WEBVTT 00:13.210 --> 00:15.234 [SPEAKER_00]: Hello and welcome back to HACRAC. 00:15.614 --> 00:19.802 [SPEAKER_00]: I'm Jed Wolpa and I am thrilled to be back for another master clinician episode. 00:20.223 --> 00:26.395 [SPEAKER_00]: I have with me a true master clinician in general and specifically with OB anesthesiology, Dr. Bridget Merrick went now. 00:26.615 --> 00:32.406 [SPEAKER_00]: You may recognize Bridget from having been on the show previously, but now she's back to represent herself as a master clinician. 00:32.426 --> 00:32.586 [SPEAKER_00]: So, 00:32.566 --> 00:36.152 [SPEAKER_00]: She is an OB anesthesiologist and an associate professor at UNC. 00:36.252 --> 00:38.416 [SPEAKER_00]: She's also one of the APDs of the residency program there. 00:38.876 --> 00:49.213 [SPEAKER_00]: And really interestingly, Dr. Marquind did an OB residency first and then practiced obstetrics and got in college for four years before they're going back and doing an anesthesiology residency. 00:49.594 --> 00:56.245 [SPEAKER_00]: And I want to read to you some of the comments that both faculty and residents who have worked with her submitted when nominating her. 00:56.225 --> 00:58.968 [SPEAKER_00]: to be a master clinician on the episode here. 00:59.369 --> 01:00.130 [SPEAKER_00]: So here we go. 01:00.290 --> 01:03.294 [SPEAKER_00]: Dr. Marquin is one of the most impactful educators in clinicians. 01:03.354 --> 01:04.696 [SPEAKER_00]: We've had the privilege to work with. 01:05.076 --> 01:08.040 [SPEAKER_00]: And we believe her insight and experience would resonate with your audience. 01:08.360 --> 01:17.172 [SPEAKER_00]: She brings a unique and valuable perspective to stetric anesthesiology as she completed a full OBGYN residency and practices an obstetrician prior to her anesthesiology training. 01:17.572 --> 01:25.422 [SPEAKER_00]: Her clinical acumen reflects the depth of both specialties, and she consistently models a thoughtful, collaborative style that elevates patient care. 01:25.402 --> 01:31.209 [SPEAKER_00]: Another one, more than her clinical expertise, however, Dr. Mariquin's leadership and teaching truly set her apart. 01:31.589 --> 01:34.773 [SPEAKER_00]: She is a gifted communicator and an emotionally intelligent leader. 01:35.254 --> 01:40.680 [SPEAKER_00]: So much so, that she led a didactic series on emotional intelligence and medicine and leadership for our residency program. 01:41.041 --> 01:46.307 [SPEAKER_00]: She fosters a team culture where everyone feels seen, supported, and empowered from chief residence to medical students. 01:46.707 --> 01:54.717 [SPEAKER_00]: Her influence has been foundational for foundational for many of us in training, myself included, and she remains a role model for the kind of 01:54.697 --> 01:57.742 [SPEAKER_00]: And finally, Dr. Merckwin is a phenomenal educator and communicator. 01:58.103 --> 02:00.907 [SPEAKER_00]: She's the kind of leader that makes everyone feel valuable to the team. 02:01.268 --> 02:06.196 [SPEAKER_00]: She handles conflict with assertive curiosity and navigates tough interdisciplinary situations with poise. 02:06.617 --> 02:09.602 [SPEAKER_00]: She has served as a role model for me and many of my co-residents. 02:09.942 --> 02:11.905 [SPEAKER_00]: I think your listeners would love to hear her perspective. 02:12.406 --> 02:14.770 [SPEAKER_00]: I couldn't agree more and I am thrilled to have her on the show. 02:14.790 --> 02:16.553 [SPEAKER_00]: Bridget, welcome back to Acreck. 02:17.647 --> 02:23.661 [SPEAKER_02]: Thank you so much, those words are very kind and humbling. 02:24.162 --> 02:30.998 [SPEAKER_02]: And I do believe no doubt my prior experience is an obstetrician. 02:32.463 --> 02:42.694 [SPEAKER_02]: definitely makes navigating this space of a little easier and I think it helps the residents and my colleagues navigated as well. 02:42.914 --> 02:43.975 [SPEAKER_02]: I hope. 02:44.015 --> 02:44.236 [SPEAKER_00]: Yeah. 02:44.296 --> 03:01.474 [SPEAKER_00]: Well clearly it does and you know I love that because I think it's such a good reminder to for folks out there who maybe you know I did not I'd start at a different residency and then switch in anesthesia you did an entire one you know for folks who are thinking maybe they're not happy in their current residency but they're thinking 03:01.454 --> 03:24.964 [SPEAKER_00]: seems like too daunting to switch you know people like you who who not only switched after an entire residency and beginning practice but who are glad they did I mean glad they they did they didn't they wouldn't go back and change it right that that experience has added to your career and clearly as we saw in these comments has been part of what has made you such an incredible teacher and mentor to the people who've had the privilege of working with you so I think that's really wonderful to see into here. 03:25.990 --> 03:37.148 [SPEAKER_02]: Yes, I couldn't agree more, and you and I were just talking before you hit the record button about interviews season and certainly the fourth year medical students are nervous and they're starting their interviews season. 03:37.428 --> 03:52.993 [SPEAKER_02]: I've never been fourth year medical students I talk to in January and they're halfway through the interview process and they say, oh my goodness, I just did four weeks of anesthesia and I love it and I can't do P to I don't want to do medicine and then we help them navigate 03:52.973 --> 03:54.296 [SPEAKER_02]: you're never too old. 03:54.797 --> 04:11.033 [SPEAKER_02]: It's never too late and yes, there were many times that three years of the anesthesia residency, you know, two kids at home and a husband who was a surgeon and I'd be in the hospital doing ICU and I would call him and tears, I can't do this, I'm exhausted, these patients are too sick. 04:11.013 --> 04:17.582 [SPEAKER_02]: Um, so I wouldn't go back and redo it, but I, but in retrospect, I'm, I'm so glad that I did. 04:17.602 --> 04:26.754 [SPEAKER_02]: Right, my husband said to me, and when I was sort of deciding to, if, if I wanted to go back or not, and he said, honey, the blood sweat and tears we put into what we do every day. 04:26.774 --> 04:29.097 [SPEAKER_02]: And I share this with students and residents as well. 04:29.557 --> 04:31.620 [SPEAKER_02]: We put so much energy into what we do. 04:31.600 --> 04:32.902 [SPEAKER_02]: you want to be happy. 04:33.043 --> 04:36.028 [SPEAKER_02]: You have to get up and go to work every day and you want to enjoy it, right? 04:36.108 --> 04:41.919 [SPEAKER_02]: So I feel like you and I and many of the people we work with safely have found our space. 04:42.040 --> 04:42.200 [SPEAKER_02]: What? 04:42.460 --> 04:43.883 [SPEAKER_02]: What fills our cup? 04:43.903 --> 04:44.344 [SPEAKER_00]: Absolutely. 04:44.925 --> 04:47.550 [SPEAKER_00]: Well, let's talk about some of the 04:47.530 --> 04:51.457 [SPEAKER_00]: pearls that you have gained over the years that you teach your trainees. 04:52.699 --> 05:02.535 [SPEAKER_00]: And so obviously, if you're going to send around your experience in OB anesthesia, that's your specialty, talk about what it means to be a pessimist and why that might be a good day. 05:03.798 --> 05:05.761 [SPEAKER_02]: So I have to give a little back on, right? 05:05.801 --> 05:10.507 [SPEAKER_02]: So in the OB world, training and residents, we would say, this is going to sound terrible. 05:10.527 --> 05:12.270 [SPEAKER_02]: We would say, all patients are liars. 05:12.390 --> 05:13.872 [SPEAKER_02]: OK, so that doesn't sound very good. 05:14.052 --> 05:15.174 [SPEAKER_02]: But patients are forgetful, right? 05:15.214 --> 05:16.616 [SPEAKER_02]: So somebody shows up in the murder's room. 05:16.636 --> 05:17.597 [SPEAKER_02]: She's got abdominal pain. 05:18.479 --> 05:23.005 [SPEAKER_02]: And you ask her if she's sexually active, she says, no, you just assume she forgot. 05:22.985 --> 05:33.777 [SPEAKER_02]: everybody gets a pregnancy test and then so all patients are sexually active, all all patients are pregnant, all pregnancy, all pregnancies are ectopic, until proven otherwise, right? 05:33.797 --> 05:36.440 [SPEAKER_02]: You sort of check, check, check off the boxes that are concerning. 05:36.840 --> 05:44.429 [SPEAKER_02]: So when I have a patient who's on labor delivery, she's got a labor epidural, I tell the resident, okay, every patient might need our care. 05:45.069 --> 05:52.958 [SPEAKER_02]: So if you're at team sign out, if the obese are telling you about somebody, even if the patient she loves to be completely natural, 05:53.478 --> 05:53.999 [SPEAKER_02]: Pay attention. 