Waching daily Aug 27 2018

A Woman Couldn't Sleep for 9 Days.

The medicine she used to help her sleep was less than optimal.

This Is What Happened To Her Colon.

JD is a 27 year old woman, presenting to the emergency room, unconscious.

Her boyfriend Jeff tells the admitting nurse at admission that she had been awake for the

last 48 hours before complaining of severe nausea.

You see, JD had been experiencing a strange insomnia over the past 7 months.

Some nights she would lay in bed, tossing and turning while hearing the morning traffic

build up in her window.

Some mornings, she would dreadfully watch the sun rise.

Without sleep, her quality of life began to rapidly deteriorate.

She was an attorney, and her job performance began to suffer, as she would have trouble

making court dates.

She began losing interest in her hobbies and her relationship began to suffer as she blamed

Jeff for the insomnia, but even after his absence, her sleep trouble worsened.

10 years ago, JD was diagnosed with a mild depression.

She was started on a low dose of quetiapine, with good results and never missed a dose

nor had any complaints about it.

About 3 months ago, JD began trying supplements to help her sleep.

Some nights, she'd sleep great, and others, she'd be wide awake for 2 consecutive nights,

exhausted by the third day.

Some supplements, became many supplements.

She'd mix and match, and take much more than she needed until finally, nothing worked.

She consulted a neurologist for her problems, who prescribed her cognitive behavioral therapy,

but in it, she found limited success.

She finally moved on to over the counter medication.

She started taking the PM branding of a drug named diphenhydramine, which helps with allergies

but also makes one drowsy.

It helped her sleep every night for a whole week, but she noticed that the medicine would

give her not only stomach pain, but also constipation.

Sometimes, she'd sit for 30 minutes, with limited movement, but finally being able to

sleep gave her new life.

Inevitably, the insomnia came back.

JD began to escalate the dose each night until she would take 4 to 5 times the recommended

dose each night to sleep just a few hours, before waking up unrefreshed and exhausted.

One evening, she was at dinner with Jeff.

She barely ate.

She told him that she hadn't had a bowel movement nor slept more than just a few hours for 9 days.

He stayed with her over night to make sure she'd be ok.

Her skin became pale as she started complaining of nausea and stomach pain.

Jeff fell asleep but as he woke up, he found her laying on her side, in a pool of cold

sweat, huddled up and unresponsive.

In a panic, he called 911 and she was brought to the emergency room where we are now.

Given this history of present illness, there are several clues as to what's happening.

At physical examination, JD was immediately identified to be in shock.

Her blood pressure was low and her heart, to compensate for this hypotension, was beating

at 150 beats per minute, 3 times that of average.

And she was completely unresponsive.

An abdominal CT scan finds that JD has Acute Megacolon.

Mega meaning enlargement and referring to the dilatation of the colon, or the large intestines

Acute meaning that there are no underlying pathophysiologic conditions that are leading

to this problem except for the massive doses of diphenhydramine JD consumed for her sleep,

which leads us to the first clue.

Diphenhydramine is an allergy medicine.

In most parts of the body, it blocks the chemical named histamine which is responsible for most

common allergic reactions, like itching from mosquito bites, and sneezing from pollen.

But in the brain, diphenhydramine blocks a different chemical that transmits signals.

This means that small amounts leads to mild sedation, helping with sleep, but by affecting

the brain and its nerves, diphenhydramine also slows down the digestive system, which

receives signals from the brain.

Large amounts of diphenhydramine can lead to an almost complete stoppage of the digestive

system which brings us back to the name of JD's condition Acute Megacolon.

If she had no bowel movements for 9 days, and CT scan did not reveal any mechanical

obstructions in her colon, then it means nothing was specifically blocking the way in her intestines.

But if that's the case, then why is her colon dilated?

Why is it megacolon?

Well, there's a few things to be known here.

First, the stomach and intestines form their own set of nerves called the enteric nervous

system, sometimes called the second brain.

This "second brain," controls the muscles of your bowel and cannot be actively controlled

by you, meaning you can't force your stomach to contract at will like you can your biceps.

But if the first brain in the head and the second brain in the gut both use the same

chemicals to transmit signals along the nerves, and JD's sleep medicine diphenhydramine

blocks the chemicals from transmitting signals in those nerves, then it means that high doses

of JD's sleep medicine were slowing down her gut to a high degree.

Inside the colon, because the digestive system is a giant tube from your mouth to the other

end, the pressure stays constant within, meaning that if one part is dilated, the pressure

has more or less, stayed the same and hasn't dropped.

This means that the tension at the wall of the dilated segment is elevated, and as the

colon keeps slowing down from high doses of diphenhydramine, and as tension keeps building

up, then blood can't flow through it, meaning those blood vessels will begin to crush up

against the sides of the wall, starving the tissue of oxygen as it slowly begins to necrose,

or quite literally die.

This necrotic tissue begins to lose it's muscular integrity, and as time continued

through JD's abdominal pain and distention starting from several days ago, the walls

of her colon began to weaken so much, that they finally perforated, spilling her intestinal

contents into her peritoneal cavity, causing bacteria from the gut to spill into her blood

stream, as they begin to flow freely, all throughout her body.

Just like how when you get an infection on your skin it becomes swollen, red and warm,

an infection that spreads into your blood causes your entire body to become "swollen,"

which translates to the body sending white blood cells systemically, promoting inflammation.

Because JD's situation isn't self-limiting, meaning it isn't containing itself, her

blood vessels have begun to vasodilate, causing her blood pressure to drop.

Her heart detects this and begins to beat faster in order to compensate for the loss

in pressure so that her organs can still receive blood, but as her brain starts to lose oxygen,

JD loses consciousness.

This dramatic escalation in signs and symptoms due to colonic perforation is known as septic shock

and means almost imminent death in JD's case, if treatment isn't initiated within

the next few minutes.

The notion of motor dysfunction in the gastrointestinal system is a persistent underlying theme that

has far reaching implications when it comes to seemingly unrelated causes of disease in

humans.

Opioids for pain control in the hospital can often cause gastric hypomotility.

This is a time when constipation becomes a common occurrence leading to fecal impaction.

