 Good morning, good afternoon, good evening saan mampaling po kayo ng mundo na roon. Welcome sa episode number 93 ng Stop COVID Deaths webinar series brought to you by the University of the Philippines. Thank you for being a part of our credible online community and to all those who have just discovered us for the day, sana po masihahan po kayo at tuloy-tuloy na po ang inyong pagtangkilik sa aming webinar series. Dalawang taon na po tayo sa ating COVID-19 pandemic, we have seen how the infection has been traveling from one part of the world to another tilap po ganoon in a matter of days or even hours. Ang mga bansa po ngayon kasabaipunon, they are on edge in relation po sa Russian invasion of Ukraine ngayong pumpanahon ng pandemic. So aside po from the increasing number of cases na mapapansin nyo po in South Korea, in Hong Kong, in other neighboring countries that we have, yung pa po ang isang alalahanin dahil po ileisip po nilak, can this war in Europe result in other dangers for those who are far away, relatively far away. Na i-report na rin po sa Balita that Russia has started to use banned weapons. Mayroon din po pag-uusap about the threat of chemical as well as other nuclear weapons. Ano po ba ang mga threats na ito? Bilang frontline healthcare workers, ano po bang kailangan po nating maalaman, kawgnai naman chemical, biological, radiological, nuclear and explosives po and other events that could affect large groups of people in different parts of the world. If you want the latest science-based and evidence-based information from our panel of distinguished experts, keep it right here. Dr. Raymond Francis Sarmiento, director of National Telehealth Center, National Institutes of Health, University of Philippines Manila. Always a pleasure to be with all of you during our regular Friday lunch date. Always looking forward to Fridays in sharing hosting duties with my beloved mentor, our junk research faculty at National Telehealth Center. Also the special envoy of the President for Global Health Initiatives, Dr. Susy Pineda Mercado. Dr. Susy, maganda po ang topic nating today. Hi Raymond. Maganda ang hapon po sa inyong lahat in the Philippines and for those who are watching from different parts of the world. Ano mga oras yan, we hope you're doing okay that you're fine. We'd like to welcome you to the webinar. As Raymond said, we have a very, very interesting topic and we have brought to the best possible speakers on this topic. So I think we're all watching what will happen to this war in Europe. Although I think more or less people are happier now na medyo, tanos sabi nityad kanina at the tail end of the pandemic. Pero nakikita natin yung mga kapit bahay nating bansa na kakaroon ang surge. Parang patong-patong hindi pa natatapos yung isang problema. Meron na naman isang problema ang dumarating na ito yung gaya na nakikita natin. Now, what will happen in the future we don't know but because we are into pandemic preparedness, this is an opportunity for us to learn. What are these chemical weapons? What are the health impacts of some kind of a nuclear detonation? Are there biological weapons that could come to our country? So ano ba yung ibang possible disruptions na? And what have we learned from the COVID-19 pandemic that we can apply now to any kind of major health disruption? Raymond, I don't know, two years na. Ano ba sabi mo kanina 93? 93? 93 episodes na ba? So, grabe. It's been a long time. But I think we're hanging on in there and I think as long as there are emergencies or situations that we need to talk about, we'll be here for you. And we're so happy that you're here. Always nice to see the same group, our community pero marami rin bagong mga naidadag-dag. So anyway, I just wanted to remind all of you that we are now approaching our second anniversary and we'll talk about the memorial later. So Raymond, over to you muna for parts. Thank you, Dr. Susie, especially for those who are joining us sa unang-unang beses po. We usually put our discussion in context by providing you an interview video na tinatagpo namin person on the street or parts interview video. For our video for today, ang tanong po that we pose our interview is na sa isang party po kayo kunwari. Tos big lang mayroon kayo na amoy at maraming nahirapang huminga. Ano ang inyong gagawin? Please watch this. Hindi kita ko na hirapang minga. So sa tin po, unang medyong magpapanik, magpapanik ako. Tapos, mahanap ako na ang taong mga katuloy na mag-respond ko sa Siva Shop. So kung na sa party, so organizer. Siguro, unang kung gagawin ni Stockpad muna ibilong. Sins ninyinit tayo. Sigurado kung ano na amoy natin. Then, find the nearest exit. As soon as na secure na yung exit na yun, call everyone's attention to lead them to safety. And everything is clear sa kanala tayong tumawag ng emergency. Uwag munahanapin ko muna. Ano yung source nung amoy? And then after nung tiktingnan ko yung situasyon sa paligod ko, kung ano yung gagawa na yung mga tao. Tapos, akording doon, sa kalama ko gagawa na aksyo. Mahanok siya rin yung tao, ito yung mawappanik na ako, sir. Hindi na kikita ko lahat na ano yun. Tapo ganoon, sir, nangyari. Pwede, tatagok sa mga ni sir. Mabawa sa malak sa amin para agad kami matulungan. So, to be honest, magpapanik mo naka ng kontin. But after a while, I think I'll try to see kung ano yung reason behind, kung sila na yung rapan uminga. And then find someone who can address yung problem, kung makat sila na yung rapan. Kung ako na, sir, mas mararam ka nang pang ako yung main responsible to respond. Tapos ganoon, na kitingin ako sa mga guests ng part kung may doctor ba, ako hindi. Kung hindi, kung wala, sa kalang humagahanap ng tulonghan ba ako sa kapit bahay, ako yung tatawag ako, kung may kakilala akong doctor, akaya kung malapit yung barang guy hall. Magingat pa. Di tayo nakakasiguro sa COVID, ulat na mga ganyong saka na. Dabad, magingat pa, sir. As much as they can. Sayang yung na-realize ko this year, some people, even if gusto nilang mag-follow ng health protocols, hindi nila magawa for different kinds of reasons. So as much as they can, still be careful and still follow yung mga health protocols. Thank you very much, TV UP. So it's very interesting to know what people on the ground are thinking and magkatakot nga naman, Raymond, palagay ko akong magpapalik na ko. That's the normal reaction. Parang game of thrones eh. Dibay ang biglang na, biglang maraming na hiimatay o hindi makahingap. But I think nowadays we want to be prepared for any kind of situation. So thank you, TV UP, for getting that person on the street perspective. So I was about to queue tanina which was mali, Raymond, kasi nga yung ko pala nga patikyo yung second-year anniversary natin. So we are going to have our second-year anniversary. And as you know last year, we did a memorial for all of the frontliners who sacrificed by giving their lives in the service of people who had COVID-19. So we are still making a call for photographs of family members, friends, colleagues who passed away because of COVID and we would need a high-resolution portrait at least 300 dots per inch. Alam ko na yun na, dots per inch. And then full name, date of birth, date of death and occupation. So we're still collecting that up to April 9 po. And we again, we feel that we should not forget those who gave the ultimate act of service and actually lost their lives in this pandemic. So it's going to be, what should I say, a moment of looking back when we do our second-year anniversary of looking back at what we learned. And in that process, we don't want to forget those who we lost in this battle. So Raymond, over to you. Thank you. Dr. Susie, the Filipino Medical Frontliners po kasi has been recognized as the best, if not one of the best of the world in terms of our response and being part of the COVID, the global COVID-19 response. So we hope to be able to immortalize their selfless contributions po sa laban po against COVID-19. Alam ko na po, ina-anayahan po namin lahat na magbigay po ng inyong mga pictures. Maybe you have a short anecdote nakasabay po na on. So please share it with us. We'll be more than happy to include that in the COVID-19 memorial po. Just to let everyone know, our webinar ka-anacomodate up to a maximum of 3,000 participants. So please join us sa Zoom para po ma-experience po ninyong fully interactive na program po natin. Meron din tayong well-presents via the livestream sa YouTube and Facebook. So hopefully you'll also be able to participate in our activities here for our webinar. We have parallel discussions happening in the chat box. Meron din po sa comment section sa YouTube, sa Facebook. Pero saan na po lahat po kayo ay makapag-participate po rito. For those who are asking, alam ko po lahat po may mga malami po nagtatanong patungkol po sa certificates of attendance nakapag-release na po kami for the last 91 webinars po lahat-lahat po ng certificates of attendance na meron po. Hindi pa po, may mga mailan-ilan pa po na hindi pa po na kakatanggap ng webinar 92 na certificates. So please let us know, especially those who have watched at least 50% of the webinar duration. We'd also like to take this opportunity to invite everyone, lahat-lahat po. Sana po, we are seeing kontin na lang po maging 800 participants na po tayo sa Zoom. Sana po makapag-participate po kayo sa ating fan quiz, ating pre-test po and those who will be participating by going to www.menti.com. So if you go to that, open your browser, type in that in the address bar and then if you could enter the code, ano po bang code natin? Di ko po makita, sa jara sa ano. Sa on the screen. 7995 3493. Yon, okay. 7995 3143. So if you... 3493. 3493. So if you're able to participate po, no, we know you're participating kasi baka po mas madali po sa inyo ang YouTube at Facebook, but hopefully you're still able to participate sa ating mentee. Today's webinar will be utilizing our standard panel discussion format with our set of speakers. Mayro lang po tayong special participation all the way from outside of the Philippines. So we are very, very thankful for our guest expert po. But before we get to her, we will have a whole set of discussions din po na yan and we are glad that you'll be able to join us during the Q&A session as well. We're in. We will be entertaining questions coming in sa lahat po, whether YouTube, Facebook, or dito po, sa Q&A box ng Zoom. So without further ado, Dr. Susie will introduce our opening remark speaker. Okay, I know you're very excited to get this discussion on the way and for our introductory remarks, opening remarks, of course, fitting that we're bringing in our own in-house expert on disasters, emergencies and trauma, kilalini po siya, siya po may nan-chairman at Department of Emergency Emergency Medicine sa UPPGH. And he is the senior advisor of the National Task Force against COVID-19 and you see malat on social media. And he has done really heroic efforts in the vaccination campaign. So we'd like to welcome Dr. Ted Arbosa. Ted, welcome. Thank you, Susie. Thank you, Raymond. And good afternoon to all the hundreds and hundreds of followers of Stop Comunities for the past 93 episodes. Wow. 93? Amazing. Yeah, go ahead, Ted. Yeah, so right now we have a nice topic at dosay-dosay ng paciente. Always our job in the emergency department is unique because they don't come with a steady flow of patients like in a clinic where people line up and queue up and then we actually have moments wherein several patients come together all at the same time and we don't understand why there are a seasonal and there is also time of the day wherein we have many cases but the most horrible part of being an emergency medicine doctor is when you are suddenly deludes with hundreds of patients with a specific problem like the last one I can remember at April was chair of this one, our speaker when we had all these cases that were poisoned with methanol from a fiesta that served tuba or lambanog that had a high content of methanol it was a big problem and I'm happy that Stop COVID that's gone to this particular area it's an area not many doctors actually go into because it's not very common the interesting thing about being an emergency doctor or disaster medicine doctor is we're the ones that always ask the question what if and that's what the question Susie that actually ask what if they start to use chemical weapons what if they start to use biologic