What are the two toxic effects? Now, what do all these drugs end in? Mice. What English word sounds like micecid? Mice. So when you think, when you see micecid, I want you to think mice. What's the most famous feature of the world's most famous mice? Earps. So that's to tell you these drugs are what? When you see micecid, I want you to think of mice. When you think of micecid, I want you to think of ears. And when you think of ears, I want you to recall, oh, they are auto-totic. Because auto means what? Ear, auto means ear. What's ophthalmomy? Ophthalmomy, eyes, auto means rhino means, nose, or omis. Very good. So what do you monitor? It's toxic to your ears. What do you monitor? Hearing? Ringing in the ears. What's that called? Canitis. Yeah. If you're saying tonight, if you're saying tonightis, that's wrong. It's tonightus or tinnitus. That last letter is a U, not a nine. So I'm saying it's T-I-N-N-I-T-U-S. Tinnitus or tonightus, not tonightus. Everybody says tonightis, it's wrong. I didn't hear it on commercials on TV. Okay, and vertigo or dizziness. Why vertigo or dizziness? Equilibrium? Because the ear also has equilibrium, doesn't it balance? So what is the three things you worry about with the ear? Hearing, ringing, and dizziness. But if you had to pick between those three, which one would you pick? Hearing. Hearing would beat the other two. Okay, number two. Number two. The human ear, not vertigo, ears. Why are we thinking ears? Because I'm eyes, right? Because I'm isin. Well, here's the human ear. You see the human ear. If we connect the dots, what's its shape like? The kidneys. So just remember the human ear is shaped like that. Kidney. So the second toxic effect of these drugs is napro-toxicity. Napro. Any pH for kidney? Napro-toxicity. So what do we monitor? Hearing? Not hearing. They'll have that there, but don't go for it. Criapment. Don't go for B1. Don't go for daily weight. Don't go for output. Go for creatinine. The creatinine is the best indicator of kidney function. The creatinine is the best indicator of kidney or renal function. If they told you serum creatinine versus 24-hour creatinine clearance, which one of those would win as the best? The 24-hour creatinine clearance would be better than the serum creatinine, but the serum creatinine would be second best and beat everything else. So you got the 24-hour creatinine clearance, the best indicator of kidney function. Serum creatinine number two and everything else are distanced. Excuse me. He distanced it. By the way, I didn't tell you guys. No. I knew I was missing something at the very beginning of this whole review. Please feel free to record it. So if you want to record what I'm saying, feel free to just record it away. Now, do you see this ear kidney thing here? I want you to have a visual of the number eight. Do you see how the number eight fits in a kidney real nicely? See how that shape fits? I want you to remember that the number eight, that's number three there. The number eight drawn inside the ear reminds you of two things about these drugs. Number one, they are toxic to cranial nerve number eight, which is the ear nerve, and you administer them every eight hours. You don't give them Q6, Q4, Q2, continuous drip. You give them everybody eight hours. All right, let's turn the page. What's the route? IM or IV. IM or IV is the route. You give these drugs IM or IV. Next point, do not give these drugs PO because they are not absorbed. Do not give them PO. They are not absorbed. So if you give a oral miceis, what will happen? It will go into your gut, dissolve, and do what? Go right through and you're making expensive stool because it's not going to be what? Not absorbed. It's not absorbed. It will have no systemic effect. That's why it has to be given IV or IM. Not because it's going to hurt you. It just isn't going to do anything. Now, except in two cases, there are two cases where we want to give these mean old miceis oral. And the first case is hepatic and cephalopathy called hepatic coma. Have you heard of liver coma or hepatic coma? Hope you've heard of it. Please turn it in a little bit. It's when your ammonia level gets too high. Do you remember that? The ammonia gets up there and it pickles your brain. You go into a coma and you can die. Well, what is the treatment goal in hepatic coma? Reduce what blood level? The ammonia. The goal in hepatic coma or hepatic cephalopathy is to get the ammonia down. That's the goal. Well, oral miceis will do that because what will oral miceis do? Well, they will dissolve in your mouth, right? In your gut and go through your gut and kill gram negative bacteria in your gut. So it will sterilize your mouth. Do you know what the number one producer of ammonia in your body is? The E. coli in your gut. And if I can kill the E. coli in your gut, what do I do to the ammonia level? I increase it. And would that help here? Yes. And because these people have liver damage, we don't want this drug to ever get to their what? Liver. Because it could hurt the liver. Will it ever get to their liver if taken orally? No, it will go in one end, sterilize the bowel and go out the other end. Do you see what is the perfect drug for this? It's going to kill the E. coli, reduce the ammonia level and it won't harm the damaged liver because it's not going to be absorbed. It's it's designer drug. Plus, it makes you have diarrhea, which makes you get rid of stuff, too, which is double better. The other time they want you to give it is in pre-op bowel surgery. Why would you want to give an oral mason? Why would you want to give an oral mason before bowel surgery? Why? Just sterilize