05:54.981 --> 05:55.622 [SPEAKER_02]: She might need us. 05:56.143 --> 05:59.869 [SPEAKER_02]: Everybody who has an epidural that epidural might go to the OR. 06:00.030 --> 06:02.033 [SPEAKER_02]: You might have to use it for starting delivery. 06:02.053 --> 06:05.259 [SPEAKER_02]: You might have to use it for a postpartum hemorrhage DNC. 06:05.299 --> 06:07.803 [SPEAKER_02]: So every epidural might go to the OR. 06:08.524 --> 06:11.149 [SPEAKER_02]: Don't be afraid to replace them. 06:11.298 --> 06:20.232 [SPEAKER_02]: You know, team up, do some up, try to, you know, check a level if he patients not happy you're not happy just replace it sooner rather than later. 06:20.493 --> 06:23.057 [SPEAKER_02]: Yeah, earlier early replacement is easy. 06:23.097 --> 06:24.679 [SPEAKER_02]: So that's sort of my pessimist. 06:25.260 --> 06:30.268 [SPEAKER_00]: Yeah, you know, that's I love that because we think pessimism is a bad thing, but you know, the way you're framing it. 06:30.248 --> 06:42.948 [SPEAKER_00]: and I agree I think it applies to so many things that can be so important and I think I tell people that I think it's important to be what I call a red light person and what I mean is if you are planning let's say okay I'm on call tonight. 06:43.008 --> 06:45.251 [SPEAKER_00]: All right, I've got to be there to get signed out of 7 p.m. 06:45.752 --> 06:47.835 [SPEAKER_00]: So if I say to myself well listen. 06:47.815 --> 06:53.005 [SPEAKER_00]: Okay, finally my house and all the lights are green on my way to work is going to take me 15 minutes. 06:53.085 --> 06:57.032 [SPEAKER_00]: So I'll leave it 645 because, you know, I'll be there 7 if all the lights are green. 06:57.052 --> 06:57.914 [SPEAKER_00]: That's a green light person. 06:58.335 --> 07:01.501 [SPEAKER_00]: If you're a red light person, you say, well, I'm going to assume all the lights are going to be red. 07:01.861 --> 07:03.745 [SPEAKER_00]: In which case, it will take me 25 minutes. 07:03.765 --> 07:08.393 [SPEAKER_00]: So I will leave at 630 in case one of those lights is broken and never turns green. 07:08.694 --> 07:11.359 [SPEAKER_00]: So I'm going to really plan as a pessimist. 07:11.339 --> 07:19.795 [SPEAKER_00]: And then you will never be late for sign out and you will always be at the least on time and often early and your colleague will feel like you care about that and respect them. 07:19.815 --> 07:19.956 [SPEAKER_00]: Right. 07:19.976 --> 07:22.581 [SPEAKER_00]: So that's that kind of pessimism. 07:22.621 --> 07:26.989 [SPEAKER_00]: I think is really important when we're working in our in our specialty. 07:27.009 --> 07:27.350 [SPEAKER_02]: Yeah. 07:27.370 --> 07:28.572 [SPEAKER_02]: And I think. 07:29.108 --> 07:34.098 [SPEAKER_02]: Another way to phrase it is, plan for the worst, hope for the best, right? 07:34.238 --> 07:35.020 [SPEAKER_02]: Yep. 07:35.040 --> 07:40.030 [SPEAKER_02]: If I think, you know, maybe I should get blood in the room. 07:40.090 --> 07:42.034 [SPEAKER_02]: If it crosses my mind, we're just getting blood in the room. 07:42.475 --> 07:49.750 [SPEAKER_02]: Like maybe she's at high risk, you know, laboring for four days, pushing for three hours, now infected. 07:50.641 --> 07:51.903 [SPEAKER_02]: Let's just get some blood in the room. 07:51.923 --> 07:53.925 [SPEAKER_02]: She's gonna have much potentially. 07:54.226 --> 07:54.727 [SPEAKER_00]: Totally right. 07:55.307 --> 07:57.751 [SPEAKER_00]: Let's talk about the specifics of replacing an epidural. 07:57.791 --> 08:01.596 [SPEAKER_00]: So let's say you have a patient, she's got an epidural in. 08:01.616 --> 08:02.317 [SPEAKER_00]: You place the epidural. 08:02.777 --> 08:03.498 [SPEAKER_00]: Maybe you do a CSE. 08:03.558 --> 08:04.520 [SPEAKER_00]: That's very common these days. 08:04.580 --> 08:06.322 [SPEAKER_00]: And she's got initial great control. 08:06.362 --> 08:07.784 [SPEAKER_00]: And then the kind of spinal part wears off. 08:07.824 --> 08:10.508 [SPEAKER_00]: And now she's got one-sided pain relief. 08:10.528 --> 08:12.110 [SPEAKER_00]: Do you immediately replace it? 08:12.130 --> 08:12.971 [SPEAKER_00]: Do you try to troubleshoot? 08:13.011 --> 08:15.174 [SPEAKER_00]: You know, what's your approach there? 08:15.194 --> 08:20.361 [SPEAKER_02]: Oh, so much last. 08:21.337 --> 08:22.504 [SPEAKER_02]: 10 to 08:23.902 --> 08:25.984 [SPEAKER_02]: So check your levels, right? 08:26.024 --> 08:28.227 [SPEAKER_02]: So now you recognize that it's one side of it. 08:28.247 --> 08:33.153 [SPEAKER_02]: And I, in my opinion, the definition of one side is more than two-term retombs off. 08:33.393 --> 08:39.961 [SPEAKER_02]: So if it's T8, T10, not really, not really one side, but T6, T10, potentially one side of it. 08:39.981 --> 08:44.126 [SPEAKER_02]: So I always try volume first. 08:44.867 --> 08:47.229 [SPEAKER_02]: I don't pull it back right away. 08:47.370 --> 08:53.757 [SPEAKER_02]: So having been doing Obianicies alone enough, 08:54.766 --> 08:59.536 [SPEAKER_02]: The textbooks would tell you that positioning doesn't matter for voicing an epidural. 08:59.556 --> 09:00.879 [SPEAKER_02]: We can put the patient on our head. 09:00.919 --> 09:03.444 [SPEAKER_02]: If it's a lumber epidural, it's going to fill the lumber space. 09:03.504 --> 09:03.664 [SPEAKER_02]: Right. 09:04.065 --> 09:07.392 [SPEAKER_02]: The RASIC epidural is going to fill the thoracic space. 09:07.540 --> 09:20.196 [SPEAKER_02]: But the way our epidural sort of drip drip slowly, certainly, if you're running 10 ml an hour over a continuous infusion, potentially patient falls asleep on a right side, she might have more of a right side of the block. 09:20.216 --> 09:22.919 [SPEAKER_02]: So I tell the residents, just try volume first. 09:23.320 --> 09:30.088 [SPEAKER_02]: And then, if you come back and check it again, it's still one-sided, the same side is higher. 09:30.220 --> 09:38.001 [SPEAKER_02]: then pull it back a half-send later, which is a later end then volume, but I feel as though especially if you've done a CEC and you've confirmed your midline. 09:38.543 --> 09:41.310 [SPEAKER_02]: I feel as though very often they're once-sided and then 09:42.151 --> 09:42.812 [SPEAKER_02]: later on there. 09:43.033 --> 09:45.297 [SPEAKER_02]: They're bilateral and maybe they're one side of the other side. 09:46.099 --> 09:49.726 [SPEAKER_02]: And I think documentation is really important too from one shift to the next. 09:49.806 --> 09:53.373 [SPEAKER_02]: Oh, she was T6, T10, the right side was higher in four hours. 09:53.454 --> 09:56.339 [SPEAKER_02]: She's T7, T10, but now it's the left side. 09:56.580 --> 09:59.125 [SPEAKER_02]: Oh, of course the epidural must be in the midline. 09:59.506 --> 09:59.846 [SPEAKER_00]: Right. 09:59.866 --> 10:01.189 [SPEAKER_00]: Yeah, that makes a lot of sense. 10:01.169 --> 10:12.586 [SPEAKER_00]: And let's say you, okay, you try volume you bullets it, it's still one side did, if that point maybe you pull it back and try, still, if that point was, I said at some point you're going to say we just need to replace this. 10:13.247 --> 10:13.448 [SPEAKER_02]: Right. 10:14.089 --> 10:14.249 [SPEAKER_02]: Yeah. 10:14.269 --> 10:23.322 [SPEAKER_02]: I think after a couple of fullbacks, it's certainly if you pull back so much that you don't have more than three centimeters in this space, it's time, it's not every place. 10:23.343 --> 10:23.963 [SPEAKER_00]: Yeah. 10:24.524 --> 10:27.649 [SPEAKER_00]: And you just go up or down a level and do it or how do you replace it? 10:29.553 --> 10:33.118 [SPEAKER_02]: Um, and I have to say not necessarily a specific up or down. 10:33.138 --> 10:35.541 [SPEAKER_02]: I think whatever space feels, feels good. 10:36.383 --> 10:36.723 [SPEAKER_02]: Okay. 10:36.743 --> 10:36.843 [SPEAKER_02]: Yeah. 10:36.863 --> 10:39.767 [SPEAKER_02]: Maybe the upper spaces, wider the lower spaces, wider. 10:40.028 --> 10:40.669 [SPEAKER_00]: Yeah. 10:40.689 --> 10:52.105 [SPEAKER_00]: And how about the classic conundrum of, uh, you are, you have an epidural it's working, uh, you know, okay for labor, you have to now go to see section. 10:52.185 --> 10:58.193 [SPEAKER_00]: You bowl a sit and you do not have adequate and how 10:59.438 --> 11:00.079 [SPEAKER_02]: Great question. 