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The Point of Caring with Tyler Guidugli · Style Points

0:09
Hello, anesthesia enthusiasts, and welcome to
0:12
another episode of Style Points. Today on the
0:14
podcast, we are joined by my friend, Dr. Tyler
0:17
Gadouli, who will be talking to us about the
0:19
challenges of implementing point -of -care testing
0:21
and why it's all worth it. Feel free to submit
0:24
the title of this podcast to the annual Best
0:27
Double Entendre -Themed Title in an Anesthesia
0:29
-Themed Podcast Awards Selection Committee. I'm
0:32
really hopeful that this year might be my year.
0:35
Before that, I want to turn it over to Nate Moore,
0:38
who will be introducing this month's RSI, which
0:40
I'll remind you stands for Resident Selected
0:44
Information. Hey, that's another double entendre.
0:47
Thank you, John. I'm thrilled to introduce Dr.
0:49
Lauren Ferdmingus, who is no stranger to spooky
0:52
season. She was born on a Friday the 13th and
0:55
will be taking the black cats dancing across
0:57
her scrub cap with us as we delve into the swirling
0:59
mists of metacognition and discuss how to make
1:02
learning new procedures a little less scary.
1:04
Welcome, Lauren. Thanks, Nate. So if you're an
1:07
anesthesia intern like myself, or if you're getting
1:09
ready to start your intern year, you're probably
1:11
wondering how you're supposed to prepare for
1:13
all the procedures you'll be doing, from arterial
1:15
line and central line placement to bronchoscopy.
1:18
The good news? There's actually a scientifically
1:20
validated framework that many anesthesia residency
1:23
programs use to assess residents' procedural
1:26
abilities based on key competencies. The assessment
1:29
tool that I'm referring to is called the Direct
1:31
Observation of Procedural Skills, or DOPS. Now,
1:34
as a full disclaimer, I'm far from an expert
1:36
in any procedure. I've just spent a lot of time
1:39
looking into effective and efficient strategies
1:41
for improving my own skills before CA1. Now,
1:45
the Direct Observation of Procedural Skills,
1:47
or DOPS, was implemented in 2016 and discussed
1:50
as part of a systemic review article by Kangali
1:54
et al. in 2018. It compiles 28 studies that utilize
1:58
the DOPS model to evaluate everyone from nursing
2:01
students to medical students to residents from
2:04
a variety of surgical specialties. This tool
2:07
enabled evaluators to provide specific and actionable
2:10
feedback that trainees could implement for efficient
2:13
skill improvement. The result demonstrated improved
2:16
performance and greater self -confidence when
2:18
their procedural skills were evaluated using
2:20
DOPS. But as anesthesia interns, much of our
2:24
time during intern year is spent on off -service
2:26
rotations, and the opportunities to place a central
2:29
line there aren't exactly plentiful. So with
2:32
this in mind, I'm going to discuss some concrete
2:34
and actionable ways that an intern can prepare,
2:36
specifically within the DOPS -assessed competencies
2:39
of procedure prep, technical ability, and insight.
2:43
Firstly, I'll discuss preparation, which DOPS
2:45
refers to as ergonomically arranging your workspace,
2:48
acquiring clinically indicated equipment, and
2:52
ensuring assisting staff are present. Even with
2:54
the best preparation, unforeseen things can happen.
2:57
This is why it's so important to control the
2:59
controllables, like familiarizing yourself with
3:02
your institution's procedure kits and how you'd
3:04
use them to set up for a procedure. I found it
3:07
helpful to take a kit home, without the sharp
3:09
things like needles, of course, and to find a
3:12
YouTube video on how to set up using that particular
3:15
kit. While it might seem trivial, when you're
3:17
nervous and in the moment, it can be tremendously
3:19
helpful to start off strong by confidently setting
3:22
up your workspace beforehand. It's also worth
3:25
spending some time acting out the procedure steps
3:27
using the equipment in the kit to help you feel
3:29
more comfortable with them. It's equally important
3:32
to refresh your memory on the relevant anatomy
3:35
of a procedure and which landmarks you should
3:37
be looking for or trying to avoid. One of my
3:40
favorite ways to do this is with an app called
3:42
Anso, which features tons of clear ultrasound
3:45
images and highlights the high -yield anatomy
3:47
and positioning considerations for common nerve
3:49
blocks. Tying this all together, I would highly
3:52
recommend making somewhat of a procedure note,
3:55
which includes high -yield reminders and key
3:57
steps of each procedure. While you might remember
4:00
these things in the moment, it may be a while
4:02
before you practice the procedure again, so it's
4:04
helpful to have all this info in one place and
4:07
readily available. I personally like to use my
4:09
phone's note app for this because it allows me
4:12
to easily search up for and pull this info up
4:14
on a particular procedure by name. Another key
4:17
competency, of course, is technical ability,
4:20
which is defined as having manual dexterity and
4:23
confidence or demonstrating correct procedural
4:25
sequence with minimal hesitation. Now, we all
4:29
know that there's no substitution for repetition,
4:31
so it's super important to take advantage of
4:33
the opportunities that do come along to perform
4:36
these procedures, whether it be in the ER or
4:39
in the OR. Now, of note, it can be tempting to
4:42
avoid procedures early on out of fear of failure
4:44
or fear that somebody would need to come and
4:47
step in. So I think it's really important to
4:49
remind yourself that you're not bad at this.
