Episode 299: Master Clinician Part 5: David Stahl
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Hello, and welcome back to ACRAC. I'm Jed Wolpaw, and I am thrilled to be back with another Master Clinician episode, this time with a great friend and true Master Clinician, Dr. David Stahl. Dave and I were in medical school together, as listeners may know, since we've done some episodes. He's been on ACRAC before, and we've mentioned that, and he has...

served as a program director for a while and is now a division chief. I'll let him give a little update on his career, but he's become really a sought after teacher and mentor and a great friend. And I'm thrilled to have him on as our next master clinician. Dave, welcome to the show. Thank you. It's great to be back. So maybe just give people a little bit of a story. Where has your path gone? What do you do now? And how'd you get there?

Sure. As you mentioned, we were in medical school at UCSF together. I then went back to Boston to do a medical internship at MGH. And then I stayed to do residency and critical care fellowship there at MGH as well. And then I moved to the middle of the country, Columbus, Ohio, to be on the faculty at Ohio State University, or I should say the Ohio State University.

And there I got involved in critical care and obstetric anesthesia and in medical education and became the associate residency program director and then the residency program director and I served there.

in that role for five years while I was also doing some other jobs in both hospital leadership and division leadership. And my most recent life event has been moving back to California this summer to start as division chief of critical care at Stanford. And so it's been a lot of fun to be back. And it's exciting because I'm starting a brand new job and getting to learn lots of things. I was on ICU rounds shadowing this morning and thinking about

what things that we do differently here at Stanford than, than I've seen before. And that's a lot of fun. That's awesome. Congrats on the new position. And, you know, I obviously were friends. I would have loved to have you on the show anyway, but this is not just because we're friends. Actually, a lot of people at Ohio state reached out a lot of the trainees to say, they really felt like you fit the description of a master clinician and they wanted to, to have you on. They thought we should have you on. And I couldn't have agreed more.

So I think, you know, let's divide this up. You and I talked a little into kind of some career and life lessons that you have kind of thought through. And then we'll do a section on the clinical piece as well. So when you think about things you've learned, the kind of advice you give to your trainees and folks, junior faculty about how to build and live their their life and career professionally.

What do you think of? I know one thing that you think about is curiosity. Tell me about that. How do you recommend people kind of build curiosity into their career?

Yeah, you know, I've reflected a lot of times in my career that I thought things were going really well and times in my career where I felt, you know, fatigued or burned out or just things weren't clicking. And I often think that the times when they were going well were the times when I was able to be the most curious, when I was thinking about why did we do it this way? Could we do it a different way? What's the root of this? And I think that where we can live our professional lives in a state of curiosity, I think we are generally happier and more fulfilled. And I think

The challenge becomes, you know, you can be curious about things. It's realizing the result of the curiosity. You know, it's kind of like if,

If you have a toddler at home and you know they want to stick everything in their mouth and you don't let them stick anything in their mouth, then they're going to be upset and scream at you. I think if I'm on ICU rounds and I'm thinking, "Gosh, I wonder if we should use dexmedetomidine for this patient," and I never go back and do reading and think about it and follow up or talk to an expert in the area, then I never get to realize curiosity. So I think it's not just being curious, but then it's following through on your curiosity. And I think when you do that,

You get this sense of fulfillment, I think, that can continue in all parts of your career, not just when you're starting out. Yeah, I think that's so important. And, you know, I would say like you, not only in your career, in life, like just trying to stay curious, so easy to say, so hard to do. But I do think it is incredibly important. Any examples of kind of like ways in which you have –

done things differently based on that curiosity and trying to maintain that open mind.

Sure. You know, I think one of my clinical passions is obstetric critical care. And it's a weird and kind of a niche thing to be interested in. And shout out to all my friends in that area. But where that came from, you know, I was a resident. I had a patient who unfortunately had a cardiac arrest during a cesarean delivery. And we ended up, you know, cannulating and putting them on ECMO. And she did really well. Like her outcome and the baby's outcome were great. Yeah.

