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The Kids Table with Marc Mecoli and Joe Weethee · Style Points

0:20
Hello anesthesia enthusiasts and welcome to another
0:23
episode of Style Points. In this episode, I have
0:26
not one, but two. two special guest anesthesiologists
0:29
from Children's Hospital, Mark McCauley and Joe
0:32
Wheathey. For all of you sharp -eared listeners
0:35
out there, you may have noticed the intro had
0:37
a bit of extra flair to it. I asked Mark to showcase
0:40
some of his talents on the violin, which he was
0:42
gracious enough to record for us. Before we talk
0:45
with them, I'll let my co -host, Nate Moore,
0:48
introduce this week's RSI, which obviously stands
0:50
for Resident Selected Information. Thank you,
0:55
John. I get to give a warm welcome to Dr. Kat
0:57
Dunshee, who will be delivering our RSI today.
1:00
She stopped in between patients in our perioperative
1:02
care clinic to give us a quick primer on safely
1:04
combining anesthesia with aortic stenosis. Welcome,
1:07
Kat. Today, we are going to be talking about
1:10
one of the most high -risk valvulopathies we
1:12
encounter in the OR, aortic stenosis. This episode,
1:16
we will recap pathophysiology of aortic stenosis,
1:19
then get into hemodynamic goals and anesthetic
1:21
approach, and then finish with some practical
1:23
pearls. Let's get right into the pathophysiology.
1:26
Aortic stenosis is characterized by an increased
1:29
left ventricular systolic pressure and an attempt
1:31
to maintain forward stroke volume through a narrowed
1:34
aortic valve. The magnitude of this pressure
1:36
gradient serves as the estimate of the severity
1:38
of the stenosis. Let's talk about the most severe
1:41
classifications. Severe stenosis is defined by
1:43
a gradient of greater than 40 millimeters of
1:45
mercury or a valve area less than 1 .0 centimeters
1:49
squared. Critical stenosis is defined by a gradient
1:52
of greater than 50 mmHg or a valvular area of
1:55
less than 0 .75. As a result of the stenosis,
1:58
the LOV then undergoes concentric hypertrophy
2:00
to overcome this pressure gradient. This change
2:03
leads to an increased myocardial oxygen demand,
2:06
and this makes sense. More muscle needs more
2:08
oxygen. To make matters worse, myocardial supply
2:11
reduces due to the marked compression of intramyocardial
2:14
coronary vessels caused by high intracavitary
2:17
systolic pressures. We now have an increased
2:20
demand and reduced supply issue. Now that we've
2:23
briefly talked about the pathophys, let's get
2:25
into the hemodynamic goals intra -op. Overarching
2:28
goals are to avoid hypotension, maintain normal
2:31
sinus rhythm, and avoid extreme changes in heart
2:34
rate, SVR, and volume. Let's take a look at these
2:36
in a bit more depth. 1. Avoid hypotension. In
2:41
patients with aortic stenosis, even brief hypotension
2:43
during induction can be dangerous. The left ventricle
2:46
is already working hard against a fixed obstruction,
2:48
so its oxygen demand is high. At the same time,
2:52
coronary perfusion depends on a good diastolic
2:54
pressure. If blood pressure drops, diastolic
2:56
pressure falls. Filling pressures rise, and the
2:59
heart muscle can't get enough oxygen. The result?
3:02
A rapid myocardial ischemia. Next is normal sinus
3:06
rhythm. The LV is dependent on properly timed
3:09
atrial contractions to ensure optimal LV filling
3:12
and systolic stroke volume. Remember, atrial
3:15
contraction accounts for up to 40 % of LV filling.
3:18
Next, avoid tachycardia. Tachycardia will result
3:21
in less filling time, leading to decreased coronary
3:24
perfusion and increased oxygen consumption. Bradycardia
3:27
is better tolerated but will reduce cardiac output,
3:30
so a normal or low normal heart rate is best.
3:34
And finally, preload. These patients cannot increase
3:37
cardiac output much by SV because of the outflow
3:40
obstruction. They rely heavily on end -diastolic
3:43
volume. If you let them get even a little dry,
3:46
from fasting, bleeding, or vasodilation, their
3:49
stroke volume will drop, blood pressure will
3:51
fall, and coronary perfusion will suffer. That
3:54
can spiral into ischemia very quickly. That being
3:57
said, too much volume is also harmful for a stiff
4:00
left ventricle. Excess pressure will just back
4:03
into the left atrium and lungs, causing pulmonary
4:05
edema. Preload and aortic stenosis is a tightrope
4:09
walk. Our job is to keep them right down the
4:11
middle. Now that we know our goals, let's talk
4:14
about the anesthetic approach, including monitors,
4:16
induction, and maintenance. For monitors, as
4:19
we know, many of our induction agents lead to
4:22
hypotension. These patients can crash quickly
4:24
if their blood pressure drops. Get an arterial
4:27
line before induction to have continuous monitoring.
4:30
For induction, be gentle. Rapid drops in SVR
4:33
with propofol can be catastrophic for a patient
4:36
with aortic stenosis. You can also consider agents
4:39
such as etomidate or ketamine with careful attention
4:41
to heart rate. Overall, slow titration is key.
4:46
For maintenance, volatile agents are fine. Keep
4:49
them light to avoid the vasodilation and loss
4:51
of normal atrial systole. And lastly, pressors.
4:55
The use of vasoconstrictors like vasopressin,
4:58
phenylephrine, and norepinephrine are often necessary
5:01
to preserve systemic blood pressure in the anesthetized
5:04
aortic stenosis patient. Have them in line on
5:07
induction. Let's recap the key points to remember
5:10
when taking care of aortic stenosis patients.
5:13
One, normal sinus rhythm is critical. Avoid the
5:16
extremes. Too fast shortens diastolic filling,
5:20
but too slow can also drop cardiac output. Stiff
5:23
ventricles need adequate filling. Don't let them
5:25
get dry, but don't flood them with volume. And
5:28
lastly, maintain SVR. A sudden drop will crash
5:31
coronary perfusion and cardiac output. Titrate
5:34
induction meds slow and have pressors ready to
5:36
avoid hypotension. We often say aortic stenosis
5:40
is poorly compatible with anesthesia, but hopefully
5:43
you are now a little bit more compatible with
5:45
aortic stenosis. Yeah, it does sound better if
5:54
you're talking at it like this, but we can kind
5:59
of like get in a little bit. I think the correct
6:02
term you're looking for is cardioid, John. Jesus
6:04
Christ. It'll be the donut. You're out. You're
6:10
supposed to be the expert here. I can't. I'm
6:18
supposed to be the guy who knows the sound equipment.
6:19
You can't just come in here and just show me
6:22
up like that. Honestly, so one of the bands I'm
6:26
playing in. is we're starting to do our own sound
6:29
and i like got i bought this xr18 mixer digital
6:32
mixer which is pretty sweet it's like i don't
6:36
know i guess this is a mixer but anyways i started
6:40
like watching youtube videos on live sound mixing
6:43
and the rabbit hole that you can go down is freaking
6:46
crazy do you guys want to go ahead and get started
6:50
yeah sure let's do it gentlemen thanks for joining
6:54
us Thanks for having us. Yeah, thanks, John.
