Lucy Tompkins and Sasha Madison

00:02 Okay.

00:07 Let me introduce myself first. My name is dr. Lucy s. Tompkins. I'm the, I'm a professor in the Department of Medicine in the division of infectious diseases. At Stanford University, Medical School and I serve stanfordhealthcare as the hospital. Epidemiologist in the medical director of the infection prevention and Control Department.

00:31 And Sasha Madison is my diabetic partner as the Director of the infection control and prevention.

00:42 And I'm Sasha Madison. I'm the administrative director for infection prevention. Patient. Safety and antimicrobial stewardship here at stanfordhealthcare. We are located in, Stanford, California. And I am doctor, Tomkinson dyadic partner, and we have worked together for 23 years.

01:05 I think we were going to talk about our journey through pandemic preparedness as our major focus of our discussion today. Will Sasha, would you like to start with how you managed to get into your career as an infection preventionist?

01:24 Yes, definitely. So I graduated from my masters of Public Health a number of decades ago on 1978 to be exact and at that time, when I was thinking about what I wanted to do with my mph and epidemiology, I asked for advice from my advisor, and I said that I was interested in going into Hospital, epidemiology infection, prevention, or actually back. Then infection control. And at that time, I remember I was told it was a waste of my time.

01:58 A waste of my education and that all infectious diseases would be cured by the year, two thousand. But I was certainly I could certainly go ahead and try if I want it. And I said, well, you know, that's my BET's on and I've been infectious diseases will still be around and I was very excited to start in a brand new field. It was only about two years old, really The Joint Commission and just required hospitals to have infection control programs in 1976. And so I was starting in a brand new profession and was very excited about about that.

02:44 And with that, I knew pretty much right from the beginning that every day would be different. I would learn something new everyday, but I never in my wildest dreams would have thought that I would see what I saw over the decades with regard to pandemics and epidemics. And I certainly never imagined that. I would have such a wonderful diabetic, partner colleague and friend as I have had and Lucy. So that's that's kind of my beginnings and Lucy. Do you want to tell us about how you got into the field of Hospital? Epidemiology? Well, it's a very different story. I always wanted to go to medical school, but I was just waited for various reasons from doing that.

03:35 And so I finally got an opportunity to go to graduate school and I got my PhD at Georgetown University and I worked in the laboratory later, you know, internationally-recognized microbe Hunter and all those Stan was very fascinated by the microorganisms that could cause disease and also would interact with human host.

04:03 I realized that just in working with him that I really wanted to be an infectious disease. This position if I ever got the opportunity, but at the time we worked on what are called are plasmids, they are the small little chromosomes, the bacteria carry that can contain antibiotic resistance genes. And so my PhD thesis was based on how these things are transferred from one microorganism to another one. And and and it the time we were using what would today would be called very primitive techniques to understand this. This really was no molecular biology or no molecular genetics.

04:46 But subsequently I did get to go to medical school. And then I finally ended up at the University of Washington for an infectious diseases Fellowship, which I did simultaneously with the clinical microbiology, fellowship. And I was looking for a scientist, someone I could work with to do my postdoctoral research and I ended up back in and Falco slab. He had moved from Georgetown to University of Washington before that. And so, I wasn't sure what I would be working in his lab. But he handed me a group of bacterial strains that have been sent to him by a wonderful physician and clinical microbiologist. Doctors in Port, who was the chief of the service, at the VA Hospital, which is a part of the University of Washington's teaching hospitals, and there was an outbreak of multidrug-resistant or

05:46 One in particular called serratia marcescens that Jim had sent to Stan and asked stand to see if he can see what what was going on there. And this was a pretty big cluster of infection. Sexually that mostly involve the patients on the Urology Wards. And so Stan handed them to me. And at that point Stan and others of had developed a lot of molecular tools that we can now use to investigate these organisms. And so I started doing what we called. I determined that if we adjusted the DNA from these organisms and looked at the plasmids on August gel that we could tell that this really wasn't outbreak of a single strength. And so I wrote my first paper,

06:38 With Dr. Plourde and Doctor Falco. And we use the term molecular, epidemiology mean 83 and also as the Director of the clinical microbiology laboratory. I, I set up a molecular fingerprinting laboratory section in the, in the Diagnostic lab as a way to implement, a real outbreak. Investigations course, there is very much more sophisticated technology out there. A whole tuna, genome sequencing and so forth, where it's, it's clearly become an absolutely essential part of understanding, the spread of infectious diseases in hospitals, in in pandemic.

