Episode 300: Reflections and Tips and Tricks with Dr. Stahl interviewing Dr. Wolpaw
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So

Hello, and welcome back to ACRAC and indeed to the 300th episode of ACRAC. It is hard for me to believe that we have done 300 of these, and it's both humbling and exciting. And I'm just really grateful to all of you listening that you've been listening for this long, especially those who have heard all 300 of these.

It's been a lot of fun. And what we decided to do, as you know, we reached out to all of you and asked what you wanted to see for the 300th episode. Some people sending questions, but the predominant thing that came in was actually people asking if I would do a master clinician episode where I was the master clinician. Now, let me be clear. I do not think of myself as a master clinician, but I

Enough people wanted to see it that I decided, okay, I'm happy to give my tips and tricks, my recommendations as compiled as I can get them. But rather than interview myself, I thought it would be fun to ask someone else to interview me. So I have asked my good friend and colleague, master clinician himself, Dr.

frequent guest in the past on ACRAC, Dr. Dave Stahl, to come in. He is actually the host of a podcast through the Society for Education and Anesthesia or the co-host of that podcast. So he's got the experience. He's been on ACRAC. He's got that experience. And I thought he would do a great job interviewing me for this 300th episode. So I'm going to turn it over to him and let him take it from there. And we'll see how it goes with him in the host chair and me on the other side of the mic. Dave, thanks for coming on and doing this.

Well, thank you. I'm thrilled and honored to be here today to interview the one and only Jed Wolpoff for the 300th episode of ACRAC. I'm going to start off by going off script a little bit to just acknowledge the 300th episode, because I think

This is really incredible. And we're going to circle back, I think, later to talk maybe about gratitude. But I want to talk a little bit about this as an accomplishment. And so I asked ChatGPT about the number 300. This is foreshadowing an upcoming episode. But it tells me that in numerology, the three and the zero, the energies together symbolize creativity and self-expression. So how has ACRAC been an example of creativity or self-expression for you?

Well, yeah, I love the foreshadowing to our upcoming kind of practical AI episode, which I'm looking forward to. But I think of myself as someone who is not particularly creative, is certainly not artistic. And yet I really enjoy the opportunity to connect with and learn from people who are. And so one of the things that ACRAC has allowed me to do is to do that on a level and at a frequency which I wouldn't normally get to do.

And so I'm able to connect with people who are being creative, creative about the research they're doing, creative about even things like, as you know, I had a chef on. I've had people who have written books, people who have invented inventions. And, you know, that to me has been really cool because I don't think I'm particularly good at that, but I'm fascinated by people who are. And so people who have that talent and that creativity, this podcast has been an opportunity for me to connect with them and just kind of hear some of their stories, which I've really loved.

Well, I think the listeners would probably agree that I think it's also just been an incredible community building opportunity for so many people who are interested in these and many other topics. So

Something that's often left me in awe during my career is when someone blazes a new trail or does something new like you've done with ACRAC, but then they take the time to reach out to others. And I've seen you reach out to teach people how to do a podcast or to talk about something educationally unique. And you're a busy guy. How do you find time to make sure you kind of leave a trail for others to follow behind you?

Yeah, it's a great question. And I think it's really been one of the highlights for me of this eight years and the time doing this is that I feel like it has been a chance to work with other people who are interested in doing something similar. And, you know, just to name a couple, the Style Points podcast, the Depth of Anesthesia podcast are two fabulous anesthesia podcasts.

And I don't by any means want to take credit for them. They are fabulous and their hosts are doing amazing work. And I think they would have been popular and taken off on their own without ACRAC or me being involved at all. But it was certainly fun to get to work with them a little bit at the beginning and to host one of their early episodes on our feed. And so I think doing that and then seeing these be successful, just as I think anyone who helps someone in any little way and then see success come from it, it's really rewarding. I also think we need

more podcasts in anesthesia. And so I'm excited to see them happening. And so that's been great. And then also just to kind of have fun at things like the Society for Education Anesthesia Conference, where you may remember a few years ago, we did a how to podcast workshop for folks who were interested. And so I think it's been really fun. And in terms of finding the time

throughout my career, and I know you feel this too, Dave, what I have found is that for the things that you care about, the things that you really get enjoyment from, you find the time because it's not really work. It's, I mean, it is work, but it's not work in the sense that we often think of work of like, oh, you know, I have to get through the workday.

it's enjoyable. It actually invigorates and gives energy. And so that is what often this work is for me. When I get to do a podcast, meet a new person, hear about their work, or help someone else who's starting a podcast, that to me is invigorating. And when I find the time for it, it actually helps me feel even more excited about my work and my time. That's wonderful. Well, I'm certain because I have asked that listeners hear you and think,

Jed's incredible. I could never do something like that. And I wonder if you'd be willing to share something in your journey where you feel like you got ahead either professionally or clinically or otherwise because there was either good luck or because someone took the time to help you out where it wasn't really something you did, but maybe to bring you down to earth so that all the mortals can aspire to do what you've done. This is such an important point because

I think every day that most of what I've accomplished is not due to anything that has to do with me. I think so much of it is luck, is support and mentorship, and is willingness to try something you don't think you can do. I mean, if anything, I think one of the things that has helped me be successful is that when I thought there's no way I could do this, I'd said, well, I'll just do it anyway. And then so many of those things...

won't work, but some of them will. And you have to be willing to. And, you know, I remember my mother when I was a kid, I have no idea why she was telling me this when I was a kid, but I do remember she told me at one point, if you wait until your plan is 100% ready before you launch your project, you'll never do it.

When it's about 75%, that's when you go, and then you figure out the other 25% along the way. And I think that's just such a great example of what you have to do. You can't say, I'm not going to try this because I'm not sure it's going to work yet, or I'm not sure I have the ability to do it. You got to just try it. And if it doesn't work, okay. But you might surprise yourself. And that's what I have felt. I mean, I could give any number of examples of where luck or support has helped me, but

One that comes to mind a lot for me is becoming program director eight years ago. I was very new. I was only two years out of training. I just happened to be kind of right place, right time in terms of luck. I had a master's in education. I had taken on the clerkship.

One of the APDs had stepped down and I had stepped into that role. All just kind of fell into my lap. There was nothing I did to kind of earn that or anything. It just was kind of right place, right time. And then when the program director stepped down, my chair decided to take a chance on a really new faculty member who she decided was was worth giving a shot. I think a lot of other chairs would not have done it. And in that scenario, I would not have been program director.

but she decided to do it. And it was thanks to her support and believing in me that I got the chance to be a program director at that point in my career. And it was, again, thanks to a lot of luck. She wouldn't have had the chance to appoint me if it hadn't been for all the other things falling into place. So that is just one example of many where I think luck, right place, right time. The podcast is an example of

Didn't know what I was doing. Had no idea how to do it. By all rights, should not have done it. But I said, I don't know. I'm going to like push record in GarageBand and see what happens and talk. And, you know, listeners know that one of the early episodes only played in one ear. You know, I mean, it's just...

I still don't know why that happened, but it was just a kind of figure it out as you go, feel like, okay, I'll bumble through it, I guess. And just by virtue of trying and not really knowing what I was doing, certainly having no confidence in my ability to do it, getting a lot of help from residents at the time who were much more tech savvy than I was.

that I was able to kind of fumble my way into a semi-decent podcast. And so, you know, the advice I would give to people from that is if you think you're something you might be interested in trying, but you're not really sure how to do it, just try it and see if you can find some help. But don't talk yourself out of it because you never know.

That's awesome. You know, we're coming up on the end of the calendar year. And I also asked Chad to be about numerology. And it said that three and zero are also about new beginnings. And so anytime we reach a milestone like graduation or just finishing a week in the ICU, I think it's an opportunity for a new beginning. And so thinking ahead now at 300 episodes, like what beginnings are you most excited about for ACRAC?

