[SPEAKER_01]: Hello and welcome back to Act Rack.
[SPEAKER_01]: I'm Jed Wolplot and I am thrilled to be here with another master clinician episode with an incredible clinician and person and a true master clinician, Dr. Phil Adams.
[SPEAKER_01]: I want to read as I tend to try to do some of the nomination letters that came in for Dr. Adams before I welcome him officially to the show.
[SPEAKER_01]: Dr. Adams is really someone who stood out amongst both his peers and his trainees.
[SPEAKER_01]: They wrote some of the following comments.
[SPEAKER_01]: Dr. Adams.
[SPEAKER_01]: For the past three and a half years, I've had the pleasure of working alongside Dr. Adams in the classroom in the operating room at conferences in most recently this year very closely as a chief resident.
[SPEAKER_01]: All I can think of is I wish everyone else had the privilege of working with him and learning from him.
[SPEAKER_01]: He's a pediatric cardiac anesthesiologist, a master, physiologist, and a wizard in the operating room, and yet he maintains a level of humility that is inspiring and comforting to all of us.
[SPEAKER_01]: Another road I had the pleasure working with him multiple times in the operating room and no matter what the situation complexity or course he always kept his cool, stuck to his principles, did right by the patient and most impressively always taught me something.
[SPEAKER_01]: He's always teaching, always laughing, and always putting others first.
[SPEAKER_01]: When I think of Dr. Adams, I think that's who I want to be.
[SPEAKER_01]: Someone who everyone loves respects and the first person they go to when something goes wrong, but also the first person they want to have a beer with after everything goes right.
[SPEAKER_01]: I'd be remiss if I did not mention just how great of a person he is outside of the OR, despite being an active researcher and loving caring father and husband and pediatric cardiac anesthesiologists, he still found so much time to show up for his residence, whether it be a social event, orientation, presentations, lectures, graduations or town halls.
[SPEAKER_01]: He was always there to show his face, have our backs and be supportive.
[SPEAKER_01]: His passion for resident well-being, education, and clinical experience is second to none.
[SPEAKER_01]: He is truly a role model for me and many of my classmates of truly special man and certainly a master clinician.
[SPEAKER_01]: Another road doctor Adams has a special place in my heart in particular and is the inspiration for my fellowship choices, both Peeds and Peeds Cardiac.
[SPEAKER_01]: Despite being a program director, father and researcher, he makes himself exceptionally available to us with his whole heart.
[SPEAKER_01]: If I can one day become half the anesthesiologist, he is, I will have accomplished more than I could have ever dreamed.
[SPEAKER_01]: I often find myself thinking, imagine how good I would be if I could work with Phil every day, because just being around him results in infectious drive to do my absolute best.
[SPEAKER_01]: And one of his colleagues wrote, I have had the privilege of working alongside him for 10 years, and he is the kind of attending who elevates everyone around him.
[SPEAKER_01]: Residents fellows and peers alike, and does so with a steadiness and generosity that is genuinely rare.
[SPEAKER_01]: So, Dr. Phil Adams is an Associate Professor of Anasthesiology and Parioperative Medicine at the University of Pittsburgh School of Medicine, and he's an attending pediatric cardiac and transplant anesthesiologist.
[SPEAKER_01]: at UPMC Children's Hospital of Pittsburgh.
[SPEAKER_01]: He served as the ANSZ Zalgi Residency Program Director for UPMC ANSZ Zalgi until just recently and he also serves on the Leadership Council of UPMC Children's Hospital of Pittsburgh and is the chair of the Professional Practice Evaluation Committee.
[SPEAKER_01]: He's also the editor-in-chief or co-editor-in-chief of the Journal of Education in Perry Operative Medicine.
[SPEAKER_01]: He's a fantastic person who I've known for a while and feel such a pleasure.
[SPEAKER_01]: Welcome to The Show.
[SPEAKER_02]: Wow, that's incredible.
[SPEAKER_02]: I swear I didn't pay any of those people.
[SPEAKER_02]: This was a, so awesome.
[SPEAKER_02]: And such an honor and privilege to be gone in the Accract Podcast.
[SPEAKER_02]: This is, this is so cool.
[SPEAKER_01]: Well, it is really a pleasure to have you.
[SPEAKER_01]: So, you know, this is a really fun opportunity for us to get to chat about some of those things that have made those people right for things they right.
[SPEAKER_01]: So, you know, we'll cover a lot of really great ground as to what makes you the person and clinician that you are.
[SPEAKER_01]: Let's start with some clinical stuff.
[SPEAKER_01]: As I mentioned, you do pediatric cardiac and transplant.
[SPEAKER_01]: anesthesiology so talk to me a little about that what are some of the things first of all that's a very intense field um how tell me a little bit about how you got it how do you decided to choose those fields and then you know what what are some of the key things you've learned over the years in doing that work that you would want to pass on to other people yeah sure um a lot of it is the combination of passion and uh probably a little sprinkle of opportunity as well um my pathway
[SPEAKER_02]: wasn't the most straightforward coming out of residency.
[SPEAKER_02]: I got into research and I was doing this research fellowship.
[SPEAKER_02]: And because you dedicate so much time to research, the clinical time was the only at 20% which, hey, you don't make a ton of money and be it's hard to, and I really wanted to keep up with my clinical skills.
[SPEAKER_02]: And that's when I was first approached to being on the transplant team.
[SPEAKER_02]: And by transplant,
[SPEAKER_02]: Well at least now we refer to it.
[SPEAKER_02]: That's basically diaphragm down.
[SPEAKER_02]: Our cardiac team handles obviously all the cardiac, but then heart and lung, diaphragm up kind of transplant.
[SPEAKER_02]: So that's what transplant refers to liver kidney small bowel.
[SPEAKER_02]: Yeah, it was in that period when they're like, hey, you like big cases.
[SPEAKER_02]: Do you want to be on this transplant team?
[SPEAKER_02]: And I'm like, sure, I get a little extra money.
[SPEAKER_02]: And then I get to, you know, I didn't quite, because it was all call it didn't interfere with the research stuff.
[SPEAKER_02]: And, you know, of course it always happens on off-bours too.
[SPEAKER_02]: So that's the opportunity component of it.
[SPEAKER_02]: But,
[SPEAKER_02]: Yeah, I just, I loved Pete's Cardiac.
[SPEAKER_02]: I thought medical school I always wanted to go into anesthesiology.
[SPEAKER_02]: That's what I went into and then kind of rolled in, rolled out as I went through, and then really never wavered.
[SPEAKER_02]: But I distinctly remember being in the Cardiology block.
[SPEAKER_02]: It's still on the die-dactic years in learning, I mean, I don't know how many of days or lectures it was on congenital heart disease.
[SPEAKER_02]: I'm like, wow, this is the coolest stuff in the world.
[SPEAKER_02]: Too bad I'm going to be an anesthesiologist and I'll never take care of these people.
[SPEAKER_02]: It's like something that the dummy, like they have to have surgery too, and as I started training and got to meet other people and learn more about the field, it was definitely the one that I knew I was going to just have a B-line straight toward.
[SPEAKER_01]: Awesome.
[SPEAKER_01]: Well, obviously it was a good choice.
[SPEAKER_01]: So as you've practiced these two specialties, pediatric cardiac, and I assume pediatric transplant, or do you do a adult transplant, too?
[SPEAKER_01]: Yeah, pizza only.
[SPEAKER_01]: Yep.
[SPEAKER_01]: Yeah.
[SPEAKER_01]: So as you've done these two fields now, you know, what are some of the things you picked up over time that have worked well for you that you teach your trainees about how to be successful in these areas?
[SPEAKER_02]: Yeah, oh gosh, there's like there's the big lessons like the big time things that stick with you forever and then, you know, there's the daily lessons or the case by case lessons, you know, I feedback is one of those tough things we'll talk about feedback right and I find best like.
[SPEAKER_02]: As soon as we're done with the case, we're kind of turning over, maybe a little distracting probably not the best, but it's like, wow, you know, remember this, like, how did that?
[SPEAKER_02]: It could have gone differently, should we have chose that?