07:30 So that's how I came to be essentially the hospital epidemiologist at Stanford when I actually took over the role, there really was no such thing as a hospital just in for a long time. Stanford Hospital paid me as the Director of the clinical microbiology like but I was really serving as they're in the role is the hospital epidemiologist and and then maybe 20 years into it. I was finally identified as the hospital if you know, I'll just stand and medical director and so 23 years ago. I was so fortunate to have Sasha is a fantastic partner and I can't tell you how much she has taught me and and how much she brings to the table in terms of our overall effort to try to prevent infections in patients.

08:24 And control them and also to study them if they happen to occur.

08:31 Interesting, Lucy talks about the kind of both the fingerprinting that kind of more technical piece of it. Will the work that when I first started an infection control in the work that you will still hear us. Talk about our really basic things like hand hygiene, and I'm when I first started in the role, it was you notes open water and we made sure people understood they have to wash their hands and that was the discussion and you fast-forward to the year 2000 and that's when we switched and Healthcare and realize that we could use alcohol gel products to ensure that we

09:13 Did hand hygiene appropriately and that was a huge game-changer for the fact that first of all, you could do it in between patients and all the times that we told people to do hand hygiene, but also, you fast-forward to the pandemic now and just think of, that's like one of the basic things that we have been discussing with everyone. So, a lot of our work when, when Lucy, and I talked about our work, it really cross has this huge spectrum of the most basic hand hygiene to these Technologies, like Lucy is talking about the gene whole genome sequencing, the ability for us, like to know about the very end this week, right? No more about the very end. And so it encompasses not only all these Technologies, but also when you think about our work, it's really we bridged.

10:13 So many bridges really, with first of all, we interpret the public health departments what they say. So we're really the Liaisons there. Also. We are the liaison between when you think about the patient as an individual, which is so much health care, but we have to think about our community and our community as the hospital. So that's the other thing that we that we really serve ass, and we also serve not and just caring for our patients, but caring for healthcare workers.

10:45 And we interact with everyone in the hospital. So we have this huge breath of

10:53 Information that we have. But also the interactions that we have that I think of very few other people in healthcare. Have that breadth of opportunity to make a difference and Lucy? And now I will talk a little bit more about this as we talked about some of the pandemic, but we span of the importance of caring for the patient, all the way into ensuring that the healthcare institution is caring for everyone. And so that's, you know, part of our work is, is really to translate it. It's when I think of the word translational research, a lot of times that's what we've done at the basic, you know, our basic work is really is really that taking public health, research, scientific research and bringing it to the bedside in the work that we do.

11:50 And I think the other thing before I switch it to tlusty. We'll talk a little bit about the AIDS. Pandemic or epidemic is that the first point at which that was the first epidemic that I've been involved in really, that it was such an important part of my career and it really prepared me in many ways for what we are seeing now with with covid. And again, it was this this translation of science, bringing it to all the caregivers and most of all it taught me to

12:32 To make sure that I respected all the people that I worked with and that no question was too dumb. Or there was no, that was no reason for me to think with or just say there's no you don't need to be worried. You don't need to be afraid. You know, I would I would be the one that would have to Model Behavior and try and calm people down while we integrated. What we knew about science to make feel people, feel comfortable enough to care for patients. And I think that's one of the the really unique opportunities and responsibilities that we have is that intersection of Science and the people that we work with making sure that they feel comfortable enough to care for the patients during pandemics and Lucy can talk to you little bit about her experience during the AIDS pen. For me. It was definitely a very defining moment.

13:32 For my career. My, my first entry into this was pretty, pretty quickly after I pretty quickly after I joined the faculty, maybe I forgotten when, when we had the first diagnostic test for HIV, but maybe 85, but my job was to convince physician leaders.

14:04 That we should start using what we call universal precautions that is that they should consider everybody fluid and and blood as potentially infected. And in the past the. I'm in infection control was that you tested people for certain things like hepatitis. And then you put a sign on the door to say. Okay. This person has hepatitis. You have to be extra careful. And what's it with the surgeons wanted to do in the air of the new era of HIV, because it was so deadly potentially deadly. Is they wanted basically, to be able to test every patient so that they would know what their status was before they would commit to doing surgery.