But it really got me thinking like,

When we have women who are pregnant who are critically ill, we don't necessarily always treat them like ICU patients. We have these patients who have preeclampsia with severe features who have really high blood pressures that we know are dangerous and we're kind of giving them little baby doses of oral labetalol. Whereas if that exact same patient had known AAA and they were in the ICU, we'd be starting them on a nicartapine infusion, starting them on an entomol infusion, putting it in A-line and really controlling every aspect of their kind of anti-impulse therapy. And so this idea that

Hey, can I be curious about like, why do we do that this way? Like what, what are the limitations? Cause there are real life limitations to how you can bring an ICU to the, to the labor floor. But then also to be curious about what, could we do it differently? Like, could we start applying some of those critical care principles to taking care of these patients? Like, could we start an iCard if you trip for the preclinic patient? And, and, um,

as it turns out, like it, yeah, it works pretty well. Like it. And so I think thinking about that, that has led me down this like years long path in thinking about a structure, critical care, all from kind of that one first case, I think. Yeah. Uh, I love that. I feel like so often if you start asking those questions, if you, if you have that curiosity and you ask, well, you know, I see this works well in here. Why not there? The answer often is,

Well, we've never just, we just never done it. Right. It's not like, Oh, because there's this study that shows it doesn't work. It's just because no one's thought about it or no one's tried it. Um, or maybe there's some old study that's since been debunked that suggests there's a better way, but it's not right. So, you know, asking those questions, I think more often than not, uh, you may actually be onto something. Right. And I think as we go through our career, sometimes we, we let ourselves fall into the box that we live in, right? Like there's the, uh,

The analogy I was talking with somebody the other day about how they can constrain an elephant because when they start, when it's a baby, they tie it to a stake in the ground with a chain that's a certain length. And the elephant learns that it can only walk in this kind of radius around the circle. And then by the time the elephant's so big that it could rip the chain or rip the stake out of the ground, it's learned that that's the radius of its life and it can only live there. And I think there's a certain aspect of medical education that

When you start to learn things, you stop being curious about what is the different thing. And so I think one of the really cool things about anesthesiology is the field that you're often moving into different spaces and you can take your knowledge from one space and ask the question in the other space and get some surprising results. Yeah, love it. Okay, so what about when you say that you really think people should think about pursuing flourishing? What does that mean and how do you go about that?

I came across the idea, the concept of flourishing, I think when I was a fellow and feeling burned out. And then again, when I was a program director and trying to think about how to burn out in residence. And, you know, I never loved the concept of burnout because trying to create a program to avoid something never felt as meaningful as trying to create a program to move towards something.

And so flourishing, it's not really the opposite of burnout in my mind, but I think it is also not just kind of the –

I'm feeling happy. And it seems more multidimensional than just wellness in the traditional fashion. And so I think of it as somewhere between, you know, I'm feeling happy and fulfilled, but I'm also feeling like in the zone, like things are working, life is working. And the other cool thing about it is I think you can be flourishing even at a hard time in your life.

I think you can have challenges in front of you, hard things that you're doing or working towards and still feel like you're flourishing. And I like the concept of working towards that rather than trying to run away or protect from burnout.

Yeah, I really like that. I've never thought about that. But having a positive goal as opposed to a negative one is, you know, meaning going, like you said, going towards something as opposed to going away from it is really an interesting way to frame that. Do you, how do you, either yourself, how do you try that? Or how do you encourage your trainees and other people to do that? Like, are there certain strategies to try to kind of pursue flourishing? Yeah, I think it, a lot of it involves like

being mindful about what's going on in your life what's working and what's not working and being able to tinker and think about that so i think when i was a program director like i realized that i was just losing control of my schedule and not you know like i need to control it but you know you know like i was not able to get done the important things that i need to get done every day because i felt like the immediate emergencies were coming up all the time and so um

you know, talking to some experts, talking to some friends, how do you do this? Actually talking to some friends of mine who were in finance and other fields, like how do you manage your really busy schedule? They were like, you got to just put things on your calendar. Like you got to put, I'm going to work on this project on this day. It's got to be on my calendar. And I'm only going to work on that thing during that block of time.