weapons and what if they start to use region nuclear weapons and what will happen to us and that question always bothers us in the field of emergency care because no hospital is prepared for any of those and I bet in fact probably the only hospital I saw that was prepared was the hospital I trained in which was in the state of Israel but Israel is a different story and in New York in the mid 90s they did a CBRNE simulation drill and what they found was 50% of the doctors and nurses were actually affected by the agents that were used during the simulation because of lack of knowledge and this is very important because we're just finishing we're just ending hopefully we're in the tail end of a global pandemic that saw how unprepared the health system is in terms of everything and this is where I get to with the final part of my message the fact that many doctors try to impose their own set of criteria and norms and frameworks to a situation as complex as chemical, biological, regional, nuclear events or mass casualty incidents and I'll give you one of the things my professor Stan Lankwist famous Swedish surgeon that looked into disaster medicine principles he had only three very important principles of disaster medicine whether it's a chemical or a traumatic mass casualty like a plane crash he enumerates three number one he said lower your level of ambition what does that mean? you know we're so used to giving everything to a patient that has what we need do everything in your power to save a patient life but in a mass casualty setting you can't do that kind of ambition so you lower your level ambition and this is I think the fault and the arguments that we kept having in the past year because many of the infectious disease and critical care people failed lower their ambition in time when there was a pandemic second second is mobilize your resources we are lucky many people complained why we have so many generals in the national task force but I'm thankful that we had so many generals in the task force because they actually know how to mobilize resources in fact the vaccination program that Susie actually mentioned is the biggest vaccination campaign this country ever implemented and probably even the most successful because we only vaccinate about 2 million children annually we vaccinated 65 million people with two doses of a vaccine against COVID-19 and the effects are visible so that's very important mobilization of resources where do you get your antidotes where do you get your protective equipment to protect your doctors and nurses and how do you mobilize all of this and see of course third third and last it to be able to prioritize which patients will live and which patients will die and this is not playing God this is all about evidence-based medicine and if you don't study the chemical agents you don't study what happens in a nuclear bomb you'll never know who to triage and you'll never you'll be wasting resources time and effort so with those three I think this will be a good segue Susie for our speaker the former chair to actually talk a little bit about her experiences her training because I'm proud to say that PGH is one of those that looked into this and is prepared in a small way because we have trained for CBRN and we have a small unit with some equipment not a lot of equipment but we're one of the agencies of government that have tried to prepare for this and of course in the Philippine General Hospital is also our poison center with our experts in CBRN in connection to our national government so I'm very happy that we have taken on this challenge to study this concept of all the difficult problems in mass casualties thank you very much Susie back to you thank you very much Ted and I hope you'll be able to stay for the discussion I think we're going to have a really interesting interesting discussion and for those of you who have questions please use the Q&A box or the chat box okay so we told we said Karina we have brought to the best the best speakers including our introductory speaker Ted who's very you know he's seen all of these all he's had so much experience in this area but he's also saying hindi tayo prepared no so I think you know we really have to talk about this because our survival depends on our preparedness no okay so our first speaker all right coming to us all the way from Leon France who is the first and only toxicology institutionalized the first and only toxicology fellowship program in the Philippines served as the program director for clinical toxicology fellowship based at the then national poison control and information service at the Philippine General Hospital but I'd just like to add that our guest has been like a voice in the wilderness on chemical biological pollution nuclear and explosive explosive threats for many many years she says she has been saying that we have to prepare for this we have to get ready because a time might come when this could happen and we need to know what we should be doing and you know so we thought we really could not do this webinar without her because she pioneered in this area and is still internationally as the Philippine expert in this field so it is my pleasure to introduce Dr. Irma Makalino who is awake early in France and is joining us for the webinar welcome Irma Good morning, good evening and good afternoon to the different participants of this webinar of course I'd like to greet my classmate Dr. Susi Dr. Reymond and of course it was good to be following the opening remarks of Dr. Herbosa because it gives me flashbacks about how we first started the proposal to create the DEMS program the emergency medicine program and the fellowship program of the UP National Poison Control Information Service for the training of toxicology so there's a bit of history with the collaboration with Dr. Herbosa as well so let me begin by bringing you to this issue about the interviews that you did where most of the people talked about fear and panic that is a natural reaction that was the same kind of reaction that I actually had when I was there during the World Trade Center 9-11 tragedy I was not in New York I was actually in an area where it was very close to the Pentagon and I was actually standing in front of the a place in the George Washington University because I was on my way out and I saw there was smoke in that particular area of the Pentagon so when I went back that was when I saw that there were people falling from buildings and there was a lot of chaos so what will we now feel if such an event happens in the Philippines so that was actually the moving factor for me that changed my career path from being a practitioner in pediatrics and also at clinical toxicologists to one that actually tried to move towards what they called at the time a man's field and that is the area of chemical, biological radiological, nuclear and explosives domain starting now not to train medical doctors first but really training our first responder community made up of the FAR, the police and to a certain extent I have also worked with the Army in their training for CBRN but somewhere along the line I asked myself again what if we now have several victims whom we have successfully taken out of the initial zone which we call the hot zone or the red zone into a cold zone and there's no receiving hospital there's no medical doctor or healthcare provider that can really manage these patients so having said that I realized that that is the missing link of all the capacity building that the Philippines has received over the years since 9-11 so I also went back to an experience of seeing patients who were victims of the Iran-Iraq War when I visited Iran for the medical CBRN training I received seeing those victims to survive actually after a mustard agent exposure was really heartbreaking and some of them even verbalized that maybe it was better for them to have died on site than to suffer all this exposure residual effects such as blindness difficulty of breathing that cannot be relieved by the common agents that we give and of course they're persistently scratching themselves because of the effect on the skin and so you can see the nail marks that are already in their bodies because they really are scratching very hard so that's just a scenario where the victims sometimes feel that being a survivor isn't necessarily a good thing but of course we want to save lives it's interesting also to see that while our normal impulse as medical doctors is to save people we also have to remember that if we don't know we should not go so when I teach people now I will always tell them bravery is not really a measure of what you should be doing if you don't know please don't go to the scene that's the thing because you can be the next victim of that particular instance but here when I look back to the experience of the people in Iran during that particular instance in their history some of the doctors are now suffering from the exposure to nerve agents because they were not aware of what particular chemical weapon was used and therefore they simply went to the site and started looking at the patients and now they have a permanent disability a neurologic disability that follows some of the nerve agent exposure so in all of this I think that when Susie mentioned being a voice in the wilderness it took a long time for our government to see the value of having this training now also focused on the medical community and successfully at least even if that particular unit in PGH is quite small it has done a good job during the pandemic as well it has done a good job for the methanol poisoning it has done a very good job during the ammonia incident I don't know people recognize that we had an ammonia ice plant explosion that led to several patients being brought to the Philippine General Hospital and to other hospitals within the area of Metro Manila so we can see that that particular training that people are receiving for CBRN is not limited to CBRN per se and can also be translated to other hazardous material incident so by and large I think what I just want to say now is that as the world looks at the medical community now and the role that we will play as people are threatened by the possibility that there will really be a use of these agents during this period in human history between the during this Ukraine and Russian war we need to be more prepared for what is happening the issue here is that it is always difficult to follow what we usually do as medical doctors to treat every patient and that's also to echo what Dr. Herbosa was saying in the principle of CBRN mass casualty events we cannot manage to treat all patients so the dictum is the greater good for the greatest number and I do hope that this particular workshop will give us an idea about the different kinds of preparedness that we have at the moment and what additional training we need just to segue now and give hope there is a pending medical CBRN training that we are negotiating also for the EU CBRN centers of excellence and with that I really want to say I am very happy in some ways that we are now open to the discussion on CBRN considering that even in the COVID-19 pandemic we had explosions in Holosolu that really gave you an idea that explosives are used we had international events that showed us that Novichok which is a nerve agent was used and this was again something that gives us an idea that there is a continuing interest in the use of chemical weapons Thank you very much Thank you so much Irma naku galing n'y Irma Di ka alis Irma happy staying We want to have a good discussion and really I think Irma has really summarized for us how urgent this is na isip ko nga Irma nagsasalita ka baka with DVUP training on this, even if it's not skills, it's just information. Kasi ano eh, parang it can happen and it can happen sooner than we know. Anyway, mga maya, pagusapan natin. So thanks so much Irma, I'm sure our audience really appreciates your words of wisdom on this but we're looking forward to having you in the discussion. Alright, so let's start with our first, with our presentation. Oh, not yet, not yet our presentation properly. We have our pre-test, Dr. Susi. Magpafanko is mo na si Raymond. Okay, game Raymond, let's go. Okay, thank you Dr. Makalinao all the way from Lyon in France and thank you for waking up so early and gracing us with your presence. Thank