14:51 And a doctor Don regular, who has been a long-standing member of infection control committee and I were sent out to convince various positions that this was really wrong headed that we really needed to start doing what I've been. Got it and use UCSF at San Francisco, General all body fluids and blood as potentially infected. That means that you should take all the precautions that you would normally take. If you knew the patient had HIV, regardless of what their status would be in the operating room and then wearing gloves and and being very careful with needles and so forth. And I remember presenting this to

15:38 A group of Physicians. I won't say who. And who just in with overhead. We didn't have you know, I don't think I had sliced really we're just looking at the tip of the iceberg. If we just did we tested everybody for the things that we knew how to test for and that there was a whole lot underneath the water that we really should pay attention to and I almost got completely shot down by a couple of that we can we can be safe. And of course, it's all changed now with the idea that yes, you have to use precautions. If you think you're going to be splashed in the eyes and so forth. So that all had to be rolled out to the staff and convince them that this is the way to go as well as for the position sensor.

16:38 Sasha, and I asked her to focus on two different groups. Although I am responsible for, everyone's safety health care workers, regular role is really to work with other Physicians to help them understand that they do and and to know that these are the appropriate policies. We should follow him. And I think I've been pretty successful. Although there were some trials and errors along the way I said some things that probably shouldn't have been said. But overall, I think ultimately, I I I have assumed respects. I mean, I believe people to respect my my opinion because they know they can always find me and I will always work with him.

17:28 But Sasha, of course, has been the person who is really, I think, I spent so much time and she said, understanding the entire staff regardless of, you know, which department or which position they might work in from the people that work in the kitchen and environmental services all the way up to the nursing Personnel. So maybe we should turn to how we got into pandemic preparedness and Sasha 911. Well, it was yes couple I guess a couple weeks maybe after that the den that then Dean Dean Piezo.

18:16 Spoke to both Lucy and myself about the need for the medical center to be prepared for and I think that that's the beginning of our department for infection control and prevention, really being elevated. I guess in the eyes of the organization, all of a sudden everyone understood that we had something very very valuable to to contribute and Lucy can talk maybe a little bit about those first few meetings with the dean and the university and how the code that we used. If we ever were to have a buyer Terrace terrorism event how that all came about. So Lucy if you want to go ahead and talk a little bit about that. So I got a call from Phil Pizzo who was the dean and

19:16 Remind me to pretty well and he knew that I was a hospital, epidemiology. And he said, look, I I really think our hospital. I want our Hospital, be the very first institution to essentially develop, a bioterrorism response program. And, and and, and so you need to consider all the potential. Bioterrorism pathogens. That might be used, but at the time of the thinks that loomed large were Anthrax and smallpox, Airborne those organisms, that could be airborne spread.

19:53 And so I was very fortunate, the time. I was no longer the department director of the chronicle microlab, but I had a wonderful colleague. Dr. Ellen, Show Baron, who would who succeeded me? And I had a wonderful fellow infectious disease, fellow and training. Who was working with me. And so together, we started to workout essentially a diagram or an algorithm of how our emergency department in particular would respond to a patient who might come in with smallpox.

20:29 And and I and I wasn't as much involved in the, in the rollout and Sasha will explain. But are ultimately our plan that we developed, which was actually used for SARS, in Toronto. Susan, went back to the Toronto to be there Hospital, epidemiologist as well as a clinical microbiologist. And the plan that we all developed of how to respond, when we should close the doors to the hospital. How could we prove? How could we prevent staph infections? How could we care for the patients? And isolation, all all the things that ultimately where we're putting the place at Stanford. She took back to the University of Toronto and those were actually that the fundamental plan that they used.