You know, I think one of the things is, and it may not be too exciting an answer to that, but it's just every new episode in some way is a new beginning, you know, and I really never know what will come my way. For example, Christian Mayhoff, very famous author in Europe, reached out. He wants to do a pro-con debate about post-op monitoring. It's not something I would have, you know, thought to kind of reach out and have, but I'm really excited to do it. And I know I'm going to learn a ton about the pros and cons of continuous monitoring for all surgical patients post-op.

So I'm excited to do that. So I love that kind of each episode is its own new beginning. I also think that this Master Clinician series that has started, Dave, you were, you know, we haven't released it yet, but you were a guest on it. And I'm excited to release your episode, you know, is something I'm very excited about, because I think what I'm seeing is that people who all across the spectrum in private practice groups, in academic centers, who people have really thought of as these Master Clinicians, but

who would not necessarily have an ability to reach beyond their group or their department, are able to come on and talk about their kind of long-established and long thought of tips and tricks, the things they teach all the time, the things that have helped them be really successful, and then share it across what is 60,000 people listening to this and all over the world. So for me, that's something I'm very excited about.

Well, I know your humility would not let you admit that you're a master clinician, but I've always known you to be an incredibly disciplined clinician and person. I think another way of saying that you're disciplined is that you've built good habits. So what do you think are your best clinical habits?

Yeah, so I think habits are so important and have to be built, you know, methodically. I'll take you through first just kind of some of the habits that I think are important and then also happy to go through kind of some specific clinical practices that I think I've developed over time that at least I find really helpful for me and that I teach our residents. But habit-wise, I think I would start with mental checklists.

We, no matter how smart you are, you are never going to be able to remember everything. Certainly not when things get stressful or someone throws you off your game. You have to have the checklist. You have to get in the habit, for example, before induction of making sure you have the

The monitor's all on. How are you going to know that? You can't just trust that you put them on because you usually put them on. You have to have a way of making sure that you do. And for me, I look up at the screen and I make sure that I can count four numbers up there. The EKG tracing and the EKG pulse tracing.

the pulse ox with its tracing, the end tidal CO2, and the blood pressure with a countdown to the next blood pressure. If I see all four of those up there, then I know I have all my monitors on and I'm okay to induce. But the only way I started doing that is because of forgetting, right? I didn't induce a patient as an attending and realize, oh my gosh, we didn't start the blood pressure. And then of course, you're going to have times where you, now you can't get a blood pressure. So what now, what do you do? Right? Right.

Or you realize, oh, the end tidal CO2 isn't there. Does that mean we intubated the esophagus or was it not working in the first place? So...

Having that habit is really important and anything like that. After I get settled, after I get the tube in and the vent on, I will go through ABC, ABC. Now, this is something that Manny Pardo, who was my program director and was my second week preceptor my CA1 year, taught me. And I have been using it and teaching it ever since. And that was like 15 years ago. And so ABC, ABC is fantastic.

The first ABC is the same ABC that we all know. Airway breathing circulation. So you say airway. Is it in? Do I have an airway? Is it in place? How do I know it's in place? I mean, so I have entitled CO2. Do I have title volume? Is it taped at the level I think it's taped at? Do I know it's not right mainstem? How do I know? Have I felt the cuff at the sternal notch? Do I have I listened for breath sounds?

Breathing. Am I breathing? Is the vent on? Do I have a reasonable tidal volume and reasonable respiratory rate? How do I know? What's the peak pressure? Do I feel comfortable with that? Are the vent settings where I want them in terms of the oxygen setting and I'm on the things that I think I'm on?

C is for circulation. What's the blood pressure? Is it cycling? You don't want to be the person who gets that one blood pressure before intubation and then you realize half an hour into the case that the number showing up there is still the one you got pre-induction. Is it cycling? Is it cycling at an appropriate? Do you still have it on every minute? We want to change that. Is it somehow on every 15 or 20 minutes? You don't want that. Make sure it's cycling. Heart rate.

heart rate, heart tracing segments, all those things that you want to make sure right up front, do they look how I want them? And then the second A is for anesthesia. Am I delivering it? How do I know? If I have entitled gas, then I know. If I don't, if I see that my SIBO and my ISO are at zero,

I want to panic for a second. And then I turn and see, okay, I'm running propofol. Thank goodness. How do I know the propofol is getting in? Well, let me check my line. Let me make sure that the pump is on and that it's a reasonable dose that's going in and that the line is not infiltrated and that the bis, if I have a bis on, is operating and has a reasonable number. The second B is for body position.

Am I happy with the position? Do the arms seem reasonable? Is the head and neck okay? Are the eyes taped? Is there anything under the body like a little cap that could be compressing and causing skin necrosis? Did I tape my tube so hard against the lip that it's going to necrose the lip? Did I tape my NG tube so hard against the nare that it's going to cause necrosis? Did I jam the tongue so far back in the mouth with my bite block that it's going to cause tongue necrosis?

checking all these things. And then under body position, I also put neuromuscular blockade, making sure that I have given it if I mean to give it, and that I'm checking twitches and have a reasonable level where I want to be. And then the final C is for Celsius. Do I have a bear hugger on? Am I measuring temperature? Am I happy with the temperature? And then I actually do come back to A again for antibiotics to remember that I have given, assuming I want to give antibiotics that I've done that. So going through that means I'm

I'll catch some of those little things like that I forgot the bear hugger or I didn't check the arms or one of the arms has fallen off the armrest and all those little things that, you know, you may not. And some of the big things like, am I delivering anesthesia? But it's amazing how often you will catch something, even as a senior attending. So you need to have those checklists. So that's a big one.

I think one habit to build, and it's hard, is to see your patients post-op when you can. It's both really important for building relationships, even the kind of small relationships that we build with patients. It's also important for your own practice to see, did they get nauseous? Did they have pain? How did it go? What do they remember? Those kinds of things can really help you refine your own practice.

In general, don't ever put off anything that can be done quickly now. People have heard me say this before, but it always amazes me how many things people put off that they could just get done immediately. It would take 30 seconds to do right now, but they put it off. And then they end up with this huge long list of things that need to get done, and then some of them don't get done because it's too overwhelming.

You can be so much more efficient if you just get little things done as often as you can. I mean, you've seen this, Dave. I do this all the time. If I'm talking to you and you say, oh, hey, send me that thing when you get a sec. I'll be like, hold on one sec, and I will send it to you right then in the middle of our conversation because A,

that way I know it gets done and B, it doesn't add to my to-do list so that what's on my to-do list are the things that are going to take a little longer, the things I have to wait until I have more time, but those things then get my attention. So really try to be efficient about getting things done whenever you can.

I love the habit of communicating with the surgeon the night before. I always, always reach out, usually by email, to the surgeon. And I say, you know, hey, I'm working with you tomorrow. I'm looking forward to it. I looked at the patient. Here's what I think. Here are my concerns. I have some questions for you. Do you want an epidural, for example? You know, what do you think about this? Are you worried about this? Do you have any other concerns? I can't tell you how often that has paid off in terms of

discovering something between the two of us that wasn't going to get discovered and simply in relationship building with the surgeon, really appreciating it and us developing a good relationship and increasing the trust they have in me as somebody who's actually starting that communication. Same, introduce yourself in general, introduce yourself. Never assume people know your name. I'm somebody who is terrible with names. I so easily forget names and I hate that. I wish I didn't have that. I wish I was good at names.

But I really appreciate it when people introduce themselves and don't assume I know their name. And I try to do the same, same in the OR, get to know people's names, introduce yourself to them, write them down. If you like me, can't remember names, write down names. I keep a list on my phone of names, like someone I'll meet up, my kid's parent, my kid's friend's parent. And I'll be like, I know I'm never gonna remember this. So I write down their names so I can refer to it and hopefully remember it. So I think that's really important. Communicating during the case, you know, we see this all the time in anesthesia, right? Like

And we'll see that the blood pressure is going down. We're kind of going up on our Levo and we don't necessarily say anything to the surgeons. Right. And then not until things get really bad, but just over communicate and ask them to do the same. Right. We want to know how's it going up there. Any concerns? We're going up on our Levo a little bit. I think it's OK. Just want to let you know. I'll let you know if it gets worse. You know, the more communication, the better. And the more we can break down that barrier, the better. And then the last thing I'll say in this kind of area is push yourself.