you also for agreeing to join us in the Q&A section later on. Nabagnitapon ni Dr. Irma, the important role that frontline healthcare workers will play and hopefully that's something that all the learnings that we will take away from this webinar with regards to prevention, mitigation, maybe even treatment kung ano po ang maukawa po natin for this webinar ay magamit po natin or at least maimbak po sa ating knowledge base yung mga yan para in fact kung magamit po natin in the future. That's something that we are aware of. And just to remind everyone for the Q&A session of this webinar, we will choose from the most upvoted questions po kung ano po yung mga katanungang, itatanung ng live sa ating mga guest experts po sa ating panel. So if your question is selected as may maikita po kayong we will promote you to panelists, sana pupaunlakan yung po kami at pumayag po kayo na mag-join po at itanung ang inyong katanungan for you to be able to ask live to our panel of experts. So we encourage everyone to start piping in your questions right now kung meron po kayo. Patarin po sa mga na sa Facebook at YouTube po, itayap nyo lang po sa comment section ang kayo ano po yung katanungan, meron po nag-scan po ng comment section for us to be able to choose which questions will be asked. Before we proceed, can we have on the screen the two questions and also on the zoom poll po, the two questions are as follows. Okay, while we're waiting for that, sorry, I'm not sure if it's on my end, but the first question is what, okay ito na po pala. What is the most common route of exposure of hazmat incidents? So tatlupo yan, tatlupo ang katanungang options po dyan. Dermal, inhalational at oral. So yun po ang mga katanungan. I'm not sure if you're able to see it on the screen nyo sa Menti, but at least yung mga na sa zoom po ang dito po sa ating zoom poll. We'd like to greet those who are joining us. Maray po kasing nag-join sa atin locally pa mo muna. Batiin lang po namin yung mga na sa Black Nazarene Hospital in San Nicolas, Ilocos Norte. Kagayan Valley Medical Center in Tugigarau, the Provincial Planning and Development Office in Mamburau, Occidental, Mindoro. Civil Aviation Authority of the Philippines in Calibu, Aklan. Visay State University Infirmary Hospital in Baybay, Leyte. Ignacio Laxon Arroyo Memorial District Hospital in Isabela, Negros, Occidental. Double Dell Norte Hospital Igakos Zone in Island Garden City of Samal, Socksurgen, General Hospital in Surala, South Kotobato, the City Health Office of Kotobato City, and the Provincial Health Office of Marawi City. For our question number two, it reads, for exposure to solids or liquids, rapid removal of the cloting is the single most important step in the contamination. It removes blank of contaminants. Ano po'ng porcento ng contaminants ang nere-remove kapag nakakarumpon ng pagtatanggal ng damit kapag na-expose po? Is it 20 to 25 percent? Option two, 30 to 40 percent. Option three, 75 to 80 percent, and option four, 80 to 90 percent. We will not be closing our fun quiz po. We'll try to greet those who are joining us all the way from the National Center for Global Health and Medicine in Japan. Chonin Hospital in Taipei, Taiwan, Ministry of Health in Bandar Seribigawan in Brunei. Ngin, Thayahok Polyclinics in Vietnam, Bukit Mertajam in Malaysia, Seha al-Dafra Hospitals in Abu Dhabi. King Saud bin Abdulaziz University for Health Sciences in Jeddah, Saudi Arabia. The Northern Border University in Arar, Saudi Arabia. Kasim University Burayda, Saudi Arabia. University of Haile in Saudi Arabia. Linchi Ali University of Bleda II in Algeria. Stockton, California. Edmonton in Alberta, Canada. And St. Eustatius Auxiliary Home Foundation from the Netherlands, Antilles. Okay po, so we are still waiting for those who will want to join at least far as ating fun quiz. But we will now move on to the main presentation po and Dr. Suzy will introduce our main presenter. Thank you very much Raymond and very interesting questions. I hope those little quizzes, we call them a fun quiz but it's really to help us continue learning and remembering key points in doing our front line work. Okay, so our first speaker. Our first speaker, right, we're very happy to have her here and we said we are bringing you only the best speakers for this topic. She is a former chair of the Department of Emergency Medicine at UPPGH. And again, another person, if you meet her in public, you won't think that she's so knowledgeable in this area. Kasi napaka quiet nya, napaka ganon, pero ano yung 2 at 3 sa Emergency Medicine? Very good in Emergency Medicine, okay. And I would say also a champion of CBRNE. So I'd like to welcome Dr. April Ganeta. April, welcome. Sa nasa April? She should be here. Oh, did we lose April? I'm not sure, I'm asking her to unmute and open her video Dr. Suzy. Okay, let's see. Yeah, I think she has trouble connecting. He dropped off for a while. Okay, wait. So we'll try to have April reconnect. So let's give that a minute or two. Wala pa, no? Okay, so anyway, while we're waiting for April to come on board, what is the latest on COVID now, Raymond, sa mga discussions nyo? Okay, so right now, more and more municipalities, highly urbanized cities, component cities po, are getting de-escalated to alert level one, which is a good sign, especially with the vaccination coverage being used as a metric po for the de-escalation. So we're happy to see that, but what is a little bit, well, at the back of our minds po, we are trying to figure out also why the Philippines is not yet experiencing po ano po yung na experience po sa ibang mga bansa, which is something na, parang anthanong po is, is this something that we should be anticipating na mangyayari or hindi na ba siya mangyayari sa atin? Because even in fact, if you look at, let's say, in Singapore, in South Korea, et cetera, talagang it's as if they were, yung ko ano po tayo nung January, danon din po sila. So that's always at the back of our minds and something that we should really be preparing for at the very least. We have been seeing, and I think this has been our conversation before Dr. Suzy, we have been seeing large crowds yung parang sa mga election rallies, et cetera, which we feel, if not for the vaccines at the very least and for masking, talagang super spreader events po po yun. So we hope there wouldn't be any such cases po that would push the Philippines back in terms of a return to the rise of cases po na ano po natin. So I, okay. Yeah, thanks for that. Thanks for the treatment, no? Because you're just talking to some folks in the Red Cross that were saying that, actually, wala nang magpapatest. So, yeah, you're right. The question is, are we, na una ba tayo dito sa mga nags-assert? Yes, yes. Or nags-assert ba si Lata susunod tayo? Anyway, okay. Dr. April Linnetta is back, and she's going to now give the main presentation. April, welcome back. Please take the floor. You have to unmute. Thank you. Okay. There we go, there we go. Okay. All right, so I'll share my slides. Okay. So before I start, I'd like to thank po the organizers of the webinar for this opportunity to share with everybody my experiences and what I have learned as a member and leader of the CBRN team of the Philippine General Hospital. And I'm also glad that my mentors in both in emergency medicine and in CBRN are here. And I would like to thank them for the opportunity to work in this particular field, na? In CBRN. So the title of my presentation is CBRN incident response. So I'll give an overview of CBRN and give you some cases. And we'll describe the role of the healthcare workers and outline an approach to a hazmat patient. So of course the CBRN term is an acronym for biological or rather chemical, biological, radiological, nuclear and explosive agents. So these are substances that are harmful to both people and their environment. So you may be more familiar with the term hazmat. So it refers to the same set of substances, harmful substances. But if you talk to experts, especially those in law enforcement and security, they will tell you that there's a line that differentiates between a hazmat incident and a CBRNE event. And that line and that difference is all about the intent, whether it's accidental or intentional describes the risk and the scope of the incident. So let me describe it. Hazmat traditionally refers to an accidental release of a harmful substance. And that substance is not meant to be used as a weapon. So for responders, the high priority is placed on the safety of both the personnel, responding and the public. It tends to occur in smaller scale. So you think about chemical spales in factories or gas leaks in an industrial zone. And usually because this events happen in establishments that are already doing or handling this harmful or chemical or this harmful substances, then there's already prior knowledge of the potential hazards. When we talk about CBRNE event, we usually refer to an event where there's a deliberate use of CBRNE warfare agents. So I'll talk about, we'll talk about chemicals used in warfare. So their intent is to incite terror and to cause harm to people or the environment. So for the rescue workers, there's an acceptance of a certain level of risk because of the nature of the incident. And a lot of times because the intent is to harm the substance is unknown or unidentified. So if you look at the incidents that involve hazardous material, we will know that this line between hazmat and accidental release and CBRNE with intent to harm, sometimes it's blurred and I'll show you why. So I'll give you cases and let us describe these events. So for case number one, the date is September 6, 1987 location in the Philippines. Fatalities resulted when members of the Philippine Constabulary, that's the former name of the Philippine National Police, suffered from poisoning after accepting bags of ice water from an individual during a fun run. So the substance is unknown. So there's very little information on this incident. But we will need to think about whether this was intentional was their intent to harm this group of Philippine Constabulary, members of the Philippine Constabulary. The risk was directed to members of the PC and the scope involved a particular segment of society. So let's talk about case number two. The date is March 11, 2011. The location is in Japan. So following a major earthquake at Junami, disable the power supply and the cooling system of three Fukushima Daiichi nuclear reactors, causing high-rage radioactive releases for the next few days. There were no deaths directly from radiation sickness, but over a thousand deaths were documented at the evacuation site. So these were people who were suffering from medical conditions and they were unable to seek treatment and those who suffered from trauma. So the substance involved here is a radioactive material. Because this is an effect of a natural event impacting on a man-made structure, which is the nuclear power plant. So the risk involves all the communities as well as responders. This is a large-scale event. Let's describe case number three. The date is September 2001. Location in the USA. Letters were sent to two U.S. senators or media organizations. People who handled these letters started to get sick. So after investigation it was confirmed that these were cases of anthrax, particularly of contagious anthrax which occurred in 11 of the cases and inhalational anthrax in another 11 of the patients. There were five fatalities in this incident which required treatment of antibiotics for a wide range of populations and cost billions in economic damage. So was this intentional? So from the investigation, yes. This was intentional. And the risk was targeting particular personalities. So the scope covered the large area. Several states were involved. Let's have case number four. The date is April 2014. Location in Mindanao. The National Epidemiologic Center received reports of human deaths allegedly due to horse mid-poisoning. Investigations done showed nine deaths with signs and symptoms of CNS infection. So the investigation showed that the agent involved is a biological agent of Henapa virus and it was determined that the primary route of transmission was to use fluids. Also identified was the carrier for fruit bats and flying foxes. So there's another dimension to this case because of a security threat. Viral