6:57
Absolutely. So let me know how the walkover was
7:01
from Children's Hospital. It was rainy. Yeah,
7:05
a little drizzly. We got locked out. Oh, you
7:08
weren't able to get in with your badge? That's
7:11
right, yeah. Apparently there's like a Children's
7:14
Hospital ban on this place or something. I don't
7:16
know. We try to keep you guys out as much as
7:18
possible. makes sense we don't want you to show
7:22
us up you understand well i had a little ptsd
7:25
because i went to medical school here yeah and
7:27
i passed by what is it e351 uh yeah the lecture
7:31
hall yeah like oh my gosh here we are again wow
7:35
yeah i can imagine i i would not want to see
7:38
my lecture hall again that would be ptsd for
7:40
me too Is this a required class or is it not
7:44
a required class? Well, that's where we match.
7:47
That's where my match day was. Oh, really? E351,
7:51
yeah. So the last time I was in that hall was
7:54
when I opened up the letter where I was able
7:58
to match into anesthesia residency. Well, let
8:01
me back up for a second because I have two guests
8:04
here and I want my audience to be able to understand
8:07
who's speaking. Let me have you introduce yourselves
8:11
and people can pair your introductions with your
8:14
voice so we know who's speaking. So my name is
8:18
Joe Weethy. I also went to medical school at
8:20
UC and I'm one of the anesthesiologists over
8:22
at Cincinnati Children's. Yeah, and this is Mark
8:26
McCauley. I'm on faculty at Cincinnati Children's.
8:31
Been there for about 12 or 13 years now. And
8:34
Mark actually happens to be... Pretty much my
8:37
next door neighbor. That's right. Yeah. Which
8:40
gets you an in to be on the podcast if you want,
8:43
if you're neighbors with me. Well, the last time
8:44
you texted me was trying to figure out where
8:46
your kid was. Well, our kids tend to roam somewhat
8:52
fairly throughout the neighborhood. Yeah. Free
8:55
range parenting in our neighborhood. Whether
8:57
or not they have shoes on or whether or not they
9:00
have shirts on, it's just sort of sometimes difficult
9:04
to ascertain. That's right. Well, let me ask
9:08
you both this question, which is one of my favorite
9:10
interview questions. If you could have dinner
9:12
with anyone in the world, could be somebody from
9:14
the past or even from fiction, who would you
9:16
have dinner with and why? So I'll start with
9:22
that. I'm a musician, so it for sure will be
9:27
a musical person. I play violin and fiddle. I
9:34
would definitely pick Itzhak Perlman. So Itzhak
9:37
Perlman is one of the preeminent classical violinists.
9:41
And when I was a kid playing violin, he was kind
9:44
of like my hero. He's a really interesting guy
9:47
who is a child prodigy violinist. And I remember
9:52
as a kid writing a letter to him, you know, sort
9:57
of introduced myself and saying, hey, like you're
10:00
my hero. And he sent me back a picture. a photograph
10:03
of him playing music with Oscar the Grouch on
10:07
Sesame Street. And he signed it. And I still
10:10
have that picture at my place, which is pretty
10:12
cool. But he's definitely a hero of mine. And
10:15
I think he would be really interesting to get
10:17
to meet and talk to. As somebody who goes over
10:21
to your place on occasion, I'm going to demand
10:23
to see that next time I go over. Oh, there you
10:25
go. Yeah, for sure. What about you, Joe? You
10:28
know, Mark had a, that was a very profound answer.
10:31
Yeah. Well, I'm not really a musician in the
10:39
regard that, you know, Mark is, but I do like
10:41
music too. And Mark and I talk a lot about records
10:45
and musicians. And I think if it could be anyone,
10:49
I think it would be Willie Nelson. I think it
10:52
would just be a good hang. You know, I don't
10:54
have a signed picture of him. I didn't write
10:56
him a letter when I was a kid, but I would love
10:59
to hear his stories and all the musicians he's
11:00
played with and all the places he's been. And
11:03
I think he would just be fun to chat with. I
11:07
think he would be an easy hang. So two musical
11:10
guests. That's excellent. I like that. That'd
11:13
be great. Would you want to meet with Willie
11:15
Nelson now or Willie Nelson from the past? What
11:19
do you think? I think that's a good follow -up
11:21
question. I think now. With all his life experience
11:25
and all the places he's played and all the things
11:27
he's seen, talking to him about Waylon and Merle
11:31
and Johnny Cash and all these guys that are passed
11:33
away now, I think it would be now. Yeah, think
11:37
about the stories that that guitar has seen over
11:40
the years. What is it, Trigger? Yeah. Trigger
11:42
the guitar. Gosh, can't even imagine. So you
11:47
both decided to do pediatric anesthesiology.
11:51
Why? You know, that's a good question for me.
11:56
I did not come into residency thinking I was
12:00
going to do pediatric anesthesia. I when I first
12:03
mentioned anesthesia, I really thought I would
12:05
do like adult cardiac. And then throughout residency,
12:10
I kind of thought that the ICU was the place
12:13
for me. And then I trained through the peak of
12:16
COVID. So when I was an intern, the COVID pandemic
12:18
started and I saw a lot and. It kind of shaped
12:23
me in a way, and I got really good training.
12:27
But when I was at the end of my CA1 year, my
12:31
first rotation as a CA2 was peds. And it was
12:34
sort of just like a breath of fresh air for me,
12:37
especially coming from, you know, the COVID ICUs
12:41
where there are lots of sick patients. And it
12:43
was really refreshing to just, like, talk to
12:45
a kid, ask them about their stuffed animal, get
12:48
on their level. And it was just way more happy
12:51
and sort of joyful. And I think those two experiences
12:54
combined sort of pushed me over to doing peds.
12:59
But I was not a peds person per se in residency
13:03
or coming into residency at least. Yeah, I mean,
13:07
I always knew I wanted to be a pediatric anesthesiologist
13:10
from a very young age. No, I... It's so weird.
13:15
It's like Perlman told me I should be. Yeah,
13:16
it's like, hey, you know, you should. I'm your
13:18
answer to the grouch picture, I'm sure. Right.
13:20
So I actually, when I was in medical school,
13:25
thought I would go into surgery or ENT or something
13:28
like that. And I really... Wanted to spend a
13:32
little bit more time thinking about that decision.
13:34
So I actually took a year off and did research
13:36
at Children's through the Department of Otolaryngology
13:40
and worked as a research coordinator on a study
13:44
looking at fMRI in deaf kids that were pre -cochlear
13:48
implant candidates. And through that experience,
13:51
I worked with several of the anesthesiologists
13:55
and CRNAs at Children's. Because the kids needed
13:58
to have anesthesia for their MRI scans. And so
14:01
I spent the year in that project. And through
14:04
that experience, got brought up to the operating
14:07
room. I was like, wow, anesthesia is awesome.
14:10
So like that, my first sort of exposure to anesthesia
14:13
was through the pediatric lens. And I just, there
14:18
was something about the innocence of taking care
14:21
of kids and, you know, the diversity and like.
14:26
You know, comorbidities and like there's just
14:29
something about that that I kind of gravitated
14:32
towards. And then it was through that experience
14:35
I wanted to go into anesthesia residency. And
14:37
then that was kind of further like when I was
14:40
in Boston at Boston Children's. It just kind
14:42
of solidified it from there. So that makes a
14:45
lot of sense. I remember when I was doing my
14:48
pediatric anesthesia months back in Oklahoma
14:50
and one of my favorite things was. taking care
14:55
of healthy kids i just thought it was great um
14:58
i really enjoyed the idea of instead of having
15:01
to wheel the patient to the pacu i could just
15:05
put them up on my shoulder and kind of carry
15:07
them to pacu and i i found that very rewarding
15:10
i think one of the trickier parts though and
15:15
part of what made me not necessarily want to
15:19
go the same route that you did was that there's
15:22
the whole other side of it Two, though, which
15:25
is the really sad cases. You can feel sorry for
15:30
and empathize with the 87 -year -old who's very
15:33
sick, who comes in and has a cardiac arrest or
15:37
something like that. But when it's a five -year
15:41
-old or a two -year -old, it really can be hard.