It's so easy at various points to just coast. I tell the CA2s, you know, when you get to be about halfway through CA2 year, you're pretty good. You probably can just coast from here on out. But man, will you miss the opportunity to become so much better than you could than you would be if you just coasted. And that's true for attendings, too. Just because you're an attending doesn't mean you don't have more learning to do. I'm

11 years into my being an attending and I have lots more learning to do and I'm excited about it. I'm always looking for ways to challenge myself, learn more. I'm willing and able to change my practice. We'll talk more about that. So those are some habits that come to mind clinically that I think are really important. I love it. I hear kind of like two big buckets. The first, you know,

habits don't mean you have to remember everything. Habits can be building these structured systems like a checklist where then you are able to facilitate remembering all these things. And then communication. And I've often thought that

That what separates the good from the great anesthesiologist is not because they're that much better intubating or that much slicker at what drug they pick. They're just better communicators. And I think a lot of people going to anesthesiology, myself included, are introverts. And when being outspoken and calling the surgeon feels scary, and I can say that because I'm married to a surgeon, but going back to your earlier point, I think just doing it, just

So holding yourself like, I'm going to call that surgeon. I'm going to lean over the drip and say the thing. Then it gets so much easier over time. And it's really, it's not because I think I got that much better at it. It's because I conquered the fear of being worried that I wasn't going to be good at it. Absolutely.

So we both did medical school at UCSF. And if you remember back in the day, UCSF was the place where ICU was Vence lines tube sedation. Like it was it was that was their their meat and potatoes. And so we'll do a little rapid fire about some clinical scenarios here. We'll go down that list. So let's start with with Vence. What are your advice for the ventilator?

Yeah, I mean, it's obviously a little different in the ICU versus in the OR. I would say that in the OR, I firmly believe that five of peep is almost always too little. And there is some data to suggest that I'm right about this. It's not that nobody ever is OK with five of peep, but a lot of people need more than that. And I mean, even just regular old normal weight people lying flat.

What is even more extreme is that when you have obese patients in Trendelenburg with an insufflated abdomen, for example, having a robotic prostatectomy or robotic hysterectomy, they need way more PEEP. And I'm talking about I will run these patients 20 plus of PEEP. And it is not only okay to do, it's actually better. I mean, these patients do better. And it will happen that I will come into one of these cases and

And the team has been running them on five a peep and they're satting, you know, 91% on 80 or 90% oxygen. And the sign that I'll get is, you know, yeah, I mean, we, the tube is not Ray Manston. We thought it might be because of the D's, you know, the, the fact that they're a little low, but they're fine. They've been stable there at 91% or they've come down just very slowly. So, you know, I think it's okay. I think it's just cause they're really obese. And, and,

I'll say to the resident, watch this. And we will do a recruitment maneuver, go up to like 40 centimeters of water for 30 seconds, and then we'll come down to 30 a peep, and then we'll walk it down every 30 seconds or so from 30 to 28 to 26. And we'll look at the driving pressure, and we'll look at the compliance, and we'll find where that compliance is maximized and the driving pressure is minimized. And it often is at somewhere around 22, 24, 26 a peep.

And they will, within about five minutes, be setting 100% on like 30% oxygen. And they were requiring 90% to set 91%. It's amazing the difference that it makes. And you can't be afraid of giving that much PEEP. It is safe because what really we're talking about is the transpulmonary pressure.

And the pressure around the lung in that setting is so high that the lung isn't actually experiencing what you think it's experiencing, which is what you see when you see a peak pressure of 40 and you're freaking out. But actually, the lung only experiences the difference between the pressure on the inside and the pressure on the outside. And so if the pressure on the outside is high, you are protected. And so it is safe to do.

uh, you have to look at hemodynamics, but in fact, when you are standing on your head, gravity will win. And so you will not prevent Venus return. You will be fine with your hemodynamics. Um, and so that's, that's one thing I really keep in mind. Um,

In the ICU, as I said, it's a little different because obviously patients are now head up, usually sitting up at 30 degrees, and they are not with an insufflated abdomen and all that. And so it's a little different, though I still think it's not uncommon for patients in the ICU who are very obese to need more than five a peep, and we should be okay with that. And, you know, the idea that we must come down to five a peep before we extubate I think is wrong. It is completely fine to have a very obese patient –

on eight or even 10 a peep and to decide to extubate them. And once they are extubated, they will have more intrinsic peep. So you are not, you know, you don't need to take them down to five. Remember little thing, but if you want to know a true plateau pressure, you have to be on volume control. Everybody likes the, you know, pressure control volume guarantee or whatever your, your events proprietary name for that is, but you have to be on a true volume control to get a real plateau pressure. And then I would say,

There's a lot of debate about this, but you really don't need to overdo the oxygen. There's no advantage to being on 80% or more oxygen throughout a case. And there is some suggestion, I think, that that may be harmful. It's hard to prove that in an hour or three hours or four hours in the OR –

there's really negative outcomes. But we do know that excess oxygen does cause harm, especially in patients with cardiac ischemia, for example. And so do we really want to take patients in the OR who maybe, you know, might have some cardiac ischemia and then subject them to all these free radicals? I don't think you need it. And I think it's not beneficial and maybe harmful. So I would not overdo it. I'm not saying you need to be on 21% oxygen in the OR, but I don't think you need to be on super high levels. So I think I'll stop there.

there. We can obviously talk about Vince for an entire episode, but those are some key things I think about.

I love it. And I love your point because I think a lot of times people who are afraid of PEEP get afraid of the hemodynamic consequences. And your point that even at these really high levels of PEEP, you often don't see the hemodynamic consequences you think you're going to change because the transformative pressure isn't that high. And so the pressure transmitted to the thorax isn't that high. And so now you've solved the lung problem and you didn't pay any hemodynamic penalty for it. So that's great.

Yep. All right, let's move on to lines. What are your thoughts on lines? Yeah, so I think, first I'll say this, shallow is often better when you're placing radial A-lines and distal IVs. It's not true for deep brachial IVs, but for distal, like hand IVs,

wrist IVs and A-lines. The number one thing I see when people miss these is that they're already through it by the time they even look either down or if they're using an ultrasound, by the time they look at the ultrasound. Or they're looking at the ultrasound and they see bouncing, quote unquote, bouncing above the artery and they think, oh, I'm not there yet, but that's because they're looking halfway down the needle. And if they find the tip of the needle, it's already way through the artery.

And if you go fast enough through it, you may not even see blood, right? So you don't know that you hit the artery and you may have gone right through it, or you may have missed it and gone too deep. So be more shallow. You can always correct if you are too shallow. If you are above the vein or above the artery, you can always go deeper.

but you will be more successful, I think, if you start much more shallow than most people start. And my suggestion to folks is use the ultrasound and see, practice this, go really shallow and see where you are, go steeper and see what happens. And then you can use that to help guide where you want to be when you're going blind. I would say it's fine to use the ultrasound. One change I've seen, Dave, and I think you've seen this too, just recently, I would say this is in the past two or three years, is that, you know, before that,

What I saw was most residents would place most A-lines blind, and then when they were having trouble, they'd go get the ultrasound. And now I see the opposite, that almost every A-line is primarily done with the ultrasound. And I'm okay with that, but I think you want to do it deliberately. In other words, don't just grab the ultrasound, visualize the artery, and go.

feel for the artery, ask yourself, if I were doing this blind, where would I go? Put a little dot with a sterile marker on the skin where you would go in, and then put another dot an inch up the arm in the direction you would head, and then put the ultrasound on and ask yourself,

how, how correct was I? If I had gone in where I said I would go in, would I have gotten the line? And that way, at least if you have to go blind, you have practiced those skills. And I would still try doing some blind. I think you don't want to be so dependent on the ultrasound that you can't do them without it. Um, I would say that, uh,

When you are unsure about an IV, a really neat trick that I learned, I have not, I did not know how to do this, you know, 10 years ago, but I've learned it in the past years, is especially if you place, let's say, an AC IV or a deep brachial. And, you know, you do it with the ultrasound. It looks like it's in. You feel pretty good about it, but, you know, you want to be sure because you're going to be like transfusing through that thing.