11:00.359 --> 11:08.347 [SPEAKER_02]: So, I will, in my mind, commit to using the epidural initially. 11:08.627 --> 11:14.493 [SPEAKER_02]: If there's any question, if I think once again, it's that plan for the worst hope for the best. 11:14.513 --> 11:22.501 [SPEAKER_02]: So if there's any question, I just pull it out and do a CSE in the back in the R. But if I'm thinking, okay, it looks like good levels. 11:23.642 --> 11:26.104 [SPEAKER_02]: I'll commit to it. 11:27.687 --> 11:30.591 [SPEAKER_02]: eight MLs like I'll do a three ML test dose and then five MLs. 11:30.792 --> 11:33.876 [SPEAKER_02]: If, after eight MLs may be 10, you could push me to 10. 11:34.757 --> 11:36.340 [SPEAKER_02]: I'm not seeing any rise. 11:37.942 --> 11:40.145 [SPEAKER_02]: Then we pause, we set up, we do a CSE. 11:41.688 --> 11:45.153 [SPEAKER_02]: If in my mind, okay, I got to 10, I'm giving more. 11:45.553 --> 11:48.678 [SPEAKER_02]: I've already committed to, I'm putting her just like, if this doesn't work, right? 11:48.718 --> 11:55.568 [SPEAKER_02]: So once I've committed to filling up that epidural space, I've already told myself, wait, it's either working. 11:56.324 --> 12:00.851 [SPEAKER_02]: I have faith in this episode, and if that doesn't work out, then we're going to go off general anesthesia. 12:01.352 --> 12:01.552 [SPEAKER_02]: Yeah. 12:02.013 --> 12:02.714 [SPEAKER_00]: Yeah. 12:02.734 --> 12:06.861 [SPEAKER_00]: And we just did an episode on this with some of your colleagues and I'll be anesthesia. 12:06.941 --> 12:15.835 [SPEAKER_00]: Obviously, the now very, you know, much listen to, podcast from, um, 12:15.815 --> 12:20.021 [SPEAKER_00]: And I'm blanking out the name, but about the pain after CSA, a pain-durched C-section. 12:20.481 --> 12:22.344 [SPEAKER_00]: Oh, we treat those. 12:22.364 --> 12:23.866 [SPEAKER_00]: The retrieval, yeah, season two of the retrieval. 12:24.967 --> 12:25.748 [SPEAKER_00]: You know, covered this. 12:25.788 --> 12:39.787 [SPEAKER_00]: So, do you think we have swung kind of as a specialty too far towards the avoid general at all costs, and we should be more willing to go to sleep if a patient is experiencing pain during CSA? 12:41.169 --> 12:43.172 [SPEAKER_02]: Or to say, I think, 12:44.789 --> 12:54.684 [SPEAKER_02]: because I accept for a patient with a terrible airway or some crazy cardiac, something, and I, for that reason, I don't wanna put them just sleep. 12:55.185 --> 13:00.433 [SPEAKER_02]: I feel as though I've always been okay, let's, we're gonna go to sleep. 13:00.513 --> 13:05.481 [SPEAKER_02]: And I try to be sort of black and white about it, but it's, you know, it's not. 13:05.461 --> 13:10.268 [SPEAKER_02]: not every clinical cases is even to decide, right? 13:11.149 --> 13:18.120 [SPEAKER_02]: I do have a story about a, um, I spinal, though, thinking about replacing the bitter roles and going back. 13:18.721 --> 13:31.820 [SPEAKER_02]: So, um, I came in and probably a Monday morning, Tuesday morning on, on labor and delivery in this woman had been induction labor, maybe for day and a half, two days. 13:31.900 --> 13:33.122 [SPEAKER_02]: She had an epidural, 13:35.026 --> 13:40.354 [SPEAKER_02]: And her epidural was working, but she was complaining a lot of scapular pain. 13:41.416 --> 13:48.788 [SPEAKER_02]: And now, in retrospect, now, no doubt her epidural space was full of volume. 13:49.369 --> 13:55.779 [SPEAKER_02]: But she was complaining about the same time that OB said, well, she's been pushing for three hours or now going to go back to the OR. 13:56.160 --> 14:02.670 [SPEAKER_02]: So she's sort of complaining, but then she's also emotionally upset about now after two days I'm going to be OR. 14:03.646 --> 14:29.991 [SPEAKER_02]: probably some intramy on a confection going on so it's a little bit of a a Russian I went and checked a level and she had you know pretty good levels maybe T10 T10 to Sharp and um oh no no no no no no no I take that back she didn't she didn't have good up that's right but she's complaining of stuff like just her neck hurts and her back hurts and she's been in this labor bed okay so so we decide okay we're not going to dose the ever to a little I didn't dose I didn't dose it up take you back we'll put it we'll do SCSE 14:30.798 --> 14:37.631 [SPEAKER_02]: She's probably five foot four, BMI of 38, sort of, not to bake, not too short, not too tall. 14:38.933 --> 14:50.595 [SPEAKER_02]: Pulled out the evidence roll, did a CSE, gave her standard 1.6, heavy bbp gain, take the evidence roll, later down, probably was in a minute of the evidence roll. 14:50.913 --> 14:58.122 [SPEAKER_02]: and she immediately could not donate, but mouth to me, I cannot breathe. 14:58.483 --> 15:02.488 [SPEAKER_02]: Well, she, that was my first and only ever high spinal. 15:04.150 --> 15:11.199 [SPEAKER_02]: And no doubt was because her fecal, epidural space was full of volume. 15:11.359 --> 15:13.822 [SPEAKER_02]: Poon, you know, how many, you know, 100, 150 of them. 15:14.123 --> 15:16.566 [SPEAKER_02]: And then this line of light gave her just went really high. 15:16.715 --> 15:24.728 [SPEAKER_02]: And so I said to the obese, she has a high spinal, and they said, is she stable? 15:24.808 --> 15:26.231 [SPEAKER_02]: And I turned the monitor towards them. 15:26.271 --> 15:27.733 [SPEAKER_02]: And I said, her blood pressure is good. 15:28.394 --> 15:30.498 [SPEAKER_02]: I grabbed the mask from the machine. 15:30.578 --> 15:32.682 [SPEAKER_02]: And I, you know, essentially did CPAP to the patient. 15:33.022 --> 15:34.445 [SPEAKER_02]: And I talked with her the whole time. 15:34.485 --> 15:36.628 [SPEAKER_02]: And I said, you have a really high spinal. 15:36.648 --> 15:39.533 [SPEAKER_02]: I'm going to help you breathe. 15:39.513 --> 15:42.316 [SPEAKER_02]: This will probably last, you know, a few minutes. 15:42.597 --> 15:46.061 [SPEAKER_02]: I said, I can put you to sleep if you're really feeling very anxious. 15:46.121 --> 15:48.484 [SPEAKER_02]: And I understand it's safe either way. 15:48.524 --> 15:49.265 [SPEAKER_02]: I can put you to sleep. 15:49.305 --> 15:51.688 [SPEAKER_02]: Do you want me to put your sleep completely and she shook her head? 15:51.728 --> 15:51.948 [SPEAKER_02]: No. 15:52.088 --> 15:54.111 [SPEAKER_02]: And I said, okay, I'll keep checking with you. 15:54.711 --> 16:00.558 [SPEAKER_02]: And I said, your husband can come back once you can breathe, you know, on your own without the support from the masks. 16:00.578 --> 16:07.647 [SPEAKER_02]: So from the time we later down to the time she could breathe on her own was about eight, nine minutes. 16:08.825 --> 16:18.918 [SPEAKER_02]: I'm retrospect, I wish I told the Obes to go faster to deliver the baby, so she was hemoured and emplaced, stable, but the baby came out really acedotic. 16:19.299 --> 16:27.389 [SPEAKER_02]: And so I think what happened was she was ventilating, but probably not effectively, even with, you know, sort of seep up much support from us. 16:27.409 --> 16:34.498 [SPEAKER_02]: So I think if I had a high spinal in the future, I would say her blood pressure is good, but her yet because she's probably going to be hypercarbic. 16:34.979 --> 16:35.980 [SPEAKER_02]: Interesting. 16:36.854 --> 16:39.279 [SPEAKER_02]: Yeah, that's my my theory. 16:40.000 --> 16:48.817 [SPEAKER_02]: And as I said, it's the only high spinal like head since then, and I talked to a number of people and most OBNC zelogists said, yes, you did the right thing. 16:48.877 --> 16:50.540 [SPEAKER_02]: You didn't, you don't have to anticipate them. 16:51.361 --> 16:53.505 [SPEAKER_02]: If they're stable, and you know, talk to her. 16:53.686 --> 17:00.178 [SPEAKER_02]: And then some people who aren't, don't do a lot of OB, say, oh my gosh, the one I had in my career, I put him just like so I think. 17:00.361 --> 17:02.604 [SPEAKER_02]: either choice is the right choice. 17:02.645 --> 17:13.862 [SPEAKER_02]: And the crazy thing is, you know, talking with the patient and the husband afterwards and the obese and telling him everything that went on and, you know, very apologetic and, you know, just sort of explain the physiology. 17:14.523 --> 17:21.694 [SPEAKER_02]: She came back three years later with her scheduled surgery for baby number two and I just happened to be on. 17:21.674 --> 17:33.398 [SPEAKER_02]: And I walked into the room and reintroduce myself, and she remembered me, and I said, I'm sure you have trauma from your first delivery, and if you want another anesthesiologist, we can get you one today. 