21:29 To try to prevent continuing spread of infection it at the University of Toronto's hospitals. So Sasha, you should talk more about this really entailed operationally because you were at a critical. I mean, you and Artie more important than operationalize. The diagrams, the Ellen show, and Susan, I had built right? Well, first, it was interesting. As this was one of the first times where we had to have the school of medicine, Stanford Hospital & Packard, all work jointly work work together. And so, there was a team that was put together a bioterrorism preparedness team that then became the emerging infectious diseases group. It really worked on this particular project, but we have to do, we have to pick a unit that we had to I'm work with our emergency management team are

22:29 Emergency preparedness groups and figured out a way to make it what we would call all under negative pressure. We made rooms separately under negative pressure. We taught nurses how to appropriately, gown and glove. And most importantly mask, how to get the patience to this unit so that you wouldn't go through the hospital at all. So, it took a lot of thought into gratien and you know, just there was a lot of Education that had to go. I want it this time because there was a lot of of fear and so always we would keep people. Abreast. The other thing is around this time. It was recommended that hospitals be prepared in order, if they did, take how the units such as we were going to have them that you had staff that could care for these patients. And you might remember that most of us

23:29 Those of us that were older had, in fact been immunized for smallpox, right? But most of a good portion of staff had not and so we had to develop a vaccination programme as well that was done along with the state of California. Now, we just, we started that program. We had a group of maybe twenty people vaccinated and then the state abruptly stopped the program. But again, it just shows all of the all of the different entities that come in and would make recommendations, which is still the case to an institution like Stanford as an academic Medical Center. We were expected to integrate this information and put be prepared for the community and which we did. And so often times again, where an academic Medical Center and we're expected to be the leaders.

24:29 And and we were. So that was, it was exciting information. And if I just can backtrack a second, never in my, as I mentioned earlier in my career, did I think I was going to have to worry about smallpox. You know what that time, right after 9/11, you know, it had been well over a decade that smallpox been eradicated from the world. And so that was like, the one disease I thought. Okay, no never have to worry about that. And here it was. I had to go into all of our manuals and we had to make recommendations on appropriate isolation rooms cetera that we used in case we ever had a patient come in, was called code zebra. And the reason for that was again. It's kind of a zebra and a horse has highly unlikely to happen. But anyway, that was, that was our code, but it again gave us this framework. So that when we had the next disease,

25:29 It was SARS and Lucy and I will both talk about that a little bit. We were a little bit more prepared. Now. The first thing to mention is that these things always happen on a Friday afternoon or weekend so bad. There's either Yuri. Do you know I would always like hesitate because the CDC puts out there mmwr or there notifications on Fridays, you know, when you doubtless think I can, I wait till Monday to read this. I took it. I better I better read it now and that's when we first read about stars and then I still remember the weekend when what was actually was it was a Friday Friday afternoon. When I was helping at my daughter's high school and I took the day off and I was called in by our vice president that said, you know, we have to set up a unit, we have to set it up now and it has to be done by, you know, by the evening. And so I can

26:28 And again incredible. That's the one thing I can say about Stanford is the ability to bring a team together and to work really quickly and efficiently under a crisis situation is one of the most amazing things to watch. You know, otherwise, there could be a lot of discussion and academic discussion etcetera, etcetera, but when push comes to shove, really was incredible work. And so, the unit was was ready and and Lucy can tell you a little bit about stars from that clinical perspective, but we were, we were ready to go.

27:10 Well, I knew obviously that, you know what, it started in Hong Kong and and what the presumed mode of transmission was. It certainly seemed to be airborne droplets Fred. And I also knew that in Toronto, for instance, there been a number of health care workers who become infected and some died actually, cuz there really was no therapy and

27:38 I also later learned that came up again in the covid times, but it turned out there were only eight patients in the United States to acquire Stars. The original Stars, two of them were in Santa Clara County. So if there was ever going to be a case, it was going to be in our neck of the woods in, in large part because we're in the Silicon Valley and because there's such a huge network of back-and-forth, Transportation of a people from here, to the, to China and Hong Kong and back and forth, many people in Silicon Valley working and then come back, and then they're many Chinese who have phones. And another do other activities in the, in the in the in the Santa Clara Valley in the silicone area. So

28:38 That all essentially what we did in preparation for Stars. One really played out really well, I think four stars Kobe to, which is our current covid-19 pandemic. Unfortunately, I would just commented during the during after 9/11, at the time of 911. I was a member of the advisory committee on infection vaccination of programs. The acip, which is an advisory committee and I was just ready to become the the team leader of the of the new discussions that we're going to have about the new HPV vaccine.

29:38 So it's very excited about this and I'll be working with, you know, specialist to CDC and we would be leading the effort at that. If the acip meetings to talk about how to roll out, TV vaccine and everything came to a screeching halt drda Henderson, who would really finished off the smallpox virus have led the World Health Organization in the cessation of smallpox transmission.

