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30,000 Feet in the Air with Jesse Pickard-Gabriel · Style Points

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Hello and welcome to another episode and the start of year two of Style Points.
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I'm your host, John Crow.
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Today we'll be joined by Air Force Critical Care anesthesiologist, Jesse Picard-Gabriel.
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Before that, I'll turn it over to Nate Moore, who will introduce this month's guest for
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our RSI, which of course stands for Resident Selected Information.
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Thank you, John.
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Our RSI today is provided by Dr. A.J. Pagan, one of our CA1 anesthesia residents, and I
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hope you're hungry for knowledge because he's going to be teaching us about GLP-1 receptor
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agonists and their perioperative management.
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Welcome to the show, A.J.
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What do drugs like semaglutide, dulaglutide, ozempic, and WIGOVI all have in common?
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If you thought that they're all GLP-1 agonists, that's right, but if you also thought they
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are a group of drugs that you are not sure how long to instruct your patients to hold
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them, that's also right.
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Luckily, this month of December, the American Society of Anesthesiologists released a new
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multi-society clinical practice guideline statement that we're going to go over today
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about the recommendations in the perioperative period.
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First, glucagon-like peptide 1 receptor agonists, the GLP-1s, are a class of medications that
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were initially introduced for the treatment of type 2 diabetes.
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They were more recently approved by the FDA back in 2021 for weight loss in patients who
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are overweight or obese by BMI with at least one comorbid condition.
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Glucagon-like peptide is an endogenous hormone that is produced and secreted by intestinal
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cells in the brainstem after we eat.
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It works by enhancing the body's natural release of insulin, but also has functions
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such as inhibiting the release of glucagon from the pancreas, slowing the rate of food
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absorption, and of course delaying gastric emptying, the buzzword when we're pre-opping
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a patient.
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All of these, in conjunction, reduce your food intake and lead to subsequent weight
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loss.
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The clinical implications and side effects of these medications have been a topic of
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debate when discussing the perioperative management.
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Common side effects include nausea, vomiting, and delayed gastric emptying, all of which
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put our patients at increased risk for gastric aspiration when considering your anesthetic
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plan.
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The ASA, in combination with the American Gastroenterological Association, American
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Society of Metabolic and Bariatric Surgery, International Society of Perioperative Care
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for Patients with Obesity, and Society of American Gastrointestinal and Endoscopic Surgeons
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have developed a consensus statement that was recently released in anesthesiology this
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December of 2024.
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The recommendations focus on shared decision-making between the patient, the surgeon or proceduralist,
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and the anesthesiologist.
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It is important to note that these are just recommendations derived from consensus opinion
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and not necessarily from rigorous clinical trial evidence, as these agents are relatively
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new.
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The consensus statement itself notes that these should be interpreted as guidance and
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not evidence-based guidelines, as the statement itself may change as more evidence is gathered.
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With that disclaimer out of the way, let's talk about the two major recommendations in
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the guidance.
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So, the first was to assess the pre-procedural risk for aspiration.
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This is as you would do for any patient prior to any anesthetic.
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Recommendations that would increase the risk of aspiration according to the statement include
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being on the escalation phase of dosing of the GLP-1.
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This is if you're increasing the dosing weekly or the daily formulation, using a higher dose
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of a GLP-1, using a long-acting GLP-1 such as the weekly formulations such as Ozempic
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and Wigovie and Truelicity, or the presence of GI symptoms or delayed gastric emptying
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in the setting of nausea, vomiting, or abdominal discomfort.
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Lastly, it mentions conditions beyond GLP-1 usage that can induce delayed gastric emptying
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such as uncontrolled diabetes, gastroparesis, pancreatitis, IBS, and then types of bariatric
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surgery.
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The second recommendation was if none of these risk factors exist in your patient, the GLP-1
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may be continued perioperatively.
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If your patient has any of these risk factors, they recommend a liquid diet for at least
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24 hours pre-procedurally.
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This is what you would tell your patients prior to like a colonoscopy or bariatric surgery
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prep.
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This is to reduce the retained gastric contents inside the stomach.
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In this scenario, the GLP-1 agent may either be held or continued, and the guidance recommends
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weighing the medical risks of holding therapy and hyperglycemia against the risk of aspiration
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when making this decision.
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If the decision is made to hold the GLP-1, the duration of holding should follow the
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original ASA statement and guidance.
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So if your patient is on a daily formulation to hold the day prior, or if they're on a
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weekly formulation to hold the week prior.
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To summarize, the perioperative assessment phase before we move into the day of procedure,
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step one of their statement says to assess your patient for signs and symptoms of delayed
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gastric emptying and conditions associated with it.
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If none of these exist, you can continue the medication perioperatively.
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If mild symptoms exist, they recommend a pure liquid diet for 24 hours similar to a
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colonoscopy or a bariatric surgery prep, and it may be okay to continue the medication.
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If severe GI symptoms or in the shared decision-making model, the decision is made to hold the medication,
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hold daily formulations the day prior to your procedure, or if a weekly formulation, to
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hold the week prior.
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Now moving on to the day of surgery.
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If the GLP-1 was continued, evaluate your patient for signs and symptoms again of delayed
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gastric emptying.
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If no symptoms exist, proceed with the procedure as planned as if there were no concern for
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delayed gastric emptying.
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When considering induction, RSI versus normal induction would be very provider and practice
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dependent in this scenario.
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If there are symptoms or a determination of elevated risk of delayed gastric emptying,
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you could consider a point-of-care gastric ultrasound.
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That being said, these can be technically and logistically difficult for these patients
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to further assess the stomach contents.
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They also mentioned this is a scenario where you can consider rapid sequence induction.
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And lastly, to engage the patient into the shared decision-making and to weigh the benefits
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and risks with proceeding with precautions such as a rapid sequence induction against
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the risks of procedural cancellation.