samples can be used as bioweapon. So areas of the investigation are also frequented by insurgents and bandits. So they needed So what's this intentional? We really don't know, not sure. There's a risk, there's a security risk. And although this is happening in a portion of the country. And this is near to our place. Case number five. The date is February 3, 2020. Location in Abota City. So 500 families mostly informal settlers were exposed to a strong odor causing coughing, nose and throat irritation. So the substance identified the ammonia. So this was the incident mentioned earlier. So it was determined that there was an ammonia leak in an ice plant which initially suffered a minor explosion causing the ammonia leak. So I'll go back to this case later. So what's this intentional? Based on investigations to determine to us an accident from failure to follow SOPs in the ice plant. So the risk is high for both the communities surrounding the ice plant and for the rescuers and the scope involved large communities around the place. So what is the government doing for these cases? So there's what we call a national CBRN action plan and Dr. Irma Makalian is part of this and the goal is to reduce the threat of and damage from CBRN incidents of accidental natural and intentional origin including terrorist acts. So as we can see the use of the CBRN term here involves incidents from accidental to intentional including terrorist acts. So what are the risk scenarios when we are dealing with CBRN agents? So we talk about natural hazards first such as diseases so what we have now is a pandemic and then we talk about natural hazards like earthquakes and floods which may impact on man-made structures containing CBRN materials and this is what happened in the Fukushima nuclear power plant after the earthquake. Then the more common ones would be accidents such as industrial accidents so we have gas leaks, chemical spills laboratory accidents as well as transportation accidents involving transportation vehicles carrying CBRN agents. And then there are the criminal CBRN hazards involving terrorism sabotage as well as illicit trafficking of CBRN agents. So what are the components of the response to CBRN events? So there is a need to detect identify and monitor these events. Information management is very critical especially for us as healthcare providers and as responders because we will not there's the risk that these responders will be exposed to the effects of the CBRN agents. So we need the proper physical protection as well as hazard management for the healthcare workers we need to involve ourselves in medical countermeasures and support. So specifically for the medical response components it follows our emergency response activities. So it starts with a bystander maybe or a factory worker wherever it happens identifying that there is potential exposure. If we take the case of the example earlier during the community questions the scenario was you are at the party and then there's an odor and then suddenly a lot of the people in the room started having difficulty in breathing. So somebody recognizes that there is a potential emergency there is in touch with authorities. So for the medical responders we have the rescue and paramedical personnel who are trained how the proper training, background and the proper protection and equipment and they may need to do primary decontamination at the site if decontamination is a form of management for the particular agent involved and then the link pre-hospital personnel and the hospital personnel would be in the form of maybe a command center or dispatch center which will link the efforts of the pre-hospital team to the hospital team or the receiving hospital. So transportation is also important so if you are transporting a patient from a hazmat or a CBRN incident then it would take a different form of knowledge and skills to transport transportation vehicle and then at the receiving hospital if this is a hospital prepared to receive these types of patients then they may be required to do secondary decontamination and provide acute management in the emergency department and later on in patient areas. So what is the role of healthcare workers? One, if we have the proper training we may need to assist first responders in managing exposed individuals at the site so we can start the management of patients exposed to CBRN agents even at the site assuming we have the proper training and skills and the proper system and for those in the hospitals that have the training they may be assigned to receive casualties from a CBRN event and the managed casualties of course with appropriate personal protective equipment and with the necessary skills and resources and then for the tertiary or the specialty centers then they could provide the required or the needed specialty services such as poison centers infection control services trauma and epidemiology section. So healthcare workers are at particular risk for CBRN threats when the hospital receives contaminated patients during mass casualty events and that's why to protect employees hospitals benefit from info to help in their emergency planning. So how do we manage patients at the ED? So let me go back to the case I mentioned earlier because this is a case that happened at the Philippine General Hospital so on February 3, 2020 and if you will remember just the start of the pandemic we were already received the Philippine General Hospital was already receiving COVID suspects beginning from January of 2020 so we received a message that some patients will be brought to the emergency department and this is a case of a community being exposed to a strong odor and the most common complaints of those patients were coughing as well as nose and throat irritation. So the substance identified was ammonia so this was related to us by the Poison Center with the National Poison Center of PGH and the challenge was that we are already dealing with the COVID suspects in this pandemic and we had to prepare to receive a large number of patients exposed to this to ammonia so you can imagine the challenges for the emergency department and for the entire hospital and how to triage and how to manage these patients in the emergency department. Okay so let me go back to some basic principles when we're dealing with C-bar in the agents in particular with chemical agents so we talk of routes of exposure there was a question earlier so the routes of exposure include inhalational, transdermal and transmicosal, absorption ingestion and injection subcontinuously intramuscularly or intravenously so remember the routes of exposure are not mutually exclusive so some agents would some exposures would involve inhalational as well as transdermal and so on so for the question earlier do I answer the question alright so the question was what is the post common route of exposure of hazmat incidence and so the answer is inhalational alright so when we receive information in the emergency department that patients will be brought to the ED so we need to verify the information we need to get the important details such as where involved what is involved if it has been identified the location of this event when it happened and why and how so this is very basic even for the more common emergencies that we encountered so just to show you in the pre-hospital setting this may be required to manage the exposed community there is a need to establish a hot zone so the hot zone refers to the site of the exposure for example chemical exposure so this is off limits to everybody except those who are trained to respond and to treat patients at the site so that's the hot zone then the next area established is the warm zone so this is where the decontamination area is placed called the decontamination so patients who are exposed to a particular south chemical agent that needs to be removed from the site will undergo decontamination in this area and then they are now brought once after decontamination they are brought to the cold zone and this cold zone is where we have our emergency medical services so this is the general setup when we are dealing with virus agents so for the medical management of hazmat patients one common treatment would be decontamination exposure solely to gases usually requires no skin or mucus membrane decontamination but exposure to irritant or corrosive gases are treated with copious stupid water irrigation exposed symptomatic I should be continuously irrigated with water or LR solution throughout the patient contact so I'm just giving an overview of medical management so for the quiz break this is the second question posted earlier for exposure to solids or liquids rapid removal of clothing is the single most important step in decontamination and it removes 80-90% of contaminants so after the initial assessment we do the primary survey and resuscitation this can be done at the site and also done at the emergency department once the patients are received so in general for patients with liquid or solid chemical contamination the primary patient assessment and resuscitation are performed only after any necessary skin decontamination in the warm zone so this is done to avoid contaminating personnel so the only procedures and to of course to minimize the effects of the chemical agent the only procedures performed before any needed skin decontamination are opening and maintaining the area open with spinal motion restriction as needed needle decompression of attention pneumothorax and control if exanguinating external hemorrhage so these are life saving measures and they can be done before any start of the decontamination with the proper personal protective for those who will respond as well as I am injection of nerve agents so for continuation from the primary survey we go through the assessment using ample so for those who are doing emergency work you may be familiar with this one this is a quick way to get necessary information from patients so we also do this for our hazmat patients so getting the allergies, medications, past medical history, last meal or other intakes and events leading to the presentation and it should occur concurrently with any necessary decontamination and or during primary survey resuscitation so for secondary survey this is the time now that we identify poisoning complications, recognize pre-existent problems with potential for exacerbation assess for accompanying trauma or burns and recognize toxic syndrome so I'll give you a review of the toxic germs this is what we usually encounter alright so the patient presents with irritation inflammation, mucos membranes edema and you know chemical burns of the exposed mucos membranes, airways and lungs so examples of chemicals that would produce these signs and symptoms would include ammonia as in the case of our ammonia leak mass casualty incident chlorine, methyl as a cyanate and phosgene so what do you think is this toxic germ, what do we call this toxic germ, is it as fiction called inergic, corrosive hydrocarbon and substituted hydrocarbon or irritant gas syndrome so you can put it in the chat your answer is in the chat box okay so answer D okay so let me show you so this is an example of a this is an irritant gas toxic germ next so this condition is caused by inadequate supply to the lungs decreased oxygen delivery via the blood or decreased oxygen extraction by the tissues so symptoms include disnia, shortness of breath, chest pain, palpitations dysrhythmias syncope, seizures, coma and death okay examples that will give us this toxic germ carbon dioxide cyanides, sulfides, azides very technical okay so what is this toxic germ, as fiction called inergic corrosive hydrocarbon, substituted hydrocarbon irritant gas okay na sagot actually I can't read the answer so anyway okay AAA very good okay alright so this is what we call as fiction syndrome very good okay next okay sorry so ito yung ating pneumonics yung dumbells and the MTWHF okay so I know you know this so examples of this would be organophosphates carbamates okay so what is this toxic germ this is ito yung ating tatag na cholinergic toxic germ okay that next is characterized by irritant and corrosive local toxic effects and it can show up chemical burns of the skin and mucous membranes examples would be acids bases, oxidizers and white phosphorus so what is this toxic germ parang ando na yung term na