4:51
You're just beginning. But when these opportunities
4:54
do come along, how do you actually improve your
4:57
technical skills? Personally, I've found a few
5:00
ways to optimize my chances of success. One of
5:03
the most important and underrated being optimizing
5:06
positioning, whether this means asking to raise
5:08
the bed or table or taking an extra 60 seconds
5:11
to find firm and stable hand position while holding
5:14
an ultrasound probe. There are also procedure
5:17
-specific things that I've picked up throughout
5:19
people over the year. For patients who are difficult
5:22
IV sticks, for example, this includes the importance
5:24
of placing a really tight and distally placed
5:27
tourniquet and having gravity be in your favor
5:29
when positioning their arm. Lastly, I want to
5:33
discuss insight or knowing when to ask for help
5:36
or stop the procedure. One way to gain insight
5:38
is by reflecting on your decision -making style.
5:41
I'm specifically referring to the framework that
5:44
when learning procedures, people often tend to
5:46
make errors of either commission or of omission.
5:49
Those who are prone to errors of commission tend
5:52
to be more confident and action -oriented, often
5:55
quote -unquote going too far or overshooting
5:58
their target with decisiveness and momentum.
6:00
Such errors include going through and through
6:02
or inserting a needle through the back wall of
6:05
a vessel. On the other hand, those who make errors
6:08
of omission tend to prioritize harm avoidance,
6:11
and their mistakes come from hesitation during
6:14
critical moments. For example, inserting a needle
6:17
too shallow and missing the vessel entirely,
6:19
or not advancing adequately and losing venous
6:22
access. Why does this matter? Research on metacognition
6:27
in procedural learning demonstrates that trainees
6:29
with higher self -awareness show better skill
6:32
acquisition and task engagement, and knowing
6:34
your own tendency allows for self -correction.
6:37
For example, those who are error - Commission
6:40
prone could remind themselves consciously to
6:42
slow down and take deliberate pauses, whereas
6:45
someone who's prone to errors of omission can
6:47
try to consciously commit to completing maneuvers
6:50
by reminding themselves that avoiding complications
6:52
out of fear might be less likely than failure
6:56
due to incompletion. With these competencies
6:59
in mind, hopefully you'll be ready to nail your
7:01
next procedure, even as an intern. You know,
7:07
I thought long and hard about it. I was like,
7:09
does it come with this profound person, or do
7:13
you just come up with someone who kind of reminds
7:18
you to take it easy every now and then and enjoy
7:21
life and have a margarita? Tyler Kadouli, thank
7:25
you for joining us. Thank you for having me,
7:27
John. I'm excited to be here. I'm excited to
7:30
have you here. You got pulled over for speeding
7:33
on the way over here, and I'm really excited
7:35
for you to tell the story. Yeah, so I was, you
7:39
know, just minding my own business, making my
7:41
way into, you know, the podcast and really wasn't
7:45
going too terribly fast. And I thought, but it
7:48
turns out going 82 in the 70 was too fast this
7:51
morning. So the kind officer pulled me over and
7:54
asked me if I was making my way into work into
7:57
the hospital. And I said, yes. He said, do you
7:59
work there? So I'm a physician. He said, well,
8:02
just have a nice day. Slow it down a little bit.
8:05
You didn't tell them that you were about to be
8:07
a guest on the very famous Style Points podcast?
8:10
You're sure that's not what got you off? You
8:12
know, that would have been a nice plug. I really
8:13
should have put that out there. Although that
8:15
may have actually gotten me a ticket instead
8:17
of vice versa. Yeah, it probably would have exhausted
8:20
the Style Points budget to pay for your ticket
8:22
there. Exactly. All right, so let's just back
8:25
up a little bit. Tell me a little bit about yourself.
8:27
What's your bio? Where did you train? My name
8:30
is Tyler Guidulli. I'm one of the newer faculty
8:33
members here at the University of Cincinnati.
8:36
Originally from this area, so I grew up here
8:38
in Cincinnati, northern Kentucky, and then went
8:42
down to the University of Kentucky for undergrad.
8:45
Spent four years there during the run of multiple
8:49
Final Fours and the National Championship, so
8:51
that was a big deal. And then I kind of always
8:55
knew I wanted to do medicine. Went into undergrad
8:57
planning to do medicine. Was a biology major.
9:01
And then went to the University of Pikeville,
9:03
so eastern Kentucky, for medical school, which
9:06
was an experience. It was a good one, but it
9:09
was definitely an experience. And then made my
9:12
way to the University of Kentucky for anesthesia
9:15
residency. And then did an OB anesthesia fellowship
9:19
following. Anesthesia residency and then kind
9:22
of came back here, came back home. So it's time
9:26
for my favorite get to know you question. If
9:28
you could have dinner with anyone in the world,
9:30
could be somebody from the past, present, or
9:32
even from fiction, who would you go out to dinner
9:35
with and why? So I will say I'm historically
9:38
bad at thinking about and answering these questions,
9:40
but I tried to put some thought into it and my
9:43
answer is going to be Jimmy Buffett. I think
9:46
I'd like to have dinner with Jimmy Buffett. Very
9:50
interesting guy. I think the conversation would
9:52
be interesting. And, you know, I've been to a
9:55
couple of his concerts. I really like his music.