[SPEAKER_02]: You know, I'm always thinking of things like that, and then of course, you know, the kind of the big time events, the ones that, you know, we never really want to go through, but inevitably and, you know, with high-cute patients, high stakes, you know, we experienced those, they really tend to stick around.
[SPEAKER_02]: I would say, you know, some of the things that stand out is we've all done it.
[SPEAKER_02]: We've been in that roller coaster, right, where, you know, let's talk blood pressure.
[SPEAKER_02]: You know, blood pressures scrape in the floor, and it's terrifying.
[SPEAKER_02]: We see that, and that number is blinking on the screen, and you want to fix it, you know, with the surge in the sea edge.
[SPEAKER_02]: We know it's bad for the patient.
[SPEAKER_02]: There's that urge to, you know, want to change five things at once, right?
[SPEAKER_02]: You know, fix every, you know, push this button, turn that knob, give this med, and then the next thing, you know, the pressure sky high, and now you're like, oh, geez, this is equally, you know, just as bad, we're bleeding.
[SPEAKER_02]: Oh, God, what did I do now?
[SPEAKER_02]: And it's just, it's, and it's hard to get off of that, because you see these horrible blinking numbers, and you want them to go away, and you want them to go away now.
[SPEAKER_02]: a lot of us go into it, we love that instant gratification, we love making those numbers be what we want them to be.
[SPEAKER_02]: And on your average patient, we do a really good job of that.
[SPEAKER_02]: I'd say in sick patients, we do a really good job of that.
[SPEAKER_02]: But super sick, critically ill, high cutie cases, really bizarre physiology.
[SPEAKER_02]: You know you only have a couple of seconds to get it fixed before some really bad things happen.
[SPEAKER_02]: And so,
[SPEAKER_02]: I tell my my train is all the time that people in the room with me.
[SPEAKER_02]: One of the hardest things to do as an anesthesiologist is nothing.
[SPEAKER_02]: It's to stand there for five seconds and don't touch anything.
[SPEAKER_02]: Just wait.
[SPEAKER_02]: Just wait a second, you know, spend, you know, the blinking number looks horrible.
[SPEAKER_02]: Maybe it's something they're doing on the surgical field like to.
[SPEAKER_02]: Let's look.
[SPEAKER_02]: What are they doing?
[SPEAKER_02]: Is this going to go away in 10 seconds because they're going to, you know, let go of whatever their squeezing, turning to the side, you know, what is the exact ideology?
[SPEAKER_02]: You know, let's not touch every knob and let's start with one thing and it's so difficult to do because, like I said, we see that horrible blinking number when you're just wanted to be gone.
[SPEAKER_02]: But yeah, I think, you know, that's one of those lessons.
[SPEAKER_02]: Stand back.
[SPEAKER_02]: don't do anything.
[SPEAKER_02]: Sometimes the surge is even this.
[SPEAKER_02]: Aren't you going to do something?
[SPEAKER_02]: I'm going to say, yeah, I'm going to wait 10 seconds and just give me one.
[SPEAKER_02]: Let me think, you know, I don't instantly know the ideology of every single bad thing.
[SPEAKER_02]: Let me think, let me figure this one out.
[SPEAKER_02]: And we're going to go one step at a time.
[SPEAKER_01]: Yeah, that ring is so true.
[SPEAKER_01]: I remember very distinctly when I was a C1 uncalled and I was in a craniumy emergent case and the patient was just crashing.
[SPEAKER_01]: Blood pressure was crashing and are attending told me to push.
[SPEAKER_01]: I think it was like a unit of vasopress and I think we were pushing vasopress.
[SPEAKER_01]: And we did, you know, I did and it didn't like nothing happened immediately in like the first one second and I was getting ready to push more and she said, just wait, just wait.
[SPEAKER_01]: And I just remember feeling like this can't be the right move to weight.
[SPEAKER_01]: Like, you know, everything seems to be getting worse.
[SPEAKER_01]: And of course, after, you know, 20 seconds, it started to get better.
[SPEAKER_01]: But that willingness to trust the intervention and weight takes some real learning and confidence.
[SPEAKER_02]: Oh, and it's only through having screwed up so many things along the way that I like jeez, if I could just pump the brakes a little bit and, um, yeah, we do an anesthesiology all the time, right?
[SPEAKER_02]: You know, create a differential, um, but sometimes we're in such a hurry that differential is like two things and you miss a lot of what's actually happening and, uh, but yeah, take that, take that, take that time, think about things,
[SPEAKER_01]: So one of the things I know, we do in, of course, an anesthesiology and gel, but certainly when you are doing pizza cardiac cases, the transplant cases, it's a big team taking care of the patient.
[SPEAKER_01]: So what are some tips you would have for people about how to work successfully in those kind of teams?
[SPEAKER_02]: Yeah, I think that's another big reason I like being in transplant cases, being in the cardiac room is I think everyone in the room recognizes they can't do it alone.
[SPEAKER_02]: That's pretty much true for everything, but we've all worked with people who
[SPEAKER_02]: Well, you know what I mean, so, but in these, you know, again, really sick patients, I think the surgeons have a real appreciation for what we do and how we keep these patients alive and safe and manage this physiology throughout.
[SPEAKER_02]: And you know, in our trust in them as well, you know, making their right decisions and, you know, cutting their right things, so we need to get their right things.
[SPEAKER_02]: the communication to, that's a tough lesson, you know, we would just talk about being on the rollercoaster, but you know, it's like any good relationship, right?
[SPEAKER_02]: It comes down to communication and there have been times where I as the anesthesiologist and
[SPEAKER_02]: feel such an obligation because this is my job is to manage this physiology throughout and I would see you know again the bad things you know rhythm issue or blood pressure issue something would change and my gut react to my instincts like I need to fix this is on me and so let's go let's work through this let's figure it out
[SPEAKER_02]: And I've come to realize that as I'm doing that, I also need to be communicating that with the surgeons.
[SPEAKER_02]: I know it sounds intuitive, but on an average day-to-day case, we're probably not thinking that all the time.
[SPEAKER_02]: Every time you give a fluid ballus to a type of tens of patient after induction, you're really not communicating that because it just kind of goes hand in hand with induction.
[SPEAKER_02]: But what I found is, when I wouldn't say things, and I'm struggling to fix them by myself,
[SPEAKER_02]: you know, once the surgeon looks up and realizes, hey, what's going on, and I say, yeah, I've been dealing with this.
[SPEAKER_02]: You know, I would have released the tension, or I would have done this, and you know, you got to tell me these things.
[SPEAKER_02]: And so again, it's not a failure to say, hey, I've noticed some rhythm issues.
[SPEAKER_02]: I'm going to check a blood gas.
[SPEAKER_02]: Make sure I look.
[SPEAKER_02]: electrolytes are good.
[SPEAKER_02]: Yeah, that's not a failure that that is just keeping everybody all in the same page Because again, it could be Using that example because they were pulling the order there was tension on the coronaries and we were having some issues so all the took really was them
[SPEAKER_02]: using the tension and it wasn't anything I was going to fix with a blood gas or potassium.
[SPEAKER_02]: So that's again one of those kind of lesson learned things.
[SPEAKER_02]: But again, especially in the cardiac room, it goes beyond even surge in an anesthesiologist.
[SPEAKER_02]: These, I mean, the scrub techs are magicians.
[SPEAKER_02]: I have no clue, like how they know they anticipate their holding in their hands.
[SPEAKER_02]: I mean, they are as much as surge in as I can be able to surge in as I sometimes are.
[SPEAKER_02]: circulators as well just being so on top of things and profusion I mean it takes it takes everybody and I really admire our senior surgeon I've heard him say to his junior surgeon to the trainees and this is coming from a surgeon he said you know letting anesthesia do anesthesia let profusion do profusion and you operate.
[SPEAKER_02]: And, you know, that freedom is like, wow, like, that's letting me do my job and trusting me and that's a big responsibility too, you know, then it really ups the stakes, like I need to be on my game, I need to be here for this space, I need to be doing this the right way, and I need to be communicating everything I'm doing so we're on the same page, so.
[SPEAKER_02]: Yeah, I've always liked to team the aspects.