okay so this is the corrosive toxic germ okay characterized by sleepiness, narcosis cardiac irritability causing disarrhythmias v-tac-v-phib examples are propane gasoline, toluin and the rest okay so what is this toxic germ okay so this is due to hydrocarbon and substituted hydrocarbon so for poisoning we have what we call this treatment paradigm na for those who have taken up courses in toxicology and for those in emergency medicine na so this is our basic treatment paradigm so we started we have the EBCDs na so this is what we want to do alter absorption, administer antidote okay the basics of response change catabolism distribute differently and enhance elimination of the agent for the poison okay so for this CBR&E incidence it is important that hospitals are prepared and if we have a proper system of dealing with these events then we maybe identify hospitals that have the capability to respond and serve as receiving hospitals for patients exposed to CBR&E incidence so part of the response would include of course getting the proper equipment and supplies to manage these cases proper training for the personnel including proper PPE and then there's a need for collaboration and coordination with the other agencies involved in CBR&E response such as our first responders then that includes our BFP purified protection the PNP and maybe also the military so these agencies have their own CBR&E units na and as mentioned by Dr. Makalino earlier what is lacking in right now in terms of developing our capability to manage CBR&E cases are the training for the medical personnel so medyo tayo yung nahuhule because if we have trained pre-hospital care personnel to take care of the patients in the pre-hospital setting right after an incident the ting naman nila sa hospital medyo kulang tayo sa preparation kulang tayo sa kaalaman in managing these cases sayang yung ating effort so what is needed is a full response from the site from the pre-hospital setting to the hospital setting okay so with that thank you very much and I'll turn you over to our house salamat po that's Dr. April Yaneta what comprehensive presentation I think some of you really enjoyed the quiz and the right answers April parang baka sabi favorite na nila yan so I hope you learned a lot and we like to thank you so much April for that comprehensive presentation it was really very good okay I'm gonna turn over to Raymond Thank you so much Dr. April Yaneta so that was really well I opened it for me I don't really have that much exposure with regards to CBRN so anything that's in relation to that something of a refresher course because a lot of these really especially when you're talking about giving examples how to manage hazardous program contamination etc very very theoretical po at least in my experience po anyway our next speaker someone who is also very very knowledgeable comes very well endorsed on this topic he is a nurse 3 at the department of psychiatry and behavioral medicine at the Pilgrim General Hospital and has received significant training for CBRNE please welcome to your screens nurse John Bernard Bernardo Sir John I good day to everyone let me just share my slides I think you're on your last slides sir John so yeah ayun okay there we go okay and then go to there we go okay hi good day to everyone first of all I would like to congratulate organizers of this webinar series for a very successful 93rd Web webinar series and I would like to thank organizers and my mentors, my team leaders for inviting me here to share this experience in CBRN actually this is emerging I think emerging specialization in nursing so I'm going to discuss my CBRN experience in particular here in UPPGH so the UPPGH CBRN so the team is composed of positions nurses, EMPs security personnel and safety officers so the area of practice actually we have divided the specialization we've encountered a chemical incident most probably the primary service that will handle the patient would be the toxicology medicine so for the biological the IDS or the infectious disease and the general medicine for the radiological and nuclear probably the most the nuclear medicine so going to trainings actually this is my training course since I'm not a physician so I'm a nurse actually I've been working mental health and psychiatric nurse I started I want to be a counselor and addiction counselor so I got fascinated in clinical toxicology and then that's the start of my career in CBRN so I went to basic training course in nurse toxicology by the UPPGH division of nursing education and training and then after that I went on a post-graduate course in clinical occupational as far as material toxicology that's to my training here also from the UPPGH division of nursing education and training and then the medical management of CBRN casualty workshop from the united states defense threat reduction agency the next weapons of mass destruction operation course also from DITRA weapons of mass destruction for development course from DITRA also and then the maintenance management course and equipment training for CBRN so when we talk about the CBRN we also talk about equipments and the detectors actually that's our first line in assessing the situation so we need the equipments so I'm lucky to undergo training for the equipments these equipments are um state of the art actually ito yung mga equipments na gina-damit din sa ibang bansa up to this point so napakaluban tayo ng mga ganito equipment and yun masati ako na isa ako doon sa napasama doon sa training na yun so here are some of the equipments that we use in CBRNE oh by the way ito yung team 1 ng UPPGH CBRN response some of the equipments slash PPE used in CBRNE yung first ko makikita yung sa left is the key ray, this is a multigas detector it can dinagamit siya for assessment of types of gas for oxygen carbons and also the LELs lalabas yung measurement na yun um po-point mo lang yun po sa area na pinagdudahan yun na may um pricinus gas and then iti-detect niya kung anong meron doon sa gas na doon sa particular area na yun actually di mo kailangan pumasok meron siyang tube na nilalagay yun sa ibabaw para siya mahabang one na pwede yung yung insert lang during in tactical operations or tactical missions pwede yung tube na yun pwede yung mo lang siyang idahan doon sa ilalim ng pinto and may-detect niya kung anong gases na meron doon sa laob na room na yun in particular room na yun next is the Rad Eye the B20ER this is detector that can detect gamma beta and x-rays for relations yung kung makikita niya sa sa palabas yung parang malaking plants yung nagilagamit nila for detection of relations para lang siya sila kinang cell phone na medyo matabak and then if ever pwede rin siyang gamating dosimeter so if ever during operations or missions pwede mo siyang ilagay sa you can wear this detector pwede siyang isabit sa PPE mo and then you can set an alarm yung equipment na yan next is the LCD-3 or J-CAD LCD-3 for industrial type J-CAD for tactical type when I say tactical yung yung maginagamit ng military personnel security personnel actually para lang yung J-CAD LCD-3 so chemical detector din yan it can detect nerve nerve agents and corrosive agents so ganun lang din siya i padadaanin mo lang din siya doon sa ano padadaanin mo lang din siya doon sa room na yan tapos mayro siyang seed pack or parang filter siya ilalim tapos yung yung mag-analyze but actually during my training some of the parang first batch na pinapapunta ng mga head of states they carry this type of detector yang ano na yan LCD-3 or J-CAD so to assess the situation at siya kaya yung area kung safe ba yung para puntahan ng head of state the LCD-3 next for the PT going back marami po mga detectors na mayro na yung Gemini yung Gemini din kasi hindi ko siya na picture na during my training pero yung Gemini na yan can detect and assess yung substance let's say powder man siya or liquid man siya tapos anohan na siya ng infrared kaya yung basahin yung component ng ano na yan yung substance na yan actually nung tayong nang pinitest namin yun yung ginamit namin yung 3N1 na coffee so nakitanya yung hindi product yung substance na yan yung Gemini na yan na yan na detect for ok, so let's talk about the PPE na man acording sa nayo siya mayro yung levels of PPE na ginagamit yung level A level B ng PPE actually mayro yung level D yung helmet yung ordinary personal protective equipment na ginagamit sa work or sa construction yung makikita yung level D so sa picture na ito makikita yung level C na PPE kong piting na nyo lahat na pag-practice hospital and nakita kong adul sa isang question can be used in a hazmat incident well for me in my opinion puwede pero ang problem lang doon is in duration yung time at yung permeability nung barrier mo kasi yun parang manikisi na yun ito yung material na ito yung cover all na yan as in ma kapalsa para siyang tarp na meron pang multiple layers na parang laminate sa ibabaw so yan patagal yan especially sa mga corrosive na agents hindi sya agad-agad na magpapasrog yung sa skin mo or papasok mo yung sa skin mo first scale, mayroon pa rin yun limitation and this one yun actually during my training yun with the DITRA I was donning a level ATPE and yan yan na sa likod na yan sa SDA or self-contained breathing apparatus so the difference between a level C and a level A yun type nung cover all and then the breathing mechanism sa level C kasi yung air na nang gagaling galing sa labas, feel firm sya ito yung air sa level A yung air na pinang gagalingan na hinihinga mo galing sya, contain sya self-contained yung air na hinihinga mo so qadalasa yung tank na yan naglalas ng mga 60 minutes depends na size nung tank pero during my training syempre in in an incident na yun bagamit ka ng level A syempre hindi maimamakas out yung 60 minutes na breathing time mo dun sa tank na yan, so qadalasan ang sinasabi nila 30 minutes lang yan yung mission duration ng level A kasi kailangan mo mag-alat ng 15 minutes going in nung sa hot zone and 15 minutes going out nung sa hot zone mas mabuti pa na meron kang may iiwan na panghinga kasi maubusan ka doon sa love mismo ng hot zone and kapag ka nakasuhut ka ng level A na PTE, sobrang may inet like it wouldn't last a minute inside the level A PTE at yan syuran ng safest na PTE level A, self-contained sya and siya may pinakamakapal na protection level of protection na gating sa cover all encapsulated ka sa loob so unlike sa level C na nakat-tape yung edges eto puli-encapsulated ka jahan sogang inet yan I'm wearing a pooling vest yung pooling vest alone and then the SEGA is like 20 kilograms so hindi lahat kaya mag-don ng level A PTE so siya check talaga yung vitals at siya yung health yung individual na would go sa hot zone especially if you're going to don level A PTE ito yan, makikita yung pooling vest pooling vest yan yung na sa katawang ko para siyang silica gel na nakababad nakalagi sa rep tapas kapag sinuot mo siya sa yung level A yung malamig lang yung katawang mo actually pero sa legs mo as in sobrang mapawisan ka na mag-pul talaga yung prowess mo sa boots at siya sa sleeves ng level A na PTE mo eto, this is yung mga trainings na ito sa our forces sa our forces pinapag-jagging sila na naka level B na PTE eto pinatakburi na ko dito siya pinag-jumping, jaka ko diyan na naka level A and medyo mahirap siya so kailangan pit to wear that level of PTE hindi lahat ayang mag-don ng level A PTE so isa yung sa mga limitations ng PTE na yan now this is the it's a mass specialty the contamination tent yung yung current or in US MCD tent na ginagamit even the US and the Europe European countries they use this tent it's a four lane tent pero in this set up we have set it up in A3 lane tent with non-ambulatory lane para kasi saka paginawatong four lane tent lahat yan puro pang ambulatory na yung tent na yan it's capable of decontaminating individuals meron yung sariling water supply meron yung sariling electrical supply and meron yung sariling air circulation supply so kahit na all weather tent yan kahit na na sa snow or kahit na sa dessert o ka mag-function yung tent na yan tapos yung tent na yung tent na yung yung waste na yung tubig na patapon sa ilal meron yung sariling waste disposal carrier so hindi niya ilikakalap yung yung tubig or yung contaminated water used for decontamination meron siya sariling bladder na tinatawan so yun maging tapag halimbat ang haling tapat tapos na ka level 8 na PTE