30:07 Was told actually passed by the the federal government the White House.

30:15 To stop everything and have the acip start talking about how we're going to deal with smallpox in the United States, which as it turns out, so that, that put the HPV vaccine discussion on on the back burner to say the least. And so ultimately, we were able to convince the government that we didn't need to immunize everyone in the United States nor certain select group of people. But we we, we we we we we, we just have some First Responders who could do ring vaccinations. And I think it turned out that they really only were six of us at Stanford who got vaccinated. I think we should talk about covid-19 relief helped us put the foundation together for

31:15 For what we did, then four for covid and also taught me, one of the most important lessons that I learned an infection prevention and I had a little sticky tape that I would put on my computer and I had it on there for many years which was the Slowdown. And the reason I mention that very briefly is when you're in the midst of a pandemic and you're trying to get information out really really quickly. And you know, what? You want to say and you read the policy and you read the letter and read the memo and everything looks fine. And then you hit the send button and then I, you know, then you look at it again and you realize that the word not is missing, It just strikes fear into your heart. So anyway, that's the H1. N1 was yet. Another example of an that case. It wasn't a Friday call. It was a weekend call and I remember it was a from dr. Eric Weiss, and we worked.

32:15 Very closely with him on, emergency preparedness. And at that time, I remember him paging me and saying, have you read the most recent information from the CDC? H1. N1 came at a very different time of the year. It came in the spring. Usually we saw influenza starting in November etcetera. So this was very unusual. And I remember the first cases that they were mentioning to us where I think from from Mexico, was where the first cases were occurring and so Lucy and I met and numerous emails went out and policy developments etcetera, but I think one of the things that was probably again the most useful

33:04 And luckily I Lucy and I stayed in the organization long enough that we could reignite this particular thing or for covid-19 vaccine was, again, University School of Medicine University, School of Medicine, Stanford and Packard all working together. Multiple disciplines all in the same room. Tackling. How do we handle this particular epidemic or pandemic? So you had people from supply chain, the Physicians nursing, the laboratory everyone, Essex all in one room. And the main thing was that there was a very specific across-the-board decision-making. And at that time the group was called cost at then when we moved to the committee.

34:04 State board.

34:12 And then, then the later got changed to court. But I think the main thing is, it provided us a structure. And so that we had across-the-board decision-making, who would get the vaccine both among healthcare workers and patients how we would prioritize. So there wasn't I think my patients are the most important. I think my bet you do know your patients aren't as important. It was a group that made these decisions the same as ensuring that we had appropriate supplies. So it really provided this destruction that we were then able to take into the covid and covid. I can just start in and Lucy will add. We I remember we had our emerging infectious diseases committee meeting in January. It was somewhere around January 10th or 11th and talked about Wuhan pneumonia and we said

35:12 They say it's not transmitted person-to-person and all of us just had this feeling that. Gosh. I hope that's true, but I'm not sure. And then we have the infection control committee, the end of January and clearly by the beginning of February. We knew we were in for something different than any of the other experiences that that we had and that we are still experience, which is the covid pandemic. And I don't know Lucy if you want to add just a little bit more and then I'll finish up just about how that pain. Demica My overall thoughts about it and myself basically out of the basement. I use that term figuratively into the top of the organization. So our our our our department members and my

36:12 So we're up on virtually every every committee that dealt with covid-19 in the in the hospital. It must have been fifteen or eighteen different committees. We had already established, the idea of an incident command which saw she was talking about initially called coke cost now court. And so we were able to convince the leadership pretty early on that. It was time for us to stop talking about Wuhan and start developing an incident response to this another that it would have to be unified. And social actually led the effort to have as part of our, our work 2 to meet with the hospital epidemiologist in the infection preventionist.

36:59 In the other two hospitals that are part of Stanford, Enterprise stanfordhealthcare and we met. As I was saying earlier, at least four times a week for an hour over the last 20, some odd months to discuss all the policies, all the procedures, all the changing guidelines, everything that that happened. As such a said translating what public health. And I mean various agencies and public health said we shouldn't be doing into house. We would operationalize. This is Stanford, and I don't think for myself. I've ever worked longer or harder.