[SPEAKER_01]: Yeah, that also brings true, I feel like I communicate.
[SPEAKER_01]: things to the surgeons so much more than I did when I was younger.
[SPEAKER_01]: I think something about maybe it's about gaining confidence in yourself and your own practice.
[SPEAKER_01]: Maybe it's about developing the relationships with the surgeons over time if you're at the same place.
[SPEAKER_01]: But I do think that there's probably something about when you're a new attending and you
[SPEAKER_01]: be worried that if you say like okay we've got some hypotension I'm addressing it that they're going to think you did something wrong or you know be critical of you somehow which I think is probably not accurate but I think people are afraid of that.
[SPEAKER_02]: Yeah, absolutely, I agree.
[SPEAKER_02]: I think starting out, you're so eager to be right all the time and to be in control all the time, it takes just a little bit of that experience to realize that sometimes things are out of your control.
[SPEAKER_02]: And like I said, sometimes things can be fixed by what they're doing.
[SPEAKER_02]: And I initially took it as a failure, like, gosh, I have to admit that I somehow let this patient become hypotensive, but it isn't that, right?
[SPEAKER_02]: that it's really you know you've noticed something you're we're working on it and you're working with them to fix it.
[SPEAKER_01]: Yeah and of course you find I'm sure I found that if you start doing it the surgeons do it back and so then you'll have them telling you things they might not have told you otherwise.
[SPEAKER_02]: Oh, isn't it so true?
[SPEAKER_02]: It's that, you know, like the psychological safety, right?
[SPEAKER_02]: I mean, I think we go into this thinking the surgeons are just these, like, you know, often angry and just I'm going to have it my way, kind of people, but we know that's not true.
[SPEAKER_02]: And I love the relationships I have with, I can honestly say, all of our surgeons are very lucky where I work.
[SPEAKER_02]: But, you know, I think they get a little scared to, right?
[SPEAKER_02]: There's the times they get in a bind and we help the bail that amount.
[SPEAKER_02]: And so I totally agree it's such a feedback.
[SPEAKER_02]: The more I am communicating, you know, to a degree.
[SPEAKER_02]: Like I said, they don't want to know every little thing that's going to bother them.
[SPEAKER_02]: They need to focus too.
[SPEAKER_02]: But you're absolutely right.
[SPEAKER_02]: I find that, you know, then they're more open to say, hey, I'm about to do this, heads up, you know, those kinds of things.
[SPEAKER_01]: Yeah, absolutely.
[SPEAKER_01]: Now, sometimes you will say to people to channel their inner five year old.
[SPEAKER_01]: Tell me about that.
[SPEAKER_01]: What does that mean?
[SPEAKER_01]: Why do you tell people to do that?
[SPEAKER_02]: Yeah, and I would say don't do it in an annoying way, but you know, you sit with the kid and you can just be looking out the window and I'll say, I don't know, you know, what's that person pushing.
[SPEAKER_02]: Oh, that's a lawn mower.
[SPEAKER_02]: What's it do?
[SPEAKER_02]: It cuts the grass.
[SPEAKER_02]: Why do they cut the grass?
[SPEAKER_02]: Well, because the grass grows long.
[SPEAKER_02]: Why is the grass grow long?
[SPEAKER_02]: Well, because it rains and then it grows.
[SPEAKER_02]: And then what happens when it gets long?
[SPEAKER_02]: The Lord, your Lord looks bad.
[SPEAKER_02]: And so he went and cut.
[SPEAKER_02]: And you know, it could go on and on.
[SPEAKER_02]: And you know, you know,
[SPEAKER_02]: I always just tell people, have that genuine curiosity about everything that we're doing, you know, I always say that as an anesthesiologist, yes, we're there to get me anesthesia, to make people asleep.
[SPEAKER_02]: You know, anesthetized and to manage physiology, so to be comfortable, to be safe, and get through these things.
[SPEAKER_02]: But it doesn't mean we shouldn't know what's going on.
[SPEAKER_02]: It doesn't mean we shouldn't understand the operation or, you know, the why, like, why are we doing this operation?
[SPEAKER_02]: What's the outcome going to be, what are we hoping to achieve?
[SPEAKER_02]: And so I think that, you know, having that inquisitiveness to not just be in there and go through motions, that's a little cliche.
[SPEAKER_02]: Because I don't.
[SPEAKER_02]: think we really go through motions.
[SPEAKER_02]: I know that people are in there.
[SPEAKER_02]: They genuinely care.
[SPEAKER_02]: We want to do a good job.
[SPEAKER_02]: But let's be honest.
[SPEAKER_02]: The anesthetic is pretty similar for the majority of our patients, and it can get easy to kind of get in that law.
[SPEAKER_02]: I think if you always have that a bit of that curiosity, you can find some little nuance in every patient, even though they're having the same operation that you've done a hundred times.
[SPEAKER_02]: Maybe they're just a little different with them.
[SPEAKER_02]: Maybe they're often going to be just a little bit different.
[SPEAKER_02]: Maybe they're going to
[SPEAKER_02]: And so, you know, ask yourself, you know, why, why are they on this medication?
[SPEAKER_02]: We do this, we've done a collectomy, I've done a hundred collectemies, and none of them are on, why is this patient taking this medicine?
[SPEAKER_02]: What does it mean?
[SPEAKER_02]: Is it going to act different?
[SPEAKER_02]: You know, I asked, I probably do bother our surgeons a little bit, but I'm, I'm, hey, do you have a second?
[SPEAKER_02]: I'm just curious.
[SPEAKER_02]: what if we did what if you didn't this instead I see that you're so in this to that you know why why did how how does that come to be with this amazing neurosurgeon of course he isn't with us anymore but uh uh she was fantastic she would always pull me to the side pull up MRIs and you just you find you learn so much and then when you're not just going through an operation blindly you know giving our cocktail of medications that we give and making blood pressure go up and down
[SPEAKER_02]: But when you're really like in the operation, when you're really in it with the surgeon and understanding it, I think that gives me a lot of professional fulfillment because if you get into that law, I think it contributes to burnout whenever you just view yourself as I, you know, patient and patient out, patient asleep, patient awake, meds in urine out, and then off I go.
[SPEAKER_02]: That's an easy way to kind of get a little jaded in the profession, but if you just keep, you know,
[SPEAKER_02]: Some of it has to be outward, you know, outwardly asking why, but you can do a lot of this on your own, you know, we're reading about a patient in the night before.
[SPEAKER_02]: And again, you know, just a little tweak, some of the weird, you know, don't just pass it by, you know, always keep that little why in the back of your mind and makes things way more fun.
[SPEAKER_01]: Yeah, I love that.
[SPEAKER_01]: That's such great advice.
[SPEAKER_01]: Let's talk about some of the technical skills.
[SPEAKER_01]: So when you are teaching airway skills, what do you tell residents to keep in mind?
[SPEAKER_02]: Yeah, I got shot really wish who had taught me had so many great teachers.
[SPEAKER_02]: And I remember one point getting like a metaphorical hands-lap, basically a physical hands-lap, but it kind of snapped me out of my sloppy way.
[SPEAKER_02]: And in this, this attending said, you know, do a larynxoscopy.
[SPEAKER_02]: Don't just stick the blade and do a larynxoscopy.
[SPEAKER_02]: And I said, well, that's what I do every single intubation.
[SPEAKER_02]: I do a larynxoscopy.
[SPEAKER_02]: I take this metal thing, I jam it in the mouth.
[SPEAKER_02]: Plastic tube tends to follow behind, isn't that the Leringos mean intubation process and and that the challenge was and what I've come to realize is so so important, they said, you know, be a doctor, be a doctor, and do an actual medical procedure of Leringoscopy.
[SPEAKER_02]: I don't know, like, oh, whoa, whoa, okay, whoa,
[SPEAKER_02]: So I say it this way, okay.
[SPEAKER_02]: If you took 100 random non-medical people off the street and asked them, you know, to identify a written noise or ask them whatever we written noise are, how many like, just again, random people off the street.
[SPEAKER_02]: Maybe a handful five ten.