If the patient is elderly and doesn't receive a stool softener, then it means they will

have to strain to pass a movement.

If they strain hard enough, their heart will temporarily stop and they can rupture blood

vessels in the brain causing a stroke, which leads to cerebral vasospasm days later, which can starve

the brain of oxygen leading to brain damage.

In the case of gastroesophageal reflux disease, stomach acid commonly splashes into the esophagus,

which isn't equipped to handle the low pH.

While laying down, this acid can enter the bronchioles of the lungs and trigger asthma

as well as damage the larynx and erode the enamel of the teeth.

The integrity of the esophageal mucus membrane is disrupted and the cells are damaged, leading

to Barrett's Esophagus which predisposes the patient to esophageal cancer, which can then undergo

a malignant transformation and then spread all throughout the body.

A common inflammatory bowel disease known as Crohn's Disease affects any part of the

digestive tract, at all layers of the bowel walls.

This is a state of mucosal inflammation that can seep into the smooth muscle of the colon,

paralyzing it, causing it to dilate.

The deep ulcerated parts of the intestines begin to degenerate and necrose as white blood

cells begin to swell into the tissue, causing it to rupture, giving way to toxic megacolon,

a more chronic condition with an underlying pathophysiology compared to JD's acute megacolon.

Her history of present illness all point to this.

The prior stomach pain.

The nausea.

The high doses of diphenhydramine in a desperate attempt to finally fall asleep.

Since the onset of shock appears to be relatively recent, it may not yet be too late for her,

she could still be resuscitated.

The first line of treatment is to remove the source of bacteria spreading into her blood.

She is admitted immediately to surgery and at laparotomy, or incision into the abdominal

cavity, massive colonic distention was found with evidence of perforation.

Her small intestines, and distal parts of her rectum were found to be viable and her

entire colon was removed.

Admission into the intensive care unit led to immediate initiation of antibiotics and

early goal-directed resuscitation as her condition began to stabilize over the following days.

The final thing to note here, is that JD's condition sould have been easily caught by

any health care provider, at any point.

Diphenhydramine as a medicine is a well known anti-cholinergic.

If a cholinergic does things like promote smooth muscle movement in the digestive system

and promote a "rest and digest" state of the body, then an anti-cholinergic prevents

digestive system movement.

Do you remember that quetiapine that JD was taking for her depression?

Well, quetiapine is also a well known anti-cholinergic, meaning the dangerous dual blockade of diphenhydramine

in large, prohibited doses in combination with quetiapine, which also exhibits anti-dopaminergic

and anti-serotonergic activity, both important neurotransmitters in "both" brains, virtually

stopped her digestive system from moving completely, and caused her colon to swell, crushing the

blood vessels, starving it of oxygen and causing the walls to perforate, leaking enteric contents

including gut bacteria into her blood.

JD's anticholinergic excess, produced from a drug interaction that should have been caught

by physicians, nurses and the pharmacist at the store where she bought the medicine, caused

this set of symptoms.

Luckily for her, it wasn't too late to begin early goal directed resuscitation in the intensive

care unit, and over a few weeks, her septic shock was resolved as she regained consciousness,

and her gut was surgically anastomosed, or rejoined together, without her colon.

And upon arriving home, a good nights sleep in her own bed, was waiting for her.

Thank you so much for watching.

Take care of yourself.

And Be well.

For more infomation >> A Woman Couldn't Sleep For 9 Days. This Is What Happened To Her Colon. - Duration: 10:42.

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Dr. Phil To Guest: 'What Is Your Payoff For Embracing The Belief That You're Being Observed?' - Duration: 1:56.

For more infomation >> Dr. Phil To Guest: 'What Is Your Payoff For Embracing The Belief That You're Being Observed?' - Duration: 1:56.

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Six UCLA Football Players Suspended For Opener - Duration: 0:30.

For more infomation >> Six UCLA Football Players Suspended For Opener - Duration: 0:30.

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Kalamazoo Public Safety Healthy For Good - Duration: 0:38.

- In order to serve our community,

it's important that police, fire, and EMS stay healthy,

both physically and mentally.

Healthy For Good is a revolutionary movement

to inspire all of us to create lasting change

for good health, one step at a time.

The approach is simple, eat smart, add color,

move more, and be well.

For more tips, visit HealthyForGood.org.

Aren't you worth being healthy for good?

- [All] Yes you are, healthy for good.

(lively music)

For more infomation >> Kalamazoo Public Safety Healthy For Good - Duration: 0:38.

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How many links are too many for a page? - Duration: 3:42.

Hi, I'm Bruce Clay, and this is the Ask Us Anything Series. After discovering that

each link on my page dilutes my PageRank transfer, I am starting to re-evaluate how

my footer and header navigation bar is set up. At the moment, my header and

footer nav amount to over 50 links each on each page. That is not including other

links in the body. How many links is too many on a single page? Well, I don't think

there's an upper limit. At one point, Google said try not to have more than

100 links on a page. I think that was because it's easier to put up a 100 link

limit than to explain how PageRank really works. In our particular case, we

try to minimize the number of destinations on any one given page. We

also believe that if you have too many links, many of them are probably to

grandchildren, not to your children, and that many of them don't convert. If

there's a reason to have a link, go ahead and link to it. You don't want to

dilute your PageRank transfer any more than you need to and you certainly do

not want to end up giving your important PageRank to pages that don't make money

for you. So, minimize them whenever you can, link only to the pages that matter.

Now, you are correct, the navigation is only part of your web page and in many

cases we see sites where the drop-down navigation is just every single possible

thing that they sell. They think that it's a usability issue to make it easy

for people to get the pages that don't make money for you. Well, it is, it's a

usability thing, but it doesn't make money for you and I think that the

reason you have an e-commerce site is typically to make money. Our view is you

minimize the navigation when you go to that

sub-page, then you can link to your children, make it a clear hierarchy. The footer

links - you could use them to balance out your linking, but there's many things in

your footer that you don't perhaps really want to give PageRank to, so pay

attention, don't link arbitrarily to things in the footer, link within the

body. The most important link in the body, by the way, is your breadcrumb. I know

you're going to find that interesting but your breadcrumb is your hierarchy

and Google relies on that to understand what is going on. One more comment, if you

link to a sitemap, an HTML sitemap, Google uses the entries in the sitemap to

identify what you believe are your more important pages and that sitemap is

almost as important as your main navigation in identifying to the search

engine what your important pages really are. Hope that helps.