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And lastly, note that these are all the recommendations for anyone taking a GLP-1 regardless of its
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indication.
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Now you have the knowledge you need to manage GLP-1 agents effectively and aspire to no
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aspiration inductions.
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Jesse Picard-Gabriel is a Lieutenant Colonel in the Air Force and a critical care anesthesiologist
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that works with me here at the University of Cincinnati Medical Center.
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Dr. Picard has been on active duty for the past 20 years, including deployments to Afghanistan,
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Djibouti and Niger, as well as numerous other operations around the world.
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In his current role here at UC, he's an instructor for the Critical Care Aeromedical Transport
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Team course or CCAT and one of the intensivists that works in a variety of critical care settings
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here at the University of Cincinnati.
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Jesse, thanks for joining us.
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Welcome.
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We should start off.
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I'm happy to be here.
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This is the first time I've done this, so forgive me if I'm nervous or if my answers
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aren't all coherent.
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You know, you don't really strike me as a nervous guy.
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That's good.
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That's good.
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That means I'm hiding it well.
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Excellent.
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And that's something that we all get really good at in anesthesia is hiding how nervous
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we are in a variety of situations.
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So obviously you heard a little bit about my intro.
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I've done a decent amount of traveling.
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I still get nervous when I take a weekend road trip 150 miles away before I leave the
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house like I have butterflies in my stomach.
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What am I forgetting?
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What's going to happen?
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What could occur on this trip?
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What have I not planned for?
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I've got three little kids with me.
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Like it doesn't keep me from going anywhere, but I still run through it.
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It's still in the OR, still in the ICU.
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Every time I'm about to stick a patient, it's like, how could this central line go wrong?
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You know, as somebody with three kids myself who experiences similar anxieties, that really
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hits home for me.
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I wonder if you could talk about that feeling a little bit more.
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Wow.
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This is not a direction I anticipated this interview going right out of the gate.
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So I guess that's fun.
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I always like to be challenged and have new experiences.
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So thank you for that and putting me on my heels.
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So that's always good too.
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I think that much of what we do, much of what I've done in the military, much of what we
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do as physicians requires a tremendous sense of skepticism.
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And we're always planning for the worst and trying to come up with a plan to avoid it.
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I think sometimes when working with residents, they aren't scared enough.
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As they start to go through training, they've done it right a few times, things are going
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well.
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And they lose sense of that fear that junior residents have.
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And they forget how quickly this can turn sideways.
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And so they don't always have a good backup plan.
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And then one of my jobs and your job as the senior physician is to make sure that we always
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have our own backup plan, but also figure out how to educate them to be appropriately
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scared.
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So be confident, move forward, but have two or three backup plans.
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In the military, we call it a pace plan, primary, alternate, contingency, and emergency plan.
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So what was your backup plan for this podcast?
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Delay, delay, put it off till tomorrow.
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But you got me.
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So this is good.
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I wouldn't want it to be all scripted.
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So I don't want to live life in a scripted way.
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So hopefully, this will be fun for people to listen to.
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And you and I don't know where this interview is going.
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So hopefully, it'll be interesting to them too.
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I'll get you back a little bit on track here.
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So I'm going to ask you a question that you have already thought about, which is, if you
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had the opportunity to have dinner with anyone, it could be somebody live or dead from past
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or from fiction.
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Who would you have dinner with and why?
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So I listened to an earlier podcast and Dr. Layman stole my favorite, which is Ben Franklin.
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I think he's a super interesting dude.
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Dr. Layman glanced over the fact that the guy had a very interesting social history.
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Anybody who's interested, look at the time that Ben Franklin spent in France.
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Lots of fun was had by him and those around him.
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Another person that I would love to meet would be Teddy Roosevelt.
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I think he had a very interesting career.
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The guy got shot and finished his speech, rode up the hill in San Juan, was a fairly
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successful president, but also made some big mistakes.
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Left on maybe not ideal terms, tried to come back, didn't know how to let go.
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There's so many interesting parts of his career that I would just love to chat with him about.
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If he was willing to actually have a vulnerable conversation.
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So it's funny, I think about some of these people I'd love to talk to.
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And honestly, one of the things that comes up in my head is I'd love to have a vulnerable
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conversation with people about what was really in their head.
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What was President Obama really thinking when he got the top secret report on the winnability
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of the war in Afghanistan in the mid teens?
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I'd love to know what he thought, not what was published and not the answer he would
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give it a cocktail party.
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Yeah, not the sanitized version.
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Right.
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Like, what was, how did you sleep with that?
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How did you make the decision to move forward?
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I went to Afghanistan the first time in 2010 and I went again in 2019 to fight the same
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war that we've been fighting for nearly 20 years by the time I went the second time.
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And so I'm curious about why I was there and what I accomplished and what other than the
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small picture things that I did, I knew I was there to help people, which is one of
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the privileges of being a military physician.
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Wherever you go, your job is to heal.
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But as an American, I'm curious why I was there.
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That's really interesting.
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Let's go back to the beginning of what motivated you to do everything here, your whole career
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pathway.
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What inspired you to become a military physician?
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What are some of the choices you made along the way?
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So I kind of always thought I wanted to be a doctor, always working in that direction
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from kind of middle school.
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I thought it was very interesting, human body and the brain.
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Congratulations.
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Right.
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Didn't know I was going to land in anesthesia.
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No idea about that.
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But had sort of a crisis of conscience in college.
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A lot of the pre meds that I was sort of classmates with or met through sort of some of the test
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prep and things like that were very focused on getting into med school.
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That was the only thing they cared about to the exclusion of the entire rest of their
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lives and the world.
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And I wasn't sure that I had that degree of commitment.
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And I was almost in some ways uncomfortable with the competitiveness.