9:57
And I think it's a nice reminder when you're
10:01
listening to his music that, you know, despite
10:02
all the crazy things going on in life, it's nice
10:04
to kind of slow down every once in a while. Forgive
10:07
my ignorance here, but what are Jimmy Buffett
10:10
fans called? Do they have like a specific name
10:13
associated with them? Oh, yes, they do, John.
10:17
Parrot heads would be the name that Jimmy Buffett
10:21
fans are called. And if I told you I had a foam
10:24
parrot head device at my house that I've worn
10:28
to his concerts before, that would be something
10:32
that's true. Well, I am going to need a picture
10:35
for that. And that is the picture that we are
10:37
going to use for the podcast for sure. That seems
10:41
very appropriate. That and a Hawaiian shirt.
10:43
Excellent. Well, I am looking forward to that.
10:46
for sure. So backing up a little bit, what drew
10:50
you to OB anesthesia specifically? Yeah, so it's
10:54
an interesting question. I was kind of one of
10:56
those residents who could have seen myself doing
10:59
any fellowship. I really enjoyed cardiac and
11:04
critical care, and I really enjoyed OB, of course,
11:07
as well. And I think the reason that I ended
11:11
up deciding to do OB was a couple things. It
11:14
kind of took, I saw that the people that really
11:20
kind of thrived and did OB anesthesia well kind
11:23
of treated it like it was an ICU unit almost.
11:27
The laboring patient you start the shift with
11:30
is not the laboring patient you finish the shift
11:32
with. People fall onto and off of their labor
11:35
curves or just like they fall onto and off of
11:37
their recovery curves in the ICU or whatever
11:39
their clinical course may be. And so I found
11:43
it really interesting to kind of merge all of
11:46
the you know different areas of anesthesia where
11:49
there's like there's a little bit of critical
11:51
care for the more sick obstetric patient and
11:53
then there's of course still or time for cesarean
11:56
delivery and all the kind of different ob procedures
11:59
that we do and then i thought naraxial was you
12:02
know some of the most fun procedures that we
12:05
do in anesthesia and i really enjoyed that and
12:07
then i also think i'm a little bit of an adrenaline
12:09
junkie and you know Traumas are fun and interesting,
12:13
but you get a little bit more of that kind of
12:15
urgent emergency sections occasionally on OB.
12:18
So that was kind of one component of it. But
12:20
I think the other thing was that I felt like
12:24
anesthesiologists are really well positioned
12:27
in obstetric anesthesia to really change outcomes.
12:32
And one of the like core things that drove me
12:36
to really understand that was. There was a laboring
12:40
patient one evening. I came in and, you know,
12:43
it's the typical coming at 5 o 'clock on a Friday
12:45
night. And they handed me off that this patient
12:49
has been here for a couple hours. She keeps having
12:51
recurrent decelerations. She does not have an
12:55
epidural, does not want an epidural. And the
12:58
obstetricians are concerned she's going to have
13:00
an emergent cesarean delivery at any moment.
13:03
And so, you know, like, oh, well, she doesn't
13:05
want an epidural, so we've just kind of just
13:07
been letting her be. No one's really talked to
13:08
her. And I said, okay, well, let me just go have
13:12
a conversation with her. So, you know, an hour
13:14
or so into my shift, I went and just sat down
13:16
with her, and I said, you know, I'm Dr. Gedule.
13:19
I'm with anesthesia. You know, we've noticed
13:22
that, you know, your baby's heart rate may not
13:24
be tolerating labor as well as we would like
13:27
it to. And, you know, our concern is that we're
13:30
going to have to. move emergently back to the
13:32
operating room at some point. Things look okay
13:34
now, but things may change. I've heard you're
13:40
not really interested in an epidural right now,
13:42
and I'm totally here to respect your decision,
13:45
but this is a little bit what an emergency section
13:48
looks like with an epidural, and this is what
13:50
it looks like if you don't have an epidural.
13:53
If we have an epidural, you'll be awake for the
13:55
birth of your child and your spouse or your partner
13:57
can be there and all these good things. And she
14:01
said, well, she said, just let me think about
14:03
it. I said, that's totally fine. I'll circle
14:04
back in about a half hour. And I came back and
14:07
sure enough, she was like, you know what? Let's,
14:10
let's do it. Let's go for it. That sounds reasonable.
14:13
And so I placed the epidural and sure enough,
14:16
about, I think it was about two hours later,
14:18
there was a stat C section from her room and
14:21
we went back to the OR and they were, you know,
14:23
forever grateful that. What was still a very
14:26
scary experience could have been an even more
14:29
kind of scary and traumatic experience. It was
14:32
actually one of the only patients that has given
14:33
me a gift over my career. They had made, like,
14:38
this is a very Kentucky thing, they had made
14:39
lemon cellos in like a mason jar and were handing
14:44
them out. So they had given me one of those for
14:47
their experience, which I did not drink, but
14:49
I did appreciate. That's fantastic. Yeah, gifts
14:54
for anesthesiologists isn't something that happens
14:56
very often. I've only gotten one or two that
14:59
I can remember. Typically, we're more the unsung
15:02
heroes, partially because we give them medicine
15:05
to make them forget us. That's a fair point.
15:08
So something that I really wanted to ask you
15:10
about is one of our shared interests, something
15:13
we've spent a lot of time in the hallway, in
15:15
the lounge, trying to figure out, which is point
15:18
-of -care testing. So for our audience that might
15:21
not be familiar, Can you talk about what it is
15:24
and the journey that you and I have been on?