[SPEAKER_02]: I think that it'd be lucky if it was that if you talk a hundred people off the street and said Assume try identify a tongue or what's a tongue?
[SPEAKER_02]: Everyone would know it right and so that that's kind of like well, let's start there start at the tongue Put your blade on the tongue and never like on the tongue.
[SPEAKER_02]: I was like, yeah, start on the tongue And then sweep that tongue go a little deeper.
[SPEAKER_02]: What's next?
[SPEAKER_02]: The lingual tauntsles you have the tauntsler pillar You can see the tauntsles the tauntsle huge is it jutting into the airway is it making things more difficult
[SPEAKER_02]: Let's go a little bit deeper now.
[SPEAKER_02]: Now.
[SPEAKER_02]: Oh, okay.
[SPEAKER_02]: Now the epiglottis is popping into view.
[SPEAKER_02]: What's going to be just deep the epiglottis?
[SPEAKER_02]: The velacula.
[SPEAKER_02]: Do we have a Mac blade with a Miller blade?
[SPEAKER_02]: What's our what's our next motion going to be?
[SPEAKER_02]: And so when you're when you're working with your attending and you're attending is saying, tell me what you see I always say that you know some people respond with the ender's all noises because what they do that they bury the blade They start to pull back.
[SPEAKER_02]: It's a tube of pink and all you hear is like And I'm like I don't I don't speak
[SPEAKER_02]: I don't speak in the end with all that, like it's a joke, I say it pleasantly, but, you know, what do they want to hear?
[SPEAKER_02]: They want to hear, okay, well, I'm at the base of the tongue, I can see the lingual tonsils, I see that the base of the tonsils are pillars, I'm going a little bit deeper, now I can see the gap of glottis, I'm going to go into the vlacula, I'm going to lift, not lean back, okay, now I've got, you know, crisp cords, wide open glottis, like that, that is telling the attending what you see, when you just bury the blade and start fishing around and
[SPEAKER_02]: area to stick your tube.
[SPEAKER_02]: That is the response.
[SPEAKER_02]: I don't know.
[SPEAKER_02]: That's just one of those little things where they like snapped me out of my sloppiness by saying do a medical procedure do a layering theoscopy and ever ever since then I've never ever done it any other way.
[SPEAKER_02]: It's always been the exact same way, just inching millimeter at a time.
[SPEAKER_02]: And even when they have a sick patient, you know, you only have, you know, you don't have forever.
[SPEAKER_02]: They're FRC full of oxygen.
[SPEAKER_02]: Spill isn't going to get you much time.
[SPEAKER_02]: I have all these blue babies all the time.
[SPEAKER_02]: But I'll tell you this.
[SPEAKER_02]: It's, you know, take going in.
[SPEAKER_02]: You know, I'm not inch by inch going millimeter by millimeter, which seems like a painfully slow, but getting success on that first try to me is way better than going through it quickly, screwing it up, getting the esophagus, now the stomach's full Niagara FRC even worse.
[SPEAKER_02]: I mean, that's just a disaster, so it's
[SPEAKER_02]: It's saved me and it's helped me to teach better because now I can communicate better with the person doing the learn gospel beat because they're telling me what they see.
[SPEAKER_02]: And yeah, like I said, I've done it the same ever since never changed.
[SPEAKER_01]: But I love that and you know, I think I don't do kids.
[SPEAKER_01]: But I remember from residency when I was rotating on peads with babies, you know, what feels
[SPEAKER_01]: to an adult and see how just like a tiny movement is their entire, you know, anyway.
[SPEAKER_01]: So you, you almost, I can absolutely see how with kids doing that really slowly is going to maximize your success.
[SPEAKER_01]: And I actually think it's a great technique for adults too to learn the anatomy, to take your time, know where you're going, and probably avoid some trauma rather than just like jamming it in and then pulling back, right, to take your time and find where you're going as gently as possible.
[SPEAKER_02]: Right, I say jam with love, you know, no one does it, but yeah, the idea that you just stick it.
[SPEAKER_02]: And I know, I'm a little fearful with all the video-laring gossipy that we have that, you know, we'll lose a little bit of that because now it is literally just insert, gently, insert this device and now you're, now you're glued to a screen and just fishing around for identifiable structures.
[SPEAKER_02]: And I still would argue that if you very methodically meticulously introduce the blade,
[SPEAKER_02]: and kind of have your eyes on the screen that even with that your success will go up more.
[SPEAKER_01]: Yeah, fabulous.
[SPEAKER_01]: All right, let's talk about access.
[SPEAKER_01]: I feel like if you can put an IV in a baby, you can put an IV in anybody.
[SPEAKER_01]: So when you're thinking about IV access, what are some tips to help people get those difficult IVs, whether it be in a baby, which I think is the absolute hardest or in any kid or even in an adult.
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[SPEAKER_01]: All right, and now back to Dr. Adams.
[SPEAKER_02]: Yeah, those comments were unbelievable and so heartwarming, but sometimes I wonder if people, they must think like I'm a lunatic, because there's some of the things.
[SPEAKER_02]: But for me, it's so much like mental imagery.
[SPEAKER_02]: I'm always imagining, like, what does this look like underneath the skin?
[SPEAKER_02]: What does this tube that I'm trying to fish this needle into look like?
[SPEAKER_02]: And whether I can see it is bald, I put the turnkin on and it evanes balding out.
[SPEAKER_02]: Okay, that's one thing.
[SPEAKER_02]: But what if it's just like a faint shadow and like you said like a tiny baby and I have a 24-gauge?
[SPEAKER_02]: So in my mind, you know, that, you know, the aperture of that needle, you know, that bevel, I tell everybody think it's a bit like a shovel, okay, and think like you're going into the dirt, okay, the skin, the ground, and you're trying to get into this pipe, and with that shovel, you're just trying to lift that most superficial part of that pipe.
[SPEAKER_02]: That's why they're like, what?
[SPEAKER_02]: And I'll just think about it because you don't want to go through and through.
[SPEAKER_02]: You don't want to be out of the side, you're kind of lifting as you go and that little bit of that lifting motion.
[SPEAKER_02]: Once you get your flash, you know, hopefully then you're not already poking the back of that vessel.
[SPEAKER_02]: So you're just kind of scooping these tiny little nanometer scoops with that needle as you're just kind of trying to lift the top part of that blood vessel and the second you do you get that flash.
[SPEAKER_02]: Now lay down, you're already lifting up and it makes it so much more difficult with that lift again to go through the back of the vessel.
[SPEAKER_02]: you pop through, you're lifting the top of that pipe, you're getting in that vessel, and then you're laying flat and just getting enough of that angiocath in that you know you're going to be able to slide it off.
[SPEAKER_02]: And I'm saying this, and I get that look like you're insane.
[SPEAKER_02]: And it takes two or three tries, which again, in kids, we're lucky if you're in the taunts or room, you're going to get 10 cases, so you're going to get 10 tries.
[SPEAKER_02]: And really by the second or third, then I get like the aha moment.
[SPEAKER_02]: I'm like, I get what you're saying.
[SPEAKER_02]: I see this now.
[SPEAKER_02]: That little lift makes all the difference to keep me from, you know, just barreling through and through in these tiny, tiny blood vessels.
[SPEAKER_00]: Stay with us.
[SPEAKER_00]: We'll be right back.
[SPEAKER_00]: All right.
[SPEAKER_00]: And we're back.
[SPEAKER_01]: Yeah.
[SPEAKER_01]: I love that.
[SPEAKER_01]: I think of it as tempting it up as you go in.
[SPEAKER_01]: But I actually, that imagery, I really like, I may steal that.
[SPEAKER_01]: I think about getting just lifting the top of that pipe.
[SPEAKER_01]: I really like that.
[SPEAKER_01]: Yeah, um, so how about when we think about physiology, um, tell me about, uh, oh, I'm as law and how you use that in your teaching.
[SPEAKER_02]: Yeah, I have zest over that.
[SPEAKER_02]: I, uh,
[SPEAKER_02]: It helps me just break things down in a pragmatic way.
[SPEAKER_02]: And I like math because math doesn't lie.
[SPEAKER_02]: And so to me it kind of eliminates, it helps to eliminate variables, right?