Google recommends having less than 100 links on each page, but this seems to be an arbitrary number in our opinion.

Try to link within the body of the page and the most important link is the breadcrumb.

We recommend you minimize the amount of links and navigation and create a clear hierarchy on your site.

For more infomation >> How many links are too many for a page? - Duration: 3:42.

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Port Arthur's Little Titans get ready for school - Duration: 1:39.

For more infomation >> Port Arthur's Little Titans get ready for school - Duration: 1:39.

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Ginkgo Biloba: Benefits for Health - Duration: 2:33.

The health benefits of Ginkgo Biloba also known as Maidenhair Tree.

1.

Ginkgo Biloba is one of the world's oldest tree's and is considered to be a living fossil.

Extracts from this tree are taken as a health supplement all around the world.

2.

This herbal supplement is especially popular in America with approximately 4.5 million

people taking this per week.

It has some excellent health benefits for the human body.

3.

It is also often prescribed by doctors in Germany where it is used to treat dementia,

memory loss, anxiety and other mental problems.

4.

It has been shown to improve cognitive function by increasing blood flow to the brain.

Memory and recall are often increased, making this excellent for those who are studying.

5.

Studies have taken place and proved that Ginkgo is an excellent supplement for women who suffer

with PMS.

It reduces the severity of PMS by reducing cramps, pain and breast tenderness.

6.

It also works to improve the vision of those who are suffering with glaucoma.

It also has been shown to help those with macular degeneration, to keep their sight

for longer.

7.

Raynaud's disease is a common condition which affects the blood vessels beneath the skin

in the hands and arms.

This leads to problems with motion, discomfort and burning sensations.

Those who suffer with this problem can take a supplement of Ginkgo Biloba to improve this

condition as it aids blood circulation.

8.

This supplement also helps to improve cardiovascular health as it has been shown to reduce "stickiness"

of the blood vessels.

This prevents plaque from forming inside the blood vessels, making you less likely to get

blood clots.

9.

Many people are also using Ginkgo Biloba for Vitiligo to stop the spreading of this disease

throughout the skin.

10.

To learn more about natural remedies and herbal cures, please see our other videos.

Thank you very much for listening, a like is always appreciated and remember to subscribe

and tap the bell for more healthy videos.

I wish you great health, wealth and happiness.

For more infomation >> Ginkgo Biloba: Benefits for Health - Duration: 2:33.

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Schweinsteiger inducted to FC Bayern Hall of Fame - Rudy signs for Schalke - Duration: 3:21.

Of course, it's a great honour to enter the Hall of Fame at such a big club

along with all the other great personalities.

A great award for a truly great player in the history of FC Bayern:

Bastian Schweinsteiger was inducted, as the 18th member,

into the FC Bayern Hall of Fame on Monday afternoon.

It's a great moment for me, I'm very proud to be here

as I come from this area and it means an awful lot to me.

The outstanding significance of Bastian Schweinsteiger to the club and his special relationship

with Bayern were also highlighted by chairman Karl-Heinz Rummenigge and president Uli Hoeneß.

He was always Mister Bayern: He grew up in Kolbermoor,

matured through our youth teams and then had a great career at Bayern Munich.

Basti was always a rascal and always made the big and small mistakes

that make a rascal. As a club we had to rein him in at times,

and I think that did him good because he turned into a fantastic player.

On Monday morning Schweinsteiger accepted a great honour from Bavarian Minister-President

Markus Söder at his official residence.

The 34-year-old player, born in Upper Bavaria, was presented with the Bavarian Order of Merit

at Prinz-Carl-Palais in the state chancellery.

Yes, it was a special moment for me as a true Bavarian to receive an award like that.

That's very prestigious in my estimation and I'd really like to thank

the Minister- President for being able to take part in an event like this.

I'm really overwhelmed.

After the special award on Monday, Schweinsteiger could well be overwhelmed

by his farewell game on Tuesday.

I'm looking forward to the moment when I'm back at the Allianz Arena, seeing the fans

and also sharing it with my new team-mates

as well as meeting my former FC Bayern team-mates.

Sebastian Rudy will not feature in Schweinsteiger's farewell match

as the midfielder has signed for Schalke 04.

FC Bayern thank the 28-year-old for his service and wish him all the best for the future.

Rudy joined the record champions a year ago and won

the 2017/18 league title with Bayern.

For more infomation >> Schweinsteiger inducted to FC Bayern Hall of Fame - Rudy signs for Schalke - Duration: 3:21.

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Trae Dauby: The Top 10 Turn-Offs for Home Buyers - Duration: 4:33.

- Hi I'm Trae with The Dauby Team

of Keller Williams Capital Realty.

Today I just wanted to talk with you for a quick minute

about the top 10

turnoffs home buyers see

whenever they're thinking about buying a home.

(slow upbeat music)

The number one turn off is

immediately as soon as they pull up to the house.

If the yard is over grown or the landscaping

has not been trimmed

or if the landscaping is full of weeds

it's often a sign of what

the inside of the home looks like.

You're putting off an impression

that you don't take care of your home.

So the curb appeal and first impression is vital.

The second thing is whenever the home buyers walk

up to your home they're often times gonna be waiting

for the realtor to get the key out of the key box.

While they're doing this

they're gonna be checking out

the immediate area a round the front door.

So a muddy door mat or the gutter above

not being clean or just a broom sitting outside

looks like the home has not been maintained again

and does not give a good impression

as they go to enter the home.

Once they step inside the home

the odor will also be one of the first things they notice.

So you typically want to have air fresheners

or some candles but you don't want it to be over bearing.

You definitely if you have pets

you don't want them to pick up

on the smell of an old dirty dog or cat urine.

So definitely make sure if you do have pets

that you're cleaning up after them keeping the home clean

and air fresheners out so that it smells great.

The next thing they'll notice

as they start to walk through the house

is if the home is cluttered.