actually during our grills na ka level silang kami na PTE sobrang init na kasi meron pang isang teammate kami jaan na nag-hit stroke at tayong so yun part noon na during ingress and egress ng responder pinukunan talaga ng vital signs pre and post decon so kukunan sila ng vital signs talaga so kailangan ang individual na maging responder sa CDRM so yun nung inakasembol namin o tinatayo namin yung tent na yan yun sabi nung trainers namin from DETRA parang yung record nila na may tayo yan ay 15 minutes kami kinayo namin yan ng i think 16 minutes atayon 16 minutes namin tayo yung fully operational na decontent now going sa experiences I would like to share my experience kung sa an yung recent experience na activate ucbrn ng UPPGH so it's the ammonially incident February 5 eto na yung kasagsagan din ang COVID so yun na na activate ucbrn ng UPPGH so ayan ucbrn sa kabila yung first picture that's the command post that's also the office of the call room of the national poison management and control so sila yung naging parang command post and then at the right side yun yung situation ng IR namin pero kuntip pa yan ng time na yan pero na puno yung ano namin yung ED namin tapos sa ammonia incident pala yun yung ipakasama yung sa COVID cases so ang struggle doon kasi meron kang pandemic na airborne yung yung transmissibility yung sakit tapos meron kang mas casualty incident na ammonia leak so yun pinandal namin yung papana namin so yung manpower resources we use the three color triaging system so sa red one demping leader two dem resident isang physician on duty one ure resident one oral resident toxicology fellow one pediasignor and then a family medicine resident and then one nurse pag-agandahan dito na kapakajurin ng ammonia incident namin yun na yung ibang services ng department namin ano rin kung bagang nag-activate din and then tumulong din talaga sa IR kasi as in sobrang traffic na nun yung ambulance yung ingress at yung egress ng ambulance namin nag-start na mag-up sa Kalsada yung time na yung so buti na lang nakagandaan na namin nung time na bago pa dumating yung influx ng pacient so the yellow one dem one pod, one toxicology fellow one pediasignor, one tamid resident and then one nurse sa green one dem in leader one pod, one pediasignor, one tamid one nurse ako yun, ako yung nurse na in-try to go sa green na area so yun during that incident we have established a unified command system the incident command system namin and then see Dr. Aprilia Neta yung kani lang yung speaker natin was the incident commander during that time she was the chair of the EE so nila is an officer CTE Strada CTE officer an EE earner, see Kerwin Garcia checking charge to yun sa pag-clear ng beds to accommodate yung influx ng mga patients at saka ko saan iilalaga yung mga pacientin public information see Dr. Jonas Del Rosario planning, see Captain Ares, operation, see Carol C. logistics, see Dr. Romer Tanghal, finance office of doctor ito yung triaging system namin, the green just to give you an overview of the triaging system that we use. I think you're all familiar with this so to green yung symptomatic patients with reliable historian patients with minor sensations of burning, low stress and respiratory tract, sight cough and diarrhea green, medical personnel if the medical personnel is that the patient has been exposed to a significant amount of ammonia so sa yellow may persistent cough, a burning or taming of the eyes, the sinus headaches and then red, cloud sinus changes insorium, chest pains and dizziness ito yung ano naging floor plan ng ED namin during that time makikita yung halas sinakot yung dalawang word because of the pandemic also yung MCI na ammonially na incident din so medyo magbigat ng time na yun well yun yung nangyari experiences actually I also want to talk about the struggles during that time yung dun sa experiences during the ammonia incident ng time na activate na yung CDRN response yung on that time was how to deploy the MCD tent kasi yung time na yun yung nung gabi parang yung namin mga nakapark na nakuot yung CDRN so yun, gila ang then decision call na pag-decision na namin na ang established namin yung emergency decon so nakapag-establish kami ng 2 emergency decons dun sa EMS so lahat ng papasok anong namin din namin ay secondary decon kami so lahat ng pumasok, dumaan din dun sa EECON namin bago pumasok dun sa EEC na assign for the MCI so that's all I hope na yun, na showcase ko yung CDRN experience for my trainings and may interest may interestado kayo dun sa CDRN thank you very much thank you very much John, I think that was a very, very interesting presentation with all the pictures and very practical and really shows us how complex this is Raymond na parang walk in the park yung COVID compared to the preparations you have to do for this but anyway thank you so much John, I think that was really very, very informative and I'm sure our audience really appreciates it also okay Raymond, what are we doing okay parang nawa wala akong yung sa sequence alright, so we're going to have our Q&A session and we're going to ask our guests to please open their videos so Doc Ted, Doc Irma, April and John please open your videos but while we're doing that Raymond's going to queue our public service announcement okay, thank you Sir John and thank you Doctor Susie before we go into our Q&A session we'll just take a very quick break for our special public service announcement today it's part of our new set of videos produced by the team, take it away hi, aunty gusto ko nang lumabasat kaya paglaro kaya di ba magkakasakit daw tayo kapag lumabas magbibis mas naman ako e kahit na, anggat pala daw tayong injection, hindi tayo pwede ng lumabas at maglaro ano ba yan, takot pa naman ako sa injection huwag ka magalala parang kagat lang daw ng langgam yun nalaga, inatakot pa rin ako kaya di sabay na lang tayo oh, siyempre blags kitay para makapaglaro na tayo dahil mahal ko kayo magpapakuna ako ayam mga bata magpapakuna na kayo stay safe and stay well mga bata, magpasama na sa bakuna center thank you so much at tvup, so the covid communication public service announcement is one of the many creative outputs that's team to push for pediatric vaccination for children five years and up this is something that we prepared very recently we hope this is something that you could also share with your colleagues family members and your friends for us to be able to be protected against covid-19 ok, so Reemad, we'll start looking at the questions in the q&a, and I saw some very interesting questions and in the chat box at to start our discussion I wanted to ask maybe Ted and Irma although we don't like to speculate on this webinar we like to base our discussions on facts we do know that because of the war in Russia in Ukraine and constant talking about chemical chemical use of chemical weapons and knowing that we have many Filipinos in that part of Europe what do you think ok, so speculation what if what would be likely agents that could be used in the current context that we should prioritize kasi marame di ba pero ano kaya yung dapat pinag-aarala natin ang mas maiging na yun whether chemical, biological whatever ok, we'll ask Ted first that's a very good question and I've been monitoring like everyone else I've been monitoring this Russia-Ukraine conflict and one of the first things that came out was really the accusation of each other of use of these types of weapons the Russians were accusing the Ukrainians that they have biological labs funded by the US to create biological weapons so there's already that problem and then the visual pictures of cluster bombs being used the type of explosive that's actually been banned because of the amount of damage to civilians in conflict and then of course nuclear I mean put it himself warn that he has nuclear bombs he even stated that as a fact in one of his speaking engagements so the threat is actually there it's actually very, very real and like for example what happened with this pandemic for many years the WHO had been warning us you prepare for a pandemic let's prepare a pandemic preparedness plan and when it comes after all the preparation you actually see there are still a lot more things you actually need to do and that's I think where we are right now when Susie talks about chemical biological nuclear and all these types of explosives we're there at this point we need to educate everyone from our first responders to our emergency department doctors to our laboratory technicians our radiologist to really understand and help each other so it takes a whole village to actually really create this just like any type of natural disaster my field has been natural disasters but obviously the principles are the same these agents, these biological weapons can create so much and April talked about local experiences but there has been many Iraq was accused of using chemical weapons in that northern part of Iraq prior to subdue dissidents and then Syria also used chemical weapons recently so mukhang hindi effective ang what we call the chemical weapons and biologic weapons conventions which have been signed by many of the UN nations even our nuclear they were supposed to be nuclear non-proliferation but it looks like kahapon lang nagtest na naman kim yung un of another intercontinental ballistic missile launch so the threats are there our problems as ourselves people used to talk to me and say don't study region nuclear and that won't happen to us did you know that all the reactors of Taiwan are actually in the southern part of the Taiwan island that means if they had a fallout or a rush of China attacks say Taiwan and explode some of those affected the northern part of Luzon and I don't know how big because probably even bigger so the key really is education and risk communication I think what's being clear now with the messages of our speakers is that risk communication is very important to understand the risk and to understand that this requires lots of logistics exactly the same problem when we had the start of the pandemic we were sending our samples to identify the disease to Australia and to other countries and then we had to start off fighting an illness by building molecular labs and we had to build 200 glass so can you imagine that so we need to actually look at all those devices that was shown by our speaker do we have enough of those devices to identify chemical agents and understand what our problem is and then do we have trained people right now we have CBNR in PGH in the Bureau of Fire and the Armed Forces but we always joke so technically di ba parang replay lang ng COVID-19 and then we had to find and source PPE so I think the key really is to stockpile all of this prior to the start of this conference Irma was talking about antidotes and we can't even stockpile antidotes because the procurement system makukawa kami kasi may expirean kami ng antidotes but it's something that would be life saving so something that needs to be corrected as well so very important to educate not only the doctors pati pala legislators pati pala kowa napad maeducate natin about CBNR so I'll stop there and give the floor Thank you Ted and we'll go to Irma in a moment but I just wanted to share na I think two years ago again when North Korea was testing its missiles merong pumasok sa airspace ng Japan so their silence went off they're prepared for this their silence went off and children actually have a drill they know what they're going to do so they have a towel which is wet, they're supposed to put that over their head they have this like foil parang foil covering and they know that they have to keep their arms close to the body and they're supposed to duck but we're training for earthquake sila sa level ng mga bata merong silang drill for a nuclear fallout I'm glad you mentioned that because I went to Israel right after the fall Okay na wala ka Ted Ted nang freeze ka go ahead Raymond wala ba si Ted I think he's still frozen Dr. Suzie because of the UP I think it's at internet connection Okay we'll get back to Ted but we're going to ask Irma a little bit about the threat the threat from the war in Europe what should we be focusing on what should we be studying more Irma go ahead So first I have to say this line that this follows the principle of no attribution because it's hard because I work with the CBRN national team of the anti-terrorism council and so