15:27
Yeah, so point -of -care testing kind of refers
15:31
to a variety of different, what would historically
15:34
be like laboratory -based tests. So whether that
15:37
be hemoglobin analysis, arterial blood gas or
15:41
venous blood gas analysis, viscoelastic testing
15:43
for hemorrhage, it could be a variety of different
15:47
things. But the idea... is taking something that
15:50
has traditionally been a laboratory -based test
15:52
and moving it to the point of care or where the
15:56
patient's actually being cared for, which in
15:59
maybe some spheres isn't as helpful, like maybe
16:03
on a medicine floor. It could be helpful, but
16:05
certainly in the perioperative area where we're
16:08
in the OR and we're making minute -to -minute
16:11
decisions as physiology and as the patient is
16:13
changing in real time. So moving things to the
16:18
point of care helps make those decisions in more
16:21
of a real time instead of leading to a little
16:23
bit of a delay when you're sending something
16:26
off to the lab and relying on runners or tube
16:29
systems and lab personnel to get the test up
16:32
and running. So just essentially it's taking
16:34
what traditionally are lab -based tests and then
16:37
moving them into wherever the patient is at the
16:41
point of care, whether that's the ICU or the
16:43
OR, so on and so forth. So we're just moving
16:45
the lab as close to the patient as possible so
16:48
that we can make those snap decisions, basically.
16:51
Yes, essentially. So what labs do you think are
16:54
most important to us in the operating room? What's
16:56
most critical for us to have right away, and
16:59
when would we need those? Absolutely. So I think
17:02
the two biggest ones, from my standpoint, that
17:06
I can think of are really... blood gas analysis,
17:09
and then viscoelastic testing, which you and
17:12
I have certainly been working on quite a bit
17:14
over the last couple months. So thankfully, thanks
17:17
to your effort, we now have point of care arterial
17:20
blood gas testing and venous blood gas testing.
17:23
And then hopefully here in the near future, we'll
17:26
have viscoelastic testing at the point of care.
17:28
I think those things are probably the two most
17:30
important because it allows you to take your
17:33
sickest patients and get... the most critical
17:36
information about their pH, what their electrolytes
17:41
are doing, if they have a rising lactate, looking
17:43
at their base deficit and their bicarbonate levels.
17:46
And then the same thing with viscoelastic testing
17:50
is taking a patient who is in the middle of a
17:52
hemorrhage, whether it be a trauma hemorrhage,
17:54
a hemorrhage from a liver transplant, post -bypass
17:58
coagulopathy, or obstetric hemorrhage. And certainly
18:01
in my view, Being able to assess those things
18:04
very rapidly has been shown and does make a major
18:10
difference in patient outcomes. So not everybody,
18:14
I think, might be familiar with the term viscoelastic
18:17
testing, but they might be familiar with something
18:21
called a TEG. Can you tell us about what a TEG
18:25
is and what that stands for? So TEG is thromboelastography.
18:29
It is... It falls under the umbrella of viscoelastic
18:33
testing. So I like to use when I talk to the
18:36
residents about this is like viscoelastic testing
18:39
is akin to using the word like soda. And then
18:42
Teg would be like Coke and Rotem would be like
18:45
Pepsi. They're just different flavors or different
18:49
brands of the same kind of category. That's perfect.
18:53
That's a really good analogy to help explain
18:55
things, I think. So what exactly are you trying
18:59
to bring to the operating room then? So we're
19:02
in the process of trying to get a – at the University
19:07
of Cincinnati, we have TAG6S at different institutions.
19:10
They have different sorts of viscoelastic tests.
19:13
For example, at Cincinnati Children's, they have
19:15
Rotem. We have TAG6S here, and at other institutions
19:18
I've been at, they've had TAG6S. The idea is
19:22
to try and move one of our TAG6S devices. from
19:27
the lab where it lives now to the point of care
19:31
and in our mind the point of care is going to
19:34
be we have a sterile core that lives right behind
19:38
our trauma room and at the intersection of like
19:41
our cardiac and transplant rooms and to essentially
19:44
create a little critical care core where we're
19:49
taking care of the sickest patients and we have
19:51
essentially almost a standalone lab to get the
19:55
information that we need the fastest to help
19:57
improve their outcome. Sometimes when a patient
20:00
is bleeding out in front of us, we have to have
20:02
information to make decisions really quickly.
20:05
Can you think of a time where having access to
20:09
a faster lab might have led you to a different
20:12
decision than you would have otherwise made?
20:15
Absolutely. I think one of the best examples
20:20
that I have of this is during a really significant
20:25
obstetric hemorrhage that I had during my OB
20:29
anesthesia fellowship. And I think it kind of
20:31
highlights the differences in at least time frame
20:36
from laboratory -based testing to point -of -care
20:39
testing. And so we had an otherwise healthy patient.
20:43
She had no comorbidities. She was just having
20:47
normal labor. She had had one prior vaginal delivery,
20:50
and then she had some fetal decelerations, and
20:53
we had to move back for an emergency section.
20:56
As we know, the patients that have been laboring
20:59
and on oxytocin for a prolonged period of time
21:01
are at higher risk for hemorrhage. And sure enough,
21:04
when they got her back to the operating room
21:07
and got baby delivered, there was a pretty profound
21:10
hemorrhage. And as we were getting another IV,
21:15
we... true labs when we were placing it and then
21:18
hooked it up. And we sent traditional labs to
21:22
the main lab. And then we fortunately, or did
21:25
fellowship, had a point of care tag success.