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It seemed kind of cutthroat at times, and I ended up taking a year off, worked as a
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firefighter, waited tables, like enjoyed my life.
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And then I realized, OK, you need a real job.
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Let's go back to med school.
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Let's do this.
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And I went to the uniformed services university applied there.
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And they were they answered a lot of the questions that I had.
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We were teammates at USU.
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There was no competition amongst us.
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If you felt like you had a good understanding of a current topic or a course, you wrote
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course notes and they got disseminated to the whole class.
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Everybody was on board with everybody else.
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We got notes from last year's class.
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People passed things around among each other.
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If somebody was struggling, like somebody who was performing well in the class sort
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of automatically paired up with them to help them.
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You knew that once you graduated, you might be an ER doc, but that OB-GYN was going to
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be delivering your wife's baby at, you know, Eglin Air Force Base in five years.
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Right.
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Like you, you know, you wanted everyone to pass and learn and do well because we were
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in this together.
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That makes sense.
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I've always been sort of an advocate, maybe subconsciously of the team mentality myself.
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I remember when I was doing medical school interviews, I went to a medical school, which
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shall remain unnamed, and they mentioned, oh yeah, you have to watch out because sometimes
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people will hide the books in the library after they find out that a particular book
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is, you know, something that the professor is going to recommend.
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That book will get hidden.
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So you have to go to the library quickly and get it.
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And that was an immediate and permanent turnoff for me for the culture of that institution.
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And I no longer was interested in going there.
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Absolutely.
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Absolutely.
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And I was fortunate.
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USU answered a lot of those questions and I did okay and I had a good time and it helped
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me get to where I needed to be in medicine.
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So how does that intersect with joining a branch of the military?
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Can you tell me how that all works?
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So you apply to USU as a medical school first.
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You have to meet certain, you know, fit to serve standards, which are just, it's a basic
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physical exam.
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You can't have any major medical problems because you have to be worldwide deployable
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when it's over.
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And USU stands for?
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Sorry, Uniformed Services University.
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Excellent.
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Okay.
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Very creative name that the government has given to its active duty medical school.
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So we're about a third army, a third Navy and a third Air Force.
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About half of us were prior service and half had no prior service.
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You had to get into the medical school on its own merits and then you could pick which
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service you wanted to be in.
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Air Force filled up first and then Army and Navy.
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But I was fortunate I have a family history of a lot of people that were in the Air Force
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and so I kind of gravitated to that pretty naturally.
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That's not normally the way that we use the words family history, but I'll take it in
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this context.
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I also have a family history of the Air Force with my dad.
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Awesome.
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Awesome.
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None of my immediate family were in the military.
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It was all kind of grandparents, aunts, uncles, cousins.
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What did your dad do for the Air Force?
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He was a lawyer in the Air Force.
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So he did sort of the JAG stuff, that kind of thing.
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Awesome.
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The docs and the lawyers tend to interact a little bit more often than some of the other
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folks.
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Not in a negative way, just as advisors to the commander.
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So you have line officers that are in charge of sort of directing planes and bombs and
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soldiers and then you have sort of the people that advise them on the side.
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Doctors and lawyers are kind of advisors.
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That makes a lot of sense.
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Okay.
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So what was next in your career pathway?
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So I did a surgical internship at Wright-Patt and then I went and did a five-year general
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medical officer tour as a flight doc for Air Force Special Operations Command.
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So I was assigned to a flying squadron, the U, sorry, the U model, the AC-130.
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So it is the gunship.
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So any of you guys that play video games where there's a gunship overhead and you can call
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in air strikes, I was the flight doc for that airplane.
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So I was responsible for the medical care of everybody in that squadron.
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So about 400 folks.
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I was their primary care doctor and I did all of their aeromedical physical exams.
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And then I deployed with them or with other special operations units to provide basic
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medical care and trauma medical care.
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Obviously, I was at a base.
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If things got complicated, we could always refer them to other sort of medical.
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But my job was to be embedded in the squadron and to be comfortable with having them come
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to me.
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Flyers are on a very strict physical profile.
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So there's a lot of things they're not allowed to do.
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There's heavy restrictions on any medications and medical problems can severely impact their
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career and so they're notorious for hiding all kinds of things.
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So one of my jobs is to get in close and make sure that I'm someone they can trust so they
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know that if it's real and if I can see that it's real, that we do need to pause and talk
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about it and that they don't need to be scared to talk about other things.
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They can come to you and say, I'm having this problem.
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Is this a big deal?
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And you can say, no, you're fine.
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Don't worry about it.
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I'll work the paperwork.
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You can keep flying or this does matter.
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It's okay.
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We need to have a pause and we need to address this.
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That way it's safe for you and it's safe for everybody else and it's safe for your family.
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So it's kind of like a Gattaca scenario almost.
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Little bit.
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Yep.
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Yep.
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Little bit.
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So held to very high standards.
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Obviously you need to be when you're flying a military aircraft, but you're the guy who
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is supposed to engender their trust such that they can tell you if they're having that problem.
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That seems like a big deal.
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Or you can see it.
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I flew combat missions downrange with these guys.
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I flew with them at home.
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It was a wonderful opportunity to just sort of make friends and hang out.
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And then if somebody's partner or wife cut their hand cooking dinner on a Saturday, I
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got a phone call.
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I went over and threw a few stitches in somebody.
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They didn't have to go to the ED.
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Obviously if it was something serious we would go to the ER, but it was concierge medicine
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if you will for pilots and crews and their families.
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And then it got a little bit less concierge in Afghanistan and Africa where I lived in
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a tent.
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But conceptually it was the same.
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Before we get to living in a tent in Afghanistan, I wanted to ask you how can you tell if a
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pilot is a little bit off of their game?
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Obviously if they crash the plane that you're on, that's probably an indication that they
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shouldn't fly anymore.