And I felt like that was a big move for me. And it's paid dividends, though, in being able to not just have everything run up to the last minute of the deadline, right? Because we're all creatures of, I'm going to study as soon as the medical test is happening this week. I'm going to prepare for the basic exam in May and June, right before it happens. And instead, if you block the time, then you kind of reclaim some of that. And then the cool thing about it is

You can block time to do other things that are important to you. You can block time to go to the gym. You can block time to spend time with your kids or to call a good friend. And it doesn't mean I worried that that felt like I was like somehow artificializing my life. But instead, what it allowed me to do is retake control over the things that were really important and priorities for me. Yeah, I couldn't agree more. I give folks who match with us the advice a lot of saying, you know, as a fourth year med student, you have

So much time, right? You don't have to hang out with my wife on your calendar. That's all you're going to do, right? But when you become a resident, if you don't schedule those kind of things, I mean, as crazy as that sounds, like if you don't put it on the calendar, this hour is for going on a walk with my wife, right? If you don't do that, guess what? It may not happen. And you're going to wonder what's going on with your relationship and just...

You know, I currently take each of my daughters out to a daddy-daughter dinner once a month. And I put it on the calendar. It's like, this is the daddy-daughter dinner, right? Spend time with my child. And it's not that that has to be the only time you ever spend. But if you don't schedule those things in the midst of a busy life, I think they can slip by. It's too easy to get caught up in other things. And then you can kind of end up

regretting that you're not doing it. So I totally agree with you putting it on the schedule, making sure it gets done. And then, and then don't you think like counting it as a win, like realizing, Hey, I did this thing that I scheduled in. And even if there's a lot of other things that haven't got done yet, I can feel good about that thing. Yes, for sure. I think that, that, that recognition that it is, it is checking off the box or something that's important is, is a really positive step forward.

So often in our jobs, we like we were just saying, you know, you don't always accomplish what you hope. You may not do as well on something as you wish you had. How do you find the ability to give yourself some grace around these things?

Yeah, I think this is something that has been probably the biggest and slowest learning curve of my kind of professional development career. I think I naturally am a perfectionist. I like things to be perfect. I tend to be analytical, so I like to think and think and think about things.

And it, it, I, I see myself, this was a struggle in two ways. Like one, it meant that if I tried and something wasn't perfect, like I was beating myself up about why it wasn't perfect. But then also sometimes it got in the way of me getting the thing done. Cause like some,

you know, the enemy of good is perfect. And so I found myself, especially as I got easier, like as a program director, like I couldn't have the perfect policy. I just needed to get policy out there that the residents could understand and we could all be on the same page and then we could work through it better. And,

And so being able to both give myself grace in the, it's okay if you screw up, like it's okay if you had this bad outcome because you're going to learn from it and you're going to get better. And then it's also okay if the thing isn't perfect, if it's just done. And, and taking some pride in like just getting the thing done. I think that's been, it's been an ongoing evolution for me. I think the biggest, the biggest help in that space has been talking about it. Like,

I think my residents might fight me on this, but my natural state is introversion. I like to think and ponder. And so I don't necessarily call someone up when I'm struggling with getting something done or call someone up when I had a bad outcome. But I think forcing myself to do those things and interact, you just realize that gets you out of your own mind. And then somebody else can look at your problem and just be like,

man, that's really not a problem. Or man, you're doing great. And that can be such a powerful statement. And so I would say for everybody who's been training, listening to this, like volunteering to do that for other people, like calling them up when you see that they had a bad day or a bad outcome, like you might make the biggest impact in their year just by doing that as well. So having grace with yourself and then being able to share grace with other people, I think is really critical. Yeah, I love all that. I remember a long time ago, my mother said to me that,

that when you're planning something, a new project you're going to implement or something, if you wait till it's 100% ready, you will never launch it.

So when it's 75% ready, you got to go. And then you can figure out the other 25%, you know, on the way and as it's going and make alterations, make changes based on how it's going, right? Like real-time implementation. And I think that was such great advice. I just think you have to be willing, like you said, to get it done and know that it's not, you know, you will be able to make changes along the way. But you can't wait until it's perfect or you're never going to get there. What about...