15:46
Yeah, for sure. I sort of want to dive into what
15:49
you guys think about that, how you handle it.
15:52
and what your mindset was for those sorts of
15:55
things. Yeah, I mean, I think that there's definitely
15:58
a certain amount of innocence that you appreciate
16:01
when you take care of kids. And when you take
16:06
care of kids with chronic medical conditions,
16:08
you really just appreciate so much about your
16:12
own kids' health and your own health. And that
16:15
is definitely something that you sort of recognize.
16:21
You know, at the end of the day, in in pediatrics,
16:26
like there is a North Star and that's the kid
16:28
that you're taking care of. And it's really cool
16:30
to see everyone in the room sort of rally behind
16:33
that. And for me, that's a big part of why I
16:37
do what I do, because I can feel like, you know,
16:40
like we're all in this together to help this
16:42
this kid. But it can be incredibly challenging.
16:46
You know, you see some pretty messed up stuff
16:48
and some really sad things. But at the end of
16:50
the day. At least for me, it allows me, it kind
16:54
of grounds me in my own life and with my own
16:58
kids, for sure. Yeah, I mean, I'll echo what
17:02
Mark says. There are times where the patient
17:05
you're taking care of that's really sick, you
17:06
see your kids, they might be the same age or
17:09
have a similar hair color or whatever, and you
17:11
see your kid in that really sick kid. I do kind
17:16
of turn the situation around and I empathize
17:19
and feel sorry for the kid and the parent, but
17:20
I'm also grateful that my kids are healthy and
17:23
at home and like the worst thing that they have
17:25
to worry about is a stomach bug. And it just
17:27
gives me perspective, you know, that like, it's
17:29
not so bad. Right. And then the other side of
17:33
it is, I think you see the resilience of children
17:35
too, especially kids with chronic medical conditions
17:38
who may have a quality of life. That's not the
17:42
same of a healthy kid, but they're just still.
17:45
joyful and resilient and you see just happiness
17:48
you know shade through their chronic medical
17:50
conditions and you see that in adults too but
17:52
i think kids just have this like tendency towards
17:55
joy and happiness and i think it's actually very
17:59
refreshing and it kind of staves off burnout
18:02
for me at least personally well beyond just the
18:07
joy that you get from seeing kids being kids
18:10
i think one of the things that is interesting
18:13
about Pediatric anesthesia is what some kids
18:18
will come in with, some of the bizarre things
18:20
that children's do. I remember, for example,
18:22
when I was on children's call during residency,
18:26
there was a child who had inhaled a purple straw
18:31
that had somehow, it was about a centimeter worth
18:35
of purple straw, and it had somehow gotten below
18:38
the vocal cords and deployed. And it was essentially
18:43
a stent. An airway stent, yeah. You paid good
18:46
money for that. The vocal cords. That caused
18:49
such an extreme bronchospasm that I think we
18:55
emptied the pyxis of all the albuterol in there.
18:58
It was a pretty wild case. What kinds of cases
19:02
have you guys seen like that? Crazy things that
19:05
you might have taken out of an airway or a stomach
19:07
that would really only happen over... the children's
19:11
yeah i mean i think both joe and i have a very
19:14
like un you know unhealthy fear of of foreign
19:18
bodies for our own kids i don't know but it's
19:21
like oh everything i see i'm like oh that could
19:23
that could definitely be a foreign body in the
19:25
airway um gosh you know i mean way it's like
19:30
so common i'm trying to think of the most interesting
19:34
thing um i don't know i will say When we do foreign
19:42
bodies for coins, I like to do this thing where
19:44
we're certainly not putting an actual wager down,
19:48
but we do try to pick the coin, pick the year
19:51
sort of thing that's always fun to do. So if
19:54
you land on like a 1967 penny and you get close,
19:57
it's like, oh, got it, nailed it. There might
20:00
be real copper in that penny too. That's right,
20:02
yeah. Exactly. um the scariest ones are are the
20:07
airway form bodies obviously and anything that
20:09
is expandable right so any organic matter is
20:13
really bad like a bean or a piece of corn that
20:16
can when it gets wet it can get uh expanding
20:19
and then um you know those those can be really
20:22
critical i seem to recall peanuts peanuts are
20:25
bad yeah for sure well that's one thing i didn't
20:28
I don't think until I was a fellow is just the
20:30
reaction to the organic material that happens
20:33
and things get inflamed and very kind of angry
20:36
very quickly. That's scary. And then button batteries
20:39
and the esophagus are always like the most feared.
20:42
I actually recently went through and like made
20:45
all my button batteries so inaccessible in my
20:48
house because you have to have them. But like
20:49
I want them far away from my three year old and
20:53
he does still put things in his mouth. We hide
20:56
the button batteries from him for sure. Yeah,
20:59
I hide the button batteries from my 12 -year
21:01
-old. I mean, I know you're 12 years old. Yeah,
21:05
exactly. I think that's probably appropriate.
21:07
No, he's a great kid. I took care of a kid recently
21:09
who was chewing the plastic top of a water bottle
21:15
and choked on it. And he came in and had pretty
21:21
bad stridor, especially when he was crying. concerned
21:26
that it was causing airway obstruction in the
21:28
upper glottis and so we got him to sleep and
21:31
the ent went in and looked and see anything like
21:33
what the heck's going on here went down to these
21:35
all the way down to the carina nothing obviously
21:37
it was too big to fit down there but just to
21:39
make sure and then all the way in the esophagus
21:41
we couldn't figure it out and um i was like well
21:45
you must have coughed it out but like why was
21:47
he still having strider right and the ent I was
21:51
like, hold on a second. And he reached down into
21:52
the kid's mouth and then stuck his finger back
21:55
up past the palate. And it had lodged up above
21:59
where the palate. So when he was crying, you
22:01
could hear this like stridulous sound. And so
22:04
he pulled it out. I'm like, wow, I would never
22:05
have thought to look there. And he was like,
22:07
Mark, I'm an ear, nose and throat doctor. You
22:11
know what I mean? So like he figured it out.
22:13
But yeah, there's all sorts of all sorts of things
22:16
you can get stuck. So a lot of the. People that
22:21
might be listening to this podcast in the future
22:23
might still be before their pediatric anesthesia
22:28
rotations. They might not have worked with kids
22:29
before. I'm curious, from the perspective of
22:33
somebody who deals with a lot of trainees, like
22:36
I know both of you do, what are some of your
22:39
pro tips for dealing with kids in these rather
22:43
extreme circumstances? I will say... The extreme
22:50
circumstances are always a challenge. If day
22:56
to day, I always tell trainees, go in, talk to
23:00
the parents, talk to the kid. It's a little harder
23:02
when if you do have kids, it makes it a little
23:06
bit easier to communicate with the parents, communicate
23:08
with the kids. But it also makes the rotation
23:11
sometimes more difficult on trainees because,
23:13
again, they're having these experiences where
23:14
they're seeing kids not doing well or kids having
23:16
injuries and stuff. And that can be really hard.