17:33.418 --> 17:36.284 [SPEAKER_02]: And she said, no, we want you to take care of us. 17:36.324 --> 17:38.589 [SPEAKER_02]: So that was sort of full circle. 17:38.649 --> 17:40.172 [SPEAKER_02]: That was um, 17:40.844 --> 17:52.238 [SPEAKER_02]: I learned a lot that day, and then even in retrospect, you know, we reviewed the M&M about the new foreign PhD such, but yeah, high spinals, there's not a radio answer. 17:52.336 --> 17:53.278 [SPEAKER_00]: Yeah, that's really interesting. 17:53.378 --> 18:01.996 [SPEAKER_00]: And what I love about that, I bet if I had to guess the reason she was so clear that she wanted you to take care of again is because you involved her in the decision, right? 18:02.016 --> 18:04.100 [SPEAKER_00]: You didn't just say, we're going to sleep, we're not going to sleep. 18:04.541 --> 18:05.563 [SPEAKER_00]: You said, listen, both are fine. 18:05.864 --> 18:06.625 [SPEAKER_00]: It's up to you, right? 18:06.966 --> 18:13.720 [SPEAKER_00]: And that's one of the things we heard a lot in the retrievals podcast and that, you know, I think people hear from when they talk to patients about this is that 18:13.700 --> 18:19.528 [SPEAKER_00]: If you make them feel like going to sleep is a mistake, then that's that they feel like they don't have a choice. 18:19.668 --> 18:22.873 [SPEAKER_00]: And if you don't, if you just put them to sleep, then they definitely didn't have a choice. 18:22.893 --> 18:29.122 [SPEAKER_00]: And so if you can offering them a choice and letting them be part of that discussion, I think that probably made her feel really supported by you. 18:31.465 --> 18:33.228 [SPEAKER_00]: Let's talk about NPO status. 18:34.710 --> 18:35.912 [SPEAKER_00]: What have you learned over the years? 18:35.952 --> 18:36.973 [SPEAKER_00]: What do you teach about that? 18:38.185 --> 18:55.911 [SPEAKER_02]: So this is the tough one to teach and even sometimes to wrap my head around and certainly the obese, I feel really badly for them because from their perspective it's like, oh, whatever anesthesiology you get on board, that's the rules today for NPO status. 18:56.492 --> 18:58.455 [SPEAKER_02]: So, you know, there's the... 18:58.688 --> 19:08.280 [SPEAKER_02]: Scheduled, I'm coming in from my scheduled repeats of serendilibrary, or I'm coming in from my scheduled breach, you know, breach positioning the serendilibrary. 19:08.440 --> 19:12.285 [SPEAKER_02]: And those patients absolutely should be appropriately NPO. 19:13.587 --> 19:16.371 [SPEAKER_02]: And then, here's a story. 19:16.451 --> 19:18.233 [SPEAKER_02]: So a woman. 19:19.715 --> 19:46.887 [SPEAKER_02]: repeat cesarean delivery scheduled for tomorrow or something, and she comes in tonight at midnight, ruptured membranes breach, and she comes in at midnight, you know, ruptured membrane, she's laboring a little bit, but she had a bowl of cereal at 10 pm, cereal with milk, and so the anesthesia team said, well, NPO will be six a.m. 19:47.153 --> 19:54.101 [SPEAKER_02]: which is true, NPO 8 hours will be 6 p.m. or 6 a.m. after the 10 p.m. serial. 19:55.162 --> 20:13.684 [SPEAKER_02]: And you know, the story goes on and then she's contracting and then she's really uncomfortable and then and then they put it in an epidural role and then finally they went back and then you know, they couldn't use the epidural just crazy crazy story and so in reviewing it with the with the resident and and you know the attending and we're muted in our m m m m m. 20:15.048 --> 20:20.956 [SPEAKER_02]: Once, like, she comes in in labor, it's not elective anymore, right? 20:20.976 --> 20:22.599 [SPEAKER_02]: She's not scheduled. 20:23.380 --> 20:34.255 [SPEAKER_02]: And even if you waited eight hours, I mean, she is in so much pain that she's requesting a labor epidural, she won't have an empty stomach at Ficthia. 20:34.235 --> 20:47.558 [SPEAKER_02]: So, better to just have the obese right in their note, you know, this is an unscheduled, not electives, the serring delivery issues, laboring, she's breached, she could drop a cord, you know, she dilated her cervix enough. 20:47.939 --> 20:49.682 [SPEAKER_02]: So that's what I try to keep through it. 20:49.702 --> 20:52.767 [SPEAKER_02]: The cookie let's just put, let's scheduled ones in one box. 20:52.747 --> 20:55.070 [SPEAKER_02]: and then the unscheduled ones in the other box. 20:55.090 --> 21:02.478 [SPEAKER_02]: It doesn't mean you have to go back at me like when she hits the door, give her some medical from my, give her some, for mode of teaching, give her her by Citra. 21:03.018 --> 21:03.259 [SPEAKER_02]: Sure. 21:04.480 --> 21:19.176 [SPEAKER_02]: But that's important is talk with your obese, how soon ideally should we go back and just put the scheduled in one box and the unscheduled in all that goes in the other box. 21:19.426 --> 21:36.085 [SPEAKER_00]: Yeah, that makes a lot of sense and you know it's it's I think there's one of those things that you gain With time and experience is that not you can't just put people in boxes So we can't just be like elective not elected You have to look at the individual the individual patient the individual situation and be willing to be flexible 21:37.499 --> 21:40.103 [SPEAKER_02]: Oh, Brett, right, and that's what it is, right? 21:40.143 --> 21:45.550 [SPEAKER_02]: It's my, it's my now years of experience that I can share that. 21:46.732 --> 21:46.832 [SPEAKER_00]: Yeah. 21:46.852 --> 21:55.164 [SPEAKER_00]: And I would imagine that, you know, a lot of this is going to come down to good communication with the OB team and then documentation, right? 21:55.204 --> 22:00.351 [SPEAKER_00]: So if what you're afraid of is, well, if we try this and she aspirates and I have no ground to stand on legally, 22:00.331 --> 22:06.780 [SPEAKER_00]: But if you document and they document that this is not elective, that this is urgent, that this needs to happen, then that's okay, right? 22:06.800 --> 22:08.303 [SPEAKER_00]: Then I think anyone would agree, that's okay. 22:09.024 --> 22:09.845 [SPEAKER_02]: Correct, right? 22:09.885 --> 22:12.028 [SPEAKER_02]: Communication and documentation. 22:12.188 --> 22:14.311 [SPEAKER_02]: And sometimes there's communication. 22:14.372 --> 22:18.137 [SPEAKER_02]: And everyone's speaking the same. 22:18.877 --> 22:26.808 [SPEAKER_02]: primary language, but the obies are saying, what's your, you know, NPO number and they're saying, well, it's eight hours. 22:28.210 --> 22:34.639 [SPEAKER_02]: We can't wait till six a.m., but yet she had cereal, but no, really, what are you concerned about? 22:34.739 --> 22:36.001 [SPEAKER_02]: You understand concerned about aspiration? 22:36.021 --> 22:36.862 [SPEAKER_02]: What are you concerned about it? 22:36.902 --> 22:45.053 [SPEAKER_02]: It would be, I'm concerned that, you know, she's going to potentially rupture her 22:45.573 --> 22:48.460 [SPEAKER_02]: She won't empty her stomach after eight hours of labor. 22:49.061 --> 22:49.242 [UNKNOWN]: Right. 22:49.663 --> 22:49.863 [SPEAKER_00]: Right. 22:50.705 --> 22:52.209 [SPEAKER_00]: Um, okay. 22:52.349 --> 22:52.570 [SPEAKER_00]: Great. 22:52.590 --> 22:54.855 [SPEAKER_00]: Let's talk about two, two, chloroproquin. 22:54.895 --> 22:56.118 [SPEAKER_00]: I think you're a fan of that. 22:56.319 --> 22:57.963 [SPEAKER_00]: Um, what do you, how do you use it? 22:58.023 --> 22:59.506 [SPEAKER_00]: What, what do you recommend people do with it? 23:00.469 --> 23:03.075 [SPEAKER_02]: I am a fan. 23:04.169 --> 23:10.943 [SPEAKER_02]: I'm a fan too cloverking for the urgent feed-up rate of cardio, we're running down the hallway. 23:11.023 --> 23:13.408 [SPEAKER_02]: We don't have monitors on as we're running down the hallway. 23:13.989 --> 23:25.131 [SPEAKER_02]: I will give 20 ml of cloverking somewhere between the labor room and the alarm, like 5 ml in the room, 5 in the hallway, another 5 in the hallway, and then 23:25.111 --> 23:28.597 [SPEAKER_02]: Get to the OR, check a blood pressure, quick, if it's good, give the other five. 23:28.617 --> 23:33.987 [SPEAKER_02]: So 20 ml is a 3% chocolate broken, probably in about five minutes time. 23:35.008 --> 23:40.538 [SPEAKER_02]: And certainly, you know, you could ask, are you, you know, any ringing areas, any patient or mouth, she could have. 23:40.636 --> 23:47.992 [SPEAKER_02]: Transient symptoms from intravascular injection, if the epidural person is an intravacitor, but she won't see, right? 