Take the ultrasound, get up in the armpit, visualize the axillary artery, or if you have a cardiac probe, you can look right at the right heart and then agitate some saline with a little bit of air. So you get air bubbles in the saline and then inject it through your IV that you just placed and watch those bubbles. It's so, you can't miss it. It's very obvious. If you've ever done it, you know, the thing lights up like a light bulb. And if you see those air bubbles up in the axillary artery or in the right heart, you know, your IV is in. Now,

it doesn't mean there's not a little hole in the vein. You may have, you know, if you went through and through and then back or something, it's not that you couldn't have any leakage, but at least, you know, it's not completely extravasated, that it is in the vein at that point. So I think that's really reassuring and a nice way to make sure, especially if it's a deep IV that you want to be sure you can use for transfusion. So I'm going to stop there. Those are some key line thoughts that I have.

Just to follow up, because I think there are probably some listeners who have never done the agitated saline thing. So how do you make the agitated saline, just so they know? Yep. So I take a stopcock. I put a syringe full of saline on, not all the way full. So I'll take like a flush. I'll squirt out a cc or two. So I'm maybe at nine cc's of saline. And then in the other syringe, on the other part of the stopcock, I will put a cc of air.

And then I will just go back and forth, squeeze one into the other, squeeze the other back so that you're mixing that air into the saline. And now you're going to have 10 cc's of saline full of air bubbles. It is totally safe. That tiny amount of air is not going to cause an air embolus. And then you...

injected very quickly into your lines. You have to be ready to go. You can actually put the stopcock on the line. So you're using your three parts of your stopcock. One is connected to your line. The other two are where you're agitating your saline and then flip your stopcock. So you're now going into the IV and push that in while you're holding or while someone else is holding the ultrasound there. The other thing, Dave, that I forgot to say,

but that I think is important is that doing in-plane views for a line placement, I think is a really nice skill to have. And people don't do this very often, but I like it better. I place as many lines as I can in-plane. You see your needle the whole way, as well as the vein or artery the whole way. And it's a really nice thing to do. It's a little harder, I think, to learn, but I think for folks who are learning, I think it's important to learn to do this and you may find you like it better.

Yeah. And then that skill translates to your other, you know, essential in placement to a line, but you can do it in other places too. Absolutely. It's great practice. Okay. We did, we did Benson lines. Let's do tubes. All right. So some, some things that come to mind, I think we've all seen this where somebody goes into intubate and they get it, let's say with a glide scope and they get a good view, but then they try to get the tube in and they can't get it up to the cord. So the tube is going low and,

And so what do they do? They bend down on the kind of on the on the stylet way up by where they're holding the tube. And they've kind of pushed down on the teeth to bend it. And that's never going to work. You need to bend your bend in your tube should be down by the cuff.

That's what's going to help you. So when you first put a bend in the tube, put it down low. You definitely don't need a hockey stick. You don't need a right angle, but put your little bit of bend down there. That's all you're normally going to need. And if you're in that situation where it's not getting up to the cords,

add the bend down at the end of the tube. That's what is going to make the biggest difference. But usually to start, and by the way, you often don't even need a stylet for intubations in a standard patient. And I think it's completely fine, but you need to have one ready, right? So it's not good to go hand your attending, you know, a tube or for your attending to pick up the tube has no stylet and there's no stylet to be found anywhere in the vicinity. Have a stylet ready, but you can certainly try without it. And if you need it, a nice soft little curve at the bottom. And then if you get into trouble, put more bend at the bottom.

I always use a 6.5 tube or lower, 6.65 in women and a 7.0 tube in men. I do not go bigger unless it's like a bronc that's being done where they need a bigger tube to bronc through. But standard cases...

What I have learned from our ENT colleagues is that you start to see more damage to the airway when the tube gets to 7.5 and above, and there is no downside to a smaller tube. I mean, if you got down to 4 or something, you probably would have trouble. But talking about 6, 6.5, those tubes, you don't have more, you know, you don't have problems with too much resistance or them getting clogged or anything like that.

I'm not saying this is necessarily true for a four-week intubation in the ICU, although even then I don't think we need 8-0 tubes. I think a 7-0 tube is fine. But in the OR, I try to stay smaller because my understanding of what the ENT surgeons see in their clinics is that you see more damage when you get to bigger tubes. So I like that as a little key thing.

I like the paraglossal approach with the Miller blade. I see a lot of people do a standard Miller, which is fine where you go straight down the middle and try to lift the epiglottis, but going over on the right side of the mouth into the tonsillar pillar on the right and trying to shift the whole tissue plane over. If you watch your ENT colleagues who are doing epiglottis,

their larynx surgery where they use their Hollinger, that's what they do. They go in on the right, they shift over to the middle, and the Hollinger scope is at an angle. It's forming kind of a hypotenuse down from the right side of the lip down to the middle of where the cords are. That is what I like to do with the Miller. I think it's really effective, and it's a good technique to learn.

I think positioning is so often not done well, but it's so important. You want the external auditory meatus to be on the same plane as the sternal notch. And with most overweight patients, you're going to need to ramp them at least a little, maybe a lot in order to make that happen. What I see people do when they have a patient well ramped

They decide, oh, I need the neck to be hanging. So they take the pillow out from under the neck, let the neck hang down because they think that super hyper extension is the way to go. We're actually not. This has been well studied. The data on this is clear. That does not improve your view. You want the head to be up. You want the neck down.

to be extended, but the face forward, that's the classic sniffing position. So you don't want to pull that pillow out from behind the head. You want that head up so that it's lined up and then you can get a better view that way. There's even some people who will say, and some studies to suggest that actually flexing the neck a little bit can help. I, I personally don't really know how to do that well, but I find that at the very least you do want to have that ramp up and you want to line the sternal notch and the external auditory meat is up. Uh,

Um, if you're having trouble, as we all know, right, you can reach around with your right hand and manipulate the neck a little bit. It's the thyroid that you want to manipulate, not the cricoid. So people often get that wrong and say that wrong. Cricoid is for if you're going to do cricoid pressure, which is its own controversial thing. But thyroid manipulation is what you want to do to try to move the larynx around a little bit and move the trachea around to try to get a better view. And then, um,

you can then lift the head. That's the other thing. So if you're having a bad view, reach your, you've got your laryngoscope in your left hand, reach your right hand under the head and lift, lift the head up. And if you, if that helps your view, you can either stick another pillow under there or ask your attending or someone else to hold that head up while you intubate. And that's a really nice move that I think works a lot. And the final thing I'll say about tubes is that I really like, I mentioned this before, feeling the cuff to confirm depth. Listening for breath sounds is fine.

But breath sounds can be transmitted. And you can hear breath sounds either on both sides when you're right main stemmed or not uncommonly, especially with obese patients, you may not hear really good breath sounds on either side. And you don't know, am I in? Am I not in? So if the cuff is at the sternal notch,

And the way you feel this is you take the pilot balloon in your hand and pinch it a little bit and hold it down, and then you bounce at the sternal notch. And if you feel that bouncing happening in the pilot balloon, then you know you're bouncing on the cuff. Now, this does not tell you if you're in the trachea or the esophagus. It just tells you that the cuff is at the sternal notch. If the cuff is at the sternal notch, you are not right mainstemmed. So I think that's the most reliable way to make sure you're not right mainstemmed. You also have to verify that you're in the trachea, end tidal CO2, etc.,

Now, most women are going to be somewhere in the 19 to 21 centimeter range and men 20 to 23. So if you it's not that no man can ever be deeper than that or really tall woman. But if you're at 26, 27, you got to ask yourself what's going on and be very suspicious that you might be right main stem. And even if you're a 24, 25, I would ask myself that, especially if it's a woman. So we often want to take the tube shallower than we may think. Again, feel for that cuff.