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But what are some more of the subtle signs that you might be picking up on?
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So I think that there's a lot.
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You can look.
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I was with a heavily deployed squadron that had a lot of combat stress at the time that
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I was there.
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And so people would at times make bad decisions in their personal lives.
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Taking behaviors, things like that.
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I was surprised how many people just came to me with normal stuff like, hey, I'm thinking
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about trying to have a kid with my wife.
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What does that look like?
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Or like, we tried to have a kid and pregnancy was hard and so this is a stressor.
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And I'm like, hey, there are people that can help with this.
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Most of the time they were pretty well balanced.
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They're very high performing, very healthy folks from a screening perspective already.
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And I think just being there to connect them with more resources to say, hey, this is heavy.
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Let's get you an appointment for, here's how you could get some mental health counseling
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if you wanted it.
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Sure.
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That makes sense.
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I imagine, and I've seen both of the Top Gun movies, the old one and the new one, I assume
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that those are 100% accurate.
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I will tell you that it's crazy flying in those jets.
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It's intense.
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Tell me more about that.
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I have had one opportunity to fly in a high performance aircraft.
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It was a T-38 trainer jet.
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It is the last jet you fly in before you fly in an F-15 or an F-16.
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And some countries actually use them as their frontline fighter jets.
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It was so much fun.
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We were in the air for an hour and it was exhausting.
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An hour is almost a full day's work in those aircraft.
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So you're just pulling Gs and it's summer in Texas.
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You're sweating to death.
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You lose three liters of water over a one hour flight.
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You're dehydrated.
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I got to fly with two other dock buddies.
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We each had an instructor in front of us, an instructor behind us, and we were in the
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seats.
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And I just chased a buddy around the sky in a fighter jet for an hour.
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It was one of the most remarkable experiences of my life.
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How did you make that happen?
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So I was at a flight surgeon training school and they said, okay, you need some experienced
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flying jets if you're going to work with pilots and know how to talk to them.
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That sounds incredible.
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It was amazing.
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And then the next week they put me in an aerobatics biplane with a stunt pilot.
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And we flew like loop deluge and Cuban eights and all these kinds of weird.
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They literally put a parachute on me.
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The pilot said, listen, dude, there's one door and I'm a big guy.
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You've got about three seconds to get out of the plane when I say bail out.
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Otherwise I am going to knock this seat flat and I'm going out the door.
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So just to be clear upfront, I was like, what is going on in my life right now?
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So I can imagine a loop do it.
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That makes sense to me.
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What did you say?
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A Cuban eight?
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It's like a figure eight in the sky.
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It's like gravity doesn't matter.
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The Air Force's big trick is we overcame gravity and I have been the beneficiary of that on
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a few different occasions.
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Wow.
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That does sound truly incredible.
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Yeah.
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I mean, I've done so many things in my career and kind of not related to medicine, just
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being in the Air Force that I didn't know to fantasize about as a child.
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Like I didn't know that I could fly an aerobatics plane.
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I didn't know that I could jump out of helicopters.
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I didn't like there's all these things.
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I was like, I didn't fantasize about that.
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It was just amazing.
24:29
Tell me about jumping out of a helicopter.
24:34
That was one of the scarier things I've ever done.
24:36
So I don't, you guys can't see this in the podcast, but I'm only about five foot seven.
24:41
I am not your classic special forces soldier, right?
24:44
I'm the doc.
24:45
My job is to be the doc.
24:47
They gave me a gun.
24:48
I kept it locked up.
24:49
Like I'm the doc.
24:52
And I got to go through some of the training with some of these guys.
24:55
And one night we were fast roping out of the back of a helicopter and the rope sits off
25:02
the tailgate of the helicopter.
25:04
We were only about 20 feet hovering 20 feet in the air and my arms aren't super long.
25:09
And they, I couldn't reach the rope with my full hand.
25:13
I could, I could feel it in the dark against the tips of my fingers and I was not going
25:19
to wimp out.
25:20
And so I just leaned forward and jumped and hoped that my hands would get wrapped around
25:26
the rope.
25:27
And I, I'm sure it was nothing, but God did it scare me.
25:32
And I was like, I'd rather break my ankle than look like a wimp.
25:36
So we're going for it.
25:38
That sounds like the kind of person that you'd have to be in order to jump out of a helicopter.
25:44
So it gets back to, I guess, where we started, right?
25:46
Like I was always scared of all these things, but also just kind of got to press forward,
25:52
right?
25:53
Like there's always butterflies and you still got to go.
25:56
So what was it like when you were in a tent in Afghanistan?
26:01
So it's funny.
26:04
I was, I spent more time in tents in Africa.
26:08
I had like a plywood hut in Afghanistan the first time I went that was highly flammable
26:15
and had a mouse problem.
26:16
But other than that, like there was good camaraderie.
26:20
The bathrooms were kind of far away.
26:22
So you had to walk outside in the snow in Afghanistan, but you know, you get over that
26:27
part.
26:28
It was a, my first trip, I went with special operations.
26:30
My second trip, I went with CCAT.
26:33
So the critical care air evacuation teams and two slightly different experiences, but
26:41
both interesting and just again, got to see amazing things and do interesting stuff.
26:48
Tell me about some of this interesting stuff.
26:50
So I guess we can, let's talk about CCAT.
26:57
So that's the critical care air transport team.
26:59
I roll here.
27:00
I can see some of the wheels turning in your head as he's trying in front of me.
27:05
Jesse is trying very hard to make everything still classified to stay classified.
27:12
I did a lot of things for air force special operations command that are sensitive topics
27:16
and probably easier to talk about some of the medical things that I did in Afghanistan.
27:22
Sure.
27:23
Let's stay away from divulging classified information on a podcast.
27:26
It's probably a bad look.
27:28
So, our team was stationed in Afghanistan in 2019, a three person team, a doc, a nurse
27:40
and a respiratory therapist.