If you have boxes sitting in the corner or a treadmill

that hasn't been used in five years

it's definitely best to move those items

out of the house and into a storage container.

If for some reason you can't do

a storage container at least get it into

the garage and get the home decluttered.

Also when they're walking through the home

they're gonna be noticing all the paint colors

so a bright red or a bright yellow or a bright orange

is gonna be really off putting.

Painting to some people

is not difficult but to others

it can be a big expense.

So you typically want neutral colors

that the home buyer can see themself living in.

As they continue to walk through the home

they will notice the flooring throughout the home

as well so if you've had any laminate flooring

or hard wood that's gotten a lot of water on it

and you have damage you definitely want to address that.

Also with carpet that's matted down or has stains

you also want to look at getting that replaced as well.

Some people want to offer an allowance

in lieu of addressing the issues

however I do not believe this

to be nearly as cost effective.

If you actually take care of the issue

the people will see the home

as move in ready and you'll get more bang for your buck.

As they're walking through the home

they'll also notice how the furniture is laid out.

If the furniture doesn't flow real well

they may not be able to picture their furniture

inside the house.

You definitely want them to be

able to visualize how their furniture

will be inside the home.

Another item is as they walk through

many families will look at the photo frames

that are throughout the house.

We typically recommend taking out family photos

and just using decorative photos in those instead.

Because many times the buyer will look

at the pictures and try to figure out

who the family is or who they know.

And they spend too much time

looking at pictures and also they can't visualize them

living in the house when they're seeing

constant photos of your family

inside the house.

Also dated light fixtures,

dated plumbing fixtures,

dated bathrooms and dated kitchens are major issues.

These are huge ticket items for the buyer

so if the home's not up to date

there are some minor little touches

that are cost effective that you could do

before you put your home on the market.

The last thing would be dirty windows as well.

The dirty windows do not allow

as much natural light in.

Natural light makes the home feel much bigger

and more airy.

So these are the 10 biggest items we see

that hold buyers up from purchasing a home.

If you're thinking about selling your home

and you'd like for us to come out

to take a look and address any of

these issues or make suggestions

we'd be happy to do that.

You can reach us

at 812-777-4611.

Again I'm Trae with The Dauby Team

of Keller Williams Capital Realty.

Have a great day.

For more infomation >> Trae Dauby: The Top 10 Turn-Offs for Home Buyers - Duration: 4:33.

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2018 NHSN LTCF Training - Surveillance for UTI: Part I - Duration: 59:04.

For more infomation >> 2018 NHSN LTCF Training - Surveillance for UTI: Part I - Duration: 59:04.

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2018 NHSN LTCF Training - Surveillance for UTI: Part II - Duration: 51:25.

For more infomation >> 2018 NHSN LTCF Training - Surveillance for UTI: Part II - Duration: 51:25.

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Ask the Preventionists!: How to put research into action for K-12 prevention policy - Duration: 46:12.

Welcome everyone to our Ask The Preventionists, our first live event, super excited to be

doing this this afternoon and before we get started with a few introductions here, just

wanted to take a poll really quick to see who all is joining us today.

So, if you wouldn't mind, go ahead and just fill out that poll for us there to kind of

let us know who we have in the room with us today.

Awesome, it looks like we of course have lots of preventionists in the room, some educators,

a few advocates, some policy workers, and some other individuals.

Wonderful, thank you so much for sharing and so I will kind of get us started here with

just introductions quickly.

My name's Taylor Teichman, I'm the Online Resource Specialist here at the National Sexual

Violence Resource Center and I help to work on some of our research to practice work that

we have through the CDC.

So that is what brings us to our Ask The Preventionists live event today, and I'll hand it off to

my colleague, Sally, next to introduce herself.

Oh, Sally, I think you're muted.

Destie Hohman Sprague: Taylor, do you want Beth and I to jump in with intros while Sally

works on that?

Yeah, go right ahead, thank you.

Sure, thank you.

Thanks.

I'm Destie Hohman Sprague.

I'm the Associate Director of the Maine Coalition Against Sexual Assault.

And I'm Beth Hamilton, also the Associate Director here at the Connecticut Alliance

to End Sexual Violence.

Well, thank you.

And sorry about that, folks.

Is my audio on now?

Yes, it is.

I'm so sorry.

Yay!

I'm so happy to be with you all today.

My name is Sally Laskey, I'm the Evaluation Coordinator at the National Sexual Violence

Resource where my work focuses on trying to support the Rape Prevention Education recipients

around the country, and I am excited to learn more from Beth and Destie and folks that are

joining us via chat today, so thank you, thank you both for being here and Taylor, thank

you for organizing.

To help us learn a little bit more about all of you on the line.

I just wanna do a quick little poll here again before we jump into hearing from our presenters.

So we would like to know how many people live in a state or territory that currently has

requirements for sexual violence prevention programming being mandatory in your schools.

Thank you so much for those of you that are already responding.

It looks like we do have almost around 40% of folks saying that they know that there

are requirements.

And we'll go ahead, I know a few folks are still adding, we'll broadcast those results

for you, and thank you.

So we've got some folks that aren't sure, some that don't, and about 40% that do have

those requirements.

So thank you so much.

Yeah, and so to get started, Beth and Destie, I was wondering if both of you wouldn't mind

sharing today just kind of a brief overview of what each of your coalitions are currently

doing with your K-12 prevention policy and evaluation work?

Sure, you can go ahead and...

Sure, so, this is the funny part of doing this all remotely with other folks around

the country.

So we passed our K-12, our version of Erin's Law essentially in 2016.

It was implemented, so started being required by schools in October of 2016, and ours includes

both awareness and prevention education within schools and that has to happen for both staff

at the schools as well as for all the students at the schools.

We were lucky and that we sort of had a leadership role within the development of that so both

we got to change some of the messaging and some of the work that was done, so it was

much more focused on prevention and I think folks were originally anticipating happening.

We work really closely with our State Department of Education as well as the Department of

Children and Families, and we developed which I think you can click on right in one of your

web links there, a guidance document ultimately that breaks down different chunks by grades,

essentially into what are some of the guiding principles that we want folks to be able to

cover for both education and also for children to be able to understand within those age.