You have said, start practicing for the next job now. What does that mean? This is some advice I think I got as a medical student. And I remember being on my medicine rotation at the VA as a third-year medical student. And they were like, my intern was like, you got to start practicing what it's like to be a sub-I. If you keep focusing on what it's like to be a really good third year, you're going to get to the end of third year, and then you're going to start over again. And it was such a kind of

mind-shock moment of like, oh yeah, I could be a sub-I. I can take total ownership of these patients. I can follow up on stuff late in the evening. I can do these things. And I felt like my learning on the rotation grew exponentially. And then I felt like when I came into my medicine sub-I, I was like, yeah, this doesn't feel that different than last year. And then when I was a resident, thinking about what would it be like if I had to make the anesthetic plan? Not just

Not to think about it, but actually be the ones to decide, this is how we're going to do the anesthetic. And so trying to force myself when I was calling my attending night before, be like, this is how I want to do the anesthesia. And yeah, of course, you're in a training program. They're going to tell you when you do things wrong. They're going to tell you, no, we're not going to do it that way. But really forcing yourself to do that. Then I felt like when I was a junior faculty, I wasn't so afraid of having plans that were not just...

Because I, as a resident, started to force myself to be like, well, how can we do this differently? What would be a different way? And then really take ownership of that kind of role. And then the same thing has happened when I was in the APD thinking about what would it be like to be a program director? When I was interim division chief, what would I need to be to be a permanent division chief? And when I was associate chief medical officer, what would it look like to be that chief medical officer? Those things...

have all taught me looking ahead, I think sometimes helps you do the job that you're doing now better. And it lets you try on that next role to see if that's really where you want to go or if you need to pivot to something else.

Totally. Do you think part of that for you is to kind of very carefully watch the people in those roles and kind of say to yourself, is that what I would do or would I do it differently? And how did that go when they did that? Like, is it kind of critical appraisal of the person in that next role an important part of that?

Definitely. And I think even like not only just their decisions, but kind of the whole situation around it, like what's happening? Why did they make that decision? What other things were motivating them that you might be completely unaware of in your role, but they have all this knowledge that you didn't have? And it gives you this broadening kind of insight into the world around you. I was talking with...

with one of the faculty recently about how, you know, if I had gone back 20 years ago and somebody had said, so much of your job is going to be negotiating kind of interpersonal communication and politics, for lack of a better word, I would have been like, no, it's not. My job's going to be being a doctor and doing medicine. But so much of what we do is interpersonal interaction and

and what people's motivations are for doing those things. And so the more you can be aware and be kind of diligently observant of those behaviors, I think the more you learn about yourself and about the situation. Yeah, absolutely. So let's turn to the clinical realm. Talk to me about how you think through fluid management. Stay with us. We'll be right back with Dave Stahl's answer to that question.

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The fluids are one of my favorite topics. I like torture, uh, my residents. We had a series of lectures from intern, uh, year all the way through to the three year about fluids. And, and I, you know, I think the biggest take home message I have about fluids is, um,

Thinking all the way through the assumptions that we make every time we give fluids and trying to be deliberate about how we think through them. So it's not just, well, the blood pressure is low, I'm going to give some fluid. It's the blood pressure is low. I think they might be hypovolemic.

Therefore, if they're hypovolemic, I think if I give them volume, that it's going to go into the intravascular space. It's going to increase preload and the heart is going to increase cardiac output. And then that's going to improve blood pressure or ultimately that's going to improve perfusion. And if I force myself to think through all those steps, then I find times where I'm like,

find errors in my judgment. Like, I get to the point where the fluid enters the heart as increased preload, and then I realize, like, actually, this person's RVEF was severely impaired, and it's probably not going to help, and maybe I need to go a different direction. Or, you know what? I have no evidence that even though the blood pressure is low, this person seems to be perfusing everything. So why am I chasing the blood pressure number? Why don't I just use a vasopressor if I'm really worried about raising blood pressure when perfusion is totally normal? And so just...

We don't have the tools right now to measure perfusion perfectly. We don't have the tools to tell you if you give this volume, their 30, 60, 90, 365-day outcomes are going to be improved. But my hypothesis is if we think through the hypotheses and think through each one of those steps, we'll be better about giving these things. And I think we often do that with other drugs. We often think

Do I really need to give this drug or not? And fluids we sometimes take for granted. And so I think if we are more thoughtful about it, we could maybe do better. Yeah, couldn't agree more. Do you have an approach to under general anesthesia in the OR? Do you use a lot of, let's say, low dose Levo or do you kind of go fluid first and then use that only if you need it? You know, how do you approach that? I definitely have my own approach to this, but I'm curious about you.