23:19
But if they don't have kids, I tell them, you
23:20
know, go in, kind of get down on their level,
23:23
talk to them, ask them about if they've got toys
23:25
in the bed with them or they're playing a game
23:27
or a stuffed animal. And I always tell them to
23:29
just sort of pay attention to how the kid is
23:31
interacting with them. If they're real hesitant
23:33
and very sort of withdrawn or shy, I always tell
23:38
them that might be a kid who it may be difficult
23:40
to separate from mom and dad. If they're interacting
23:43
with you and you've developed some rapport and
23:45
trust with them, that might be a kid that might
23:47
separate fine and not need a premedication like
23:49
midazolam or something to separate from mom and
23:52
dad. And it's sort of these like subtle things
23:56
that are hard to explain or teach to someone.
23:58
But I think by the end of the month, they kind
24:00
of start to grasp how these interactions are.
24:03
And then you also have the parents too, right?
24:06
And so the kid might not be anxious at all, but
24:08
the parents might be anxious. And the kids do
24:10
pick up on our emotions and our general aura,
24:14
you know, is how I would call it. And so sometimes
24:17
the kid is okay, but when it's time to separate
24:20
from mom and dad, mom and dad start feeling a
24:21
little bit more anxious than the kid might too.
24:23
And so those are like very subtle, hard to explain
24:29
things to a trainee, but I say go in there and
24:31
just get a feel. You know, you're not looking
24:33
for any specific things. Just go into the room
24:35
and see how it feels when you walk in there.
24:37
Is it calm? Is it cool, collected? Or is it like
24:40
the kid is running to the corner and hiding from
24:43
you? It's like you start to pick up these things.
24:45
And I think as the month or two goes on, they
24:48
start to appreciate those things a little bit
24:49
better. Yeah, I will say that in general, to
24:54
be successful with getting kids through stressful
24:57
situations, giving them Very explicit options
25:02
is important and not asking them, do you want
25:05
to like, can I put this mask on your face? Right.
25:08
Like if you have a two year old at home and you
25:11
ask them, do you want to go in the car seat now?
25:13
Like they're going to tell you no. So giving
25:16
them options that are that are sort of directive
25:18
is very important. And I think that's one of
25:21
the challenges of pediatric anesthesia is establishing
25:23
rapport with not only the kid, but with the parents
25:26
like really quickly. And you literally are taking
25:29
their most important thing in their entire life
25:31
and and taking that that life in your hands is
25:35
pretty, pretty profound. I mean, you don't think
25:38
about that so explicitly all the time, but it
25:41
takes a skill to establish trust and rapport
25:44
very quickly in oftentimes a very stressful situation.
25:50
So I remember from my pediatrics rotation, I
25:54
saw a bunch of syndromes that I had never seen
25:58
or heard of before. They all have proper names
26:00
attached to them. And while I remember a few
26:03
of them, at least enough to pass my boards, which
26:07
is increasingly a longer and longer amount of
26:11
time ago, I still have trouble remembering all
26:15
of that stuff. My question for you guys is, I'm
26:18
sure that at Cincy Children's, which is, of course,
26:20
the number one pediatric hospital, you're going
26:24
to see an extremely wide variety of different
26:28
conditions that you probably have never seen
26:31
before or might not have heard of. So when something
26:35
pops up for your case the next day that you might
26:39
not have any experience with, what's your strategy
26:42
for that? Yeah, I mean, we take care of a lot
26:48
of really medically complex children. I mean,
26:50
we've taken care of kids who are one of maybe
26:53
10 in the entire world that have a certain syndrome
26:57
or problem. And then we take care of kids who
27:00
have problems that are yet to be identified,
27:02
right? And so the way I sort of look at it is
27:05
just break it down by body system and really,
27:08
you know, evaluate the airway, evaluate the cardiac
27:11
and lung exams, and then just... go systematically
27:15
through all the body systems. And then certain
27:18
syndromes are known to have, you know, involvement
27:23
of different body systems. And so you get to
27:27
kind of know about what those are and can plan
27:31
ahead. But just to go through systematically
27:33
and think about the whole big picture. Yeah,
27:40
I agree with that. And I think the biggies that
27:42
are always tested on are the ones you think of
27:45
pierre robin and treacher collins and charge
27:48
syndrome and you become familiar with those but
27:51
we do have you'll have you know syndromes that
27:54
are just exceedingly rare and you're you're basically
27:57
reading a journal article to figure out like
28:00
mark said airway cardiopulmonary and then the
28:03
other one i think about it's like metabolic metabolic
28:05
yeah so you have you know lysosomal storage disease
28:08
and things that may affect like should you be
28:11
using propofol should you be using a different
28:12
fluid or something like that but those four buckets
28:15
are probably the big ones you need to hit and
28:19
usually there's some sort of description of the
28:23
process and and then i kind of start to clump
28:26
them into different buckets so like the more
28:28
metabolic the lysosomal or mitochondrial diseases
28:30
are sort of in a bucket the airway disease, you
28:33
know, syndromes are kind of in a bucket and I
28:35
just kind of keep those familiar, but it's not
28:38
in free. I mean, once or twice a week, I'm probably
28:40
reading an article or a textbook about some syndrome
28:43
that I've never heard of or are not super familiar
28:46
with. And I'm guessing that's going to continue
28:49
for the next, you know, 10 years. For sure. And,
28:52
you know, don't forget, you got to figure out
28:54
what color popsicle the kid wants and pack you
28:56
too. Critical information. Critical information.
28:58
Yeah. I will say that the. This is another kind
29:02
of thing that I think a lot of us really enjoy
29:04
about pediatrics is that you're constantly learning
29:07
new things, right? And it's a very humbling practice,
29:13
right? If you're walking into a day where you're
29:17
like, I've literally never heard of this before,
29:18
and how am I going to figure out what I need
29:21
to know, how to keep this kid safe? And it keeps,
29:25
especially if you've been doing it for a while,
29:27
it keeps you kind of fresh. What I remember about
29:31
my pediatric anesthesia rotation is we would
29:35
sort of religiously make up our rescue syringes
29:39
in the morning, calculate our doses, and make
29:43
sure that our weights and everything was appropriate.
29:45
And I always thought that the pediatric anesthesiologists
29:50
that I were around were a little bit even more
29:52
on the control freak side than I was. As an anesthesiologist,
29:58
we're all... control freaks to a degree, but
30:01
you guys always had that little bit extra level
30:05
to you. And I didn't quite understand it until
30:08
I came upon one of my first pediatric emergency
30:13
situations, or really more of a mini emergency
30:17
situation. The prototypical one that I always
30:21
think of is a bronchospasm. It happened so much
30:27
more quickly. than any adult emergency that I
30:31
had seen. And the pediatric anesthesiologist
30:34
that I was with had to respond and figure it
30:37
out so much faster than I was even prepared for.
30:41
It was fixed in a hurry, but I just remember
30:45
it was a totally different pace than the rest
30:50
of what I had experienced in adult anesthesia.
30:54
And I wonder if you guys could... talk through
30:56
some of those many emergencies that you might
30:59
see on a day -to -day basis. Yeah. So what you're
31:02
describing is laryngospasm or bronchospasm. And
31:06
I have to say that one of my key teaching points
31:12
when people come over and rotate with us is the
31:15
main difference between pediatric and adult anesthesia
31:18
is that green bag that's going up and down. And
31:22
if your right hand is on the bag, you can get
31:24
so much information by just feeling what that
31:29
feels like, looking at the patient. And, you
31:33
know, in some ways you can almost completely
31:35
ignore the vital signs in the monitor because
31:38
you're getting so much information from just
31:40
being present with the patient. Before I was
31:44
a fellow, so a long time ago. there was an anesthesiologist
31:48
who used to shut the monitor off completely during
31:51
induction because he said, there's really nothing
31:53
that you're getting here that's giving you information
31:56
in the moment. And it's absolutely true. You
31:59
know, that wouldn't fly now, obviously. But if
32:01
you have a laryngospasm, you're going to identify
32:04
that by feeling the bag going up and down or
32:06
not going up and down and having to make a decision
32:09
before the oxygen saturation changes at all.