21:28
So I went in and ran the tag success. And if
21:32
you're interpreting the tracing, you can get
21:34
actionable results within a couple minutes. Specifically,
21:40
in this instance, the thing that really made
21:42
the biggest difference was fibrinogen. So we
21:45
know that fibrinogen in obstetric hemorrhage
21:47
is the most important coagulation factor. In
21:50
fact, a fibrinogen level of less than 200 has
21:53
a 100 % positive predictive value for progression
21:56
to severe postpartum hemorrhage. So it's really,
21:59
really important that we're assessing fibrinogen
22:00
rapidly. A Klaus fibrinogen that you get from
22:04
the main lab takes 45 minutes to an hour. You
22:10
can assess fibrinogen. via the CFF tracing on
22:13
the TEG6S within about three or four minutes.
22:17
So in this patient, we could see that her fibrinogen
22:21
was, I mean, it was flat. I've actually never
22:24
seen one look like that before. It did not even
22:27
attempt to create a graph at all. It was just
22:30
a completely flat line. So we were able to rapidly
22:34
identify that, and then we were able to replace
22:36
it quickly with fibrinogen concentrate. It's
22:39
even more important for places that may not have
22:41
fibrinogen concentrate because, as we know, to
22:43
replace fibrinogen, you need cryo. And any time
22:46
you call for cryo, it takes them 20, 30 minutes
22:49
to get it to the bedside because they have to
22:50
thaw it. So in this instance, we were able to
22:53
really control her hemorrhage rapidly and save
22:57
her probably some additional blood product transfusion.
23:02
Yeah, that's a really big deal. So fortunately,
23:05
we've been able to adopt the GEM 7000, which
23:08
is our new ABG analyzer, and it's been really
23:11
good so far. It sounds like really a simple thing.
23:14
We ask for the department to purchase the device,
23:16
we put it where we want it, and we run the lab.
23:19
It's that easy, right? That's what I thought.
23:23
I thought I just needed a Teg6F, an Ethernet
23:26
cable, and a dream, but it turns out it's a little
23:29
more complex than that. So what I have recently
23:33
learned, and I think you have definitely learned
23:36
over the last little bit as well, is that there
23:39
is a lot more nuance to bringing devices on to
23:43
point of care, certainly than I would have ever
23:45
imagined. I did truly think it was going to be
23:47
a little bit, you know, somewhat as simple as
23:51
plugging the device in and connecting it to our
23:53
server and then it transmits the results from
23:57
the lab. Why can't it transmit results from wherever?
24:00
the device is living. So what we have learned
24:04
is that after meeting with the lab multiple times
24:06
is that there are a lot of nuances to it. One,
24:11
the lab needs to have approval of it because
24:14
it is their device and needs to have some buy
24:18
-in and some reasons to actually move it there.
24:21
One of the things that we ran into specifically
24:24
for TEG was that historically these have been
24:27
torsion pin and cup, spinning devices to measure
24:32
clot string. So the historical model for Teg
24:36
and Rotem was that there was a cup and there
24:38
was a torsion wire in the cup of blood and the
24:41
cup spins and its fibrin strands adhere to the
24:43
torsion pin. It creates a graph and that's the
24:45
typical Teg tracing that we get. As you can imagine,
24:50
that is fraught with potential errors. If anyone
24:53
bumps the table or anything like that, it would
24:55
make the results inaccurate. And so when I had
24:59
mentioned this to the lab, that was one of the
25:01
things they brought up. Fortunately, the newer
25:04
TAG -6S device and the newer, I think it's Rotem
25:07
Delta, the newer, or maybe Sigma, the newer Rotem
25:11
devices and TAG devices use piezoelectric crystals
25:14
for clot penetrance, and that's how they measure
25:17
it. So it's much less dependent on if there's
25:21
table movement or vibration or anything like
25:23
that. They're not very sensitive to that at all.
25:26
So they're more adept to making them point of
25:28
care. But with speaking with the lab, one of
25:32
the important things that you have to have is
25:34
a middleware that I was not quite aware of. So
25:38
having a middleware to be able to communicate
25:40
the results from the point of care device to
25:44
Epic for not only resulting so that other people
25:47
can see the results, but also for billing is
25:50
something that needs to happen before just bringing
25:53
a device on point of care. And so by middleware,
25:56
you mean a computer program? Yes, a computer
25:59
program that has licensing fees and is associated
26:02
with costs. And these are costs that you would
26:04
prefer not to come out of your personal paycheck?
26:08
Ideally, yes. So let's talk a little bit about
26:11
incentive structure within the hospital system.
26:13
There's people that benefit from the change,
26:16
our patients and us. That's the most obvious
26:19
benefit that we see as clinicians. But that's
26:22
not often the people that have to approve or
26:24
maintain these devices. So how does this mismatch
26:27
work? How does it play out when we're making
26:30
a change like this? Yeah, so I think it definitely
26:34
can be challenging. And one of the things is
26:38
that when we had some of these meetings with
26:40
our own laboratory here is talking about the
26:44
clinical argument. And I think a lot of them,
26:47
after kind of going through things, they understand
26:49
the clinical side of things. When it still comes
26:51
down to operationally and then also cost -wise,
26:55
that still plays a major factor. So I think one
26:59
of the key things is that there has to be some
27:04
financial input from your institution to help
27:07
make these things a reality. And helping the
27:12
people at play that are just looking at numbers
27:15
understand that... Yes, there will be an upfront
27:18
investment, and I think we all understand that
27:20
that's not insignificant. The devices alone run
27:24
about $40 ,000 to $45 ,000 for a tech success.