The tricky thing for us is that we were very successful in passing the legislation, but

there's not a lot of teeth or accountability to what happens after the passage of that

legislation.

So, what we're currently doing is in a process of pulling folks back around the table to

do some evaluation work, an event that will be in the form of a survey that will go out

to some of the same folks that we worked with earlier and some of the same principles that

we probably feel that we had an initial survey that we sent out in 2014 in anticipation of

doing some of this work.

So, I expect some of the same people both filling that out, but what we really wanna

get a grasp on is what are folks currently doing?

What percentage of schools, how many school essentially are actually doing the implementations

of the work 'cause we sort of have gotten some feedback that some schools are taking

it a little bit more seriously than others.

We also want to be able to find out what are some of the successes and challenges folks

have faced when doing the work, and then also it's really important to identify some champions

or some folks that we feel are really doing the work super well, so that they can be models

for other folks who are either not prioritizing it or finding some more challenges within

their districts to be able to implement it.

So that's what we're doing this fall that survey will happen.

And then about midway through the next academic year, our plan would be that there's a written

report that goes out, sort of like a report card which we've done, for example, in the

past campus legislation, and that's something that we can use then to get folks some more

buy-ins to address some of maybe the trends that are happening for schools who are not

implementing any of the education as a tool to really address to see what's going on two

years after its passage.

Alright, great, thanks, Beth.

I'll jump in then.

Is that...

Okay.

So we have really sort of a name too distinct kind of sets of prevention programming.

One is for K-12, all the way through K-12 that we implement with local Sexual Assault

Support Centers, our MECASA member centers.

But my focus here today is on just the prevention policy, we have...

The K-12 is our own work, but it's fairly robust, but we also passed our version in

Maine of Erin's law in 2015, so it's actually been quite a while and it's really specific

to just K-5 and specific to child sexual abuse prevention and awareness.

So we're really focusing on just kind of young kids, bodies, body empowerment, and that policy

has three different components.

It's required training on both some concepts related to healthy sexuality promotion for

school personnel but then also like ability to identify indicators and respond effectively.

That's for all personnel including cafeteria folks, everybody working within the school.

It also has a required training for all students or required education for all students and

that is focused on prevention concepts rather than how to tell when something is happening

after the fact.

And then there's also a required policy that schools have to have a policy that aligns

to a state-wide Department of Education model policy.

That was signed into law in 2015 or '16.

I'm mortified that I can't remember now.

I'm pretty sure it was '15 though, but we are actually only really fully implementing

it this fall.

We actually just launched the website publicly this week so hey, go over there.

It's really great.

But the intervening years have been about making sure that even though we're only focused

on the K-5 and a fairly kind of small bit of work in terms of the universe of prevention,

we wanted to make sure that we had all the pieces in place for schools to really be able

to implement it thoroughly.

I expect that like Beth in Connecticut will have lots of schools who give it lip service,

and then lots of schools who are really committed to it, but we've been building lots of pieces,

so that hopefully we can kind of spoon-feed to the extent if that's possible.

And so we have, in addition to creating guidelines for what the school personnel training should

look like, we kind of got modeled personnel training.

We have a whole resource guide for education for students that we've tried to make sure

aligned with what we know about what works with prevention practice.

So it's not kind of lesson plans in a box, but rather, when we do prevention with kids,

it needs to be multi-session.

It needs to be multiple conversations that needs to be embedded in the kind of flow of

their understanding, it also should include books and reading and etcetera.

And then we have the model policy as well, it's all housed in a website that includes

information for schools about implementation but also information about child sexual abuse

prevention for families.

That's outside the scope of the policy.

But we wanted to be able to bring that in so that we had a bit of a one-stop shop, so

that it all rules out this fall, and it will include regional trainings that we'll do in

partnership with the Department of Education about how to implement it, and then training

for teachers so they can become the experts within their own community training their

fellow staff and providing education or leading education efforts for kids in the classroom.

Well, we are getting Beth and Destie lots of interesting things coming in through Q&A.

We'll ask to follow up on some of those a little bit later.

But before we jump to some of those, I was wondering since you've given us kind of an

overview of your approach and what you're doing, could you talk a little more specifically

about what collaborative approaches really look like in the day-to-day work of developing

a state and community plan for implementing these policies but also doing that follow-up,

look at evaluating if they're meeting the intended outcomes?

Sure, I can start if that's okay.

Yeah, Beth, that's great.

Yeah, for us it's been a bit of a challenge.

I wish we had the stuff that Destie talks about every time we'd talk with all of you

are things that I would strive for, that I hope we have that ability at some point to

put as much guidance and as much of a package together for folks to just sort of take and

be able to use.

For us and at different times a challenge to get some of the buy-in from folks, and

a lot of what we did similar to what Destie was talking about is we have required comprehensive

sexual health education in the state, and so because that was long fought for and there

were group of folks that had already worked on that we were able not only to use some

of their guiding documents but to pull some of the folks who are responsible for the creation

of that and who helped to get the buy-in from some of the more challenging places, to be

a part of our cooperative group together and that was something that was hugely helpful,

not only to sort of hear some of their lessons learned, but a little bit more about how you

have to message certain things and pieces like that.

We also, we really looked at who was important to have around the table and continue to do

so and thinking that yes, we want administrators and systems level people to be involved because

ultimately that's who's gonna help us get approved to get all the work done but we have

lots of school social workers, healthcare workers, school nurses and those folks are

actually probably the most helpful to be honest with you in all of the folks we had around

the table because not only did they know the schools but when we have challenges getting

into the schools, those are the folks that are actually the people that we are gonna

directly reach out to to be able to help who's the right administrator.

Who is the more sympathetic to the work we're doing?

They really know both in their districts as well as in their individual schools who the

right people are.

So those are some of the most important people that we were able to pull together for some

of those groups.

We also, like I said, in doing that pre-survey, so we've started a couple of years prior to

really working on the legislation and it gave folks an introduction to us in some ways which

was nice.

I think that we encountered a lot of...

Both on the school side and from other places, a lot of resistance to the extent of being

something that should happen in schools, that sexual violence prevention should not be something

that schools are responsible for, it's a parent job.