27:43
And we were one of the tactical teams.
27:45
So we had a little bit of extra tactical training so that we could take patients in and out
27:51
of less secure locations.
27:57
And we also provided transport from Afghanistan back to Germany, which was our first staging
28:04
hospital outside of the theater of operations.
28:08
So I had a few interesting little missions around Afghanistan, often quick, fun stuff.
28:14
Go sit here and pick this guy up.
28:18
Took care of a gentleman that was on a team that was hunting for a sniper.
28:23
They had killed one of our special operations soldiers two nights prior.
28:28
And so they went back to look for the guy in the same spot and they found him.
28:32
And he found them first again and shot another one of our soldiers.
28:36
This was a GSW through the patient, right to left through the abdomen.
28:43
So interestingly, the round went through his rifle, through his abdomen and lodged in his
28:48
wrist.
28:49
Wow.
28:50
So he got eventually...
28:54
So we found out that he was shot before he was even taken out of the field.
28:58
I was able to get to the tent hospital that was going to do his damage control surgery
29:05
about the same time that he did.
29:07
He went into the operating room.
29:09
They stabilized him there.
29:11
And then we picked him up, packaged him up and flew him back to Bagram for additional
29:18
surgery.
29:19
And we eventually flight back to Germany and then back to the United States.
29:24
That sounds like the most condensed version of what you did that I can possibly imagine.
29:30
I wonder if you could set the scene for us about what it looks like when you're loading
29:37
a wounded soldier onto an aircraft and what your specific job is when you're doing all
29:42
of these really interesting things and sort of how that intersects with what we do in
29:46
anesthesia.
29:47
Right.
29:48
That's fair.
29:49
So yeah, I brushed through a few details there.
29:52
So we were staged outside of the main hospital in Bagram and we've got aircraft staged there
30:01
for us and a full set of equipment.
30:03
And when we get notified that there is an injury or patient that needs to be transported
30:07
quickly, it takes us about 30 minutes to grab all of our equipment, throw it in a truck,
30:12
drive it to the aircraft, load the aircraft, and then get up in the air.
30:17
From there, it really depends on how far away you are.
30:20
I think it takes a lot of attention to detail to make sure that you're being organized when
30:27
you're doing something so quickly and so emergently.
30:30
You could be dead asleep and you have 30 minutes to be awake, dressed, packaged, and out the
30:35
door.
30:36
Checklists became a huge thing.
30:38
So I always have a checklist hanging in the garage where we kept all of our equipment.
30:43
We would load it onto the trucks or sometimes other folks would help us load it onto the
30:47
trucks.
30:49
But the last thing we always did before we left is my respiratory therapist would stand
30:53
at the truck and he would eyeball equipment bag by bag and I would read the checklist.
31:00
And until I got an affirmative on each item, we didn't go.
31:03
Because once you're in the air, you can't...
31:05
If I forgot my defibrillator, well, there's no defibrillator.
31:08
There's no...
31:09
You're your own thing.
31:12
And so we were able to load up.
31:14
We didn't know what we were getting.
31:16
We knew that the guys were still taking fire when we were first notified.
31:21
And then when we finally landed, it was dark.
31:25
Special Operations works at night.
31:26
It gives us an advantage with our NVGs.
31:29
Sorry, night vision goggles.
31:32
The enemy mostly doesn't have those and we have them for almost every one of our soldiers
31:39
that needs them.
31:40
And so that gives us a huge advantage.
31:43
So we fly at night, land at night.
31:46
We waited on the runway and we were able to watch the medevac helicopter.
31:50
So the local dust off helicopters are army point of injury evacuation.
31:56
So they can go into kind of like in Vietnam, you know, the helicopter flies in and picks
32:01
somebody up while they're still potentially not a secure area.
32:07
My job with CCAT is more traditionally a somewhat secure scene.
32:13
And the reason for that is that I'm on a fixed wing aircraft, so it's less maneuverable and
32:17
it's a bigger target than say a traditional helicopter.
32:20
So the helicopter would bring them back to the tent surgeon.
32:25
They're set up to do one or two operations and they did their operations, stabilized
32:32
the guy, took him about an hour and a half, I think.
32:36
And I was able to then transfer him to our equipment.
32:42
So we bring our own ventilators, we bring our own monitors, suction, all of that.
32:46
I've got all my own drugs.
32:48
I've got gear and a backpack essentially for any kind of trauma that could come up to stabilize
32:54
the patient, chest tubes, CRIQ kits.
32:59
This guy was in a baited, so we put him on our ventilator.
33:02
We loaded him in the back of a pickup truck and drove him about, I don't know, 15, 20
33:09
minutes back to the airfield with his buddies.
33:13
So his buddies helped me transport him back to the aircraft, which I think was important
33:16
for them.
33:17
They were able to see him.
33:19
They had just lost a fellow soldier the night before and then this guy got shot.
33:25
And so they were able to see him go into the operating room, see him come out stable and
33:30
then get transported back to Bagram.
33:34
In flight, pretty uneventful.
33:36
The surgeon did a good job.
33:39
The patient, we kept them sedated.
33:41
It was only about, I want to say a 30 or 45 minute flight, land in Bagram and unload
33:47
the guy, put him on an ambulance, take him into the main hospital where they have tremendous
33:52
medical capability.
33:54
They had a trauma surgeon as well as a dozen other surgeons, so vascular, ENT, OMFS, orthopedic
34:03
surgery, general surgery, nurses, all of that stuff.
34:09
The hospital is very robust that we had at that time.
34:15
So when you're on this critical care transport and there's this guy in front of you that
34:21
you're keeping alive, what's going through your head?
34:24
What's your mental model for all this?
34:26
Don't screw it up.
34:30
Wow.
34:32
So there is so much that can go on.