32:12
So you can have a florid laryngospasm and the
32:15
oxygen is 100 % and you need to have already
32:18
identified what the problem is and treated it
32:21
before anything changes. And so for, you know,
32:27
that's just like a really good example of how,
32:29
you know, being kind of in tune and in touch
32:32
with the patient is really important. And I think
32:36
too, with some of those emergencies, when it
32:38
seems like people are responding so quickly,
32:40
I... I think people start to get like an almost
32:43
intuitive sense. This kid was sniffly and pre
32:46
-op, you know, the brother's really sick. That's
32:50
in the back of my mind where we're going to sleep.
32:52
So if something is awry, we just start to assume
32:55
this is a bronchospasm. This is laryngospasm.
32:57
It's one of the two. And I think we reach for
33:01
epinephrine and bronchospasm much quicker than,
33:04
you know, in the adult practice, just because.
33:07
They're so heart rate dependent. We're very quickly
33:09
giving that epinephrine for multiple reasons.
33:12
But it always works. If the bronchospasm is severe
33:15
enough, the epinephrine will get in there and
33:17
get you out of trouble quickly. I think someone,
33:20
one of our cardiac anesthesiologists said epinephrine
33:23
is like bread. Everybody likes it. And I still
33:27
tell people that because it's like you can pretty
33:29
much give it even in cardiac lesions. Most people
33:32
are going to be okay with epinephrine. It's like
33:34
Brad, everybody likes it. So I still tell the
33:36
residents that. Wow. That's an extremely memorable
33:43
quote. I may have to steal that for my practice.
33:46
That's great. I'm sure pediatric anesthesia has
33:50
probably changed since I was doing it a long
33:53
time ago in residency. What's sort of new within
33:57
pediatric anesthesia? What have you seen over
33:59
the past? five to 10 year period where practices
34:04
changed or I assume you're probably using more
34:09
Sugamidex now than you probably used to. What
34:13
else is changing in pediatric anesthesia? Yeah.
34:16
So, I mean, I think in general, if you look at
34:20
all medical specialties, the practice of anesthesia
34:24
changed very significantly. back in the 80s and
34:27
90s, and since has been relatively slow to change,
34:31
right? It's incredibly effective. It's incredibly
34:33
safe. Since my residency, I would say that the
34:40
three biggest changes have been Sugamidex. There's
34:45
some newer regional blocks that we're doing now
34:48
that we didn't when I trained. So like Erectrospinae
34:51
blocks, IPAC blocks, Ping blocks, things like
34:54
that. And then I think the biggest thing is the
34:57
implementation of point -of -care ultrasound
35:00
and how that is applicable in our world. And
35:04
that's one of my clinical interests is trying
35:07
to understand how that applies to pediatrics
35:10
and specifically gastric ultrasound. So we're
35:12
doing a lot of work with trying to figure out
35:15
how that can be incorporated into decision -making
35:17
in NPO violation. And then conditions of delayed
35:23
gastric emptying and gastroparesis. But that's
35:27
what I think is exciting about, you know, doing
35:31
something that, you know, there's like a forefront
35:33
of clinical change. And, you know, we're lucky
35:38
to work in an institution where we're able to
35:40
explore some of those things. And I'll piggyback
35:45
off of Mark. I think the biggest thing was his
35:47
gastric ultrasound, which, you know, now they're.
35:50
they're sort of pushing people applying for board
35:53
certification through the aba right it's part
35:55
of the oski now is doing gastric ultrasound the
35:57
biggest thing i've noticed a change is in kids
36:01
with pyloric stenosis so textbook teaching is
36:04
you take an awake you know four to five week
36:07
old baby and you suction out their stomach awake
36:11
which is like the worst thing you can do to somebody
36:13
and you you tilt them around a little bit to
36:15
make sure you empty their stomach And then you
36:18
cross your fingers and you do a rapid sequence
36:20
and induction and a five week old, which is very
36:22
nerve wracking. And you hope that the breathing
36:25
tube goes in the first time and that hopefully
36:26
the kid doesn't aspirate and you've emptied the
36:29
stomach. With gastric ultrasound, we're able
36:32
to look at the stomach, see that it's obviously
36:35
distended, empty out the stomach and then rescan
36:38
and look to see that it's empty. And then we're
36:41
able to do. sort of a gentle mask induction,
36:45
which in a baby is much safer. And it has changed.
36:48
I'll toot Mark's horn a little bit here because
36:51
he presented some of the stuff at our pediatric
36:52
anesthesia conference. But I remember hearing
36:54
someone saying for this particular poster, this
36:57
is going to change my practice. And I think we
37:00
don't come across things that often that people
37:02
say stuff like that. But I know that I told,
37:05
I have buddies at other institutions that do
37:08
peds and I told them about what we were doing
37:10
and they sort of. you know self -taught and they're
37:12
like this has changed the way i'm doing these
37:15
cases and honestly it's still one of the most
37:18
stressful things we do as an rsi it's just very
37:21
high stakes and very stressful and whoever's
37:23
doing the airway is usually a little on edge
37:25
we're all a little on edge but it kind of takes
37:27
that away which is huge yeah that that is it's
37:33
really exciting to hear people say like hey this
37:35
is actually going to change what i'm doing in
37:37
my practice and we're working on a paper right
37:40
now looking at retrospective review of kids who
37:44
have had pyloric stenosis and kids that we did
37:48
gastric ultrasound in and those that we did not.
37:51
And so we'll look to hopefully publish that within
37:54
the next year. But basically, the overall findings
37:57
were that in kids who had a mask induction or
38:01
a modified rapid sequence induction had a much
38:05
lower incidence of hypoxia during the induction.
38:10
So we called it like a ventilating induction,
38:13
basically. And it's not new. I mean, Boston Children's
38:16
published a paper several years ago looking at
38:19
modified rapid sequence induction in that patient
38:21
population, showing that it had reduced incidence
38:25
of hypoxia than more of a classic RSI. But the
38:30
use of gastric ultrasound was significantly associated
38:33
with higher incidence of mask ventilation. in
38:38
that patient population. And so we're hoping
38:41
that this will, you know, change people's practice
38:44
and that they'll use it to guide their induction
38:48
technique in these patients. And we've seen that
38:52
in other situations too, in kids who have had,
38:56
you know, sort of an ambiguous or unknown MPO
38:59
status and using gastric ultrasound to... sort
39:02
of sort out what's going on and then it changes
39:04
our either induction or decision to proceed or
39:07
cancel a case and so you can see a kind of real
39:10
world application which is really exciting because
39:14
it's changing kind of you know how we practice
39:17
hearing joe you talk about that case stem and
39:24
having to take care of a baby with pyloric stenosis
39:30
Really just internally made my heart start to
39:34
race. Just thinking about the prospect of handling
39:37
that sort of stressful situation. And I handle
39:41
stressful situations. I see people code. I have
39:44
to throw in lines in very stressful situations.