what I might say might be taken misconstrued just for the purpose of what has happened over the years so in the issue of the chemical weapons convention people are looking at the experience of Syria right now the use of VX in Kuala Lumpur the use of again Novichok which is a nerve agent similar to the original soaman sarin tabun and VX so it's there the threat for the use of chemical weapons is really very real so that's one of the areas because we know that of course the chemical weapons convention requested the countries who had stockpiled during World War I and World War II this chemical agents but some of them probably have not completely destroyed what they promised to destroy so there is really that possibility that the stockpiles for this old chemical warfare agents do exist so again if we talk about what priorities do we really need to understand I think the chemical weapons threat is one of the most real threats because at least it is not going to cause harm in the magnitude perhaps of a radio nuclear fallout but in the end you don't want that kind of an event because it is going to affect not only the area of Ukraine but other areas in Europe but again what we need to understand when we talk about the use of radio nuclear material so if you have a radiological material in a hospital like PGH that probably uses Trontium 90 those are types of radiological materials which we need to safeguard because somebody can break in and steal them so that's where it's very important that our hospital also has a lot of security measures where these materials are because this has been used in improvised explosive devices so you have a chemical that's really with therapeutic use but at the same time it can be misused by people at interested parties so again when we talk about radio nuclear we have to understand what kind of particle is actually in the fallout so depending on what material it is so we have what we call the beta, the gamma and so on and of course the alpha particle that probably is the one that they are shielding using the aluminum foil but it might not be enough to shield yourself with a beta emitter and a gamma emitter so it all depends on the type of radiological material so these are the things that we really need to watch out for and when we talk about Soman, Sarin and Sarin has been used and the other one that we need to consider is the use of the blister agent or the vesicant agent like mustard agents hindi po ito yung mustard agent a mustard na nilalagay natin sa hot dog or hamburger so it's called mustard agent but it has nothing to do with the sauce but this is very difficult because as I've said you might not even know that a mustard agent has already been deployed or weaponized because it might take 24 hours to 48 hours before you see the full effect and so you will have people coming into the emergency room presenting with sore eyes and some redness of the skin and they might think that they just had a sun burn because they exposed themselves to the sun not knowing that it has happened but one last thing I want to point out now is the delivery system the threat associated with the use of drones we have to be careful because the drones are very good delivery systems they can fly over a certain airspace you might think that this is just a toy but it is the delivery system that can be used to push these agents spray the people with VX or whatever toxicant people might use Thank you Irma Ted, before you froze you were in the middle of saying something so would you like to finish? So you're talking about the children in Japan being taught what to do so I was there in Israel after the first galf war with the father bush and the children were all taught to carry their gas masks and when the siren goes off everybody starts to wear it properly so even kids walking to school knew how to wear a mask and the interesting thing was that they showed me the underbelly of the hospital and in the underbelly of the hospital there was an airlock so it's probably the safest hospital I've seen where in the Kim Shiba Medical Center had an underground that used as a minor surgery and OPD and then the boss shows me that the whole thing can take in about 500 beds of injured and it's also where all the doctors will go if an atomic bomb or a nuclear attack was staged in Tel Aviv and they would all go there it's got an airlock and food and water to supply them for 6 months can you imagine? Another place I saw this kind of bunker was in Switzerland a neutral country who invest in all of these underground hospitals and basements you can't construct a building in Israel without a basement or a bomb shelter so na kita mo all the people in Ukraine that were saved were rescued from basements so very important the use of basements tayo walang basements mga bahay natin and you see the aerial photo of Mario Paul talagang flatten siya so if that were bombs thrown at the Philippines for an area of the Philippines kahit ano pa yan, kahit akorintians or forms park, ubus yung tao talaga kasi hindi naman tayo standard na ng gagawa ng basement so it's very important yung training infact yung hospital namin sa Kim Shiba ahead the decontamination showers and the decontamination showers were placed in the parking lot so that when they did their drills the people that were contaminated before they were brought in were decontaminated in the parking lot in an open air where they would be washed thoroughly so yung naman nga things that we need to actually think about how to decontaminate people who are affected by agents similar to the ammonia experience yun lang mo na Susie, thank you thank you Ted okay Raymond we have a question from the audience, let's pick that up okay, thank you Dr. Susie we have already well promoted Dr. Joseph Tartona one of our avid Miss Inertian viewers po no to be able to ask his question I'm not sure if your camera is working Dr. Tartona but please go ahead with your question ah yes can you hear me? yes sir, loud and clear probably my question was a little bit wrong I asked if the LGUs are oriented properly on CBRNE events probably the best question would be are they trained to handle CBRNE events or will they just rely on the national government to interfere okay, thanks a lot I think that's a great question let's throw that to April and then we'll ask Irma and Ted also to respond but Irma, sorry April you've been involved in some training or has that been just PGH so with the PGH team we were able to train with the BFP the AFP and some foreign groups as partners local government for that question for the LGUs siguro awareness po ang kulang pano sa local level so awareness and then wala pa tayo we're not talking about the system yet so doon pa lang po siguro malaki pa yung kailangan natin go in thank you, Irma you were raising your hand, go ahead I actually just wanted to stress so all this training that we are getting is really part of a strategic plan and the strategic plan is called the Philippine CBRN National Action Plan so as I've said earlier the UP College of Medicine was instrumental in finalizing that plan and it became what is now known as the Anti-Terrorism Council Resolution 40 that also created what we call the CBRN National Team so within that strategic document our specific recommendations so one of them is actually increasing awareness at the level of the local government units so over the during the pandemic we were able to conduct four virtual training programs for the through the Department of Interior and local government and we are now hoping that with the easing up of the restrictions that we will be able to do the operational level so aside from just awareness level train some of the people in the barang guys to at least be able to first recognize and do some kind of immediate action and just to emphasize also that in terms of where we are in relation to equipment we might not have all the equipment that we need to fully respond to CBRN but at least we now have better equipment than what we had in 2001 in the case of Bureau of Fire Protection that's why I said when the level when we talk about levels of personal protective equipment we don't want our doctors and healthcare providers at level 8 PTE I tried that before when I was younger in 2007 and really the amount of sweat that I had on my boots was really tremendous so when you do those procedures of intubating a patient you don't want to be in level A so you let the Bureau of Fire Protection who has the proper equipment scan the area they do that what they call it later first they determine what are the most toxic chemicals if there's radionuclear material and then they give feedback to the health people so that they can don the proper PTE so in most of the circumstances for decontamination we want the doctors to be at least at the very least or at the highest maximum containment of a level B PTE which means that you have removed the fully encapsulated suit but you still have self-contained reading apparatus in your back so that whatever contaminants there are you can still protect yourself so there's really a lot more that we need to train our medical people for and again just to maybe help people recognize their efforts now so with the COVID-19 pandemic we recognize one of the gaps of the local government units they do not have a laboratory really that is owned by the LGU so that people can so when we now have a project that we are engaging again with one of our international donors we are going to build a minimum of 3 at least at the level of what we call a biosafety level 2 plus laboratory so that we can address better the surge of infectious disease we are now trying to build this in low resource because we know that in Manila we have built this molecular labs but what if it happens in a remote area so the only question we're trying to deal with now is sustainability if we build it there how will the local government unit sustain the laboratory so these are just some of the things that we are doing with the local government unit oh thank you so much thank you so much Irma I wish we had more time Raymond but I think we're out of time and we have to wrap up in the chat that people are asking for part 2 training and all of that and Irma and I have been exchanging on text that maybe we will think about the specialized training on this I mean it's timely I think there's going to be reception to it anyway so Raymond we want to we're going to give our speakers a couple of minutes to think about their parting words but meanwhile Raymond's going to answer the questions and give the evaluation okay thank you so much to our panel of experts but hopefully we'll be able to get you again for another well a third part of this discussion for our fun quiz do we have two questions again nasugot naman na pa na pa na doktor April but we'll call her again just to reiterate the first question reads what is the most common route of exposure of hazmat incidents kung kayo po ay nakikimig alam nyo na po but let's allow doktor April to reiterate po mam april ay nabalasi april sagutip mo nalang Raymond ang tamang kasagutan is the one selected by 67% at least on the zoom inhalation inhalation yun po ang tamang kasagutan and then for our second question thank you menti yun for exposure to solids or dequids rapid removal of clothing is the single most important step in decontamination it removes blank of contaminants po so ano po ang porcento ang porcento po pinakamatas at least in the zoom 48% 75 to 80% at 52% naman po sa menti so ano po ang tamang kasagutan we'll call insurgian for this question 50 to 90% ayun okay thank you so much sir jansup ano po after our participants pakitandaan po ang tamang kasagutan will give a few more moments so that doctor april can also come in and join us as we go on to the evaluation poll, sana po ay gumagana rin po siya at can we have that on the screen okay so there are five questions po and of the five questions ito po ay four point Likert scale I'll just read them as I go through the list number one the panelist demonstrated thorough knowledge of the topic number two the panelist were well prepared and organized number three the panelist spoke clearly and audibly number four the panelist used appropriate language with technical medical jargon adequately explained and number five the panelist contributed to new perspectives and knowledge on managing virus kicovid-19 