We heard lots of those pieces.

So getting folks to understand who we are and what we did earlier than we even started

asking folks to support legislation or create guidance documents and we'll evaluate it.

It was something that was really helpful and we also in one of the pieces that we tried

really hard to have folks engaged that we were minimally successful in some ways was

youth themselves.

And that's another piece that I would hope that as other folks are doing this work, you're

really mindful about...

We do a lot of work for many communities, not just youth where we really are saying,

"We know what's best for them where we actually don't have them in the room telling us that

information," and that's something that we had a real challenge for in a lot of ways,

one, because we're set up as a non-profit, nine to five, Monday through Friday, when

they're in school.

And also, because there were a lot of extra hoops to jump through to get access to them,

and then to keep them committed to coming back to the process and to the table because

some of them were the best spoke persons that I could think of to have at those tables.

But that was some of the pre-planning and the collaboration we've done and then we've

had to do it all over again with the evaluation components with some of the same people trying

to get them back to the table, get folks re-invested in the work.

A lot of folks felt that once the legislation was passed and once we created that guidance

document, we should have been done and that we don't need to you know, why do we need

to evaluate it?

Why do we need to look at how we're doing?

And for us, doing the work, the realities we fully understand that the work is being

done different, even though there's some standards, it's not standardized and that lots of folks

just aren't doing the work.

So we're encountering some of the same resistance doing the evaluation.

But the nice thing is, we have so many relationships that we built along the way that we have been

able to pull back together.

Really good core group of folks.

Thank you so much for talking about the level of preparation that you need to do and that

it continues to be this on going, on growing more, and definitely for talking about putting

youth at the center of this work.

Destie, could you share a little bit with us about where you started, the kind of prep

work you did and who were key collaborators for you in this work?

Sure.

Well, and this is my turn to say, "Ooh, I wish we had some of that because what...

I think we have developed really exciting resources and some fairly comprehensive resources.

I think that they've also been really collaborative but not with the wide audience that that's

refers to.

And that's for a couple of different reasons.

But we have not necessarily identified Erin's law as a priority at our coalition for lots

of different reasons, including that Maine has a long tradition of being a local control

state, and so we do not have any mandatory curriculum for any topic at any age in Maine.

And so, that just felt...

We also additionally didn't have the resources within the sexual assault prevention and response

community to implement state-wide blanket programming.

And so when this policy was made itself known to us, we just had not built a team partnership.

Any of those things that you refer to about like what would we like this to look like?

We just sort of had it.

And so what we did spend the time on was, well, now that we have it, what do we want

it to look like?

And so that was a really deep partnership between MECASA and our main Department of

Education.

So we worked in lockstep with them, their health policy, and health promotion department,

which is one person, 'cause we are a very small state who really cares about this work.

We trusted her to...

Her and that department to talk about what was realistic with the schools, to talk about

what they could really implement to bring the voices of health educators, guidance,

counselors and school nurses into the process.

But we really did.

[chuckle] It was a bit of a party of two, and I think we might have done that differently

if we were starting from whole cloth and envisioning how this would really be a community project.

So we all work with the pieces that we're sort of given and so for us, we thought well,

we have no money, we have almost no time we'll be implementing this on top of what already

exists.

And so our collaboration was deep, but small and we worked really hard though, to make

sure that we were reaching out to local sexual assault educators who were already in schools

who were already doing related programming like Parents in the Know, if folks are familiar

with that parent education program out of Pennsylvania, I think really highly of it.

And so we tried to bring our local preventionist voices into the project, but for us, this

was really an add-on.

And so it's a long long time and I think the deep collaboration is probably what fell by

the wayside in that decision-making process.

I hope that what we have tried to prioritize is seeding an opportunity for local preventionists

to collaborate with their local schools and school systems.

And so if it doesn't exist at the state-wide level, it will at least have the pieces in

place so that local preventionists can engage with schools who really wanna have a deep

conversation about this to the extent that their capacity allows.

Great, we've got a question on the floor that I thought might be good to just insert right

here on your ideas about rape prevention in the sex education worlds working together

on policy and implementation, so folks would like to know how you think the work overlaps

and how it might be different, or if there are any implications in doing that collaborative

work.

So I can say, we definitely here in fact that we see that there's a significant overlap.

We feel like sexual violence prevention and discussions of sexual violence in general

have to be a part of healthy sexuality.

Both to give folks language to be able to talk about it but also because we want to

know, right, you can't determine what's bad without determining what's good.

And so we have really great relationships with folks like Planned Parenthood and with

other folks in and outside of schools, essentially that are doing healthy sexuality education,

and we've challenged them over the years...

Quite frank, I've been here for a number of years and it took probably five years, in

some ways for us to continuing having conversations with folks, where both of us see it as something

that we should be taking on an working collaboratively together, in order to maximize the audiences

and the folks that we're in front of.

Like I said, the other thing for us is that one of the really critical things that we

had is we had that healthy sexuality document...

That Connecticut had already done the work of going through the resistance, having to

be created and right within when you look at our guidance we put theirs each one of

the guiding principles for healthy sexuality education, the State right next to ours, because

that's how closely we feel like those two things align.

And also because it's a lot of the same educators doing both of the work, so it's health teachers

at school, social workers, having the conversations with kids in both topics, and so, the better

that we can equip folks and really help them to see the connections also the more meaningful

that education is gonna be.

I actually don't think I have anything to add to that because I would totally agree

that we count on our allies who also share our same philosophical approach, even if we're

not working as closely as we wish we were just because time doesn't always permit to

come up with ways to do shared or joint programming, but we count on them to also be out in the

community, sharing the philosophy and being partners and allies.

Sally would you mind repeating, I think we lost your audio.

I was just gonna say...

Turn it back over to you.

Oh yeah.

Okay.

Thank you.

Well, I think you both already touched on this a little bit, but maybe if there's a

piece that you want to share a little bit more about.

I thank you both so much for sharing today and being willing to talk about how your states

are doing this work.

I think it's always so helpful for others to just get to hear these stories, and see

how this work is being done in different states.

So I was just wondering if you wouldn't mind being able to maybe touch a little bit more

on what has been one challenge and one success that you all have been kind of living in as

of late, with all of the work that you both are doing in your state.