39:48
But I imagine when it's a baby, that was even
39:52
harder for me to deal with. And that's a lot
39:54
of stress to carry with you. It's a very stressful
39:57
profession that you're in. My question is, how
40:02
do you manage it at home? How do you deal with
40:07
the comedown from that stress? What kind of techniques
40:11
do you have in your life to just not have a heart
40:17
attack when you're 35? Yeah, I mean, I will say
40:22
that. These situations are incredibly stressful.
40:25
I will say, though, that we work in an institution
40:28
and a perioperative environment where, like I
40:30
said before, the North Star is the kid. And so
40:33
even when things are going poorly or there's
40:37
a lot of stress in the room, everyone in that
40:39
room, the nurses, the anesthesia provider, the
40:42
surgeon, are all there to make sure that the
40:44
kid does as well as they can. And I really do.
40:48
I'm very grateful for, you know, our surgical
40:50
colleagues that like, if I have a concern and
40:53
I voice it, like they listen to what I'm saying
40:55
and they, they do such a great job of, you know,
40:59
sort of like thinking about that expertise and
41:02
that perspective. And I feel like we work in
41:05
a really good team environment. So that in a
41:08
way helps with the stress, right? Even though
41:10
it's, there's a lot of stress going on, you can
41:12
walk away from those things and feel like. you
41:16
know, everyone's doing what they can to help
41:18
with the kid. When I get home, you know, I think
41:22
it gives perspective for my own kids that they're
41:26
healthy and, you know, that it gives, you know,
41:29
it's like super grateful to say like, my gosh,
41:32
like here, you know, it's my pain in the butt
41:35
kid who's, you know, not listening or whatever.
41:37
It gives me a little bit more grace, I think.
41:40
But I think having interests outside of medicine
41:43
isn't really important for me personally. Like
41:45
playing music is like a big part of who I am
41:49
and what I do. And, you know, that's, I think,
41:55
something that I've been lucky to have an opportunity
41:58
to do over the last several decades of my life.
42:03
My brother plays bass in the same band, so having
42:05
that connection is really cool to have. connection
42:09
with him and just having something outside of
42:13
what we do. It's great. And I will put this in
42:17
the show notes as well, but I would love for
42:19
you to go ahead and name check your band. Oh,
42:22
yeah. And talk a little bit about it. Sure. So
42:24
I play in a band called Moonshine Drive. It's
42:26
a Cincinnati -based bluegrass band. We've been,
42:29
gosh, we've been playing for probably 15 years
42:33
now. But we play at bars and festivals around
42:36
Cincinnati. We play a lot at Arnold's and other
42:40
kind of city fests around. So you can check us
42:43
out on moonshinedrive .com or Spotify, Amazon
42:47
Music, YouTube, whatever it is. But we have a
42:50
lot of fun. And yeah, it's really cool to be
42:56
able to just totally escape and play music and
43:00
have a totally different part of my life that
43:04
I can think about. What about you? uh for stress
43:08
management what are what are your thoughts yeah
43:10
i mean i think before we started recording so
43:13
i i have a second phone as well and i keep my
43:16
work stuff on my that second phone so that's
43:18
one thing is sort of trying to compartmentalize
43:22
work and life and so when i cross the threshold
43:24
of my house it's just my life now it's not it's
43:27
hopefully not work and then you know i love to
43:32
be out in the garden And I love to take care
43:35
of and even just pulling weeds. Sometimes just
43:37
being out in the front yard, pulling weeds where
43:39
it's like, I can't mess this up. It's just pulling
43:41
weeds. You know, I can only make it better. Or
43:44
cooking. Like, I can't mess. Like, you can mess
43:47
up cooking. I messed up both of these. Sometimes
43:51
you leave the whole root in there. It's. But,
43:54
you know, at least it looks better right on the
43:56
surface. So. Just anything. I mean, you know,
44:01
I like to listen to music on the way home. I
44:03
sit in traffic on the main interstate here in
44:06
Cincinnati for 45 minutes every day. And I just
44:08
turn off my brain, listen to music and try to
44:12
just be Joe when I walk through the door and
44:15
not the anesthesia attending. And I think doing
44:18
that, fortunately, anesthesia is a field where
44:21
you can mostly leave things at work. Right. Most
44:24
of the clinical burden you can leave at work.
44:27
But. We're kind of fortunate in that regard,
44:29
but I did choose a career where I felt like it
44:31
was easier to do that versus primary care physicians
44:35
are on the hook constantly for messaging and
44:39
with patients and parents. And we're fortunate
44:42
enough to not always have to deal with that stuff.
44:44
And that's very helpful for me too. One of the
44:49
things that I think is great about Cincy Children's
44:52
is the pediatric fellowship program. We send
44:57
a lot of our residents to do fellowship with
45:00
you guys, and they always end up being amazing.
45:06
Even previous guest of the podcast, Yusuf Razlan,
45:09
now over at Cynthia Children's. My question is,
45:13
I wonder if you guys could talk a little bit
45:15
about the fellowship that you guys have over
45:18
there, how many fellows you take every year,
45:22
because it's quite a big program. and maybe just
45:27
a little bit of information about it. Yeah, so
45:31
we have 12 fellowship spots. Which is enormous.
45:36
It is large. My residency class, I think, was
45:39
14 or 15, so it's almost as big as an entire
45:42
residency class. I think we have room to accommodate
45:46
more, but just historically, traditionally, we've
45:48
kept it at 12, which seems to be a nice, large
45:51
size for the fellowship program. it's a one -year
45:54
fellowship just like the rest of the fellowships
45:57
there are opportunities for advanced fellowships
46:01
in chronic pain and cardiac as well as some non
46:05
-accredited fellowships that we offer and so
46:08
folks who want to do pete's cardiac spend that
46:10
extra year as super fellows as we call them but
46:15
it's a great experience and i think It's a unique
46:19
experience because in anesthesia residency, you're
46:21
off service sometimes. You're in the emergency
46:23
department. You're on OB. You're in the ICU.
46:25
With a pediatric anesthesia residency, you're
46:28
doing OR anesthesia every day, which I really
46:30
enjoyed. I always really enjoyed OR anesthesia.
46:33
And so it was just a good experience. Mark and
46:36
I both did the fellowship, obviously, different
46:38
times. But it's just good to do. OR anesthesia
46:43
every day and take care of kids. I think it's
46:46
one of the best experiences from a fellowship
46:48
standpoint. We're very clinical focused and there
46:51
are certainly opportunities to do research or
46:55
academic things while you're a fellow, but it's
46:57
a busy year and you're really there to get that
47:00
clinical experience and repetition. Yeah, I'll
47:05
echo that and also say that when you rotate with
47:09
us, Even if you're not interested in pursuing
47:12
a fellowship in pediatric anesthesia, I think
47:16
that we will make you a better anesthesiologist
47:20
because of the attention to detail. Some of the
47:23
things we talked about before, how you make decisions
47:25
in the operating room, how you plan, I think
47:28
they're all skills that really being in focus
47:32
and in touch with the patient is really important.
47:35
But, yeah, our fellowship is super strong. We
47:38
have Jeremy Deers, the program or the fellowship
47:42
director now, and does a great job advocating
47:45
for the fellows. And, you know, the experience
47:48
that we're able to give them is is top notch.
47:52
It's a very clinically focused year, and I feel
47:55
strongly that that's very important. You know,
47:58
you're not going to spend a lot of time in a
47:59
lab or doing research projects. You're going
48:02
to be in the operating room taking care of sick
48:03
kids. And that's really what you want out of
48:05
it. I wonder if either of you would be willing
48:11
to tell me about a case that you found particularly
48:14
challenging or memorable that you would kind
48:17
of use as a case that you would tell a medical
48:21
student or resident about to potentially make
48:24
them more interested in pediatric anesthesia.