[SPEAKER_02]: And anytime you can eliminate variables, things become more successful and more predictable.
[SPEAKER_02]: And so, again, if I use the example of hypotension,
[SPEAKER_02]: You know, you know, for the attendings out there for trainees about to become attendings.
[SPEAKER_02]: When you're working with someone and even even like a good veteran skilled hands-on person, you usually don't get the phone call at the first and since I have a tension, right?
[SPEAKER_02]: You usually get the phone call when a patient's high-potensive, I've given 10 liters of flu and I've gone through 18 sticks of phenylifer and nothing works, you know.
[SPEAKER_02]: So they're just going to be some intervention and those are always the kind of the knee-jerk reactions.
[SPEAKER_02]: And it's because often times they are right.
[SPEAKER_02]: Our patients come to us with fluid deficits.
[SPEAKER_02]: They vase a dilate from induction.
[SPEAKER_02]: They're steps, whatever it is.
[SPEAKER_02]: So those often are the corrections.
[SPEAKER_02]: But I hate only having two weapons in the bag.
[SPEAKER_02]: And of course, you know, we all know that there's more than that, but I really rely on the thought of OMS law to expand that arsenal in a way.
[SPEAKER_02]: And so again, it comes down to, you know, it's it was created for electricity.
[SPEAKER_02]: You know, it was voltage equals current times resistance.
[SPEAKER_02]: And we can translate that into fluid dynamics where it's pressure equals flow times resistance.
[SPEAKER_02]: you know, vascular resistance.
[SPEAKER_02]: And then you can keep breaking all those things down, right?
[SPEAKER_02]: So cardiac output is a stroke volume and heart rate.
[SPEAKER_02]: So now you have, okay, so again, the outcome that the bad ugly blinking light on the screen is blood pressure.
[SPEAKER_02]: But now we have, you know, we can think of as a stroke volume problem, a heart rate problem, or a vascular resistance problem.
[SPEAKER_02]: And then we know that, you know, stroke volume breaks down into preload after load and
[SPEAKER_02]: Okay, now I have, you know, bad blood pressure.
[SPEAKER_02]: I don't like that.
[SPEAKER_02]: But now I'm thinking, okay, is this a preload problem, a contractility problem, and after load problem, a heart rate problem, or a vast of the resistance problem.
[SPEAKER_02]: And then use it can start to say, like, okay, well, you know, maybe this patient needs a higher heart rate, you know, they're able.
[SPEAKER_02]: lower EF, or again, I'm trying to be general over the audience, but my mind is very peed's mind, but you know, it might be that this heart rate's fine, but maybe in this heart rate isn't fine for this patient and they're going to need a bump.
[SPEAKER_02]: Then when you throw in congenital heart disease, you know, now is, you know, we put so much emphasis on the systemic side of things, so the systemic cardiac output and the systemic vascular resistance.
[SPEAKER_02]: But with all the shunts and things that go with congenital heart disease, now it's a, you know, now it's pulmonary blood flow and pulmonary bascular resistance.
[SPEAKER_02]: And so basically now I have, you know, all of the things, you know, the preload, the afterload of the contractility from a right heart perspective, from a left heart perspective, from a pulmonary, from a systemic, and it just gives me such an arsenal to approach problems to where, you know, my, my solution for hypoxia might be systemic vascular resistance.
[SPEAKER_02]: And that's like mind blowing to the average person out there, but I know that I need to alter a shunt, alter a flow, change a resistance in order to augment a different flow.
[SPEAKER_02]: And um...
[SPEAKER_02]: and then someone is so forth.
[SPEAKER_02]: So that's always come back on those things because I feel like, again, it's math.
[SPEAKER_02]: So it's not to say it's infallible, but if I'm convinced I have a UV-Lemic patient that's still high-potensive, then I'm not gonna go with more volume.
[SPEAKER_02]: And sometimes people think, oh, well,
[SPEAKER_02]: this that and the other thing you know the deficit and this and I say well we have good evidence you know our stroke following variation you're now put all the different tools and tricks we have you know I'm a big fan of SVO of of getting you know Venus oxygen saturation from from an IJ is kind of a surrogate for cardiac output you know if that SVO 2 is 85
[SPEAKER_02]: than, and I think the patients you've elimic, then we don't need more volume, we need more squeeze, we need bascular resistance, and it takes, again, that gross ugly number that gives us palpitations and gives us a big arsenal to come up with a plan and do it for the more true ideology, so to speak.
[SPEAKER_01]: Yeah, I love that idea of breaking it down into component parts to try to identify the right place to intervene, which makes a ton of sense.
[SPEAKER_01]: You alluded to some of the differences and really what I always think of as the reason pediatric cardiac anesthesiology is in some ways the most complex, I think of all the different specialties in anesthesiology.
[SPEAKER_01]: You have a definite particular interest in single ventricle physiology, patients with
[SPEAKER_01]: Any, any little, I mean, that's obviously very complex topic that you could talk about for a long time.
[SPEAKER_01]: But anything you would say, like, if you're dealing with that, you know, with these patients, keep this or that in mind.
[SPEAKER_02]: Yeah, I'd say first and foremost, even though we consider them to, you know, all have the same, you know, plumbing, so to speak, so for anyone unfamiliar, and you have a single ventricle, we try to separate the systemic deoxygenated blood from the oxygenate blood getting into the body, and so.
[SPEAKER_02]: the surgical procedures are to connect the soup here being a cave directly to the pulmonary arteries and then the inferior being a cave directly to the pulmonary arteries.
[SPEAKER_02]: And so all of that systemic blood really just passively drains through the pulmonary arteries and then gets back into the heart and pumped out to the body.
[SPEAKER_02]: I think the first take away is even though they come with that sort of, you know, blueprint so to speak, no to our like.
[SPEAKER_02]: And so I think that's very important to put into your mind from the beginning.
[SPEAKER_02]: I think a good tip is keep people at baseline.
[SPEAKER_02]: Let's say if on tan patients, even in adult, let's say they tear an ACL, they're in a work basketball league and they tear their ACL and they're coming in for an ACL repair, okay?
[SPEAKER_02]: You're not going to fix their lifelong cardiac disease or cyanosis with this ACL or a pair.
[SPEAKER_02]: So figure out what these patients, what is baselines for them.
[SPEAKER_02]: Again, it's one of those trust things.
[SPEAKER_02]: It's sometimes hard, you know, patients will say this, you know, a lot of things to us.
[SPEAKER_02]: And it is up to us to, you know, take some of it with a grain of salt.
[SPEAKER_02]: Sometimes our patients aren't the best historians, but
[SPEAKER_02]: When you meet a, you know, 30 year old adult who says, I, you know, I'm fond and in my baseline oxygen saturation is 88 to 92 percent don't feel like you have to achieve somehow achieve 99 a hundred percent all operation while you're driving yourself nuts doing it.
[SPEAKER_02]: So know that that's a baseline, know that with that baseline, their hemoglobin's probably going to be in the upper teens, and so again, if you get into trouble, maybe not an ACL repair, but you know, a fontan patient who lives with a hemoglobin of 18.
[SPEAKER_02]: they need that to keep their oxygen content up, right?
[SPEAKER_02]: Because if we dig into our content equation, it's, you know, saturation and, you know, our conversion factor in hemoglobin basically, it's saturation, hemoglobin.
[SPEAKER_02]: So living with the lower saturation, they need, they develop this polycytheemia.
[SPEAKER_02]: So if you're ever scratching your head, your patient doesn't look good in their hemoglobin is 13.
[SPEAKER_02]: Yeah, I mean, to any patient walking in off the street, 13, you're going to be like, oh, man, this is luxury.
[SPEAKER_02]: I got bonus hemoglobin to deal with maybe not in that patient because they've for the past, you know, 25 years of their life have been relying on it much higher hemoglobin.
[SPEAKER_02]: for oxygen delivery.
[SPEAKER_02]: So there's just a lot of the things that, you know, the policies or the protocols or the guidelines tell us that, you know, it really has to be individualized for that patient.