I'm going to end there on that topic. I love it. It reminds me of the old school light wand. Do you remember the light wand? I sure do. The lighted stylet where you'd see the cuff right there as you see the light and then slide the cuff in. But I think we often, we have so many monitors now that I think sometimes looking at the patient is the best reminder. But I also, you know, you're pointing about the airway. It's so common. Like, I think

Keith Baker brought it up on his Master Clinician episode that people who are inexperienced tend to put the head in extension and then hurt themselves. And so just to point out that I think that is a really common thing that people do to set them up. Stay with us. We'll be right back.

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All right, and we're back.

All right, let's do sedation or meds. Like, what are your medication tips? Well, my residents will laugh because there's – I'm going to just hit about three things that I do that I think are fairly different than what a lot of people do. And I really like them. I think there's some good reason to do them. But, you know, I'm very – I stand out as one who does this and not everybody does.

So one, I don't use fentanyl for induction. I use Esmolol instead in almost everyone. And I give 100 milligrams. That sounds like a lot. It's incredibly well tolerated. Esmolol is this really interesting drug. If you start off at a heart rate of 50, it's not going to do anything to your heart rate. It will prevent it from going up, but it won't take you down. If you start at 100, it may well take you down to 60. But I have never seen Esmolol take a patient below about 40. And that's even that is rare. And

So it's very safe. It has kind of a floor effect. It won't go below and it will prevent tachycardia much more effectively than the little bit of fentanyl we usually give with induction. And so if you look at the charts, when I do inductions, it's the heart rate is just dead stable throughout the induction period and the intubation period. So it's really nice and it goes away within, you know, five to eight minutes. So it's not going to stick around and cause you problems. So I like that.

I give methadone to almost everybody. I don't give it if it's a surgery that isn't going to be painful and they're not going to need any opiates post-op. But if it's a patient who's going to get opiates post-op, either in the PACU or to go home or both, I give them methadone. And I give somewhere between 0.15 up to maybe up to 0.3 at the most of milligrams per kilogram of ideal body weight. That's really key. This is ideal body weight, not total body weight.

I give the higher dose for major things like a big spine in a healthy patient who's maybe got some opioid tolerance. That's where I might think about going up to 0.3. For kind of your everyday inpatient, I give about 0.2.

And for older patients, patients who are opioid naive, patients who are frailer, I will get go. I'll edge that down closer to the point one five. I give that with induction IV. And then at the end of the case, once they are breathing, I will give more if they are to keep naked, they're breathing themselves down to a low CO2. Or if they wake up and they say, I'm having pain, then I will treat that with some more methadone.

It's an incredible drug. We could do a whole podcast on it. In fact, we have with Evan Karish, who's the person I learned this from, and I'm so grateful to him for helping me change my practice. And this was, you know, eight or so years into my practice, I completely changed my approach to this and started doing methadone thanks to him. And I can't encourage people enough to really think about this. I wouldn't just start doing it, especially residents. I would talk to your attendings, obviously, but think about it. It's a really, really effective drug. And the data is pretty clear on this, that patients are happier with

Their pain is better controlled and they use less total opiate when they get methadone.

And then the last is norepi. I don't ever use phenylephrine anymore. I mean, I would use it in a Hocum patient, but I don't take care of Hocum patients all that often. So I use norepinephrine, both push dose and drip. I started norepi drip before induction on almost everybody. If it's like a 19-year-old having an ankle surgery or something, I probably won't. But for most bigger cases and older patients, I will start a norepi drip before induction. I started at 0.05%.

happy to run it peripherally. We know it's totally safe. And then what I find is you don't see that hypotension during the period where you're putting in lines and you're waiting for the surgeon to start. And then once they start, if you don't need it, you turn it off. But I find a lot of patients end up running a low dose of norepinephrine throughout the case. There are some studies, I've talked about this before, that suggest this probably is helpful. And it is clearly a better presser than phenylephrine. I think that's very, very clear.

Um, and so I think both for push dose and for a drip, I use Norepi push dose. The act, the actual equivalent dose, eight mics of Norepi is equivalent to a hundred mics of phenylephrine. I think it can be a little bit of a pain to mix up eight mics. So I just usually take one milligram, put it in a hundred MLs of saline. That gives me 10 mics per ML. You can push that just like you would push phenylephrine one or two CCs at a time. So I'm going to stop there. Those are my three med recommendations.

I love it. So we got esmol, methadone, and norepinephrine. I encourage you guys to step outside of your comfort zone, as we talked about earlier, and try some new things. All right, so we know that you're an intensivist, and we've talked about how a lot of what you know in one space crosses over to your role in the OR, but what are things when you're in the ICU that you feel like are your kind of clinical pearls?

Yeah. So, you know, just something, you know, and I'll just say again, like, please don't see any of what I'm saying today as an exhaustive list. There's so many things that we could talk about in any one of these areas. But these are some things I just thought would be useful to share. So one is, I think, going back over things again and again, rounding and rounding and rounding in the ICU.

I'll say this for sure for residents and fellows. The more you walk around that unit as you're on call during the day, you're walking around, you're checking in with the nurses, you're checking on patients, you're taking a look, as opposed to hiding back in a room with a computer somewhere. First of all, you're going to enjoy your experience much more because you're talking to people and you're talking to patients.

Also, you will know what's going on better. Also, you will build better relationships with the nurses. Also, the nurses will trust you more. So I can't emphasize that enough. And for attendings, I will say the same thing, like just rounding in the morning and never again. I suggest not doing that. I round in the morning. I do try to give the fellows some autonomy to kind of run things for a while.

Then I do afternoon rounds again where we round. We walk around, not card flip rounds. We walk around and we stop by each room. We check in with the nurse. We go over the plan so they can update me on what's happened throughout the course of the day and what we want to keep doing. And we make sure we're all on the same page. I think that's really important. Talk to families and patients. It is so sad how we've gotten to the point where we spend most of our time in front of a computer and we've really gotten away from this. But it is sad.

Really important, I think, to remember that we're here to talk to and help and care for people. And I think a lot of the burnout that comes in medicine is from losing that connection and just being in front of a computer all day. So, you know, again, walk around, talk to patients, go into the room, talk to the family, make phone calls, talk to the families. You know, I think attendings do this pretty regularly.

but it is really important, I think, for residents and fellows to do it too. And, you know, if you get in there and you ask questions

I tell our medical students this, you know, because they have the time to do it. Like, get in the room and just – you don't have to be the expert on the medical stuff going on. It's fine to say, you know, I'm just a student. I'm learning too. I'm not sure what the answer to that is, but I'm happy to ask. But I'd love to ask you just some things about your loved one. You know, what did they do for a living before they got sick? Do you have kids? What do they do? How old are they? You know, do you have any pictures of him or her from when they were younger or from before they were here? You know, asking those questions –

is going to make such a difference for the family and feeling that they and their loved one are cared about and will really help you get to know them as a person. I love during COVID, I'm sure you saw this too, Dave, how, you know, when we couldn't go into the rooms, we had a lot of times on the wind, on the screen, on the glass, the nurses would write, like, I am a UPS worker. I worked for UPS for 30 years. I did such and such. I have three kids.

And I think that's what we always should be trying to learn is like, who are these, who are our patients as people?