23:48.012 --> 23:59.438 [SPEAKER_02]: She won't see, isn't so my thought is if you push 3% to clipper cocaine, you get back to the OR, you check a level, you still have fetal bread of cardio, you've lost nothing, if she doesn't have a block, she's going to go to sleep. 24:00.548 --> 24:08.337 [SPEAKER_00]: And so, the reason, when you say she won't see, is that because two-core broken is much less toxic than it might be. 24:08.497 --> 24:10.379 [SPEAKER_00]: It's because it's an ester. 24:11.441 --> 24:12.221 [SPEAKER_02]: So it'll get my test. 24:12.242 --> 24:22.634 [SPEAKER_02]: So by rare chance that calculator is intravascular, the her suitable anestrates will metabolize that ester. 24:23.154 --> 24:29.982 [SPEAKER_02]: And so she might get plenty of symptoms, but she won't see it, you won't put her into cardiac arrest, like it would be pifigaine. 24:29.962 --> 24:45.017 [SPEAKER_02]: Yeah, but lie to King if for some reason that Katherine that's when working well for some reason maybe some of the endables are in a vessel and you didn't know it or when you're pushing really fast You pop open some vessel you hit during placement You could make her seize with lie to King interested. 24:45.037 --> 24:57.049 [SPEAKER_02]: She won't have she won't have cardiac arrest But she could seize and nobody likes to see you in pregnant patient Definitely stay what that's will be right back All right, and we're back 24:57.552 --> 24:58.674 [SPEAKER_00]: This is why you're the expert. 24:58.694 --> 25:09.312 [SPEAKER_00]: So yeah, I mean, I knew two core point came was fast, but I did not realize that you could kind of be safer from a side effects standpoint if you have to give it fast and you're worried about that. 25:09.332 --> 25:10.795 [SPEAKER_00]: So that's a really interesting point. 25:12.518 --> 25:22.615 [SPEAKER_02]: And for the residents who are listening, who may have to take their boy that's some boards at some point, I'm said has to do with, 25:23.675 --> 25:31.024 [SPEAKER_02]: PKA, right, the closer the PKA is to pH, you're more likely to traverse over the cell membrane. 25:32.346 --> 25:35.550 [SPEAKER_02]: Lidecane's PKA is actually closer to pH. 25:35.570 --> 25:39.876 [SPEAKER_02]: I think Lidecane is high-7s. 25:40.517 --> 25:43.460 [SPEAKER_02]: Cliprocane is high-8s. 25:43.480 --> 25:53.293 [SPEAKER_02]: So you would think Lidecane would work faster, but we're using 3% Cliprocane, which is 30 milligrams 25:53.527 --> 25:53.908 [SPEAKER_00]: Right. 25:54.188 --> 25:55.130 [SPEAKER_00]: So you're giving more. 25:55.551 --> 25:57.535 [SPEAKER_00]: Yeah, more mental or molecules. 25:57.555 --> 25:57.695 [SPEAKER_00]: Right. 25:57.715 --> 25:58.857 [SPEAKER_00]: Yeah. 25:58.877 --> 25:59.097 [SPEAKER_00]: Yeah. 25:59.278 --> 26:01.362 [SPEAKER_00]: I remember that from studying for for my boards. 26:03.365 --> 26:06.772 [SPEAKER_00]: So that's where epidermals for pushing it if you're going for a statsc section. 26:06.892 --> 26:08.595 [SPEAKER_00]: How about you ever use it in spinals? 26:09.597 --> 26:10.459 [SPEAKER_02]: I do. 26:10.579 --> 26:13.585 [SPEAKER_02]: I actually I like it for circlogians. 26:14.667 --> 26:15.889 [SPEAKER_02]: Once again. 26:16.426 --> 26:21.060 [SPEAKER_02]: The schedules are closed 13, 14, 15 weeks like oh, we're coming in. 26:21.582 --> 26:27.118 [SPEAKER_02]: Should we print the obese, the MFM should be pretty quick, stitch, stitch, stitch, clipped broken is great. 26:27.239 --> 26:30.368 [SPEAKER_02]: I've had some nurses who 26:30.972 --> 26:50.837 [SPEAKER_02]: Maybe almost work with routinely work with OBNC's knowledge, so the USB-PIP became which also is great, but then if it's an outpatient, she's supposed to go home, she might go home for four or five, six hours at the time, or late, and back even if you give a small dose, you know, nine milligrams or eight milligrams or something of the heavy people who can't so. 26:50.817 --> 26:54.364 [SPEAKER_02]: Talk with your surgeon and if you say to the surgeon, I'll give you an anesthetic that is the last. 26:54.544 --> 26:55.526 [SPEAKER_02]: You've got 45 minutes. 26:55.867 --> 26:57.470 [SPEAKER_02]: And usually they say, yeah, that's plenty of time. 26:57.911 --> 27:02.620 [SPEAKER_02]: Now, if it's the circlas that's 19, 20 weeks, maybe she's already dialing. 27:02.680 --> 27:05.204 [SPEAKER_02]: She's got maybe hour-classing membranes. 27:05.224 --> 27:06.547 [SPEAKER_02]: You have to put her in trend notebooks. 27:06.567 --> 27:09.332 [SPEAKER_02]: They might want to push the membrane back before they do the circlas. 27:10.114 --> 27:12.859 [SPEAKER_02]: She's probably not going home after the procedure. 27:12.940 --> 27:16.263 [SPEAKER_02]: I will definitely give the obese, if you're pivicking, longer acting. 27:18.485 --> 27:38.145 [SPEAKER_02]: I actually did a postpartum tumble recently with court-procane, the anesthesia resident after the case said, oh my goodness, Dr. Mary, I've never done a court-procane spinal for a postpartum tumble and I said, me, that was my first one. 27:38.265 --> 27:41.428 [SPEAKER_02]: That worked well. 27:42.353 --> 28:05.830 [SPEAKER_02]: family planning fellowship here at UNC so the family planning fellow who is a second year who also sometimes covers labor and delivery on the weekends I knew he was efficient fast surgeon so it was just a fellow in the attending and I said do you think you could do this to bull in a normal size patient she delivered you know 18 hours by her as it can you do this under an hour and he said absolutely. 28:06.215 --> 28:16.541 [SPEAKER_02]: So we did 60 milligrams, which should give you about 90 minutes, and it worked really well, and then it got up and she went home later on that day. 28:16.661 --> 28:17.163 [SPEAKER_00]: It was beautiful. 28:17.383 --> 28:18.105 [SPEAKER_00]: Yeah, it's awesome. 28:18.125 --> 28:23.278 [SPEAKER_00]: Yeah, and then how about give her use it for non OB cases? 28:24.001 --> 28:27.244 [SPEAKER_02]: I think it can be great in urology. 28:27.604 --> 28:30.847 [SPEAKER_02]: Once again, Sisto Stanton or something, have a conversation with a surgeon. 28:30.867 --> 28:34.730 [SPEAKER_02]: Once again, I think a lot of what we do is like we talk to the beginning of communication. 28:35.751 --> 28:39.795 [SPEAKER_02]: Maybe the surgeon will say, no, I've got to do some lithotripsia. 28:39.895 --> 28:45.199 [SPEAKER_02]: Oh, there's two stones, or it might be a little torturous yearder, I can't, I need more than an hour. 28:45.259 --> 28:48.942 [SPEAKER_02]: But sometimes it's quick, just put up the stanton and be done. 28:49.243 --> 28:53.046 [SPEAKER_02]: And then I have not used it for ortho, 28:53.026 --> 28:57.170 [SPEAKER_02]: there's some relatively efficient joint surgeons. 28:57.431 --> 29:03.837 [SPEAKER_02]: So they use quick-broken for hips and knees and then they're sending those patients home the same day. 29:04.358 --> 29:05.539 [SPEAKER_00]: Yeah, very cool. 29:05.619 --> 29:05.759 [SPEAKER_02]: Yeah. 29:06.901 --> 29:08.582 [SPEAKER_00]: So an underutilized drug, but an interesting one. 29:09.804 --> 29:11.085 [SPEAKER_00]: We talked a lot about communication. 29:11.786 --> 29:15.990 [SPEAKER_00]: Let's talk a little bit more about that in terms of kind of the terminology that we use. 29:16.310 --> 29:18.793 [SPEAKER_00]: And I know you've said the terminology can be confusing. 29:18.833 --> 29:22.577 [SPEAKER_00]: Miss leading, we need to be really careful about how we communicate. 29:24.042 --> 29:29.597 [SPEAKER_02]: So I, well, I just have to sort of, this sort of makes me think. 29:30.640 --> 29:41.051 [SPEAKER_02]: I think a big reason why probably residents nominated me for this master clinician or residents like working with me, I will admit I'm old, right? 29:41.071 --> 29:47.297 [SPEAKER_02]: So there's a benefit to being old and graduating medical school more than 25 years about you've seen a lot. 29:47.598 --> 29:59.230 [SPEAKER_02]: And if you've worked with a lot of different surgeons and maybe encountered some different crises or conflict 29:59.412 --> 30:02.536 [SPEAKER_02]: And I've been at four different academic institutions. 