27:28
Fortunately, we don't have to buy one. We're
27:30
just kind of reallocating one in our instance.
27:34
But to buy the software is an upfront investment
27:36
to make that happen. So I think when you're approaching
27:40
the administration to say, hey, this is something
27:42
that we need and that would be really beneficial
27:45
to our patients, Yes, it's going to cost X amount
27:48
of dollars, but when you look at the bigger picture,
27:52
because TAG has been shown over many, many studies,
27:56
over many, many years at this point, to lead
27:59
to less ICU admissions, less taco, less trolley
28:04
in cesarean history. So less transfusion -associated
28:09
cardiac overload and less transfusion -related
28:13
acute lung injury. So complications related to
28:17
blood transfusions. In OB anesthesia particularly,
28:21
it's been shown to lead to less hysterectomies,
28:25
which is a really big deal when you're looking
28:27
at someone's permanent fertility. And again,
28:31
same things, less ICU admissions and less transfusions.
28:35
So it's complex to try and bring this point to
28:41
the administration where, yes, we're going to
28:42
have to make an upfront investment. But over
28:45
time, we will eventually save money when looking
28:50
at less blood products being transfused. If we
28:53
have one or two less ICU admissions per year,
28:57
that is a significant cost savings. And so trying
29:00
to frame it when you're talking to the administration
29:03
and, yes, we'll have to spend a little bit. But
29:05
we are going to, over time, actually save money
29:08
by making a move like this. And the most important
29:11
thing that you and I care about is you're taking
29:13
the best care of patients. One thing that I've
29:16
noticed to be a little tricky in these scenarios
29:18
is that even though we're one big hospital system,
29:21
each department has its own specific budget.
29:24
So even if we're saving money by not admitting
29:27
a patient to the ICU, the lab who's running these
29:30
tests just sees a chunk of their budget taken
29:32
up by this device. So money isn't saved by the
29:36
lab specifically whenever we run these tests
29:38
and find we can do something more on the preventive
29:41
side of things. So how do we navigate this space
29:44
where we're trying to bring everyone under the
29:47
same umbrella? How is this our job? And I think
29:52
that was a little bit of an unanticipated on
29:55
my end, you know, kind of issue to run into is
29:58
that, you know, I agree. We were one big. And
30:02
I thought it was, you know, we're going to improve
30:04
care and save costs to the system. But as you
30:07
said, each kind of division department has their
30:10
own priorities and their own finances that have
30:15
to play a part in this. And so I think one of
30:18
the reassuring things that I think has been part
30:22
of this process is when I first started emailing
30:26
back and forth with the lab about bringing this
30:29
device on point of care. there was a lot of caution.
30:34
There was a lot of concern. And over time, as
30:39
we've discussed it more and more and had meetings
30:42
in person, and I've got to know these people
30:44
a lot better, the nice thing that I've seen is
30:47
that after really making good clinical arguments
30:51
and showing how we can kind of all benefit from
30:54
this, there has been a little bit of a change
30:57
in the ability to make this work. And so I think
31:03
reemphasizing that, you know, at the center of
31:06
all of this is patient care and that this is
31:09
the best thing for the patient. And I think they
31:11
have started to understand exactly how important
31:15
it is and starting to understand why we have
31:17
to make decisions on a minute by minute basis.
31:20
And so I think emphasizing that because not everyone
31:23
thinks the way we do. And so when you kind of
31:27
explain to them. I think one of the examples
31:30
I gave is when I had a liver transplant a couple
31:32
weeks ago where we gave 70 units of product.
31:37
Turns out that's quite a few units. And I think
31:43
when you start mentioning things like this, I'm
31:45
like, oh my gosh, well, yeah, of course that
31:48
device would be helpful to you. And then I think
31:51
also framing it in a way that we can help. offload
31:57
some of your staff as well by moving some devices
32:01
to the point of care it does take away some of
32:05
the you know labor intensivity from the people
32:08
within the lab now it may create the point of
32:12
care department may need a few more people but
32:14
the nice thing is if if you have people that
32:17
are really invested in this like you and i we
32:20
can kind of stay on top of the qc and keeping
32:25
up with making sure we have the supplies we need.
32:27
And we can help offload the lab in some ways
32:30
to be more of a symbiotic relationship. So I
32:34
feel like there's a version of this where you're
32:36
a junior faculty member and you have a great
32:38
idea, but you have repeated interactions that
32:41
are roadblocks that sort of grind you down over
32:43
a while. But you've persisted through all this.
32:46
So my question for you, what do you think it
32:49
is that keeps you going, that keeps you focused
32:51
on making this happen? I think the biggest thing
32:54
for me is that I certainly, there have been some
32:58
more roadblocks than I would have guessed. I
33:01
knew it wouldn't just be a walk -in and this
33:04
is what we're doing and that's how it's going
33:05
to work. So I think I understood from the beginning
33:09
that it was not just going to be a super simple
33:12
process and that it would take some time. But
33:16
the thing that really keeps me going in this
33:18
is a couple different things. Number one, it's...
33:22
One of the most important, in my mind, technologies
33:26
that we have that has been demonstrated to make
33:29
a difference in patients' lives. And I've seen
33:33
that happen. Some of the examples that I've given.