48:27
Or perhaps let them gauge for themselves whether
48:30
or not they'd be interested in pediatric anesthesia.
48:37
Gosh, taking care of thousands of kids over the
48:41
years. It's crazy to think about that. I mean,
48:43
I think the ones that are most memorable to me
48:46
are the ones where I have a personal connection
48:48
with the kid or the family. And oftentimes that
48:53
comes. from from knowing them over time. Right.
48:57
So I've, you know, taken care of little two year
49:00
olds with a battle blastoma and, you know, just
49:04
getting to know the families. I do a lot of anesthesia
49:08
up in our CBDI clinic. And so what what kind
49:12
of I'm sorry, CBDI is Cancer Blood Disease Institute.
49:15
So it's like the oncology clinic. So I take care
49:20
of a lot of kids who have new diagnosis of cancer
49:23
in our oncology suite and seeing families come
49:29
in with a new diagnosis of, you know, leukemia
49:32
or hepatoblastoma and just seeing how they process
49:36
that and then establishing a connection with
49:39
them, you know, assuring that I'm going to take
49:42
good care of their kid. And then, you know, having
49:45
that relationship over time and then seeing them
49:47
come back. for repeated procedures and how they
49:51
become sort of adjusted to their new normal is
49:54
really kind of powerful. I will also say that
49:58
when we take care of kids in the operating room
50:01
that have really, you know, bad malignancies
50:03
and things like that, you just feel like you
50:06
can really rally behind them. And so I've, you
50:10
know, taken care of kids, like I said before,
50:12
with hepatoblastoma. And, you know, it's like.
50:16
either for liver transplantation or liver resection
50:19
and just seeing how you know like all of the
50:22
things you want out of anesthesia you're there
50:24
you're putting big lines in you're doing an epidural
50:27
you're doing resuscitation and then setting them
50:32
up for success for pain control afterwards and
50:35
so those are the types of cases that I think
50:37
are most gratifying and then on top of that getting
50:39
to see them three months from now, six months
50:42
from now and saying like, oh my gosh, like this
50:44
kid is doing really well. They recovered from
50:47
the surgery. Their cancer is under control now.
50:50
And just having that kind of long, short term
50:52
kind of immediate feedback of like a really cool
50:56
case. And then also the long term, you know,
50:58
relationship that you can have with patients.
51:03
Yeah, I think the ones that stick out to me are
51:07
our patients who are in the NICU. who have congenital
51:12
diaphragmatic hernias. And usually these moms
51:16
give birth at our fetal care center, especially
51:20
if it's a known CDH that's known to be severe
51:22
that might end up going on to ECMO shortly after
51:25
birth. So usually the moms are in -house, but
51:29
they're often bedside. But there's a lot of uncertainty
51:32
with those cases, which I think can make some
51:35
people feel very uncomfortable. you know, very
51:40
tearful, especially if it's a severe lesion.
51:44
But I always just tell the parents that I'll
51:47
watch your baby closely and I'll keep them comfortable
51:50
and keep them as safe as I possibly can during
51:52
the surgery. And sometimes that's kind of all
51:55
you can offer. You don't know what's going to
51:58
happen. Even if they repair the lesion, you don't
52:01
know if the kid's going to get much better. But
52:04
those moments where you're offering some sort
52:07
of comfort any comfort that you can to the parent
52:10
because that's kind of all they've got at that
52:13
point those always stick out to me and that's
52:15
something i would tell you know i think that
52:17
could make some people run the other direction
52:19
like i those those that's hard for me or that's
52:22
an uncomfortable moment i don't want to be involved
52:24
with that but if that is something that interests
52:27
you and then learning how to take care of those
52:29
you know neonates we're very sick that's someone
52:33
who should probably consider doing a fellowship.
52:37
I really liked hearing you say that you talk
52:42
to parents about keeping their kids safe and
52:46
comfortable, because that's something that I
52:48
actually say every day to my patients. My two
52:52
jobs, number one is keeping you safe. Number
52:54
two is keeping you comfortable. And everything
52:56
I do is one of those two things. And I found
52:59
that a lot of people that I've talked to, independently
53:04
also seemingly have that mantra about keeping
53:07
people safe and comfortable. Although I don't
53:10
think that that's necessarily taught specifically.
53:14
I think that a lot of us just sort of come to
53:18
that ideal of that's really what we do, which
53:22
I think is, it's really neat to hear other people
53:25
say it as well. Yeah, and I guess, I don't know,
53:29
maybe I've heard other people say that too. But
53:32
I agree with you. I've never been taught that
53:34
or told that. But I think when you boil down
53:37
the specialty, it is those two things, right?
53:39
And things that are frustrating to people like
53:42
NPO times and why do I have to not eat before
53:45
surgery? I think when you boil it down to those
53:48
things, we want to keep you safe. We want to
53:50
keep you comfortable. Everybody understands that.
53:52
And it makes people feel, you know, more comfortable
53:56
going back to surgery. And sometimes... safe
54:01
and comfortable is all you really have to offer
54:02
you don't know what's going to happen with a
54:04
prognosis or with you know the development of
54:07
the disease after the fact and you say i'll keep
54:09
you safe and i'll keep you comfortable and i
54:11
feel like it's it at least gives people some
54:14
comfort in a time that maybe is very stressful
54:17
for them we mentioned stuffed animals earlier
54:21
and all the different toys and such that people
54:26
will bring back to the or the kids will bring
54:28
back to the or although sometimes we do see adults
54:31
with stuffed animals over here sure sure but
54:34
uh have wanted to bring them back to the or before
54:37
which i think is interesting um my question though
54:42
is what i seem to remember from one of my rotations
54:46
is for a kid with a broken leg we would take
54:51
their bear back with them to the or and we would
54:55
wrap the leg and similar dressings um that we
54:59
would the child and so i'm wondering do you guys
55:02
do anything like that is there anything like
55:04
that over at sensi children's i mean i think
55:08
that that is something that is done yeah that
55:11
i've seen before we i'm personally not putting
55:14
the wrapper around the child the stuffed animal
55:17
but i think it does sort of speak to um We're
55:21
very patient and family -centered, and we really
55:24
try our best to make kids feel okay about what's
55:28
going on to them. I remember when I was a kid,
55:32
I broke my arm, and I have a very vivid memory
55:36
of going back to the procedure room with two
55:40
orthopedic residents. put my hand in some sort
55:44
of contraption and set my arm with no anesthesia.
55:47
And I don't I also don't remember getting to
55:49
fill out a patient satisfaction survey back in
55:52
those days. But like, I don't know, I think that,
55:56
you know, at the end of the day, we're keeping
55:59
kids, you know, doing what we need to for them
56:02
medically. But it's we go a little bit above
56:04
that and try to make their experience as positive
56:07
as possible with recognizing that you can't get
56:09
rid of all sort of, you know. or agitating or
56:14
anxious provoking things, but we make an effort.
56:19
Yeah, the nurses and the patient care assistants
56:22
are really good about that. I've seen them, you
56:24
know, if a kid's getting a dialysis line, they'll
56:27
put something that looks a little bit like the
56:29
dialysis line on their teddy bear and put a dressing
56:31
over it and put the lure locks on the end of
56:33
the, just so that, you know, that stuffy, I mean,
56:38
my kid's stuffy. look like they've been dragged
56:40
through the desert for six years. They're so
56:42
dirty. But that's like their thing, right? That's
56:44
what they always want with them. And if their
56:46
thing has gone through the same thing they have,
56:48
I think it does help kids. And if it helps them
56:51
process things, why not? But yeah, it's usually
56:53
not me applying the bandages. But at the end
56:56
of the case, usually the teddy bear's got a little
56:58
bouffant on and a gown and some dressings. Everyone
57:02
is just taking care of the kid as best they can.