30:02.556 --> 30:06.942 [SPEAKER_02]: So once again, you sort of learn what your colleagues do at this institution, what the surgeons do. 30:07.663 --> 30:19.819 [SPEAKER_02]: And so I think all the places I've been, we all struggle with, well, what do we call the hurry up, bad baby stat section, do we call that stat? 30:19.839 --> 30:20.860 [SPEAKER_02]: Do we call that emergent? 30:21.521 --> 30:26.668 [SPEAKER_02]: What do we call the one that's well, she's been laboring 30:26.986 --> 30:32.217 [SPEAKER_02]: I don't know, half a day, and now she's got some late decelerations, but not terminal fetal birdie party. 30:32.718 --> 30:46.648 [SPEAKER_02]: That's not as urgent as the birdie party, but still kind of urgent, and then you've got the one who's been laboring for three days, and now she's infected, and her baby looks, you know, flat tracing, and maybe some T-cell now, and then, and then there's the... 30:47.742 --> 30:50.166 [SPEAKER_02]: I came in and I'm stuck at four centimeters. 30:50.186 --> 30:53.713 [SPEAKER_02]: Baby looks fine, I would find, but at the patient's been here for four days. 30:54.254 --> 30:59.002 [SPEAKER_02]: Or, or the one we already talked about, the one who comes in from home, Rep. Membranes, scheduled section. 30:59.042 --> 31:06.055 [SPEAKER_02]: So, I think terminology is, there's probably some value in it. 31:06.254 --> 31:12.302 [SPEAKER_02]: Um, keeping track of how quickly do you go back with a urgent, how quickly we go back with a stat? 31:12.382 --> 31:15.506 [SPEAKER_02]: Probably I imagine more from maybe a nursing perspective. 31:15.546 --> 31:18.630 [SPEAKER_02]: They probably have to keep track of some of those statistics and things. 31:18.670 --> 31:22.976 [SPEAKER_02]: But really for me, I think it just comes down to communication. 31:22.996 --> 31:32.649 [SPEAKER_02]: I mean, we have an overset overhead system here, and it'll say, you know, fetal bread of cardio room three, and we all, we all run and we know what we're getting into. 31:32.669 --> 31:34.371 [SPEAKER_02]: But we didn't know we said it would be, 31:34.351 --> 31:36.073 [SPEAKER_02]: what do you what do you need? 31:36.654 --> 31:37.795 [SPEAKER_02]: And sometimes it's better. 31:37.995 --> 31:40.298 [SPEAKER_02]: Okay, you know, heart rate's back up. 31:40.638 --> 31:42.180 [SPEAKER_02]: We don't we don't need to do anything right now. 31:44.503 --> 31:52.432 [SPEAKER_02]: So it comes down to tell me what the clinical scenario is and how urgent do we need to do that? 31:52.712 --> 32:04.105 [SPEAKER_02]: And no doubt at your institution and many institutions across the country, you know, the smaller rural hospitals that you 32:04.625 --> 32:08.050 [SPEAKER_02]: deliveries are coming to these bigger hospitals, which is great. 32:08.090 --> 32:09.172 [SPEAKER_02]: This is where the resources are. 32:09.993 --> 32:15.301 [SPEAKER_02]: But I'm here at UNC where I trained, I finished 16 years ago. 32:15.341 --> 32:26.818 [SPEAKER_02]: We have the same labor delivery space, same labor rooms, three ORs that we had 16 years ago, and we're doing twice as many deliveries. 32:27.322 --> 32:38.195 [SPEAKER_02]: Um, though sometimes it's a matter of I've got two things going on right now, I don't want to fill that third room unless I really have to, how, how worried it is. 32:38.315 --> 32:42.020 [SPEAKER_02]: And, and the OB's and the nurses certainly understand that too, right? 32:42.100 --> 32:48.248 [SPEAKER_02]: Once you've filled that up, and our next option is she'll build things over three floors down, um, main hospital. 32:48.288 --> 32:56.738 [SPEAKER_02]: So, my, my advice is don't get, don't get hung up on terminology, right? 32:56.954 --> 32:58.556 [SPEAKER_00]: and be careful with it as you said, right? 32:58.616 --> 32:59.918 [SPEAKER_00]: I mean, like it can be misunderstood. 33:00.018 --> 33:09.730 [SPEAKER_00]: I have this very, very distinct memory from what I was a C two on OB and we'd been told on our end, you know, if they if they call a stat C section in the middle of the night, right? 33:09.770 --> 33:15.617 [SPEAKER_00]: Like we're going back and we are going to sleep and we are in the and if they have to splash and whatever, like they're going to start. 33:15.637 --> 33:19.802 [SPEAKER_00]: So we got to get to sleep as soon as we can and and sure enough, right? 33:19.822 --> 33:25.729 [SPEAKER_00]: There's a stat C section called and I'm running from a call room and I get in there and my attending does not does not show up. 33:25.709 --> 33:28.876 [SPEAKER_00]: And so I was in just pure panic mode. 33:28.956 --> 33:33.625 [SPEAKER_00]: My first OB rotation, but in my head, I'm hearing like they said stat and what I was told is this. 33:33.645 --> 33:40.359 [SPEAKER_00]: So I, I tell them, please call my attending one more time and they do and she still doesn't come and so I just intimate and thank God it went fine. 33:40.860 --> 33:46.131 [SPEAKER_00]: But after the patient is intimated, you know, I look over and the OB attending was like, well, 33:46.111 --> 33:53.068 [SPEAKER_00]: No, I told you already into, oh, I don't want to show you, but I was just going to like watch for a little while and I was like, that's not like you said it was a stat, right? 33:53.209 --> 33:56.256 [SPEAKER_00]: And so like knowing that is really important. 33:57.063 --> 33:57.384 [SPEAKER_02]: Yeah. 33:57.784 --> 34:17.977 [SPEAKER_02]: And I think, um, and for a month where I came from the anesthesia attending a night still covers OB and OR, and that can be frustrating when you're covering the OR and you're running up from the second floor to the seventh floor and you get to the room and nobody's actually in the operating room, but, but you said it was that. 34:18.037 --> 34:21.923 [SPEAKER_02]: And I think that's where 34:22.696 --> 34:23.657 [SPEAKER_02]: attending to attending. 34:23.738 --> 34:25.901 [SPEAKER_02]: I like to say adult adult phone conversation. 34:26.402 --> 34:28.705 [SPEAKER_02]: Like the OB attending could call the anesthesia attending. 34:28.725 --> 34:31.610 [SPEAKER_02]: It's a we need you stat or we've got some lights. 34:31.690 --> 34:32.892 [SPEAKER_02]: We're moving as fast as we can. 34:32.952 --> 34:34.034 [SPEAKER_02]: The nurses are opening up. 34:34.054 --> 34:34.655 [SPEAKER_02]: We're counting. 34:34.695 --> 34:34.895 [SPEAKER_02]: Right. 34:34.915 --> 34:38.441 [SPEAKER_02]: I mean, that's, you know, people might say, well, why do you just do everything in a hurry? 34:38.481 --> 34:43.709 [SPEAKER_02]: Well, the nurses have to count because if you don't have time to count instruments, then you gotta take the x-ray at the end. 34:43.769 --> 34:46.052 [SPEAKER_02]: And, you know, that's a whole, a whole hassle too. 34:46.092 --> 34:47.775 [SPEAKER_02]: So, there, there are, there are, 34:48.278 --> 34:55.234 [SPEAKER_02]: Things we have to do before we cake the patient back when we have time to be safe. 34:55.653 --> 35:13.749 [SPEAKER_02]: But I also feel as though if we, as anesthesologists are not receptive to communication, to leaving your page or number, or leaving your vocera number, and they get, you know, recommend when they call you, well, then nobody wants to call you. 35:13.949 --> 35:23.938 [SPEAKER_02]: So once again, we have to keep communication lines open, and, you know, the resident's calling me middle of the night or if I'm going to lay down and I'm on call and I see 35:24.138 --> 35:51.900 [SPEAKER_00]: any time but but need me when you call me right right right right right right right yeah I will come absolutely that that's my job even if it's really question but that's why I'm here yeah yeah absolutely let's look about setting up a safe space for learning how do you do that and and what are some key things that you think people should be practicing and trying to learn these days so when the resident come back for their second 35:52.488 --> 36:04.061 [SPEAKER_02]: I give them a little bit of the responsibility because I feel as though we get so busy and we just say, okay, you know, spinal, sea sections, spinal, sea section, okay, labor epidural, sit up, patients sitting up, labor epidural, patients sitting up. 36:04.081 --> 36:08.526 [SPEAKER_02]: But I tried it, I tried to tell them, hey, so let's just do some things different year's second month. 36:08.546 --> 36:13.692 [SPEAKER_02]: But, but remind me, and ask your other findings, because I'm maybe in the whole month, I might be year four times. 