[SPEAKER_01]: Yeah, no, I mean, I think that's really good advice, and I say this as someone who doesn't ever do it, but it sounds like good advice, but no, I mean, I think that little things like that, I mean, I love the idea of, that's such a great example of how we have to think about the individual patient, right?
[SPEAKER_01]: Because just like you said, 13, man, if I have a patient with a starting humble over
[SPEAKER_01]: that isn't good in a patient who starts at 19 right I mean that's a really important distinction and you may miss it if you're not thinking about it and so making sure you are it's like I tell our residents you know be careful don't don't fall in the trap of just cutting and pasting your pre-op right into every every patient is the same pre-op because you've got to think about this patient specifically or you're going to miss something like that.
[SPEAKER_02]: Well the other mantra of mine
[SPEAKER_02]: that I tell everybody is, remember to always treat patients and not procedures because I think to sometimes we even get pressured a little bit, you know, you might, you might tell, again, say it's an ACL repair and you might say, I'm going to have two units of blood on hold.
[SPEAKER_02]: But we never do that, you're wasting resources, you're out of your mind and you're like,
[SPEAKER_02]: Yeah, for 90, probably more than 99% of patients, but for this one patient, though, this is something they might need.
[SPEAKER_02]: I don't see how you can lose that much blood, maybe an ACL, but you get the point.
[SPEAKER_02]: You know, the joke I make all the time is if you come in for a fingernail clipping with a 9 or a 10, I'm getting FFP in the room for your fingernail clipping, and so
[SPEAKER_02]: always, always treat the patient in front of you, we don't treat procedures, we don't treat appendectomies, we don't treat collectemies, we treat human beings who are having appendectomies and human beings who are having collectemies.
[SPEAKER_01]: Yeah, and I wonder if you'd agree, I actually had this conversation with a resident today who was saying, how do you deal with a surgeon who you think the patient needs something and the surgeon's telling you that to do something else?
[SPEAKER_01]: And I said, I think so much of this, that those challenging interactions can be prevented if you reach out beforehand, right?
[SPEAKER_01]: So I always reach out to surgeons that day before the surgery.
[SPEAKER_01]: And a lot of those discussions, and I think this is one of them, right?
[SPEAKER_01]: If you say in the operating room, hold on, you know, we got a, I need blood or, or I'm going to put in a central line for this fingernail clipping, right?
[SPEAKER_01]: I mean, they're going to be like, what are you talking about?
[SPEAKER_01]: But if you reach out the day before and you explain, this is my reasoning, this is why I think we need this, right?
[SPEAKER_01]: That's a much more reasonable time to do it.
[SPEAKER_01]: And people, surgeons are going to be much more open to your, you know, to thinking about your reasoning rather than trying to have the debate in the operating room.
[SPEAKER_02]: Oh, it's priceless.
[SPEAKER_02]: It is.
[SPEAKER_02]: And again, it could be a little uncomfortable, so I'm just a little fear for like, I don't want them to think I'm stupid.
[SPEAKER_02]: I don't want them to think I'm a scaredy cat and I'm doing all these extra things.
[SPEAKER_02]: But when I have sent the, you know, those preparatory things.
[SPEAKER_02]: And we've had the back and forth.
[SPEAKER_02]: There's sometimes I overestimate.
[SPEAKER_02]: I think this operation be horrible and you know a big tumor debugging and then I come to find like Oh, it's a biopsy.
[SPEAKER_02]: It's literally going to be in four steps an out and two sound like oh G is okay You know put put the put the guard down a little But yeah, you know running the list with the surgeon in the morning.
[SPEAKER_02]: You know we got these cases together You know that was very kind of you just say you know It impedes cardiac out health tough it is but again one of the things I always say is you know
[SPEAKER_02]: My garbage man that comes and picks my guard.
[SPEAKER_02]: I don't understand that truck to say my life.
[SPEAKER_02]: I don't know what lever to pull.
[SPEAKER_02]: I probably couldn't get it out of park.
[SPEAKER_02]: So I think the dude, whatever you do on a day to day, you get really good at.
[SPEAKER_02]: And so a lot of times my discomfort is in some of the non-cardiacase is really, but yeah, just to have that brief moment is they like, hey, I haven't done this in a very long time.
[SPEAKER_02]: You know, my neurosurgeon every day I go up and I say, man, a tall deck of John, like I know these are neurosurgery things.
[SPEAKER_02]: I'm not in the room with you.
[SPEAKER_02]: And you can just see there's like such an appreciation that you're like, you're at least thinking about there.
[SPEAKER_02]: And they're like, oh, yeah, the yesterday deck of John, no to man at all.
[SPEAKER_02]: And so yeah, totally.
[SPEAKER_01]: Yeah, absolutely agree.
[SPEAKER_01]: Let's talk about the importance of empathy.
[SPEAKER_01]: I know this is something you try to impart to your trainees.
[SPEAKER_01]: What are some key lessons that you try to impart about the importance of empathy in our specialty?
[SPEAKER_02]: I think it's one of those things.
[SPEAKER_02]: Again, you can really get caught up in AMC'siology and for any training out there,
[SPEAKER_02]: when when you become an attending life kind of changes abruptly so to speak you might get into it in a you know practice that's mostly hands on and maybe won't change a ton but if you're going to be in a team model you
[SPEAKER_02]: A lot of times you get locked in your room and sometimes you can feel like you're just just sitting and know that you aren't.
[SPEAKER_02]: I mean, you're really taking care of, you are taking care of somebody's, people love that person, you're working in that team, you're working with that surgeon, they're relying on you.
[SPEAKER_02]: So know that you won't never just sitting and you're here that we're raw to a lot.
[SPEAKER_02]: I'm just rawting in this room, know that you aren't, no matter the case, you really are doing something, how say miraculous, I mean, there's not a lot of people that can just jump in off the street and do it.
[SPEAKER_02]: When you're in a 10 day and you spend so much time running, and that's one of the big wakeups, the amount of running that you do.
[SPEAKER_02]: I can't wear a clogged shoes.
[SPEAKER_02]: I have to wear like tennis shoes because I would trip.
[SPEAKER_02]: I just, you know, you're in pre-op, you're in pack you, you're inducing, you're emerging, you're back to pack you.
[SPEAKER_02]: One of those 30,000 foot views is you see how stressed everybody is and you see the anxiety, you see it on everybody's face and you get to know people day to day and you know that when someone's a little off maybe they're bringing something home from home to work and we have that ability we're really running the room, we're managing things, we kind of control the flow of the entire
[SPEAKER_02]: And I think just really understanding, like, understanding your surgeon and, like, where are they at?
[SPEAKER_02]: You know, what's their head space today?
[SPEAKER_02]: They're in a good mood.
[SPEAKER_02]: That's great.
[SPEAKER_02]: It doesn't just mean that, you know, you can hide behind the drab in the leave you alone.
[SPEAKER_02]: But, you know, they may be, they'll be more open to conversing with you and nicer to the circulators.
[SPEAKER_02]: Or maybe the circulators having a bad day.
[SPEAKER_02]: I think it really just comes down to understanding that, you know,
[SPEAKER_02]: Yeah, I'll show up to work in with my bad days, with my baggage from home.
[SPEAKER_02]: And but like I said, that 30,000 foot view of just seeing all the interplay of how everybody else is, you know, a lot of times, if we, if we see an anesthesiologist,
[SPEAKER_02]: can take a step back and just knowing that we manage, we run so much of this to say like, hey, maybe this room needs a 10 minute break or, you know, to the surge and like, you know, maybe talk to them about something non-mechanical related between cases.
[SPEAKER_02]: It's, you know, we have a little break room and, you know,
[SPEAKER_02]: trying to like cut loose a little bit.
[SPEAKER_02]: I don't know.
[SPEAKER_02]: I guess just the bottom line is to know that like some, I remember being a trainee and thinking all these people around me were invincible, you know.
[SPEAKER_02]: The surges never wrong.
[SPEAKER_02]: They're always directing things.
[SPEAKER_02]: The circulator knows these operations inside and them out.
[SPEAKER_02]: I'm always screwing things up for them.
[SPEAKER_02]: I remember feeling that with I, but, but know that there's like all these vulnerabilities too and these people and
[SPEAKER_02]: you know, as we're working with people.