So I think that's really important. Don't be afraid to give tough news. You know, this is something we learn in the ICU that you don't want to be telling a family, well, we just don't know. Let's hang in there. Let's give it some more time when you know the patient is going to die. You have to be willing to do your job, which in the scenario where you know they're going to die is to tell the family, I'm so sorry to have to tell you this, but they are going to die from this illness.

it's hard to do, but you owe it to people. And I will tell you, I have had more families come tell me afterwards that they were grateful that I was honest with them. They'll say things like, you know, doc, you were the first person to tell us the truth, to tell us that he wasn't going to make it. And it helped us start preparing. And that means a lot to families. It's hard to do. And we don't like giving bad news to people, but if you're going to be in a career where you're taking care of critically ill patients, you have to be willing to do that. Um,

If you want to get better at TTE, you got to just do it. You got to do it over and over. You got to echo patients. You've got to do it, you know, not just in the people who are acutely crashing, but in anyone who you can learn anything and offer anything to them from that exam.

and get someone to help you. I am not a super expert at TTE. I am still very much learning. I ask my colleagues who are better at this than me, hey, will you do one with me? Can I send you the images? And I'm trying to get better. And I think the only way to do that is to keep doing it over and over.

I would say it's crucial to make sure everyone on the team knows their voice is valued and heard. That's from the medical student to the nurses, to the respiratory therapist, to the family, patient, everybody. But from the care team, we want to make sure that everyone is comfortable speaking up. I've been doing this long enough, and I'm sure you've seen this too, Dave, where, you know, the medical student will say something like, you know, I'm sure I'm just missing something. I know I don't know what I'm talking about, but, you know, is there a reason we didn't do such and such? And we'll be like,

We should have done such and such. You're totally right, right? Thank goodness they felt comfortable speaking up. They often don't. We have to really create that environment as doctors, as leaders, once we become attendings especially, but same goes for residence fellows, anybody, where we're looking to and asking everybody for their contribution and making sure people feel comfortable speaking up. I think that's really crucial for medical care in general and definitely in the ICU. When you're doing an intubation in the ICU, I think it's crucial to do a timeout.

It's the kind of thing where in the OR, you know, we kind of have all our stuff. We've maybe already prepared for it. So we don't necessarily aren't as careful about kind of making sure, for example, that we have our tube and that we have, you know, we certainly don't think about is

is the patient DNI when they come to the OR for an elective surgery. But when you're in the ICU, you got to ask all this stuff. And so I go through my SOAP IM just like I would in the OR. I say, do I have suction? Do I have oxygen? Do I have my airway equipment and my backup airway equipment? Do I have a free-flowing IV? Is my oxygen, is my ambu bag hooked up to oxygen? You don't know how many times you find out that the ambu bag's sitting there and nobody ever hooked it up to the oxygen or the suction isn't hooked up. So going through all that stuff and then consent, right? Is the patient consented

Or if it's an emergency, you may not get consent, but do we know what their code status is? I mean, it has happened to me where I'm about to intubate a patient in the ICU and then we realize their DNI, right? So that's really important. You do not want to do that. So you want to find out what's going on. If they're already on pressers,

go up, go up on the presser before you intubate. Okay. So if there, if I'm sitting there and they're on 0.1 of Levo, I will double that. I will go to 0.2 of Levo before I push any meds. Even if I'm pushing something like a Tomodate or ketamine, I still go up on that Levo. You can always come back down.

But you're probably going to want that Levo to go up. And if someone's on a lot of Levo, please don't push phenylephrine as a presser. Get some Levo or Epi or something more powerful. And then, of course, don't be afraid to call for help preemptively. And what I mean is if you're doing an intubation in the ICU and it looks like it might get a little hairy or the patient looks like they might be a difficult airway,

You don't have to wait until you're in the midst of a cannot intubate, cannot ventilate situation to call for help. Hopefully your hospital has some sort of difficult airway response team. If so, you can call them preemptively. If not, maybe it's as simple as like calling another anesthesiologist or if you're not an anesthesiologist, calling an anesthesiologist to be there to just help out before you start, before you burn any bridges. I think that's really key. And I'm going to stop there. Love all of these tips. You've talked in a couple of different times about

Keeping your ability to still learn and to still grow as you've grown in your professional career. Like, what are some tips that you have to continue to learn throughout your career?

Yeah, you know, I think there's a lot of really important stuff that comes just with life that you want to keep in mind in life, in your career, in everything that I think are really important. This again, I'm going to try not to be too exhaustive here, but we've already talked about learning people's names. I think that's really key. Asking for input from others. I like the phrases, tell me more or help me understand that. When someone says something, rather than say, nope,

I don't think so. Or I disagree. Say, tell me more. I'm not sure I understand. Help me understand that. You will learn things from people that you might not have learned. Get their input and then ask them to help explain so that you really understand what they're saying. Take time to express appreciation, not just frustration. The way I like to think about this is in a restaurant, right? If you're in a restaurant, you have a bad experience.

everybody's willing to complain, right? If you think the rater was really rude, you'll ask to talk to the manager. You'll say, you know, that waiter was incredibly rude, right? I want you to know I was really upset. People will complain when things are bad.

But very few people will go out of their way to express gratitude and praise. How often have you asked to speak to the manager in a restaurant and said, I want you to know our waiter was fabulous, really, really enjoyed. I thought they did a great job. Very few people do that. I know because my wife and I do it and the managers are always shocked.

They're like, no one has ever done this before, right? When the manager gets called over, they think, oh my God, here we go again. They're going to complain about something. And when you call them over to say, I just want you to know how great of an experience we had. It not only makes their day, it's meaningful to the waiter who then gets that feedback.

It's true in work. If a nurse, an RT, a resident, a fellow, a medical student, another attending, if somebody just really does something that you feel grateful for, don't just feel it and walk away. Express it. Tell them you're grateful and tell somebody who can recognize them for it. Tell the people that you're grateful for that you are grateful. And I mean the people in your life. Tell them you love them.

This goes for anyone. If you have kids, I think it really matters. I am way over the top in this. I like tell my kids I love them, you know, a million times a day. My 13 year old will roll her eyes. But I think it really matters. And I think just telling people I'm grateful for you. I care about you and going out of your way to do that.

We've talked about this a little already, but I'll say being reliable is so important. If you say you're going to do something, be the person who will always do it. At least...

Let people know if you can't. So let's say that you let's say you say, OK, I'll do it. And then you realize there's no way that's getting done by that deadline. OK, it's not that that can't ever happen, but then don't just not do it. Reach out to the person who you agree to do it and say, hey, I'm so sorry. I know I said I'd have this to you by Friday. I'm just looking and realizing there's no way I'm going to get it done by then. I'm so sorry. Is it OK if I get it to you by Monday or whatever?

they're going to be fine with that. That shouldn't be the thing that happens all the time. But if you, you know, if you, if you run into that problem, it's okay. What really isn't okay is you agree to do something and then you just don't do it. And the deadline passes and then they have to follow up with you and be like, Hey, I never got that thing. So,

Think about it like this. If you're the one asking a lot of people for stuff and they say they'll do it, but then you can't really trust it'll get done. So now you have to remember to follow up and be like, hey, did you do this thing? Hey, did you do this thing? Right? It'll drive them crazy. So be that reliable person who gets the stuff done that you say you'll get done and that people can really trust. I like to think of it as being, there are two types of people. You

You can be a green light person or a red light person. So the green light person says, all right, I need to get to this place by this time. And it's going to take me, if all the lights are green on my drive over there and I don't hit any traffic, I'll get there in 15 minutes. So I'm going to leave 15 minutes before I need to be there. The red light person says, okay, I need to be there by this time. If all the lights are red and I hit a lot of traffic, it's going to take me a half an hour. So I'm going to leave a half an hour before.

The red light person will never be late and often will be early. The green light person at best will be on time and often will be late. Right? So,

I know it sounds like being a pessimist, but I think in some ways it helps to be a pessimist. And when it comes to reliability, you don't want to keep people waiting. You don't want to be late. Be the red light person who says, I'm going to leave with enough time to be safe and make sure that I'm there. I'm going to be reliable. I want you to be able to trust me. And again, like we talked about before, don't put things off. If you need to get something done, don't wait till the last minute or you will inevitably sometimes not get it done.