36:13.732 --> 36:21.280 [SPEAKER_02]: But, after all, Jane, you know, if the patient looks totally normal size, 36:22.188 --> 36:25.473 [SPEAKER_02]: I think, and then, and they're like, but God can be like, and the nurse is always set them up. 36:25.493 --> 36:26.935 [SPEAKER_02]: And like, we'll get the nurse on your side. 36:26.975 --> 36:31.602 [SPEAKER_02]: Like, hey, you know, if the patient, if this patient wants an epidural later on, we could offer her lateral. 36:31.622 --> 36:38.993 [SPEAKER_02]: I mean, some patients are more comfortable, lateral, in labor, and some patients are more comfortable fitting for the epidural in labor. 36:39.033 --> 36:51.452 [SPEAKER_02]: But I think if we don't think about it, but sometimes you have to, for whatever reason, it's a terrible looking baby, or the patient says, oh, no, no, no, no, like I just can't sit up. 36:52.124 --> 37:02.279 [SPEAKER_02]: or you've got a hurry up, hurry up, see section we'll say for ruptured membranes and they're worried about a cord prolapse on somebody who's breached in five centimeters. 37:03.521 --> 37:07.687 [SPEAKER_02]: So having the ability to do something lateral is key. 37:09.009 --> 37:12.193 [SPEAKER_02]: So I think practicing it in the non-urgent scenario. 37:12.434 --> 37:21.507 [SPEAKER_02]: Actually, when I was a resident, it has gone by the waste side, but we used plain pupivicane 37:22.668 --> 37:23.689 [SPEAKER_02]: and we used heavy. 37:23.849 --> 37:26.672 [SPEAKER_02]: And once again, I think the attending just wanted us to get comfortable with both. 37:26.752 --> 37:33.118 [SPEAKER_02]: So if it was a scheduled surgery in delivery, and it was a normal size patient, we did it lateral. 37:33.718 --> 37:38.402 [SPEAKER_02]: She'd be right side down, we'd do the heavy pivot game, and then that's when we used to do left to you during tilt. 37:38.443 --> 37:40.604 [SPEAKER_02]: And then so this fine it would float to the left, and we'd tilt it. 37:41.165 --> 37:44.748 [SPEAKER_02]: And then if we said, no, no, no, no, don't like the BMI's 40, we can't do lateral. 37:44.768 --> 37:47.691 [SPEAKER_02]: And they would say, okay, we'll say, no, and we use half percent. 37:47.851 --> 37:49.873 [SPEAKER_02]: 0.5 percent plain pivot game. 37:49.853 --> 37:52.958 [SPEAKER_02]: and the idea was that it would just spread up and spread down. 37:53.819 --> 38:00.770 [SPEAKER_02]: Yeah, so I think having that ability to do lateral when you need to is key. 38:00.850 --> 38:03.835 [SPEAKER_02]: So practicing it in the non-urgent setting is important. 38:05.037 --> 38:11.487 [SPEAKER_02]: The same sort of thing in Raxial ultrasound, I tell them, let's just ultrasound all our schedules, cesarean deliveries. 38:11.587 --> 38:12.889 [SPEAKER_02]: It takes two minutes. 38:13.189 --> 38:18.257 [SPEAKER_02]: You absolutely will palpate afterwards while you're doing the procedure. 38:18.237 --> 38:27.389 [SPEAKER_02]: normal looks like because when you have a BMI of 50 or 60, you really have to use your imagination and say, I think that's the ligament and flavor. 38:27.409 --> 38:35.659 [SPEAKER_02]: I think that's a good window between the spines, maybe those are transverse processes, but seeing it on a BMI of 25, 30, it's really easy to see the pretty pictures. 38:36.420 --> 38:45.932 [SPEAKER_02]: Yeah, and then sort of the same thing that we talked about earlier, 38:46.840 --> 38:47.201 [SPEAKER_02]: Why not? 38:47.281 --> 38:48.703 [SPEAKER_02]: You see that you can use it. 38:49.224 --> 38:49.724 [SPEAKER_00]: Yeah. 38:49.744 --> 38:50.285 [SPEAKER_00]: No, I love that. 38:50.365 --> 39:00.320 [SPEAKER_00]: I often tell our C2s, you know, if you're at a good program and you're, you know, halfway through residency and your halfway through C2 year, you know, you're probably pretty good at anesthesia. 39:00.440 --> 39:04.326 [SPEAKER_00]: You probably could coast to the end. 39:04.306 --> 39:06.669 [SPEAKER_00]: But you will never be the best you can be if you do that. 39:06.929 --> 39:11.374 [SPEAKER_00]: The way to be the best you can be is to push yourself, even though you don't have to. 39:11.834 --> 39:17.360 [SPEAKER_00]: And that's exactly that's things like when you're on OB, ask your attending, could we try some lateral epidurals, right? 39:17.380 --> 39:20.143 [SPEAKER_00]: Can we use the ultrasound when you're in the ORs? 39:20.223 --> 39:22.206 [SPEAKER_00]: And they're just doing the intubation, which will come easy to you. 39:22.226 --> 39:24.808 [SPEAKER_00]: You know, give yourself that great three-view on purpose. 39:24.828 --> 39:28.953 [SPEAKER_00]: You know, get the great one, do you then pull back until you have a great three-view and then use the bougie, right? 39:28.993 --> 39:32.777 [SPEAKER_00]: So figure out ways to challenge yourself, and that's how you'll really grow. 39:33.331 --> 39:33.631 [SPEAKER_02]: Yeah. 39:33.932 --> 39:48.595 [SPEAKER_02]: And I think the other thing I try to have the residents do at least once during their mother rotation is, if everything's stable out on the floor and we're, you know, in the OR, I say that I'll sit here at the head, you go stand at the feet and just get that surgical perspective. 39:48.715 --> 39:58.250 [SPEAKER_02]: Like watching the obies push on the upper abdomen as they're delivered in that head through that tiny little incision that's, it's a good perspective to have when you're up on the other side. 39:58.350 --> 40:01.735 [SPEAKER_02]: Because for many of them, they probably haven't seen it 40:01.951 --> 40:02.793 [SPEAKER_02]: third year of med school. 40:03.033 --> 40:04.056 [SPEAKER_00]: Yeah, absolutely. 40:04.076 --> 40:05.258 [SPEAKER_00]: Yeah. 40:05.279 --> 40:11.533 [SPEAKER_00]: When when when when residents are doing a lateral epidural, are there kind of, you know, things to keep in mind that are different than sitting? 40:11.573 --> 40:16.103 [SPEAKER_00]: I mean, I would imagine that the spine sag, still bright, you're not, it's not just going straight anymore. 40:16.183 --> 40:20.533 [SPEAKER_00]: Like, how do you, what tips do you give them to try to maximize success in the lateral position? 40:20.513 --> 40:21.595 [SPEAKER_02]: Good question. 40:21.655 --> 40:27.065 [SPEAKER_02]: So commonly in the pregnant patient, the hips are a little wider. 40:27.145 --> 40:35.820 [SPEAKER_02]: So if you just lay her on a flat or our table or a flat, flat bed, the spine will sort of be in a little bit of trend Ellenburg position. 40:35.900 --> 40:45.357 [SPEAKER_02]: So if we're in the operating room, the easiest thing to do is move the bed into reverse T till the spine is parallel to the floor. 40:46.822 --> 40:53.131 [SPEAKER_02]: And then in the labor rooms, I just, we just prop the head and our shoulders up. 40:53.151 --> 40:56.937 [SPEAKER_02]: So ideally start with the spine parallel to the floor. 40:56.977 --> 41:11.378 [SPEAKER_02]: And then I find the space and the way I do it actually is, once I find the space with the lidaking in, I have my chewy positioned as if the patient is 41:11.645 --> 41:12.187 [SPEAKER_02]: sitting up. 41:12.529 --> 41:17.489 [SPEAKER_02]: So the wings are going left and right, not up and down. 41:18.031 --> 41:20.541 [SPEAKER_02]: It's horizontal. 41:22.141 --> 41:32.316 [SPEAKER_02]: In my opinion, I feel as though that's what we do every day, like that hand-eye coordination of the wings being in that position, rather than turning your body to match the patient's body. 41:33.417 --> 41:42.310 [SPEAKER_02]: So, your hands are in that position, but every time you hit bone, you have to remember the spine is 90 degrees to what I'm used to it. 41:42.330 --> 41:49.060 [SPEAKER_02]: So, if you hit bone and you think you're on spine, you'll come back and move slightly probably towards the patient's head. 41:49.040 --> 41:51.265 [SPEAKER_00]: right, which is left instead of up. 41:51.285 --> 41:51.525 [SPEAKER_00]: Yeah. 41:51.926 --> 41:52.347 [SPEAKER_00]: Right. 41:52.367 --> 41:52.587 [SPEAKER_02]: Yeah. 41:52.968 --> 42:05.715 [SPEAKER_02]: And the other thing is I try to teach residents certainly early in their rotation and then if they're doing something new like a lateral spinal or a lateral epidural that every time you hit bone, 42:06.758 --> 42:13.745 [SPEAKER_02]: That's a win, like take that information and build that 3D model of the spine in your brain. 42:13.865 --> 42:18.509 [SPEAKER_02]: Like, okay, I hit bone, I think I'm on spine, come back, blow bit deeper, a little bit deeper. 