33:37
I've seen it happen over time. I've seen the
33:39
real -time, personally, difference that this
33:42
can make. So knowing that it's the best thing
33:45
we're doing for the patients and trying to, you
33:48
know, staying up to date with the most. up -to
33:51
-date practice in ways that we can not only take
33:55
the best care of patients, but also if we're
33:57
using it and we're using less blood products
34:00
and we're giving goal -directed therapy instead
34:03
of kind of our traditional one -to -one -to -one
34:06
transfusions and we're doing exactly giving what
34:10
the patient needs, blood products are not a benign
34:14
thing to give. They have complications associated
34:17
with them. kind of always on a blood product
34:20
shortage. And so also just being good stewards
34:25
of the healthcare system and making sure that
34:28
we're giving the precious resources that we need
34:32
and we're not just giving, you know, kind of
34:34
precious resources based on not as data -driven
34:38
as we can. So I think what keeps me going is
34:40
just knowing that this is one of the best things
34:43
that we can do for patients that really makes
34:45
a difference in outcomes. That's kind of what
34:48
keeps me moving forward, and particularly in
34:49
obstetric hemorrhage too, knowing that this is
34:52
such an important way to assess obstetric hemorrhage.
34:56
And if we can save one life or one ICU admission
35:00
or improve one outcome, then that to me is enough.
35:06
So let's try to go over a real -life example
35:09
where having access to one of these systems like
35:15
TAG might... help you make a different decision
35:18
clinically. So the nice thing is that let's say
35:23
you had point of care viscoelastic testing, point
35:26
of care tag, and we have an OB patient that's
35:30
bleeding on the table or is coming back for an
35:33
emergent DNC. And, you know, people are saying,
35:36
well, let's get two reds and two FFP and let's
35:40
just get products in the room. And oftentimes
35:42
I'll say, well, let's send a tag. Let's send
35:44
a tag. Let's send co -eggs. Let's just get some
35:46
data. And then we'll give things that we need
35:50
to give to keep the patient stable, of course.
35:53
But oftentimes I'll try to make a data -driven
35:55
decision knowing how obstetric hemorrhage plays
35:58
out. And so an example I can give you from a
36:02
couple months ago is we had a really profound
36:04
obstetric hemorrhage. And the obstetricians were
36:07
asking to give FFP and all of these different
36:10
blood medications. And I had already sent a tag,
36:13
thankfully. And it came back. And in this case,
36:16
the tag was profoundly normal. The patient had
36:19
lost, I think, close to two liters of blood,
36:23
maybe a little bit under. And our tag at that
36:26
time was normal. And so they wanted to give some
36:29
units of FFP and things like that. And we ended
36:31
up holding off because at that time we didn't
36:35
need any. And she was actually not bleeding any
36:38
further. The bleeding had stopped with, you know,
36:40
D &C and removal of retained products. We replaced
36:43
her blood volume, but we ended up not giving
36:46
extra units in that case. So saving that patient
36:51
an exposure to blood products was a big deal.
36:54
Now, if the fibrinogen was low, we would look
36:56
to give something like cryo. And by getting a
36:59
fibrinogen level on a tag within a couple minutes,
37:02
we can get that cryo much, much faster. So it
37:05
could definitely make a difference there. So
37:07
what advice would you give for a resident or
37:10
a... junior attending who has an idea that they
37:13
really believe in, but they might be having trouble
37:16
getting traction on it. Yeah, so I think I would
37:20
definitely, if it's something that you really
37:22
feel strongly about, then certainly don't give
37:26
up on it. Just know, and I think coming in with
37:29
the right mindset is probably the biggest thing.
37:32
I came in knowing that this might be a little
37:35
bit of a challenge. You know, people when I had
37:38
left other institutions that had gotten this
37:40
push through said it was a lot of work and it
37:43
took a lot of meetings and a lot of convincing.
37:45
And so that's a normal part of the process. Change
37:48
is slow and that's OK. It doesn't mean it's not
37:51
worth it and it doesn't mean it's not the right
37:54
thing to do. So I think coming in with the expectation
37:57
that it's going to be challenging, try to be
38:00
as well prepared as you can and be ready to.
38:03
Answer questions. You know, there's no need to
38:04
be defensive about anything. Like the lab has,
38:08
you know, reasons for the questions they're asking
38:10
and their priorities. And we have reasons for
38:12
the questions that we're asking and our priorities
38:15
and trying to find a balance where all your priorities
38:19
can align. And you can get, you know, a positive
38:23
traction and positive outcomes for all parties
38:25
involved is really the end goal. So working,
38:28
you know, with those people and just knowing
38:30
that. There's going to be road bumps along the
38:33
way as expected. So let's say over a long time
38:37
horizon, maybe the next five to ten years, you
38:40
get everything that you want as far as point
38:43
-of -care testing in our ORs. What does that
38:46
look like? So I think ideally we would get, we
38:52
already have the arterial blood gas testing at
38:55
the point -of -care with our new GEM 7000, thanks
38:57
to your very hard work on that. Well, you have
39:00
also helped significantly with the meetings and
39:03
with the rollout. So it's been a joint effort.
39:06
It has certainly been a lot of effort. So I think
39:11
that is a huge start. And I think it actually,
39:14
that will, I'm hoping, lay the groundwork that,
39:18
one, that we can do this. We can show the lab.