I wonder if there are red light anesthesiologists and green light anesthesiologists. Like it's, it's a great, it's a great paradigm to think about where your comfort level is with the preparation for the things that we do every day and encouraging people to take the ownership of being as prepared as you could be. Absolutely. And I think there are Dave, right? I mean, I think there are anesthesiologists who, um,

don't have, right? They're doing an intubation in the ICU and they basically just assume, okay, it's going to be fine. And they don't have a backup, you know, plan. And most of the time it's going to go fine, but if it doesn't, they're in big trouble, right? Whereas the red light anesthesiologist has a backup plan and a backup to the backup. And right. So those are the people who are going to have less trouble over the course of a career. Um, I think doing unexpected nice things for people is really, uh, wonderful. Uh, for example, um,

you're on call overnight, you know, you've got some free time. You could catch a, you know, a 15 minute nap, but you know what you're going to do? You're going to set up somebody's room for them, leave them a little note in the, in the front, in the top drawer that says, Hey, uh, you know, have a great day. Um, hope everything goes well for you. And now you just bought them an extra 20 minutes. They don't have to set that drawer up. They can get some coffee in the morning. It's going to make their day that little, those little kindnesses go a really long way. Um, and,

I think this is really key. You can empathize with people without agreeing with them. You can say to someone, I am so sorry. I can't imagine how hard that must be or how frustrating that must be without saying, yes, you're right. I did a terrible thing. I'm wrong. I screwed up. I should do what you want me to do. Now, if you were wrong, you should also admit that because it is so important to be able to say,

look, you're right. I screwed up. I'm sorry. When you did in fact screw up rather than be so reluctant to apologize. And I think that's important. But even if you disagree with someone, but you can see they're upset or they're frustrated or they're hurting, you can still empathize. You don't have to, you know, you don't have to say, yes, I'm wrong to be able to say, I'm so sorry that this is so difficult or so frustrating. I can't imagine how you're feeling right now. What can I do to help? So that's really important.

I think the best leaders listen to the people around them and aren't afraid to change their minds. And I mean that you've seen this. People who just – they pick a course and they think they'll be a weak leader if they change course, and they just plow ahead to the detriment of the organization. Watch good leaders. They will be willing to change when they realize that they didn't pick the right course at first. And the best leaders seek to support and empower the people they lead.

They are not the ones just issuing commands. They're the ones on the front lines, helping people, helping get barriers out of the way for the people in the organization so those people can be successful. I think it's really important to watch the leaders around you. Watch what they do. Watch anyone. It doesn't have to be a leader. Watch someone in a position that you want to be in someday. If you're a resident and you want to be an attending someday, you should be watching your attendings. If you're an attending and you want to be a chair someday, watch your chair.

look at what they do and evaluate it critically. Ask yourself, hmm, I saw they did this. Like, what do I think about that? Would I have done that if I were in their position? If not, what would I have done instead? You may not be in a position to do anything about it now, but when you are a leader later, when you're in that position, you will be a better leader for having evaluated the people who you got to watch along the way.

I will say it's important to find time to spend one-on-one with the people that you care about and you love. And a great example of this is your kids. I think small amounts of high quality time is better than little amounts, sorry, than lots of amounts of low quality time. I do a thing where I take each of my three daughters out to dinner for a daddy-daughter dinner once a month, just the two of us. And it really is meaningful. And I would encourage people to think about doing that.

it's tempting to like do the group, right? Like hang out with the whole group of friends or with the whole family. And that's fine. There's nothing wrong with that. But one-on-one time I find to be much more impactful, both with friends and with kids and family. So trying to find that time I think is really worthwhile. I suggest that people be graceful with themselves. Be graceful with yourself. No one is perfect at being anything. Not a spouse, a doctor, a parent.

It may look from the outside, especially in the age of social media, where everyone's posting their perfect pictures on Instagram or whatever, that everyone else has got it down and they're doing it perfect and you're not. But of course, that's not real. No one's perfect. And if you can find that grace to say to yourself, you know, I may not be perfect, but I'm doing a pretty good job and I'm going to keep working on it. And of course, we all should continue to strive to be better at everything, not beating ourselves up, saying I'm terrible at it, but thinking, listen, I want to keep growing and learning and being better. That's a lifelong goal. We'd all be

better off. And along the way to doing that, you have to ask for feedback, right? I tell our residents, if you want to know how to get the best feedback, you got to ask for it. Ask your attending, what could I do to be better? Or say to them, you know, hey, when we're working together tomorrow, I'd love to hear from you, like one or two things you think I could do better.

And that will get you so much better feedback, but you've got to ask for it because otherwise people are not necessarily going to be comfortable telling you, you know, I think you need to work on this. They're going to think that you might not want to hear that or that you might have your feelings hurt. Ask for feedback. It gets even harder when you're in a leadership position, but, you know, ask the people you are leading, hey, could you give me some feedback on my leadership? How am I doing? Part of that is asking for it anonymously, right? You have to give people a way to give you anonymous feedback because they may not be comfortable saying it with their name attached.

I do that all the time with my residents. I ask for anonymous feedback, and I think it's really important for anyone to do if they want to really grow in their position. There's a wonderful concept called having a beginner's mind that means that if you try to continue to think like a beginner, even when you are not a beginner, even when you are an expert, you will do much better. For example, if you as a senior attending still think,

I want to discover new things. If I see someone doing something that I don't understand, I'm going to say, hey, teach me. Teach me what you're doing. I want to know. You would do that in a heartbeat as a brand new CA1 because you don't know anything. But when you're a senior attending, you may not because you kind of think, I don't want to be that senior attending who says, I don't know what's going on here. But ask, learn. I've been so impressed with some senior attendings who have said, I want to learn ultrasound. I never learned it as a resident. It wasn't a thing. I'm going to ask the fellows.

to teach me, right? I mean, imagine how hard that is. If you've been practicing critical care for 30 years and now you're going to go to a brand new fellow and say, could you teach me some of the TTE skills that you know, right? But people who do that, I'm so impressed by. So I think that's really, really important. Think like a beginner. The same is true, of course, in anything. I mean, think about in your marriage. If you can treat your spouse with that same excitement and love that you felt when you first started dating, that's going to do wonders for your marriage. You

It's hard, right, when you've been married 15, 20 years. But I think finding times to do that is really, really worthwhile. I love the concept of challenging paradigms and not getting stuck in old habits. It's just...

I say to our residents every year when they graduate that I hope, as much as I'm proud of what we've taught you, I hope that 10 years from now, your practice is very different than what it is right now. Because I hope you are willing to challenge the things we've taught you. And when new data comes out or new practices become available, you are willing to say, you know, I think I need to make a change. And so being willing to challenge those paradigms, you know, there are

so many examples of people who are still doing things they did as a resident 40 years later, because that's what they know and that's what they're comfortable with. And they're not willing to make changes. On the other hand, there are people who 40 years in are willing to make changes. And those are the people we should be emulating. It's so important to when you become an attending, especially a more senior attending and a leader to talk about your mistakes and failures.

Everyone has imposter syndrome, but it's worse in our young folks, right? The residents, the new attendings. And if they make a mistake or they have a bad outcome, they're going to beat themselves up. They're going to think they're a bad doctor.

And if they have heard from their mentors and their leaders about the times where we screwed up, where we had bad outcomes, at least they'll realize they're not alone. And I think it makes a big difference where they, instead of thinking they're a terrible doctor, they may realize, you know, I'm actually in good company. I remember when my chair or my program director or my division chief told me about the time that he had that really horrible outcome because he made a medical error. And so I know I can talk to him about it because he won't think I'm a bad doctor because he did it too.