Yeah, I think I use more continuous vasopressor infusions than my colleagues. It's definitely at OSU. It'll be interesting to see at Stanford, whether it's phenylephrine or norepinephrine. Like, I think that I often feel like the hypotension that we're seeing is the decrease in SVR from our anesthetics.

And that actually the patient's relatively euvolemic in every kind of measurement that I can do, whether it's my best look at pulse pressure variation, my ultrasound ability of the heart or something. All imperfect measurements for sure. But my kind of general gestalt is like, no, actually, I don't think they need a bunch of volume right now. I think I just need to manage this low SVR state. And then...

Not being tied to that being true for the whole case, because I've definitely had cases where I start phenylephrine. I think everything's going great. And then three or four hours later, you know, we get them lab, the lactate five. And I'm like, well, I, then I, I happened to notice, oh, there was a bunch of bleeding that, that happened under the drapes that none of us was aware of. And we need to really adjust our plan here. And so I think that's my starting place, but also my willingness to change. Yeah. Fabulous. All right. What does it mean to take the freebies?

So, you know, I love the times when I get to do a solo case. I mean, I love teaching. I love working with residents. But there's every once in a while, and this happens sometimes with like a request case where somebody will ask you to do their anesthesia, which is like an incredible honor. But I think about when I'm sitting in those cases, I'm doing anesthesia for somebody I often really care about.

And I have all this time because once, you know, and don't feel bad if you're a new day one, you don't feel like that because that is totally normal. But once you've been doing this for a while and you, the, the actual minute to minute aspect of anesthesia, do not take all of your cognitive effort. And so,

When that's the case, I think about all of these little things that I could do that to me are free. Like, can I adjust and optimize the ventilator so that the tunnel volumes are as perfect as I think they can be and the PEEP is as perfect as I think I can be? And mechanically, I think I'm doing everything possible to give the patient the optimal individualized vent setting.

Because that didn't take any – it doesn't cost anything. Like, I'm sitting there anyway. Like, I'm not going anywhere. And so I feel like that's – to me, it's a free win. And the number needed to treat, like the number that – at times, I need to do that to improve one postoperative respiratory complication, for example, with the ventilator. It's probably huge. Like –

But for me, it's free. So if there's no cost, even if it takes me, you know, 100 patients to improve an outcome, then it's a win. And probably for many of our real sick patients, it doesn't take that many. And so in that circumstance, I think, you know, why not take the free win? Yeah, I think that's such a great point. You know, the preparation when it's not needed will really pay off when it is. Yeah. Yeah.

What advice do you give your trainees about how to do procedures in an effective way or how to optimize their kind of skills around procedures? So this is, I'll give a caveat up front for this advice, which is that I am, I think I was meant to be a left-handed person, but my grandma who watched me when I was little wanted me to use my right hand. So like I hit a golf ball,

better left-handed than right-handed and a baseball better left-handed than right-handed, but I write with my right hand. But one of my faculty when I was a fellow was like, you should get good at doing procedures with both hands. And I had never thought about, like, I'd only placed A lines with my right hand, I'd only placed IDs with my right hand, but I started doing all of my lines with my left hand. And then it became clear

such a helpful thing because particularly in ICU, you're often not in an optimal position to do a procedure. So, you know, if you're doing a right-sided subclavian and you're standing on the right side of the patient, it's great to use your right hand. Your angle is perfect, you know, but if you're doing a left IJ and you're standing at the head of the bed, it's super awkward to use your right hand. But if you can use your left hand, you actually have a really good angle on it. And so getting comfortable at that

it really frees you up then to kind of optimize your ergonomics in a situation where you don't otherwise control the ergonomics. And so I think getting good with both hands on procedures is a really good, it's really good to practice. I will say that is not true with the lingering telescope. You should just use your left hand. I love that. Yeah. You know, it reminds me of, I often will tell senior residents, you know, even say twos, like,

you know, you're pretty good at this stuff at this point, right? Like you could just kind of cruise, but don't do that, right? Look for ways to challenge yourself. And I've never even thought about that one, but that's a great example, right? So instead of using your right hand, use your left hand for some of this stuff and get good at that in case you ever need it. Yeah. Awesome. What about airway? How do you think kind of about instructing and thinking about how to optimize airway skills? You know, this came up when I was a junior faculty and I felt like,