39:22
We can run tests without causing a lot of quality
39:25
issues. um, without, you know, causing any CLIA,
39:29
you know, laboratory standards issues. Um, and
39:34
then if we have, maybe can start ramping up and
39:38
getting more of those devices someday to expand
39:41
that coverage and then getting a tag success
39:45
move to the point of care as well. And having
39:48
a kind of, like I said earlier, a critical care
39:51
core offsite lab, essentially where we can run
39:56
all the tests that we need to take care of the
39:58
sickest patients. So when a trauma comes in or
40:01
an obstetric hemorrhage happens, I can take a
40:04
couple steps and I can get two labs within minutes
40:08
that are going to change all of my decision making
40:11
in patient outcomes. And I think that's where
40:15
we really want to take this. We're such a high
40:17
volume liver transplant center here that I think
40:20
the TAG6S being at the point of care is really
40:24
going to make a difference on Our ability to
40:27
take care of our liver patients and how much
40:29
product they're getting and giving them the most
40:32
accurate, goal -directed therapies that we can
40:34
give is going to, I think, make a big difference
40:37
in their recoveries as well. So I think, ideally,
40:41
in a couple years, we'll have maybe a couple
40:43
more ABG testing devices and at least one Teg6S
40:49
to be able to run everything, get real -time
40:52
data, and get patients well taken care of. Lastly,
40:56
I wanted to ask you about your style points or
40:58
points of personal preference that have helped
41:00
you both in and out of the OR. So I think there's
41:05
a couple things that I would say. One, something
41:09
that you and I kind of mentioned yesterday. Yesterday
41:11
I gave a talk to the residents on caring for
41:16
the intellectually disabled or patients on the
41:18
autism spectrum disorder. And I think one of
41:21
the things to just always... Keep in mind is
41:25
it's easy to be jaded in medicine. It's easy
41:28
to be frustrated by all of these different issues
41:31
we've been talking about, whether it's from the
41:32
lab or from administration. But patient care
41:35
is kind of at the center of this. And so just
41:37
being a good person and taking care of that patient
41:42
and just talking to them and hearing them out
41:45
and just listening to what the listening to patients,
41:48
listening to what they have to say. One just
41:51
very. Brief example of this is yesterday on OB,
41:54
I had a patient that had a cerclage a couple
41:57
years ago and kind of described how like uncomfortable
42:00
the experience was for her. And I went back and
42:03
looked and she had received chlorprocaine for
42:05
her spinal for a cerclage, which is not uncommon
42:07
to do. And that was actually what my plan was
42:11
going to be, was to use chlorprocaine for the
42:13
spinal for her. But after talking to her, you
42:16
know, I was like, well, let's switch to traditional
42:19
bupivacaine. Her recovery is going to be a little
42:21
bit longer. And I told her about that. But I
42:24
said, I think you might be more comfortable if
42:26
you really had a lot of visceral sensation from
42:29
the chlorpropane. And so that's what we did.
42:32
And afterwards, it was very rewarding to go talk
42:35
to her. And she was like, you know, it was night
42:38
and day difference. It was so much better than
42:39
last time. I'm so much more comfortable. Like,
42:41
I don't care that my legs are numb and that I'm
42:43
here for another hour or so. Like, I didn't absolutely
42:47
hate that whole experience. And so I think just
42:51
listening to patients and talking to them is
42:53
a huge thing that's really important. And then
42:58
one of the other things that I personally like
43:01
to do, and I'll have to give credit to one of
43:03
my mentors from residency, Shira Gambrell, that
43:08
I've tried to impart on the residents here is
43:09
anytime I place an arterial line, I like to put
43:14
the pulse oximeter on the same extremity. that
43:18
I'm doing the arterial line on. Because that
43:22
way, once I've placed the line, I can still see
43:25
that there's perfusion getting past the catheter.
43:29
And this is what we were always taught to do
43:31
in residency. And I honestly thought it was voodoo
43:33
for a while until we had a vasculopath come in
43:37
one night for an emergent surgery. And she was
43:40
on and I placed the pulse oximeter. Then I did
43:43
the arterial line. And sure enough, right when
43:46
I placed it, The pleth on the pulse oximeter
43:49
was very, very dampened. And she said, why don't
43:54
you go ahead and take that out? And about 30
43:57
seconds later, it resumed back to normal. And
43:59
I was like, okay, all right, well, I believe
44:01
you now. And as someone who's had family members
44:06
experience complications from line placements
44:09
and things like that, it's something that I take
44:10
pretty seriously. So I think... It always gives
44:14
me reassurance and I think it's good practice
44:17
to try and do that. So you can measure, you know,
44:19
profusion to the hand and profusion to whatever
44:22
extremity that you're placing a line in. So that's
44:24
one of the things that I like to try and do in
44:26
my practice. Well, Tyler, thank you so much for
44:29
coming by. I really appreciated you coming to
44:33
join us today. I really appreciate you having
44:35
me. Thanks so much. Thanks for joining us for
44:39
another episode of Style Points. If you liked
44:41
the show, please consider leaving us a rating
44:44
or a review. If you write a review, I would be
44:47
really interested to know where you're listening
44:48
from. I would love to hear if you or other people
44:51
from your department enjoy the podcast. What
44:54
institutional changes are you working on? You
44:57
can always email me at stylepointspodcast at
44:59
gmail .com. Take a deep breath. Open your eyes.
45:04
We're all done.