And so I think that's really, really important. That's the most powerful tool we have against imposter syndrome. And along those lines, I think we want to create an environment where it's okay to make mistakes, where mistakes are seen as opportunities for learning and not failures. If a resident misses an A-line or a tube, we want to tell them, hey, look, I'm actually glad that that happened because it's

if you didn't make that mistake, what would I have to teach you? Right. If you nailed every line, if you got the tube in perfectly, if you got every line in smooth as can be, then, you know, you don't need me. I'm glad it didn't go well because now I can give you some tips on how maybe it could be better. So, you know, make it a great learning opportunity, not something to be embarrassed about. And of course, tell them about the times when you missed all the lines in front of your attending or, you know, at working solo or whatever, because first of all, those stories are definitely true and it'll help them feel better.

I think never forget that you can learn from everyone around you, no matter how junior they may be. I learn from my residents, my kids, my medical students all the time. And I think we want to all remember that this is not a one way transfer where I'm the expert. You're the novice. I will transfer information to you. This is about building relationships and learning from each other. And if you remember that, I think that the interaction will be much better between faculty and residents and anyone learning.

It is really interesting to me that sometimes we have folks who kind of think that the way mentorship works is you enter residency or medical school or whatever it is, and you will be given a mentor, and that is mentorship. You now have a mentor. Where that – I mean, that does happen. We do give you mentors. But also –

You must build your mentorship pool. And to do that, you have to be willing to step out of your comfort zone. I mean, some people are very comfortable doing this, but if you're not comfortable with it, step out of your comfort zone and reach out to people. Cold call somebody. Call an attending or text an attending or write an attending who you worked with and enjoyed working with and say, hey, I really enjoyed working with you today. Could I come by your office sometime and talk more about your career and how you got where you are and the research you're doing? You have to be able to build those relationships.

For whatever reason, I have always just done that. I've been willing to kind of reach out to people, and I still have mentors from college, med school, and residency who I reached out to out of the blue, got to know, and who have still become people in my life who are mentors and have become, of course, friends and colleagues. But it really pays off, but you have to do it. You have to be willing to do it, and I can't tell you how many people –

They just go through an entire residency full of amazing people and they don't build those relationships because they're not willing to be a little uncomfortable and basically, you know, ask out on a date. I mean, obviously it's not a date, but to reach out like you would ask someone out on a date or at least when dates were a thing before social media and all that, where you would actually have to go up to someone in a bar and you'd have to say, hey, you know, can I buy you a drink? Can I talk to you? Would you like to go out sometime? And that's,

that is kind of what it's like, except that it's safer because no attending is ever going to say no to it. No attending is going to say to a resident, what, you want to have coffee? No, right? Of course they're going to do it. They're going to be happy to. In fact, they will love talking about their career and helping you think about yours. So don't be afraid to reach out and that will help you build your mentorship pool. I want to talk about complaining. I think complaining is just never productive. And don't get me wrong. It's fine to express concerns, right?

But there is a difference between complaining and expressing a concern. If you have a concern, the first thing you want to do is think, okay, I don't think this is going well. What would make it better? And then when you go to someone who could hopefully help, you want to say, here's my concern. Here's what I think might be able to make it better. Is there any way that that could happen? I'd be happy to help make it happen. That is always okay. What isn't okay is to say, this sucks. I hate it.

Right. All that does is suck the energy out of the room and out of the situation. And it's not helping anyone. Let's just say you're in a tough ICU call and you're

You are tired and stressed, and you can go to your team who you're on call with, and you can say, oh, this sucks. We are so unlucky that we got stuck with this call night. It's miserable. We've been so busy. We haven't gotten any sleep. We're hungry. Oh, God, this is the worst. And that's going to make everyone feel terrible. They're already feeling terrible. It's going to make them feel even worse. But...

You can choose instead to be positive, to say to the people around you, hey, guys, is there anything you need? Can I make your night a little better? Is there anything I can do for you? Hey, we've only got a few hours left. What can we do to make this the best last three hours we could possibly have? Because guess what? You're going to be there for those three hours either way. So you can make it miserable or you can make it great.

And if you do the latter, you will feel better and you will infuse energy into everyone around you. I still remember when I was a freshman in high school, which was a long time ago, and they brought in this speaker and he got up in front of us, our high school at this assembly. And I remember two things about him. One, he started his talk by starting to sing. I believe I can fly. And I'll never forget that because it was just out of nowhere. And he started singing and everyone was like, what's happening?

But then he talked about there being two kinds of people in the world, energizers and energy stealers. And he said, you want to be an energizer and you want to surround yourself by energizers. And these are the people who...

help energize the people around them, even when things are hard, even when things are not going well, even 23 hours into the 28-hour call, even when people are hungry, tired, and stressed, they are still energizing the people around them. And those are the superstars, and those are the people who you want to be. So be an energizer. Don't be an energy stealer.

And I'm going to end by saying that I recommend showing gratitude and accepting it too. We talked about showing gratitude. I will say one of the most powerful things I've seen, I went to a workshop by Brian Sexton on wellbeing and burnout, and he had us sit there in the workshop and take 10 minutes in the middle of the workshop to write a gratitude letter to someone in our lives who we were grateful to. And then he gave us the assignment at the end to call that person and read it to them. And I,

And it was just a really powerful experience. And I highly recommend doing that and finding those ways, as we've already talked about, to express your gratitude. But also practice accepting it because so many people, when you express gratitude to them, you say something nice to them, they'll be like, oh, whatever. That's not true. I can't.

But, you know, learn to be able to say thank you. That really means a lot, you know, because it does. And you don't want to kind of you don't want to be too self-deprecating. You want to be able to say, you know, thank you. I really appreciate that. Those words really mean a lot. So I recommend both writing a letter and reading it to someone. And I think Brian Sexton for teaching me that and then practice being good at accepting other people's gratitude. It's both of those things are very powerful.

And I'll end by saying how grateful I am to you, Dave, for being a great friend, colleague, and for doing this with me today. And to all the listeners of ACRAC, it has been a true pleasure to be able to have you as part of my community for these past eight years and 300 episodes. And I look forward to a lot more to come.

Well, thank you for having me today. I feel like we have to end by saying the thing that you're going to recommend because I get to be the host. Yes. So we definitely have to do random recommendations. I'm going to say, and of course, this is a little bit location specific, but over the Thanksgiving holiday, which although this won't come out for a little while, we are recording right after the Thanksgiving holiday. And we went to New York city where my in-laws are. And we took the kids to go ice skating in Bryant park and,

And it is really fun. You don't have to be good at ice skating. They have these little penguins you can lean on. And there's all kinds of people who have clearly never ice skated before who are ice skating there. But it's a blast. And there's a whole winter wonderland, winter village built around there with like a million places to get hot chocolate and food and like essentially food trucks except they're food stalls.

And then you get to skate and it's beautiful and it's fun and they play good music. If you have your own skates, it's free, which is amazing. If you don't, you have to pay and it's not cheap, actually. I think it's like 40 bucks a person or something like that. But it is really fun to do. And so I recommend checking out the Bryant Park Winter Village and ice skating in New York City if you can get there.

Well, my recommendation, I want to say, I think stems from something you said earlier, which is, you know, the best leaders support and empower those that they lead. And I think that has been the leadership style that I have seen you exhibit. And so there's a book that actually my former division chief, Ravi Tripathi, gave me a long time ago that I finally started reading, which is Let Them Go Surfing by Yvonne Swinard, who's the founder of Patagonia. And it's interesting to hear even from a business lingo about

how important it is to empower people. And when you do, what incredible results you can see. So a fun book if you have some time over the holiday. Awesome. Thanks, Dave. And I'll say a big thank you to my ACRAC crew and not just the current folks who have done an amazing job with the social media and all of that, but also everyone who's helped out with ACRAC from the beginning. I can't name everybody here, but I'll just say it's really been a pleasure and an honor to get to work with you. And I'll

say to everybody for the 300th time, but I really mean it. And I think it's so important to hear. And as I said, I say it every time and I mean it truly from the bottom of my heart that all of you, what you're doing out there every day is truly, truly so important and is really, really valued. Thank you so much, Dave. Thank you for being here and for doing this. Thank you. And congratulations on 300. Thanks.

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