37:41 Or was more worried at least at the beginning. Then I have been over the over the last 21 months is certainly going to slow down but there was a time when the group of us were on the phone early on just just talking to one another and holding our hands off each others hands. We were working 20 hours a day. I'm pretty sure it. Just try to get the organization ready for patients and how to prevent infection. So it's been a huge effort. I think we've had an incredible success rate. Looking at all the possible outcomes that there could have been keeping our patients safe, keeping our staff safe.

38:35 And doing the right thing.

38:38 Yeah, I think Lucy the One Shining Light when I think about I mean it's been an incredible difficult, you know, incredibly difficult 21 months, but barriers were broken down silos were broken down and we worked truly as one team the organization. I would say, Stanford Packard valleycare, our sister hospital and the school of medicine. I think for us again early on, it was the fear that we might not have enough supplies. And you're, you're sending your team's. They're sending out health care workers in a quote on quote battle. And and where did we have everything for them? That we could possibly have to protect them if they cared for patient. So that they wouldn't be worried about themselves and could focus their energy on the care of the patient. That was very scary at the beginning, but we had incredible support from like our supply chain etcetera. So it really

39:38 Show the importance of a village the hospital as a village caring for our own caring for on the public the community. And it was on the days when you could reflect. It's very heartwarming to see that when we weren't completely tired and and scared. But if I think we were able to they knew we were always there to answer questions. My teams were there at night on the weekends? And there was no question. That was that was too trivial and I think that's the one thing when I think about the work that we do is that again that I talked about translation of the work science into practice and the heart that we carry with us into caring for our patients and healthcare workers that really to me is the symbol of the work that hospital epidemiologist.

40:38 Infection prevention do and its people think it's just data, but it's not its data and heart and it's the merging of the two, that makes it

40:50 Makes it possible for us to do the work we do and make me proud of the work that I've done all these decades. So, with an incredible colleague, and I add a partner and I could, I could have been luckier. So will you should be proud? So I should, I always say that when Sasha and resonate regardless of whether you're actually here or not. Hopefully I can translate it.

41:19 Anyway, that's that's it. Thank you. Thank you for listening to our story.

41:28 So, I think the other thing we were discussing Lucy was just our our love of music and I know you're you're going to add a little bit but part of what I was reflecting on was particularly during the pandemic. How we had to nourish ourselves. We had to make these decisions that are really weighty decisions. That's the organization expected of us. Expected us to make. And so for me nourishing my my soul. So then I couldn't worry about these other things. I could just think about the beauty of Music, my love of music, all kinds of music and also walking and nature. Those are the two. The two things that definitely nourish me and to be able to share my love of music with one of my best friends was another gift. So it's that that's something that you share with some

42:28 One. But, and also music. It was hard. Obviously, we couldn't go to the symphony for at least a year, but we could talk about music. And so, I don't know if you wanted to add anything else about nourishing yourself. Again, during this very difficult time for me, music has been my, you know, my, my Escape ever since I started playing piano at age four and my other. And so after my husband died, it was wonderful to have Sasha is my partner to attend all these concerts, and the Opera and, and so forth. And we were able to do that for a whole year.

43:13 I've been very lucky that I have another home in Bitterroot Valley of Montana where my late husband, and I were a part of the Rocky Mountain, Laboratories scientific Advisory Group. And and so, I spend every summer in Montana, which is also been my great getaway. And and again, loving loving nature.

43:43 Hiking in riding fly-fishing, to take my my mind off of the work, even though it really kind of never ended. So, I think,

43:57 It was possible for most people who weren't infirm, be able to go outside and even just taking a walk. And for me. I have to walk my dog everyday and it's been really good for me to do it. Even though there's a lot of mornings. When I think God do I really have to do this? Just just to just to be out and now I don't have to wear outside. Although certainly did at least a year just to be conscious of my fellow dog walker.

44:33 Yeah, I am very isolating because I've been working from home pretty much the entire time and sitting in front of the zoo. All day long is innovating the least and it and it is lonely. And so my opportunities to see people are special, very, very special.

45:03 That's that's that's a big deal for me.

45:08 We're lucky to have a joint. The things that we love doing together, you know, the Music and start hiking and and I love of animals as well. So again, very very strong bonds there. But yeah. Music there's a very good song by Gary Clark jr. Very good blues. Rock and roll guitarist called music is my healing. I think definitely was.

45:35 Lucy, and I experienced during the