57:05
Does a tablet count as a stuffy? these games
57:09
probably should yeah yeah you're probably actually
57:12
our job is way easier now with tablets what's
57:15
your favorite um game for kids to play do you
57:18
have one joe i feel like fruit ninja is a good
57:21
one old but it's good because they just you know
57:24
there's also the one where they're like running
57:26
on the road or the subway or whatever and they're
57:29
jumping that one's usually good yeah the other
57:31
day a kid was playing mario run like the mario
57:34
jumping game and i Took it from him and ended
57:36
up playing it while the resident or whoever put
57:39
the kid to sleep. And they're like, is that for
57:40
you? Or is that for the kid? That's a little
57:43
both. I want to see if I can get Fruit Ninja
57:45
to sponsor the podcast. Oh, gosh. Yeah. No, it's
57:49
super effective because it gives the kids something
57:50
to do, right? Like if they're engaged. Every
57:53
once in a while, I'll pull out the driving the
57:57
car game. And so I'll have that. We have these
57:59
like pink foam pillows that, you know, I'll give
58:03
the kid as a steering wheel. And then I'll take
58:06
the lock off the bed and tell them the story
58:09
about getting into a car. So their hands are
58:11
on the pillow. Right. And that's a really important
58:13
of the kids holding on to something else. They're
58:17
less likely to pull the mask away. And then,
58:19
you know, you got to go through the whole spiel.
58:22
There's the exhaust, et cetera, et cetera. But
58:24
then you can actually move the bed and shake
58:25
it around. It's a lot of fun. These are really
58:29
great style points to share. I wonder if you
58:31
guys have any other. style points that you want
58:34
to share about whether it's talking to parents
58:37
or taking care of the kids that have brought
58:40
you success in and out of the operating room
58:43
yeah i mean just to be clear if i have a resident
58:46
come over and start doing the car game i'm going
58:48
to be would be irritated that they stole my thunder
58:51
but no i think like i said before i think you
58:55
have to meet the kid where they are you have
58:58
to think about their developmental stage For
59:03
school -age kids, asking them if they want to
59:08
do something is not appropriate, especially if
59:10
you know that they're going to have to do what
59:12
you want them to do. Being honest with kids is
59:15
really important, I think. Trying to sugarcoat
59:19
things too much sometimes is a problem. Kids
59:22
are a lot smarter than we think they are. I find
59:26
that the age, you know, the eight to 12 year
59:29
age is really interesting to me because those
59:32
kids know way more than you think that they do.
59:35
And they think about a lot of things. And so
59:38
I always ask kids, you know, I care a lot about
59:42
what your parents are asking, but I like literally
59:44
talk to the kid and say, what do you want to
59:46
know more about? Do you have a question? And
59:49
like, is there something you're nervous about?
59:51
And I tell them, if you are, you know, ask somebody
59:56
we can talk about it and i think that's really
59:58
important for kids of that age to feel like they
1:00:01
have some agency in it and you'd be surprised
1:00:05
i mean i had a kid once who had youtube videos
1:00:09
of tonsillectomies and he was like super interested
1:00:12
and it was really helpful for him to understand
1:00:15
like what are they actually doing i mean not
1:00:17
something i would advise my own kid looking at
1:00:21
before surgery but They know a lot, and I think
1:00:25
it's important not to gloss over that. You should
1:00:28
make sure and tell them that they can put that
1:00:30
on their ARIS application. Oh, for sure. I'm
1:00:34
familiar with all the steps of a tonsillectomy.
1:00:39
No, it's true what Mark said, and I had a kid
1:00:42
who was pretty young within the past six months
1:00:46
or so. he was most worried about waking up during
1:00:49
anesthesia, which in the adult world is very
1:00:51
common, right? Awareness under anesthesia. But
1:00:53
I would have never thought that would have been
1:00:55
what he was most worried about, but he was, that's
1:00:58
all he cared about. I'm not going to wake up,
1:01:00
right? You're not going to wake up. And then
1:01:01
he was like, okay, I'm fine. And so sometimes
1:01:04
it's things you don't expect that they're like
1:01:06
ruminating on. And I know my kids do that too
1:01:08
with weird, you're like, what are you thinking
1:01:10
about? And then they tell you and you're like,
1:01:11
huh, well, we're eating dinner right now. So
1:01:13
why are you thinking about that? You know? And
1:01:16
right. kids kids definitely surprise you and
1:01:18
I think Mark's right engaging the temptation
1:01:20
I think is just to engage the parents but always
1:01:23
like getting down on the level of the kid and
1:01:26
sometimes it's literally like if it's a little
1:01:28
guy or a little girl get squatting down and saying
1:01:31
who's this who'd you bring with you and just
1:01:33
talking to them and seeing how they interact
1:01:34
with you and that tells you about 90 percent
1:01:37
of what you need to know about how this kid's
1:01:39
gonna you know sort of act when you're doing
1:01:41
the induction but that's it's hard to teach but
1:01:44
I always try to remind any trainee that comes
1:01:47
over is it's sort of a gestalt thing and you'll
1:01:50
get used to it but just talk to the kid talk
1:01:53
to the parent you'll start to get those pick
1:01:54
up on those cues one of the things that i want
1:01:58
to mention based on what you said is that While
1:02:02
having a fear of waking up under anesthesia is
1:02:06
extremely common. Yes. It is not common. I heard
1:02:10
that. We want to make sure as anesthesiologists
1:02:14
that we appropriately tell everybody that waking
1:02:17
up under anesthesia is not a thing that you should
1:02:20
be concerned about any more than a piano falling
1:02:24
on your head. Correct. That's a great point.
1:02:26
I didn't think of how I worded that. Sorry, listeners.
1:02:31
No, I think that what Joe said, too, about getting
1:02:34
down to the level of the patient is super important.
1:02:37
And we have to establish this rapport with kids
1:02:41
and families so quickly. And this is not specific
1:02:45
to pediatric anesthesia, but in general, anesthesiologists
1:02:48
have to establish that rapport very quickly.
1:02:52
And so strategies, I think, are, you know. bringing
1:02:55
yourself to the level like I always sit down
1:02:58
next to the kid when I talk to the family I'm
1:03:00
always sitting at the level of the kid and I
1:03:03
think that's really important just to like position
1:03:06
yourself in that way it's less intimidating I
1:03:10
think and small talk is fine but you know just
1:03:15
like being honest with kids I think is really
1:03:17
important I think that the hardest Times for
1:03:21
me is when parents are asking you to not tell
1:03:24
their children things. Those are really difficult
1:03:26
situations to navigate. And at the end of the
1:03:28
day, you kind of have to follow their lead. But
1:03:31
I always worry about that. Like if the parents
1:03:34
are asking you to withhold information from their
1:03:36
child, that can be difficult to sort out. Well,
1:03:42
Mark, Joe, I really enjoyed talking to you. And
1:03:45
thank you so much for coming by. This was a great
1:03:47
conversation. yeah thank you never done anything
1:03:50
like this but it was fun yeah thanks john thanks
1:03:55
for listening to another episode of style points
1:03:57
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