[SPEAKER_02]: And I think that, you know, you can be smart, you can make the right decisions all the time, but I think what stands out the people and when when when you hear things like, oh, everyone wants to talk or so and so in the room, I don't have the right answers all the time, but I'll work with people and I'll relate with people and, you know, be on the same level with anybody who's willing to be on the same level.
[SPEAKER_01]: Yeah, and you know, I love that you said for the trainees right who are all thinking I'm never going to be as good as my attending this person that person, right?
[SPEAKER_01]: Well said it right I mean you right you're here on this show as a master clinician and we just heard you say you remember very much being a trainee thinking I'm never going to be as good as these people right so.
[SPEAKER_01]: I mean, if that's such a great message for our trainees is that none of the people you see as these master clinicians started off as master clinicians, right?
[SPEAKER_01]: They were once a trainee who knew nothing.
[SPEAKER_02]: Oh, terrified.
[SPEAKER_02]: And making wrong decisions all the time.
[SPEAKER_01]: That's absolutely.
[SPEAKER_01]: Absolutely.
[SPEAKER_01]: That's a great point, right?
[SPEAKER_01]: And even the master clinicians make mistakes all the time.
[SPEAKER_01]: It asks for help and need help, right?
[SPEAKER_01]: So you're never perfect.
[SPEAKER_01]: How about, um,
[SPEAKER_01]: how how can trainees be a good mentee you know I think we we hear a lot about how to be a mentor as you get to be a more senior attending but you know it's not all one way right so what what's the advice you have for people who want to be a successful mentee in a meet in a in a relationship with a mentor.
[SPEAKER_02]: Yeah, again, I can remember filling out faculty evaluations and voting for best teacher of the year and writing these same exact things.
[SPEAKER_02]: Like, this is the person I want to be like, these are the things they do.
[SPEAKER_02]: And so that's kind of one point.
[SPEAKER_02]: So I'll talk that in the background.
[SPEAKER_02]: And then the other point being like you had just said,
[SPEAKER_02]: Especially as an attending, and even as a resident for some degree, right, maybe you're a C.A.
[SPEAKER_02]: 3.
[SPEAKER_02]: And there's like, okay, well, you really need to help the C.A.
[SPEAKER_02]: 1.
[SPEAKER_02]: You're going to be on the senior on call or you're going to help them set the room.
[SPEAKER_02]: Or you've come in attending and it's like, okay, you're going to be a mentor.
[SPEAKER_02]: There's so much of this designation of mentor and
[SPEAKER_02]: One, I don't think we do a really great job of teaching people to be mentors, but I think there's essentially nothing that ever Says how do you be a mentee like how do you allow yourself to be pulled in in a way and I've always thought of it that way I've always thought of myself kind of like like a little puppet like a little marionette kind of thing and you know, I
[SPEAKER_02]: I would say this, you know, don't allow yourself to be pulled in the directions that you don't like or don't agree with or by people that, you know, maybe you don't see as doing everything the right way, but for those people that you really emulate, that you see as successful or positions that you want to be in, you know, let them.
[SPEAKER_02]: make you uncomfortable.
[SPEAKER_02]: And I mean that from the standpoint of, you know, ask them, how did you get to where you are?
[SPEAKER_02]: Oh, why did X, Y and Z?
[SPEAKER_02]: X, Y and Z sounds a little difficult.
[SPEAKER_02]: I don't know that I'm ready for that.
[SPEAKER_02]: You're never going to be if you have that man.
[SPEAKER_02]: Like you're always going to be waiting to be ready and that time will never come.
[SPEAKER_02]: So when you go up to the person that you admire and say, how do I get to a position like that you're in and they say, well,
[SPEAKER_02]: say great how I'm ready to jump in how do we get there so you got to allow yourself to be pulled you got to be uncomfortable and remember uncomfortable doesn't mean mistreated or you know any of these kinds of things uncomfortable in the sense that
[SPEAKER_02]: things might be unfamiliar to you.
[SPEAKER_02]: You might be great at taking multiple choice tests and you might be the best intubator and IV getter in your whole residency, but being uncomfortable is maybe getting into research or getting into QI or maybe getting involved in advocacy and reaching out to the representative.
[SPEAKER_02]: Whatever it is, it's not going to feel great at first because it can be new and foreign to you, but let those really successful people
[SPEAKER_02]: You know, pull you in those directions and and then just remember that the greatest mentor They can't do it for you.
[SPEAKER_02]: They can they can show you the way they can knock down barriers Introduce you to people networking But at no point can somebody just like get you from A to B They can just really kind of help with the pathway to get there But if you commit if you you know take the advice and put in the work there's
[SPEAKER_02]: It's again, one of those cliche things, but anybody can get anywhere they want with that sort of mentality.
[SPEAKER_01]: Yeah, I love that.
[SPEAKER_01]: It's so important.
[SPEAKER_01]: I try to impart this to our trainees all the time is the best way to get good, constructive feedback to help you grow is to ask for it.
[SPEAKER_01]: Go get it, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the
[SPEAKER_01]: You know, it would be wonderful if every attending just automatically gave all this wonderful constructive feedback every day.
[SPEAKER_01]: I would love that, but that's not the reality, but if you as a trainee specifically ask for it, you're much more likely to get it, right?
[SPEAKER_01]: So you want to take some ownership of your own growth and go get what you need, go ask for what you need.
[SPEAKER_02]: Yeah, and on that topic, I get it, but one of the most gut-wrenching things to me is that the end of the day, someone will come up and say, what's my feedback for the day?
[SPEAKER_02]: And I'm just...
[SPEAKER_02]: I don't know.
[SPEAKER_02]: I just felt undone CPR in the other room and, you know, my kid stuck at practice as no one there to pick him.
[SPEAKER_02]: You know, my mind is blown at the end of the day, and it's such a just an open general question.
[SPEAKER_02]: But, like, even for me, as an attending now, we'll go up to a senior attending, and when I say, hey, I see that you're on the board of directors of these, you know, societies.
[SPEAKER_02]: Like, what does it take?
[SPEAKER_02]: What does one have to do to get there?
[SPEAKER_02]: And where am I off?
[SPEAKER_02]: What am I missing?
[SPEAKER_02]: And I think even, you know, so that's me personally isn't attending now in an academic career, but even as a trainee, if you go back to IV, if you say, you know, I missed the IV twice.
[SPEAKER_02]: You got enough for what did you do?
[SPEAKER_02]: How did that is so much more directed?
[SPEAKER_02]: And I can work with that.
[SPEAKER_02]: I can walk you step by step, but I get that
[SPEAKER_02]: When you get that good job, I think that's because a vague question gets a vague response, but when you go in there and say, I wish I had made a better decision on the high vote attention in our second case.
[SPEAKER_02]: Now you say, oh, okay.
[SPEAKER_02]: Well, here's the thing we could have done differently.
[SPEAKER_02]: Like that'd be my advice on that.
[SPEAKER_01]: That's a great piece of advice.
[SPEAKER_01]: Let's talk about staying grounded.
[SPEAKER_01]: How do you stay grounded?
[SPEAKER_01]: How do you recommend that folks amidst the craziness that is a life in medicine stay grounded?
[SPEAKER_02]: Yeah, this, a lot of my, again, I can't feel weird even uttering the words like master clinician.
[SPEAKER_02]: It's it's so flattering, but I, you know, it's, it's the culmination of a lot of different life events.
[SPEAKER_02]: And I definitely wouldn't be the clinician I was without the other things I'd been involved in like research and especially being a program director.
[SPEAKER_02]: And having a lot of really difficult conversations with residents and finding so many common denominators, you know, not so much like the residents who are having difficulty with, you know, passing boards or ITEs.
[SPEAKER_02]: You know, that's usually easier to fix, right?
[SPEAKER_02]: Come up with a study plan or someone who's having trouble with technical skills, let's do some coaching.