34:36
So I think the first thing you have to do is think about the injury pattern and what
34:41
are the risks.
34:43
So this guy was an abdominal wound.
34:45
There's a certain set of things you worry about in a patient that's been shot in the
34:47
abdomen versus a patient that fell and broke a leg or a patient, a person that was in a
34:52
blast injury and has a TBI or had a heart attack.
34:55
I flew a patient from Bagram back to Germany emergently that had a heart attack.
35:01
There's no cath lab in Bagram.
35:03
So we took him to Germany and went to the cath lab and emergent cabbage.
35:08
Right?
35:09
So it's a different, obviously, subset of injuries, complications.
35:13
So you run through what could go wrong in this patient and then you come up with your
35:19
top three things that could go wrong and are life threatening.
35:23
So there's a few things that can go wrong that just doesn't matter that much.
35:29
If you, I don't know, over sedation, we can give a little bit more pressure.
35:36
I'm not trying to extubate this guy in flight.
35:37
If he's a little deep, so be it.
35:39
I'm going to err on the side of heavy sedation and pain control.
35:42
Yeah, that makes a lot of sense.
35:44
Versus what happens if we hook the ET tube or the ventilator circuit on a random bag
35:52
as we're walking down the aisle in this airplane and I extubate the patient.
35:56
Okay, what's my plan?
35:57
Where is my gear?
35:58
What do I need to do to re-innovate this guy?
35:59
Is he a difficult airway?
36:00
Does he have trauma in his airway or is this just a normal?
36:03
No, this was an isolated GSW to the abdomen.
36:06
We can bag him for half an hour until we get to Bagram.
36:08
We can put it in an LMA.
36:09
I keep a crank in my pocket.
36:11
I have all the ET tubes.
36:14
I have a video.
36:15
I have a DL.
36:16
I have options.
36:18
It's all those things go through your head.
36:22
Then looking out for your team is part of it too.
36:25
I was the most experienced person on the team, the senior physician.
36:28
I was the only physician, senior medical provider.
36:32
But also, this was my fourth deployment and my colleagues were newer that were on my team.
36:40
Several things like making sure that everybody's clipped into the floor and secure for takeoff.
36:47
Just double checking stuff like that, helping ensure that we're all on the same page and
36:52
communicating well with the air crew and with each other.
36:57
What does it look like when you reach your destination?
37:01
Again, really depends on where you're going.
37:05
I flew into all kinds of crazy places, never knew what I was getting.
37:09
Going to pick patients up.
37:11
They always ask me, so what's the plan?
37:14
We always had a plan.
37:16
The only thing that never happened was the plan.
37:19
Literally guaranteed something else would happen.
37:21
They tell me that you're going to just land at the airfield and we're going to bring the
37:25
patient out to you.
37:26
They should be there.
37:27
They're going to radio us on final approach and we'll drive them right out.
37:30
They opened the tailgate on the C-130 and somebody is sitting there in a Ford Taurus
37:34
waiting to take me to the hospital.
37:35
I'm like, bro, where do I put the litter in a Ford Taurus?
37:40
I got 600 pounds of gear, three dudes in armor, a guy, a gal and me.
37:45
Sorry, not three dudes.
37:50
Go get a truck.
37:52
Go get a truck.
37:54
Go get a truck, man.
37:56
I'll wait.
37:57
Yeah, I don't know that the Taurus is necessarily equipped to handle all of your gear.
38:03
Or the patient.
38:04
How are we going to get back from the hospital in a Ford Taurus?
38:07
It was so... anyway, the plan was always something other than the plan.
38:14
It takes a lot of sense.
38:16
And then when you get back to Bagram, you come into a big trauma bay and you hand off
38:24
to very well-equipped teams of ER physicians, nurses.
38:31
Traumas are overseeing it all.
38:32
There's more hands.
38:33
And I was always amazed at how many hands there were at Bagram.
38:39
When we flew into Ramstein, that was a little different too.
38:43
In Germany, Ramstein Airfield, where we fly in and out of, is geographically separated
38:48
from Lahnstuhl Army Base, which has the hospital.
38:53
So it's about a 20 or 30 minute ride.
38:56
So you land, unload, get in an ambulance and you have to drive through Germany.
39:03
The patient I took care of that had the MI.
39:06
We drove him downtown actually.
39:08
So we rolled into a civilian hospital and full military fatigues, sweaty and smelly
39:15
after 18 hours starting the day in Afghanistan and rolled right up into the hospital.
39:21
My nurse was amazing.
39:22
She had spent some of her grade school in Germany.
39:26
Her father was military 40 years prior and she spoke German.
39:32
Who would have thought that that was going to be such a useful skill?
39:36
And so we were able to very seamlessly hand the patient over to the German team and they
39:41
evaluated him and took him to the operating room.
39:43
Wow.
39:44
This all sounds like incredible experience.
39:47
It is.
39:48
It's funny you asked, what does it look like?
39:50
And the answer is it looks like whatever you plan and come up with and have three backup
39:56
plans for.
39:58
So if you don't come up with a plan and a backup plan, it does not work well.
40:04
You really do have to continue to communicate, communicate, communicate to try to come up
40:07
with a way to make it happen for the patient.
40:12
That's really what matters is making it happen for the patient.
40:14
So you've had all of this military experience.
40:19
How does that translate to what you do here at the University of Cincinnati?
40:25
So obviously one of my roles is teaching that course so that other people can go do that
40:30
job.
40:31
So obviously that's a direct translation.
40:33
That one's pretty easy.
40:34
I'm surprised how often it helps in sort of civilian medicine too.
40:40
We transport a patient every time we leave the operating room, right?
40:44
And sometimes they're critically ill.
40:46
And when you're packaging up your patient to bring them to the ICU, it's really easy
40:53
to overlook that.
40:55
And I think that that can result in complications.