Getting to do left and left airways. So I'm like, how do I stay really good at intubating when I'm just not doing so many? And often when I get to do them, it's because somebody else tried and failed and I need to be prepared to take over something more difficult. And I started getting in this habit of doing, you know, taking a direct or video microscope, getting my grade one or my best possible view, and then giving myself intentionally a

like a grade three view and just being able to maybe see the posterior retinoid and then trying to intubate and then lifting the ring scope, making sure it was in the right place and then moving on. And I felt like all of a sudden that meant rather than getting the 10 airways or 20 airways a year that I would get, I was getting 20 grade three airways. And so then when I have a patient who unexpectedly was a grade three airway because their anterior or conditioning wasn't great, they'd be like, oh yeah, this is just like any other airway. And it would go in. And so

Kind of to your point of thinking about training is like when you're getting good and not coasting, instead, when you're getting good, like make it harder for yourself. And I think if you do it in that, you're not, in my mind, adding any increased risk to patient safety because you're ultimately being able to verify what you're doing. But then you're also preparing yourself for the times when it's unexpectedly hard that you're going to be a lot more comfortable with it.

Totally. I give that same advice, you know, whether it's just trying to intubate with a grade three view or whether it's using a bougie. Right. There's really no point in using a bougie with a grade one view. So if you give yourself that grade three view and try the bougie, then you're going to get to practice doing that. Yeah. And then when the one comes up like you're, you know, just your anxiety, your comfort level are just going to be so much better to get it done. Yeah. How about when we think about asking good clinical questions? How do you approach that?

I think that this is where doing critical care fellowship really helped because you have this magical time as a fellow where you can call any other fellow in the hospital. And if you introduce yourself as a fellow, they have this innate respect for you because you're not the intern calling. But you're also not the attending, so they're not so afraid of you. And there's this kind of collegiality. And so I remember calling them and just asking questions like, why are we doing it this way? Or what do you think about this?

But in that, it also started to force me to think about how do I ask a really good clinical question? And so not just what do you think is going on, but what is your recommendation for normalizing the sodium in this patient? Or how would you further work up the anemia in this patient given that the iron studies were normal? And that, you know, it's kind of like figuring out where is the end of my knowledge and asking them to pick up

where it goes. But if you have someone with limited time, you have a limited interaction, you're going to get the most out of their answer if you do this. And, you know, that's kind of what the oral board does. Like the applied exam, it asks some of these really good, direct questions to force you to answer them. But getting good at asking those questions, I think, helps you grow your knowledge, particularly when you're getting pretty knowledgeable, but you want to continue to grow further. Yeah.

Yeah, I think that's a great point. You know, it happens all the time in the ICU where we'll be on rounds and, you know, we'll decide to, you know, ask a consultant a question. And then, you know, we'll get back. Well, I do afternoon rounds and I'll check with the team. I'll say, so what was the answer to that? And they'll say, oh, they said this. And I'll say, well, did they explain why? And they'll say, no. And I said, well, did you did you ask why? The answer is no. Right. And you have to approach.

those, those questions with, you know, with curiosity, right? This takes us back to where we started. Like you have to say, like, I'm not just trying to check a box that says got the consult. Like I'm trying to learn and I want to know. And I always tell them you can use me as an, you can say, you know, if you're afraid to kind of push, you can say, you know, my attending is going to want me to tell him why you're saying that. Like, can you help me learn that? Yeah. Yeah. I love that. And feel free to use that excuse or use the like,

I'm new here. I just don't know how this works. Could you help me understand it? It never hurts to play dumb in some of those situations. I feel like, and I don't know if you've seen this, but I feel like COVID took a major hit on that kind of clinical discourse. People got used to doing e-consults, putting things in the chart, not having face-to-face conversation, and everyone's busy. And so I think

but it's a real service that we can do in both directions. Like we can be the ones to ask questions, but also when someone asks us one of those great questions, we can take the time. You know, you're on the pain service, you're grounding on this patient and the thoracic fellow is like, well, why are we keeping the epidural? Can't we just take it out? And, and,

Not just say because we're the pain service, like, but actually think, well, here's our thought process. We'd really like to get them, you know, take an oral intake one more day before we switch them to oral medications. And that we think is going to be better for the patient. Those kinds of answers can also be really helpful. Absolutely. So, you know, you're someone who works in a lot of domains. You work in the ICU, you do OB anesthesia, you do OR anesthesia. How do you think about kind of applying knowledge from one area of expertise to different domains? Yeah.