[SPEAKER_02]: but it's really a lot more of the personal or sometimes professional kinds of things and there's so many common denominators of anxiety and, you know, imposter syndrome and all these different things that we hear and people getting in their own ways and a lot of times making bad, you know, just kind of personal decisions, you know, the things that people decide to do and
[SPEAKER_02]: I find that so much of what got people to where they are, the way they grew up, upbringing, different things, people give up and I get it, I get the residency as an extremely difficult time.
[SPEAKER_02]: I wish I could say that being an attending was that much easier, I mean, life never gets easier, it just changes.
[SPEAKER_02]: I mean, there's no such thing, like it's harder, everything is going to get harder and I'll give credit to our current program director Mike Best because he plays this amazing video that,
[SPEAKER_02]: you know, nothing ever gets easier.
[SPEAKER_02]: Everything is only going to get harder, but you're going to learn better ways to deal with it and better time management and better, you know, communication skills.
[SPEAKER_02]: And so I find that people give up so much of what made them them.
[SPEAKER_02]: You know, thanks from their childhood, hobbies or, you know,
[SPEAKER_02]: You know, even if it's not religion, but just mindfulness and just taking time out, you know, if you're someone who used to jog all the time, but gave that up because residency's really tough and you're stuck in the hour, you gotta find time.
[SPEAKER_02]: You gotta find a way to commit because being in that head space and that, uh, I don't think it happens anymore.
[SPEAKER_02]: Jed, maybe you remember this, like,
[SPEAKER_02]: I remember old like desktop computers when they first came out.
[SPEAKER_02]: There was this thing you would do, like every three or six months called D-Fragment.
[SPEAKER_02]: It would like clear out the junk files and it would like re-organize.
[SPEAKER_02]: It was one of those like just computer maintenance things that with a clunky desktop, like eight gig computer you had to do.
[SPEAKER_02]: So I would say, don't give up your religion.
[SPEAKER_02]: If you grew up going to the church or the temple or the mosque or if you, you know, if yoga was your routine or running, like, we'll be giving those up, that's where our brain goes to defragment and like break things down.
[SPEAKER_02]: And I know that without me committing to those things, you know, you know, you know, I don't
[SPEAKER_02]: There's no way I could beat you the kind of physician I am.
[SPEAKER_02]: There's zero percent chance because you gotta do that brain dump every now and then and and keep your priorities straight and keep your focus.
[SPEAKER_02]: I'm a big outdoorsman and so someone could be like, oh my gosh, how do you sit at a river for three hours and not catch a single fish and do nothing but stare at water?
[SPEAKER_02]: Well that's avoided me like thousands of dollars of psychiatry bills because I just, you know,
[SPEAKER_02]: I mean, it is everything and so whatever it is for you, whatever it is for you personally, you know, they committed to it.
[SPEAKER_02]: It will not just make it a better person, but of course it will, I mean, make it better doctor.
[SPEAKER_02]: I truly believe it.
[SPEAKER_01]: So I love that.
[SPEAKER_01]: Couldn't agree more fabulous.
[SPEAKER_01]: Phil, we've covered so much great stuff, anything you want to add before we move on.
[SPEAKER_02]: Ah, you know, again, this is an amazing honor, I had, so you're all these orientations that we do, you know, you meet your new residents every year and everyone does like a fun fact to get to know you and this will now have been the second podcast I've been on, but my fun fact is that I've been on podcast, I've never in my life listened to a podcast and that's no offense.
[SPEAKER_02]: But you know, when you reach out, I've listened, I've listened to these other master clinician series, you're such a great conversationalist, and so I've broken it.
[SPEAKER_02]: I've now listened to podcasts, I've listened to ACRAC, and I see why everyone loves it, and so this is so cool, and I'm so honored to be here.
[SPEAKER_01]: Well thanks fellas, quite an honor that we were your first podcast.
[SPEAKER_01]: I will definitely keep that as a as a great great honor Let's move to the portion of our show where we make random recommendations.
[SPEAKER_01]: Do you have something you'd recommend the audience check out for fun?
[SPEAKER_02]: fun.
[SPEAKER_02]: Yeah
[SPEAKER_02]: You know, I, I don't read much.
[SPEAKER_02]: I'm really into sports, and so I'll put in a quick plug, you know, Pittsburgh tonight, the NFL draft, lives about the change for a lot of young men.
[SPEAKER_02]: Also, it's the springtime, and maybe not quite a major sport.
[SPEAKER_02]: If you're in, if you want to look, find something that's super competitive, super fun to watch.
[SPEAKER_02]: college softball.
[SPEAKER_02]: I get so excited for the college softball world series.
[SPEAKER_02]: It's so much fun and so competitive.
[SPEAKER_02]: I'm trying so hard to get my daughter into softball just because I fall in love with it.
[SPEAKER_02]: You know, from a TV standpoint, I don't really watch a lot of TV either, but there is this series.
[SPEAKER_02]: It's on Netflix.
[SPEAKER_02]: It's called a night agent, I think, and it's had two seasons.
[SPEAKER_02]: And the third one has come out, but I'm gone to it, but the first two are
[SPEAKER_02]: I'll be one that I know I'm going to commit some time to try and catch up with.
[SPEAKER_01]: Nice.
[SPEAKER_01]: Awesome.
[SPEAKER_01]: Well, fabulous.
[SPEAKER_01]: Both suggestions.
[SPEAKER_01]: I am going to recommend.
[SPEAKER_01]: I think I've shouted out the pit before the first season of the pit.
[SPEAKER_01]: Really enjoyed.
[SPEAKER_01]: And just my wife and I just finished the second season.
[SPEAKER_01]: And I will say I think the second season not quite as good as the first, but it's still pretty good.
[SPEAKER_01]: And even though it's there are definitely pieces
[SPEAKER_01]: in some of the things that residents, for example, do alone without an attending, but I think it's pretty impressive if you think about the amount of accuracy there is in things like just drug doses and the things that they get right is impressive and of course there's a lot of compelling storylines which are fun.
[SPEAKER_01]: So if you haven't watched it, I would recommend checking out the pit a season one for sure and also season two.
[SPEAKER_02]: No, people say like, hey, how accurate is the pit?
[SPEAKER_02]: How accurate is the pit?
[SPEAKER_02]: The thing I keep coming back to, if you remember from season one, I think it was early in the season the episode where every time he tried to go pee, he just kept getting distracted and never actually got, and that's the one I grant, because I feel like that is there is every single time I walk into the bathroom and I'm just about to, I finally get to go to my phone range, like, we need you in, or then I'm like, you have to run out.
[SPEAKER_02]: So that's the one that resonates with me.
[SPEAKER_01]: totally.
[SPEAKER_01]: That is at 100%.
[SPEAKER_01]: It reminds me of a study that I used to refer to years ago, but they looked at residents and how much water residents would drink on a, on a, on a call shift.
[SPEAKER_01]: And they found that, you know, they actually did like a motion monitoring.
[SPEAKER_01]: And they found that the residents would get up with the intention of going to get a drink of water.
[SPEAKER_01]: all the time and then they never made it to the water cooler they'd all they'd get paid just before they'd go back to the computer they'd go to a room and so they found the only way to get residents to actually get a chance to drink the water was to put the water in the charting room with the residents and when they did that then the amount of water actually went up.
[SPEAKER_01]: Classic, classic.
[SPEAKER_01]: Well Phil this has been fabulous thank you so much for all that you do and thanks for coming on the show.
[SPEAKER_02]: Yeah thank you it's incredible really appreciate it.
[SPEAKER_01]: All right, hopefully you got as much out of that as I did.
[SPEAKER_01]: That was really fantastic.
[SPEAKER_01]: Let us know what you thought.
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[SPEAKER_01]: Thanks as always to our fantastic acrack crew.
[SPEAKER_01]: Sonia Aminat is our tech lead, Taylor Duggen, William Mao and Rachel Furman are our production assistance and social media managers.
[SPEAKER_01]: Thanks so much for all you do.
[SPEAKER_01]: Our original ACRAG Music is by Dr. Dennis Quow.
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[SPEAKER_01]: All right, that is it for today.
[SPEAKER_01]: For the ACRAG podcast, I'm Jed Wolpa.
[SPEAKER_01]: Thanks for listening.
[SPEAKER_01]: Remember what you're doing out there every day is really important and valued.