40:58
I know I've seen some at various hospitals of people failing to sort of adequately prepare
41:07
and continue to monitor that patient, even if it's only for 10 minutes.
41:11
That's all it takes to have a bad outcome.
41:14
And I take that opportunity.
41:17
One of the things that I always do with the residents is I ask them what could go wrong
41:22
in the next 10 minutes and what's your plan, right?
41:25
And that's obviously that got drilled into my head because I had to fly for 10 hours.
41:32
But you still need to have a plan.
41:35
You still need to think about those things.
41:37
It's a shorter list of things that can go wrong in 10 minutes, right?
41:42
But I still think it's there.
41:43
And so the fact that it's been so drilled into my head, I just use that opportunity.
41:47
I expect residents to learn something different from everybody they work with every day.
41:51
And so maybe that's one of the things they can learn from me if we have a chance to work
41:55
together.
41:56
So how old are your kids?
41:58
7, 11, and 13.
42:02
Whenever you're getting ready to go on a family vacation, do you go through a list of all
42:07
the things that could go wrong with them and what you expect them to do in those situations?
42:16
I go through the list of things that could go wrong with the weather.
42:20
Do you have a coat?
42:21
Excellent.
42:22
Other than that, no, I try not to put too much of that on them.
42:26
I try to take that responsibility.
42:29
I've noticed, you know, my wife is actually very good at this sort of thing.
42:34
And she is responsible for the pre-mission checklist.
42:38
Yeah.
42:39
Whatever it is.
42:41
But in my head, I'm also with you.
42:44
I'm constantly imagining what things could go wrong.
42:47
You know, what would happen if the car stopped here?
42:50
What would we do?
42:53
And I think that that's just sort of one of the ways that our brains operate as anesthesiologists.
42:58
Right?
42:59
Like that's the worst case scenario is sort of always on our mind, or at least in the
43:03
back of our minds so that we can plan for it and do something about it if ever were
43:09
to happen.
43:10
Yeah, I do.
43:11
And I think I definitely as things come up, I do find myself getting into pedantic doctor,
43:19
dad, attending instructor, whatever role with the kids too.
43:25
So and then they roll their eyes.
43:26
But I like to think maybe the words are going into their ears, even if they're, you know,
43:32
sort of, you know, blowing me off with their eyes that that maybe in the future those words
43:36
will be there.
43:38
You know, I didn't really think that as a dad, I was super into safety any more than
43:45
any other parent.
43:46
But the first time that I realized what I was doing to my children was when my son came
43:52
home after having ridden a school bus for the first time.
43:55
And I said, Hey, how's how's school?
43:58
Did you like riding the school bus?
43:59
He said, No, dad, not really.
44:01
Why?
44:02
It's like, Dad, the school bus, it doesn't have seat belts.
44:07
That's funny.
44:08
Yeah, yeah.
44:10
It's like, Wow, I have really drilled that into you about the critical importance of
44:16
it.
44:17
But I didn't I didn't realize that that I wasn't trying to damage it.
44:20
I wasn't trying to scar you.
44:24
It's gonna be okay, buddy.
44:25
The school bus, you know, cars usually will stop for this.
44:29
No, same thing in my house.
44:30
Same thing.
44:31
Like, if you start driving before the seat belts on, like, some of the kids get anxious.
44:35
Yeah.
44:36
Absolutely.
44:37
Like, I, my son has also commented like, Hey, dad, you need to put your seat belt on, buddy,
44:43
we're still in the driveway.
44:45
Yes.
44:46
You know, your concern has been noted.
44:48
And you know, you're right.
44:50
I'm back in the boat down a ramp.
44:53
Okay.
44:54
It's okay.
44:55
It'll be okay.
44:56
It'll be okay.
44:57
Okay.
44:58
So let's talk a little bit more in granular detail about what you do in your teaching
45:04
roles.
45:05
You took me on this excellent tour of the simulation center that's here.
45:10
Tell me all about it.
45:12
Wow.
45:13
So we have, I think the preeminent, if I can say that simulation facility in the country,
45:23
at least as far as the product that we deliver with the students.
45:27
It's not all of our mannequins aren't the newest.
45:30
All of our drugs aren't always the freshest, but they're mannequin drugs.
45:36
So and we do a lot of repairs on a day to day basis.
45:40
But I think that the medical scenarios that we present are so high fidelity and the way
45:46
we run our simulations.
45:48
It's absolutely incredible.
45:50
We the course is a two week course.
45:53
So the first week is primarily academics with some introduction to simulation and a big
45:58
logistics exercise that involves real flight on a C 130.
46:03
And then the second week is the grading week where they go into one 30 to 60 minute high
46:10
fidelity simulation with two to three patients as a team every day.
46:15
So you get graded each day.
46:17
We rotate the team.
46:18
So you do five simulations with a variety of partners.
46:21
You're graded by a strict rubric and then you get feedback and you watch your own videos
46:29
so that you can try to continue to learn each day and improve.
46:33
I think that the things that set apart our simulations are very robust patient scenarios.
46:42
So our patients have they're all almost all of them except for the distractor patients
46:47
are critically ill.
46:49
And so they have real A B G's.
46:52
Many of them are real patients that have been flown by various cadre around the world.
46:58
So they have a full story and then we make the patient look like the story.
47:03
We don't give the students information.
47:06
The students evaluate the patient and learn information.
47:10
So the instructor doesn't tell you what the blood pressure is.
47:14
You can zero the A line and plug it into your monitor and then you will get an A line tracing
47:18
or you can run a cuff pressure and then you will get a blood pressure.
47:21
If you run one cuff pressure and you don't set it to automatic when the pressure falls
47:26
in the next three to five minutes you won't notice.
47:31
And so it is very real.
47:34
If you want to sedate your patient you don't tell us what you're going to give.