42:18.529 --> 42:20.371 [SPEAKER_02]: Oh, now I'm shallow. 42:20.431 --> 42:22.113 [SPEAKER_02]: Okay, so you're probably, we're hitting this spine below. 42:22.473 --> 42:24.155 [SPEAKER_02]: And now all of a sudden, this is so much more sharp. 42:24.175 --> 42:28.939 [SPEAKER_02]: Spinal, you know, probably hitting this spine about, so come back and redirect. 42:28.959 --> 42:33.103 [SPEAKER_02]: So, I'm gonna make your wheel bigger, a little bit higher on the, in the space. 42:33.083 --> 42:36.368 [SPEAKER_02]: Yeah, but it's not, it's not, it's not a, it shouldn't frustrate you. 42:36.588 --> 42:37.870 [SPEAKER_02]: I mean, we all get frustrated. 42:37.990 --> 42:39.052 [SPEAKER_02]: But, but that's a win. 42:39.092 --> 42:40.534 [SPEAKER_02]: Like, okay, now where am I? 42:41.215 --> 42:41.415 [SPEAKER_00]: Yeah. 42:41.435 --> 42:41.776 [SPEAKER_00]: Yeah. 42:41.796 --> 42:42.136 [SPEAKER_00]: Yeah. 42:42.156 --> 42:42.417 [SPEAKER_00]: Awesome. 42:43.178 --> 42:55.015 [SPEAKER_00]: Anything new coming down the pike in, in OB anesthesia for folks who are, you know, residents who are thinking about going into it, is there anything that you think, oh, this is like, you know, in the next five or 10 years, this is what to keep your eye on. 42:55.035 --> 42:56.037 [SPEAKER_00]: This is going to be really exciting. 42:56.798 --> 42:59.462 [SPEAKER_00]: Maybe the answer is no, but I'm curious what you think. 43:01.028 --> 43:07.316 [SPEAKER_02]: Um, if there's any, uh, fellows or C.A.3s, um, listening, we're, we're hiring here at UNC. 43:08.562 --> 43:09.486 [SPEAKER_00]: Ha ha ha, shameless plug. 43:10.597 --> 43:17.448 [SPEAKER_02]: I do think, and this is true, I think, in every aspect of anesthesia, patients are getting thicker. 43:17.508 --> 43:33.936 [SPEAKER_02]: So, I think, certainly, you know, somebody with a cardiac fellowship, who maybe ends up at an academic center, and they, but they really loved OB, but they couldn't decide between OB and cardiac. 43:33.976 --> 43:36.520 [SPEAKER_02]: If you do cardiac and you still want to do OB, 43:36.500 --> 43:44.489 [SPEAKER_02]: You can end up somewhere, you could end up in private practice in a big group, you could end up at academic medical center and you can be the OB cardiac console, right? 43:44.509 --> 43:46.171 [SPEAKER_02]: You're the person that is on our team. 43:46.651 --> 44:04.971 [SPEAKER_02]: You go to the multidisciplinary meetings about the patient with congenital cardiac disease or the patient with Hokem and we're going to deliver her in the main OR and you will be right there holding our hands during the TE or whatever it is. 44:05.153 --> 44:14.373 [SPEAKER_02]: Cardiac and ICU, critical care, those are definitely very close colleagues of ours in the near future. 44:14.633 --> 44:22.791 [SPEAKER_02]: And, you know, somebody wants to do two years that I would say cardiac OB, critical care OB, you can't do, you can't go wrong. 44:22.771 --> 44:25.155 [SPEAKER_00]: Yeah, and we're starting to see that, you know, I think it's so cool. 44:25.235 --> 44:28.700 [SPEAKER_00]: I remember I loved Obie as a resident and I knew I wanted to critical care. 44:29.221 --> 44:35.550 [SPEAKER_00]: I briefly toyed with the idea of doing both, but A, I was already older in my wife was not so interested in me doing two fellowships. 44:35.590 --> 44:40.498 [SPEAKER_00]: And also, it wasn't, I didn't know anybody, I wasn't a thing I could like talk to and nobody was doing that. 44:40.518 --> 44:41.599 [SPEAKER_00]: I didn't know anybody who had done. 44:41.619 --> 44:45.585 [SPEAKER_00]: But now there are people doing critical care and Obie, as you said, there are people doing cardiac and, and Obie. 44:45.966 --> 44:49.251 [SPEAKER_00]: So I think that's really neat, and those people are going to have, I think, really cool careers. 44:50.311 --> 44:54.359 [SPEAKER_02]: Yeah, and they'll be sought after, for sure, right? 44:55.361 --> 45:02.395 [SPEAKER_00]: Well, Bridget, this has been fabulous, so interesting, so much great stuff for people to think about and learn. 45:03.317 --> 45:05.822 [SPEAKER_00]: Let's turn to the portion of our show where we make random recommendations. 45:06.363 --> 45:08.708 [SPEAKER_00]: Anything you would recommend people to check out for fun. 45:09.700 --> 45:12.303 [SPEAKER_02]: I love reading in my free time. 45:12.323 --> 45:14.205 [SPEAKER_02]: I love historical fiction. 45:14.245 --> 45:15.106 [SPEAKER_02]: I just finished one. 45:15.766 --> 45:21.933 [SPEAKER_02]: Last week, it's called The Great Divide by Christina Henrykane. 45:23.395 --> 45:35.067 [SPEAKER_02]: And it tracks a couple of different characters in the digging building of the Pian Machinau. 45:35.620 --> 45:59.013 [SPEAKER_02]: Admittedly, I knew nothing about the colonization of Panama by the United States and really the 10, 12 years of digging this, I think it's 10 miles across Central America, but people from Barbados and people from Cuba and local people. 45:59.053 --> 46:05.121 [SPEAKER_02]: And so the United States, yes, we funded it, 46:05.101 --> 46:13.834 [SPEAKER_02]: essentially enslaved people to dig it, but a really great stories within the big story of different people that are there at the time. 46:14.114 --> 46:14.575 [SPEAKER_02]: Yeah. 46:14.595 --> 46:15.035 [SPEAKER_00]: Very cool. 46:15.176 --> 46:17.118 [SPEAKER_00]: I have not heard of it, but I'll have to check it out. 46:17.759 --> 46:24.609 [SPEAKER_00]: I'm going to recommend a podcast that a friend of mine recently got me into and I really love called Plane English by Derek Thompson. 46:25.190 --> 46:26.552 [SPEAKER_00]: And it is 46:26.532 --> 46:30.716 [SPEAKER_00]: just a really, covers all kinds of things from a recent one. 46:30.796 --> 46:34.079 [SPEAKER_00]: He did on kind of, is AI going to take our jobs. 46:35.120 --> 46:37.943 [SPEAKER_00]: He's not a doctor or anything, but he did do one recently. 46:38.103 --> 46:39.525 [SPEAKER_00]: And he interviews people, so you know, brings on. 46:39.545 --> 46:44.370 [SPEAKER_00]: But he talked to somebody about GLP1 agonists, like should they be in the drinking water, right? 46:44.390 --> 46:45.871 [SPEAKER_00]: Like, what do we need to do? 46:46.492 --> 46:53.839 [SPEAKER_00]: Economics, I mean, kind of everything, but from a really just thoughtful and I think very kind of, 46:53.819 --> 47:09.668 [SPEAKER_00]: uh... unbiased standpoint just like thinking about the issues in a very open way asking people for thoughts and and putting interesting thoughts out there so uh... highly recommend uh... plain English by direct up all right bridge and thank you so much for coming on the show thank you jadeham great day 47:10.694 --> 47:13.117 [SPEAKER_00]: All right, hopefully you got as much out of that as I did. 47:13.557 --> 47:14.638 [SPEAKER_00]: That was really fantastic. 47:14.919 --> 47:16.020 [SPEAKER_00]: Let us know what you thought. 47:16.260 --> 47:19.744 [SPEAKER_00]: Go to the website,acrack.com where you can leave a comment. 47:20.145 --> 47:22.027 [SPEAKER_00]: Others can learn from what you have to say. 47:22.067 --> 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48:01.857 [SPEAKER_00]: Even if it's just a dollar or two that you pledge, it makes a big difference and we really appreciate it. 48:02.257 --> 48:10.109 [SPEAKER_00]: You can also make donations anytime by going to paypal.me-slashacrack or looking up J.Wallpa on Venmo. 48:10.430 --> 48:15.077 [SPEAKER_00]: Thank you so much to those who have already made donations and become patrons, we really appreciate it. 48:15.537 --> 48:18.442 [SPEAKER_00]: Thanks as always to our fantastic acrack crew. 48:19.143 --> 48:27.175 [SPEAKER_00]: Sonia Aminat is our tech lead, Taylor Duggen, William Mao, and Rachel Furman are our production assistance and social media managers. 48:27.155 --> 48:28.577 [SPEAKER_00]: Thanks so much for all you do. 48:28.617 --> 48:32.082 [SPEAKER_00]: Our original ACRAG music is by Dr. Dennis Quow. 48:32.443 --> 48:36.329 [SPEAKER_00]: You can check out his website at studymusicproject.com. 48:36.349 --> 48:38.713 [SPEAKER_00]: All right, that is it for today. 48:38.753 --> 48:41.817 [SPEAKER_00]: For the ACRAG podcast, I'm Jed Wolpa. 48:42.338 --> 48:43.099 [SPEAKER_00]: Thanks for listening. 48:43.620 --> 48:55.558 [SPEAKER_00]: Remember what you're doing out there every day is really important and valued.