the mouth. Clean it out. Better than animals. So for a few days before bowel surgery, what might a patient take? An oral, mean old mason? Will we have any ototoxicity or nephrotoxicity with this? No, one. It's not absorbed. Now, when I am a IV, we would have ototoxicity and nephrotoxicity, but because it's not absorbed, we won't. So in both cases, the hepatic and cephalopathy and the pre-op bowel, what did the oral mason do? It sterilized your bowel. Did it not? So what is the number one action that an oral mason will have? Sterilize the bowel. So these oral masons are called the bowel sterilizers. Now, there are any of these drugs would do it, but there are two of them that are used exclusively for bowel sterilization. And they are neo-myson and canemyson, neo-myson and canemyson. So what do I want you to remember about neo-myson and canemyson? Did their bowel sterilizers, right? Because that's all they're going to be used for. To take it orally for the purpose of sterilizing your bowel. So whenever you see neo or can, what should you think of? Bowel sterilization. Now, how do I want you to remember that? Do you see where it says this? Do you see it says, "Remember this military sound off? Do you see that?" Do you remember or do you ever see or hear or experience a military situation where the troops are marching down the road or jogging down the road, and the drill sergeant says, "Dada, da, da, da, da." And the troops go sound all three. You know, I'm talking about like a cadence. Do you got what I'm talking about here? Well, think of this military cadence. It's rather weird, but it'll work for you. The question that the drill sergeant asks, do you see the cue there? The question the drill sergeant asks is, who can sterilize my bowel? And who can sterilize my bowel? That's what the sergeant asks. Well, the troops are going to shout something back. In answer to that question, the answer will be "Neo can." Because he said, "What? Who can?" So they say, "Neo can. Neo, what? Mycin and can, mycin." So Neo, mycin and can, mycin. So whenever you see Neo or can, what should you think? Who can sterilize my bowel? You'll know they are bowel sterilizers, and you'll know what you're talking about. All right. Now, don't forget to book. Don't forget to book. I say, Amino, Lycoside. Do you say? Amino is. Okay, which shows you they treat what? Amino infections. Like what? Serious, life-retting, resistant, gram-negative things. They all end in, except for the throats. When you see Mycin, you think of what rodent, which makes you think of, which tells you they are, so you monitor there, hearing, dreaming, and busyness. And the ear shake like that. So they are also so you monitor there, breath. And what number do you draw on the ear? So, preel number eight is damaged, and you give it every, what route? Do you give it PO? Why? No, I'm sorry, but if you give it PO, what will it do? What two situations do you want bowel sterilization? Vatican several off the end, preel. Who can sterilize your bowel? PO, Mycin, and can. All right. So do you know those drives? Get it from mean old Mycin. Okay, so you can know the whole treatment. There is a question they would ask you about these drugs that that does not cover. That covers it all. Okay. I had a nurse from, I was touring Miami Valley Hospital about four or five years ago, and nurse comes up to me in the hallway and says, who can sterilize my bowel? And I think she says, excuse me. And she says, who can sterilize my bowel? And I said, I thought. And she says, answer the question. And so I said, me okay. Yeah, I had your, I had your class a year and a half ago. And I felt like I said, honey, you can delete this stuff. You don't have to keep this stuff forever. Whatever is evidently stuck with her, maybe you'll stay with me. Okay, let's talk about trough and peaks and go, go on a break. Trough and peak gloves there at the bottom of the bay. Trough means when the drugs add it's what. Lois and peak is when the drugs add it's highest. I call them tap levels, because that's what you do. The order you do things in, what do you do first? T, draw your, trough A, administer your drug, P, draw your peak. So I like, I teach students tap, trough administer peak. So when is the peak drawn after the administration? When is the trough drawn before the administration? Tap, T, A, peak. Well, what's the reason for drawing tap levels? What we call narrow therapeutic window? Have you heard that term narrow therapeutic window? And that means there's a very small difference between what works and what kills. So if a drug has a very small difference between what works and what kills, what will we draw on them? Tap, taps. If they have a wide range, will we draw taps on them? No. So let me ask you this. What's the smallest dose of Lasix you ever gave or saw given? Lasix. You're awesome. I, the diuretic. I've seen 10, 5 or 10. What's the most you've ever seen? 80, 120. So it goes anywhere from 2010 to 120. Is that a narrow or wide range? So would you draw troughs and peaks on Lasix? No. What about ditch? What's the lowest you've given of ditch? 0.125. What's the highest you give of ditch? 