Sure.

Sorry I'm doing a lot of talking.

Destie please cut me off at any point that I am talking too much.

So for us, I think one of the large successes is that which is what we were just talking

about, we were able to align ourselves with work and with folks who have already done

some establishing work along the lines of the comprehensive sexual health education,

that gave us a really amazing starting place.

If there are places within other folk states where they have things like that, I would

suggest spending some time getting to know those pieces, those documents, getting to

know the individuals who help put them into place.

I would also say that one of our successes which we already touched on, is being able

to at different points, and not as meaningfully as I hope that we would in the future but

to engage youth voices and figure out what makes sense.

What kids think make sense for them.

And again, this was also thinking more high school age than elementary and middle school,

but I would hope in the future, we're able to engage across that spectrum different folks.

The biggest challenge for us was probably the fact that not every showed up and some

of the people who were critical in moving things forward, did not show up often.

So, we had different partners where even though they maybe were earmarked in the legislation

or folks that we felt were really critical to be at the table, we had some challenges

with getting folks to stay at the table or had the right people show up, so oftentimes

people would send a designee, who had no power or no ability to move something forward, but

that would be who was coming to the table.

So at different times, but with us, especially with creating that guidance document, we would

just be at a standstill while we waited for the various systems to "approve" or sort of

move through that process.

And so that was something that took a lot of patience, and just sort of diligence as

we moved through knowing that we'd get there eventually, but being somewhat frustrated

as we moved through the process.

I would say for us a couple of the key successes were using what already exists.

And so we also have "comprehensive sexuality education in Maine, but we have a comprehensive

health education standards, generally speaking and so we really wanted to make sure that

we referenced those that we brought things...

Brought issues back to those, and so I think looking to what already did exist and connecting

with it, as Beth said was a success, but then also for us was using the policy, which I

think the policy was great but it did lead to a challenge because we just weren't really

prepared in terms of capacity.

It was a success for us though to use that policy as a launching off point to bring tools

that we really wanted to have out in the community and make them available.

We wanted to have a one-stop shop for schools, for teachers, also for parents, for families,

for both prevention ideas but also knowing that a lot of folks need response information

right now and that we as preventionists have an opportunity to bring both of those to the

table in the same place, knowing that families are not dissecting levels of tertiary prevent

blah, blah, folks just out in our communities aren't thinking like that.

And so we wanted to be able to bring that whole range into one place even if it was

outside the auspices of the policy, and so I think that that was a success to use that

as a tool or a hook for us to bring this range of information.

The challenge was really around not having the dedicated capacity.

It took us easily two years longer than it might have otherwise.

And if there are any local Maine sexual assault providers on this, on this call, I'm sure

they're sitting around thinking, "Wow, it's been really awkward couple of years."

Well, we couldn't get our emails and phone calls answered, and that's been hard; hard

for folks.

I would also say that one last piece in terms of the evaluation component that a success

and a challenge is that we have looked at what is, we really have wanted to focus on

what's possible, what's achievable, what we know we can afford and control and so we will

not have an evaluation that will turn any of this into magical science evidence-based

programming that we'll be publishing.

What we will have are some process evaluations, both to teachers who are kind of trained as

the leaders and champions in their community and some more state-wide kind of school by

school process evaluation like, "Where are you on this?

Did you do the things?

What other tools do you need?"

But we hope that we will...

We have four or five different pieces that we hope will give us the information we need

to continue to improve our system.

But it's not a dream outcome evaluation approach...

Thank you so much for sharing both those successes and being vulnerable enough to share some

of those challenges that you all are having, because I think certainly the challenges are

challenges for a reason, and so often that's where a lot of our growth and our learning

comes from.

So I really appreciate you both being able to share those today and hopefully for our

viewers that that's really helpful information that they're able to take forward in the work

that they're doing and so I can kind of jump in with our last question, if that makes sense,

Sally.

So I was just wondering if you both wouldn't mind then sharing just what's one take away,

what is one lesson learned maybe from those challenges, maybe from those successes that

you all would like to share with the folks who are on the call with us today who maybe

are just starting to do some of this work or maybe halfway through doing some of this

work or wherever it is on their journey as I'm sure folks on the event today are probably

on a spectrum of different places, but what's one take away...

Sure.

So for us, I think part of it is thinking pass...

So it's really easy to get mired down in public policy work and to have that be the focus

of what you're doing, right?

The passing of the law.

For us I think that it would have been helpful to think more about the implementation along

the way.

So for us, we have a really wonderful law that includes lots of great things in there,

but there is no accountability in that process.

In other words, there's no report that schools are required to put into our general legislature.

There is no accountability if somebody were to just say, "Hey look we're a school, we're

not gonna do this."

And so we didn't think through what the implementation would look like.

So really, I would say take some time to think through what schools would have to do on a

state-wide level and across that K through...

At least for us K-12 spectrum, what they would have to do to implement it.

But then also, what does it mean if they're not, right?

So, what are the ways in which we could build in some...

Even if it's indirect accountability or some pieces along that way, what are the both intended

and unintended consequences of building those pieces?

And I would say take a look at that.

I wish we had done more of that.

Yeah, I guess my takeaway lesson learned or what I would offer to folks thinking about

doing this, is that I think it's really important to honor modest goals, and achievable goals,

and I am...

As a preventionist who has also spent a number of years as essentially a lobbyist or a policy

person, I think it's really okay to identify incremental goals, and so hold in your mind

what the dream is and in the meantime, just chip away at what's possible.

So it doesn't have to be, it doesn't have to be everything now.

I've been working on this policy or some element of this policy for about eight years in my

current role.

And if I stay, which I expect to, I imagine, I have a good six years of work ahead of me

before we are close to the dream.

And so if you don't have a million dollars, I'm guessing you don't, then pat yourself

on the back for having a vision and just doing the tiny, tiny pieces to get there.

And that might be a more modest policy, it might be a more modest training or education

but look at your strengths, look at where the barriers are going to be, and then just

throw all your effort at the small achievable and practical wins that will lead you down

your path toward a bigger and more of maybe exciting future later.

Thank you.