health issues hindi po namin isasaram mo na ang evaluation poll wala po kaming hiwalayin eto lang po yung meron po kami as we move back for the final messages of our speakers for today doctor susie thank you so much parting messages first we'll start with john please go ahead actually I only have two two points as my parting message so first preparation is half the battle so no matter how difficult it is as long as we have some sort of preparation we have an edge to everything to be unknown or kaya tanong kaharapin namin and next continue to be curious wag tayong huminto alamin yung mga bagong knowledges ang emerging sub specializations sa profession natin kasi na moment na huminto tayo na maging curious the learning stops so be curious learn and then in preparation thank you so much john April so for me po as an emergency medicine specialist very critical sa akin is that we are open to learning new skills and open to new knowledge especially when it comes to management of potential emergencies so itong cbrn is a new field marambu pataing ka lang matutunan which leads me to my second point that there is a need for coordination and communication among the different agencies involved in responding to such incidents so for that, thank you very much thank you very much so after April na nata okay, we'll go to Irma actually i think the message i'd like to impart right now is that tackling a topic on cbrn which was probably not something popular in the past is very timely now because so we can see that there's really a need to have more people trained but again, as i've said i think i placed it in the chat that the whole response is actually multi-sectorial and therefore we are part of that particular response, we have to acknowledge the strengths of the other agencies and we should not actually fight with them in a scenario so that we can actually have coordinated action and i think that when we talk about science and technology we also have to be aware of the developments in science and technology that may add to the harm and i always want to believe that knowledge is key but again in this and science and knowledge are linked together but the aim of science is to set a limit to infinite error because in the end we don't want to be able to have terrorism Thank you so much Irma and thank you for joining us all the way from France Ted, go ahead One of the first things i'd like to say is i'd like to thank Irma for being on this since we were very young We have white hair The two of us now have white hair and the issues continue to evolve and the first message i'll have is that yes, our capacity for CVR and e-response isn't there yet like other first world countries but it's improved a lot from the time Irma and i were starting and all our DRRM offices just need to know is where to ask for help there's Irma to call and then there's the Bureau of Fire CVR and the team and the PGH now and then there are some private industries that also prepare based on the chemical hazards that they actually handle so there'll be a lot of sharing of resources when we do encounter this. The key is for the region or the LGU to know where and who to ask help from The second i'd like to address is number a question that was placed in the Q&A that we failed to answer. It's asking about triage when you do triage and it's very important that when you deal with chemicals and all these biologicals and nuclear it's the decon that happens first April showed a very nice photo of the hot zone the cold zone. Doctors never enter the hot zone. You're too precious to be lost so it's safety first for us responders in the healthcare profession, you never enter the hot zone. It's the guys who are trained to wear those PPEs who are fit enough to stay for what a couple of hours only I've worn those PPEs as well and tried to intubate and put ibilize in them because our training in the US was like that. We had to wear the PPE and intubate and you'll do it 10 times slower than when you were not wearing it. So it's very important that we consolidate our resources and our training maybe regional hazmat units so that can respond to different regions of the Philippines where there is high risk for chemical damage and lastly, my most important message is that we have as a disaster guy, we have the DRRM framework. We have the Disaster Risk Reduction and Management Act. It has been focused on natural disasters but we saw what happened. Epidemiological emergencies were kept aside and we were hit by COVID-19 let's make sure that when we encounter again a big CBRN event that we are now ready. So we should follow the framework. The framework is there. Let's build from there, build capacity, build capability, stockpile the necessary equipment and consolidate all of this so that we can help. Thank you Suzy. Okay thank you very much Ted. Irma was facing your hand. Just to respond to Ted's comments. So just to let the people know that the Bureau of Fire Protection has regional capability. So they have resources in Luzon, besides at Mindanao and for the medical part that's the other area that we're doing capability building on. So before the pandemic happened the equipment for Mindanao for the SPMC actually arrived. It's still I think in the container van. We will do the training soon. We will probably request April and maybe John to go with us to Davao to start training the people in Mindanao for some equipment, earmark also for Kagayandi Oro for Palawan and also for Sibu. So there's that kind of mindset now to really make sure that it's distributed not only in the Metro Manila area. Thank you. Thank you so much Irma. Okay. Thank you so much. Clearly we're out of time and clearly our community wants more of this so we are going to discuss how we can continue the discussion. We're going to have a summary now from the deputy director of the Philippine General Hospital, Dr. Stella Jose. Go ahead Stella. Hi everyone. Again it's a very informative webinar series. I'm always glad to be here watching everyone. It's a nice review then because that was in med school when he was lectured to us so first I would just like to summarize on a few speakers so Dr. April Yanetta mentioned the CBRNE so don't nating kalimutan yung key which is the explosives so she mentioned the hazmat versus CBRNE so what's the difference so the intent and the scope yun yun ang difference so Tabini April yung hazmat is an accidental release so again there is increased priority for safety of the personnel and the public and if it's a smaller scale there is prior knowledge or potential unlike the TBRNE when there is delivery use of this weapons of mass destruction so again she mentioned yung mga risk scenario so there are natural and accidental causes of the response such as detection identification monitoring again physical presence and hazardous management what is the role of the healthcare provider healthcare worker first you assist the responders you receive the casualties and you manage the casualties in the PTE so she mentioned about chemical agent you have the inhalational transdermal ingestion and ejection so natutuwang ako sa atendans natin talagang ganado sila mag-answer ng ating fall so that's very nice so the question that we should ask who will be affected what, where, when, why and how now we know that there is a war going on in Ukraine and there are already patunog na baka magkaroon ng chemical or biological warfare I think we should really delve on this some more because we'll never know if it might really happen and our nurse John Bernard John Bernard Bernardo I appreciate your lecture ang ko lam na realize kung ano kahirap ang sinosaot na level ATTP kasi akong nagahasmat ninyo ako when I do ORC in PCH pero ibang kanasiyong hasmat nila Bernard so albrang pinit, talagang makita mo lang talagang tutulu ang pawis mo so it is self-contained there's a cooling vest and you are fully encapsulated so of course you also want to protect yourself and what struck me with what you said we should have time 30 minutes to go in and 30 minutes to go out napapag hindi mo ubut yung oxygen that you're using and of course from Dr. Irma Makalino si Irma Icon yan talaga dito sa PCH talagang yung Bureau of Fire Protection talagang binigensyan and special award I think kung baga isang webinar natin si Irma lang yung mutsasalita I wouldn't re-reclamaw mo and thank you for coming here for attending despite you're in France we know and we're very grateful for all the knowledge that you shared and she was binensyan na nandun siya sa 911 and you know that's really something just watching it from TV is already frightful and being there yourself is additional I'm sure tension and stress for you thank you very much for all those participants who answered our call back to you Suzy oh thank you so much so that's our Deputy Director for the Philippine General Hospital excellent summary Stella Marie Legaspi Jose and we always look forward to some kind of closing summary so that we can cap our knowledge for the day okay next week nice topic okay very exciting you're going to talk about vaccination of children six years old and above don't miss it again we will bring you our best speakers and you know we are campaigning for vaccination of children but what do we need to know what is the status of this whatever questions you have on vaccination of children thank you so much Raymond over to you thank you Deputy Director Stella Jose thank you Dr. Suzy for next week po no that we want to be able to gain more awareness po with regards to the pediatric vaccination so not just the elderly but also the pediatric population po it would need mas maikting pa po ang push for more vaccination but before we conclude our program let us first acknowledge the very hard working team behind the stop covid death webinar series without each and every one of you we won't be able to turn out quality content po week in week out we were really impressed na marami po ang nag-attend for this topic for this week and something that we hope will be sustained in Parts 3 and Parts 4 of our continuation for this topic we also would like to let you know that all stop covid death webinars are archived for viewing at the TVU YouTube channel so if you just go to www.youtube.com forward slash TVU PPH you'll be able to see all 92 webinars to date and then after this webinar ilalagay na rin po namin ang webinar No. 93 we also understand that all of you are busy and jam packed ay hectic po ang inyo schedule so we have also prepared so kung matutulog po kayo or anything nasa boost or nakokomute we have prepared our YouTube short spot these are just snippets very very easily consumable po short video clips of our webinars we hope that something that will be mas magugustoan po ninyo dahil di po siya ganung po kasing haba ng aming mga archive ng mga episodes we are also seeing on the screen at least 90% po of our attend yes, 89% to 90% of our attendees chose strongly agree for our evaluation for today's webinar maraming maraming salamat po sa inyong lahat we really are out of time it's just unfortunate that that's the case so this formally brings our webinar for this week to a close makita kita po tayo again next week friday from 12 noon to 2pm it's a date together we can stop COVID deaths so keep safe, keep healthy see you online i'll keep your hand in mind let's say a prayer one more time i know you long for home but i am here, you're not alone i'll stay with you until the coast is clear the other's pain before my fears the other's life before my tears but right behind the mask i look into myself and ask do i have strength to carry on oh god, oh lord, what's this going on and leave you here to keep me strong i'm here to hold the line i'll keep my hand until my just hold on to the word he gave this time we'll come to pass because this salvation makes a last you'll carry you to see the break of day the other's pain before my fears the other's life before my tears but right behind the mask i look into myself and ask do i have strength to carry on oh god, oh lord, what's this going on and leave you here to keep me strong i'm here to hold the line i'll keep my hand until my just hold on to the word he gave the other's life before my tears but right behind the mask i look into myself and ask do i have strength to carry on if you're here to keep me strong i'll keep my word before my tears pushing on the spite of tears