I think it's such an important thing. We got a puppy like a year ago and you get to see this with training a dog so well. So like they, you'll teach the dog to sit in the living room and then you like go outside and you try to get that sit. They're just like, look at you like, well, the sitting skill is a living room skill and we are outside now. So I'm going to run around like, and you know, I think sometimes we fall victim to that in our training. Like this knowledge is, this is like,

you know, starting, uh, or repeating someone's calcium to fix their mild hypotension. It's a PACU skill to get the patient out of the PACU. But then you think, well, am I making sure that some of these calcumes replete when I'm in the OR? Like probably not. Like, but is that something that could be useful? Uh,

So I had a case early on in my time at OSU when I was on OB call where I had happened to have been on trauma call recently and they had a – it was a big lower extremity bleed and they – the trauma surgeon cross clamped the aorta.

and we were able to catch up and get a lot of resuscitation done. They were able to fix the vascular injury and then we communicated about when they were going to unclamp so we could prepare for it. And then I was up on OB and we had this massive hemorrhage case and we were so far behind. Blood pressure is in the 30s systolic and we were trying to get access, trying to get to Belmont and doing all these things, but we

we were just really far behind. And so I remember asking, uh, then the, the guy, like, did you cross clamp a or two? And they were like, sure. And they did. And then all of a sudden, like blood pressure was better. We got time to catch up and process. Hey, we didn't leave a clamp for very long, but then we came up like all of a sudden we had a blood pressure that was perfusing the brain and, and, and the organs and everything else. And so, uh,

you know, thinking about how, how do we make sure that the knowledge we have in one area gets applied to all the parts of our career? Because I think that makes us so much better clinicians. Totally agree. Dave, this has been great. Anything we didn't cover that you want to add before we move on? No, I don't think so. It was a great discussion. Awesome. I agree. All right. Well, let's turn to the portion of our show where we make random recommendations. Is there something you would recommend the audience check out for fun?

So there's a book called The Boy, the Mole, the Fox, and the Horse. It's by Charles Mackenzie. And it is a book that you could read in an hour or two. It's actually now, I think, been made into a little mini cartoon. But it is, you know, going back to talking about flourishing, I think it's a book that like,

is mostly in pencil cartoon. And it has just some like really impactful statements in it that I think if you're at a hard time in your life or you've been going through something, I think it can be a book that you can read in an hour or two that I think can really kind of reconnect you with what flourishing means. So give it a try.

Awesome. Thanks, Dave. We'll check it out. I'm going to recommend the new season of the Great British Baking Show. Always just a fun show to watch. It's like something you can watch with any age kid. So like my six-year-old loves watching it. And this new season is so far, we're just getting started. I think we're on week three or four, but it's off to a, I'd say, great but also interesting start. It's been, this is like a mild spoiler alert. So if you don't want to know anything, then stop listening now. But within the first three episodes, we're going to be talking about

One person quits, which is the only time I've ever seen anybody quit. One person faints and one person crashes to the ground in what it turns out to be no big deal, but you think is another faint. And it feels like what is happening? Like all of a sudden everybody's dropping here. But I think then it settles out after that. But really fun show. And I recommend checking it out. Awesome. Dave, thank you so much for coming on the show. Thank you for having me. And thanks for everybody who nominated me. It's an incredible honor to talk in this regard.

All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say. If you are a fan of the show, you can follow us. We're on Twitter. We are on Facebook. We are on Reddit. And we are on Instagram. I'm

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Thank you so much for the great work that you do. Our original ACRAC music is by Dr. Dennis Kuo. You can check out his website at studymusicproject.com. All right. That is it for today. For the ACRAC podcast, I'm Jed Wolpaw. Thanks for listening. Remember, what you're doing out there every day is really important and valued.

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