Yeah, and that's a great connection to something I wanna let folks know will be coming.

We're really grateful that Dorothy Espionage out of the University of Florida has offered

to do a follow-up blog for us about this complex...

How to evaluate a complex process like this.

So she's gonna be able to provide some tips, some things to consider and I know some folks

have posted in the Q&A asking if any of the evaluation tools and instruments that you

two are using will at some point be available for others to look at, adapt.

So you're welcome to share any thoughts you have about that now or we can also follow

up in our blog piece about if any evaluation instruments that seem to be working.

So, we're happy...

I can entirely say that myself, but I anticipate that we would be very happy to share.

We are working with that group.

So this fall, we would put out that survey, so I don't see any reason why we could not

share the survey questions that we used to ask schools how they're doing with the implementation.

And I think we would also be happy to share.

We don't have proprietary tools.

I would say that I think our approach...

I'm not positive how many of our tools could be picked up and used elsewhere because it's

a collection of like, "Oh our statewide honored this public opinion survey will gift us one

question.

Alright, so that's something.

[chuckle] That's one piece, and also we'll...

All of the educators that we train, we will ask a process, "Did you do step one, two,

three, four at the end of the school year?"

And so I guess I would say that that's both a...

It's more complicated than a shareable tool, but it's also a really good example of how

you cobble together something out of nothing.

Well, that connects to another question that's come up in a few different ways through the

Q&A and that's really wanting to know if you have any recommendations of specific training

and curricula, looking at factors for youth perpetration, but also about educator abuse

against youth and I know in your guidelines and your tools that are available in the weblink,

there are some things that are referenced there, but are there any kind of take-aways

that you like to share about a statewide mandate for the use of specific tools for this work

or approaches to do community-specific development of the training and educational curriculum

used in schools.

I don't know what I could point to be on.

There are some pieces like you said that are...

Yeah don't and don't forget...

This is a...

And some points of reference within that guidance document.

We're still as a state working to get within our youth data collection, so that they're...

I think they're bi-annual questions...

Like we have no questions about perpetration whatsoever that are asked to youth.

And our only sexual violence questions are linked to relationships.

So for us, we have a lot of work to do within our state to actually get some of that data

and my hope is that in the short term that we will see some of those questions getting

added and being able to pull out.

I don't have an answer in terms of teacher abuses beyond to say that you could probably

get some really good examples from the news and use those as points of reference or conversation

starters with the folks that you're working with.

But I think perpetration stuff is we have a harder time asking those questions, because

we don't always have solutions and it makes folks, especially within schools, in my experience,

what they tell me is that I have to do something about it, and that's much scarier, 'cause

once you identify a problem you have to identify a solution.

So I don't have a tonne unfortunately that I would necessarily be able to to direct folks

to...

I'm Sorry.

It is not your responsibility to have any answer...

I think we're working as a large global community for those answers.

So thanks for all they need.

And Destie what were you gonna say?

The only thing that I would add is that I do think that there're more and more are good

resources for say "hiring screening and training in coming school professionals, or professionals

who are working with youth and that sometimes we think of that kind of work as outside the

role of preventionists, but it doesn't have to be it's connected, it's related, it certainly

are the policy in Maine is silent on that, but that's a good example of one of the things

that we just went ahead and added in since we were making the website.

So we don't have tools of our own related to that, but we did make sure in our supporting

schools and systems section that we were kind of pointing to places where schools can increase

safety simply by ensuring that their practices around hiring and screening and orienting

staff are really tight.

Thank you, so much.

There have been a lot of resources shared in the Q&A as well.

There are some new programs being funded through the Vision of Hope Fund out of Pennsylvania,

folks have mentioned Sesame as resource for educator, sexual misconducts.

So thanks for folks that have...

And then just being mindful of our time, we have about three minutes left, so we wanna

just leave it open for potentially any other questions that come in in the next minute

or so.

And then if not...

Our time has quickly come to an end.

You know what, the only other thing I can...

I was thinking as I was prepping for us and I've been talking with you all is, it's been

interesting now as a parent.

So I worked on this legislation professionally.

I have two young daughters one of whom entered into public schools recently and so it's been

interesting even as a parent to be able to then go to the school administrators which

clearly I'm comfortable doing and challenging them and seeing how much they do and don't

know.

And I live in a pretty progressive I mean, town within Connecticut.

And so it's been fascinating to see the ways in which as a parent, how that plays out differently

and how much my assumption is how much education schools are giving to the students and how

much what that can look like and what it doesn't look like in terms of my expectations, and

how much they're meeting them.

So it's been interesting to take literally, take the legislation, take the guidance document

and to meet with my daughter's principal, and of the head of social work then and be

like, so did you know this is there...

What are you doing in that way?

And that's not something that I thought of a few years ago when I was doing this work.

But for those folks who are parents you have a really unique opportunity than more than

we have as professionals, excuse me going in there to be able to use these documents

and challenge folks and say, "Hey I'm a parent, I one of your stakeholders you get to answer

me in terms of what you're doing with these pieces so it's another...

It's been an interesting and another conversation to have in an entirely different lens than

I ever anticipated a few years ago.

I had my kids second grader read our implementation guide, and tell me all the places it went

wrong.

So don't hesitate to make your neighbors and co-workers and everybody help you.

Right.

Sally, you're mute again.

Sorry about that, I'm really grateful for you all and I see that folks are sharing their

thanks for offering your insight, your experience, especially some of these gems like you just

shared about all of the different ways that we can be working to create safety for the

folks in our community.

And I see that there is a resource coming out from Minnesota Coalition Against Sexual

Assault about how to message Comprehensive Sex Ed healthy relationship education to schools

and parents.

That's gonna be useful.

So, right on...

Thanks, Minnesota.

Well, thanks everyone for joining and Beth and Destie, thank you so much for being amazing

conversationalist, today and for sharing all of your experiences with us.

And everyone, we will make sure to get that blog post ready and available with additional

resources out to you all as soon as we can...

That'll be great.

So be on the look out for those and for our next Ask a Preventionist.

Bye bye until then.

Thanks for having us.

Thank you.

Which should be happening in September.

Thanks everyone.

Thank you all so much.