0.25. That's only 0.125 difference. That's pretty narrow. Would you do a peak and a trough on a ditch? Yes. So these mean old license all have what drawn on them? Yes. Taps because they have what? Nero therapeutic windows. Now I want to understand, a mean old license are not the only class of drugs which have taps drawn. But they are a major class in which you draw taps. Therefore, that's why I'm talking about it here. Do you know what I'm saying? This discussion of troughs and peaks could apply to a lot of other drugs besides these, but it definitely applies to these. So what sportswoman knows when you draw and when you draw the trough, when you draw the peak? Good news. You don't even have to know what the drug is because it depends on the route which is great. This would be a fantastic question to get a drug you've never heard of because it doesn't matter. The route matters. So if they say when would you draw the peak on a patient getting L-spherogenase IV pushed? What does not matter at all? L-spherogenase. What matters? IV pushed. So let's talk about this. Troughs who fill in the trough column first. When you draw a sublingual trough, a trough before when you draw the trough before you give a sublingual man. 30 minutes. 30. That's 3-0. I'm not saying 13. 30. 3-0. 30 minutes before the next dose. So if the meta is being given at 10, sublingually when do you draw your trough? 9-30. 30 minutes before that next dose. Let's talk about IV. We're going down the column. When do you draw a trough before an IV met? I am. When you draw the trough, 30 minutes before the next dose. When you draw a subq, 30 minutes before the next dose. And low in the hole, what do you think the answer is? Or a p-o-man? So how hard is a trough question? Not hard. Because it doesn't matter what drop? And it doesn't matter what route. It's always 30 minutes. So how many trough questions do you want on your list of things in? 75. And that's the answer you want 85. Because you're going to ace it. So I'll sweat it. Great place. Other people are going to be sweating bullets and you're going to be laughing. Okay, the peak. Now sorry to say the peak is going to change. It's not going to be like a trough. But here again it will depend on the trough. It will depend on the route. Because I'm going to say something that is correct. Do not write this down. But this is true. The same drug given by two different routes at the same time will have two different peaks. I give p-o morphine and IV push morphine at the same time. I'm going to have two peaks. One is the same drug. However, two different drugs given at the same time by the same route will peak together. Morphine and fender again. Two different drugs given IV same route at the same time will peak together. So what determines the peak? The drug or the route? The route. So always pay attention to the route. So let's talk about it. When you draw a sublimal peak, five to ten minutes after the drug is dissolved. Five to ten minutes after the drug is dissolved. IV, 15 to 30 minutes after the drug is finished. Why did I say finished? Not when you want. Hang it. You don't start your clock when you hang it. You start your clock when it's finished when the bag is empty. Then you go 15 to 30 minutes after that. What if they told you you were going to give 100 mil of a drug at 200 mil per hour. You're going to give 100 mil at 200 now. So how long is that going to take to run it? Okay, you hang it at 10 a.m. Some a second of finish. 10 30. When would you draw the peak? From 10 25. Well, they say A, 10 15. V, 10 30. C, 10 45. Yes, D, 11 o'clock. Yes, they do this all the time. Two right answers. Right once 15 after it's in, once 30 after it's in. It's in the, is another range. Which one are you supposed to pick? 11. Whenever you get two in the same correct range, when you ever get two values in the range and they're both correct. Play, the price is right. Who wins on price is right? Highest without going over. So who's the highest here without going over 11? And that's who wins all the time. For example, just to show you how this works in every case. Do you remember antidepressant meds antidepressant meds? How long does it take the typical antidepressant med to work? Two to four weeks, two to four weeks. If boards told you that the client had been on it for one week already, got it? It's been on for one week already and they're saying it didn't work and you didn't help it. I feel horrible. What would you teach them? A, it may take another week to work. Is that true? Might it? Yes, that's the true. And then B says it may take three more weeks to work. That's also true. So you got two right answers. One week and three weeks. Which one wins? Three weeks, because you picked the highest without going over. When would a child be able to be potty trained during the night? Three years or five years? Well, that's three to five years. Next time potty training for you're in. So what would be your answer? Five and you'd be right. So always whenever you're sitting there and you have two right answers, they both are correct numbers. Pick the highest without going over and that will always win. That's not just on this, but on everything. Okay, the I am. The I am is 30 to 60 minutes. You draw the I am peak 30 to 60 minutes after you give it. So if you were between 30 and 60, what would you pick? 60. See they love to test this. You gave an I am demo all for pain. When would you check them for relief in 30 minutes or in now? Well, it's going to peak in 32. 60. So it's even going to take in 30 or 60. What would you say? 60. Yeah, because you want to give it enough. You can check it in 30, but you should at least check them within an hour. Okay, some cue. Here I want you to write the word S E C S E C diabetes lecture, which we'll talk about tomorrow, because the only subcutaneous peaks they talk about are the insolence and we'll just talk about effect. They don't talk about tributely, so you are anything like that. And then in the field box, but forget about it, because they don't test POPs. It's all too variable. All right, take it to come back at 720 and finish up.