47:40
You draw a medication.
47:41
You pull a medication from your bag your backpack whatever your gear set.
47:46
We have a medication box that's our real world medication box.
47:50
It's got fake drugs at this point but it's all of the drugs that you would normally carry
47:53
in the real world.
47:55
You draw it out in a syringe and you push it in the appropriate dose and you flush it.
48:00
And until you flush that medication and I watch you flush it from one of a dozen cameras
48:06
in the room they don't get a response.
48:10
And when you flush that sedation medication I don't say okay the patient feels more relaxed.
48:15
I drop the heart rate.
48:17
I lower the blood pressure a touch.
48:18
I close the patient's eyes and I make them stop over breathing the vent.
48:23
And that's how you know that it worked.
48:25
You may cause hypotension if you choose to give propofol as your sedative of choice in
48:29
a trauma patient.
48:31
Obviously that's high risk.
48:32
You want to give 10 cc's of propofol sorry you want to give 10 milligrams of propofol
48:36
to a patient.
48:37
I'm not going to give you any response because I don't think 10 milligrams does anything.
48:41
On the other hand if you give 70 milligrams of propofol to a patient who is volume down
48:48
after a damage control surgery I'm going to tank their pressure.
48:52
I would prefer that you pick something a little more hemodynamically stable like a benzo or
48:57
ketamine or even fentanyl.
48:59
Any one of those is going to have a lesser impact on their hemodynamics and so I'm grading
49:05
that.
49:06
Not only am I grading your decision making I'm watching to see if you can execute the
49:12
task correctly.
49:13
So it's surprising how challenging that can be at times with things that you're not used
49:18
to doing.
49:19
So as an example setting up a leave of fed drip if you program the pump wrong and you
49:23
deliver a hundred times the dose of medication your blood pressure is going to be 300 over
49:27
200.
49:28
Right.
49:29
And so then you're going to have to go back and say why is my blood pressure 300 over
49:33
200.
49:35
And so it's all real.
49:36
It's not.
49:38
We don't feed information to the patient to the to the teams.
49:42
They have to provide care to the patient and then they will see what happens and continue
49:47
to adjust and zero in.
49:49
So I assume afterwards you're doing a big debrief with them.
49:53
So yes we debrief all of our simulations we debrief as a group.
49:58
Unfortunately it's only about 10 minutes and then we debrief as individuals doc to doc
50:02
nurse to nurse RT to RT respiratory therapist respiratory therapist.
50:07
And you get more feedback on how to function in the team and how to improve your skills
50:15
as an individual.
50:16
But then you do get the chance to watch the simulation with your team.
50:20
And we consider that to be part of the debrief.
50:22
If I say something to you after the simulation and then you get a chance to see yourself
50:27
doing it it really kind of highlights highlights what it was that you were doing.
50:33
So a common area that we focus on is communication.
50:36
So people will say something and their partner doesn't hear it.
50:40
And so we focus on closed loop communication.
50:43
So it's amazing how often you will you can see this as the instructor and they don't
50:47
see it as students.
50:48
The doc doesn't know that the nurse told them something and the nurse is like I said it
50:54
I said it.
50:55
And so it's like oh no you said it while the doctor was trying to innovate the patient
50:59
and there was no closed loop feedback.
51:01
So you have to make sure that you're telling somebody at a time when they are able to listen
51:06
and then you want closed loop feedback.
51:07
And if you don't get the answer you want you need to circle back and like you have to maintain
51:11
situational awareness and all these things.
51:14
And on one hand they can sort of grasp it when they go back and they watch the video
51:18
and they're like oh yeah.
51:22
Nope.
51:23
Yep.
51:24
That's what they're talking about right.
51:27
That really hammers that home.
51:29
And then we have additional cadre that are available for further clarification and debrief
51:34
as they sort of reflect on their simulation throughout the course of the rest of the day
51:38
or the next day.
51:39
So I'm sure you've seen a lot of situations where people have done a variety of different
51:46
performances during their simulation.
51:48
You've seen people that have done very very well and I'm sure you've seen people who have
51:53
done very very poorly.
51:55
As an instructor for some time now what's your approach to talking to the people who
52:00
have done poorly and then maybe to the people who've done well.
52:04
So let me start with the easy one is the people that do well.
52:11
We kind of warn the students you're going to get feedback no matter how well you do.
52:14
Everybody gets feedback on every simulation no matter what.
52:17
Nobody's perfect.
52:19
And so I try to highlight hey you know what were the goals what did you achieve.
52:25
That's good.
52:26
You guys did a good job.
52:27
Here's little things that you can think about or things that could have come up that didn't
52:30
or things that you did that are you know in a different situation might be more challenging
52:36
as far as feedback for the ones that are kind of performing at or above goal.
52:43
For people that are struggling I think that everybody struggles for different reasons
52:51
and some things we can coach and correct and some things we can't.
52:56
I think one of the challenges is people that don't have the opportunity to practice medicine
53:05
on a daily basis with sick patients and it's really hard to come here and then manage even
53:11
a simulation manage a simulated really sick patient if you don't get a chance to do that
53:15
on a regular basis.
53:17
And so we need people that are clinically current in their practice and that's one of
53:20
the things we ask of people when they show up.
53:23
We need you to bring your clinical currency if you think that you're sort of out of practice
53:28
on something we'd like you to seek that out before you get here.
53:33
One of the big areas that we focus on is communication and team dynamics.
53:38
We're a three-person team most ICU patients in a fixed facility are not cared for by one
53:46
doctor one nurse and one respiratory therapist.
53:49
So we all take on slightly different roles.
53:52
I do a lot of nursing tasks.
53:53
My nurse can do a lot of doctor things.
53:55
They can titrate meds they can titrate pressors and sedation.
53:59
They don't need permission to give a bolus of an opioid to a critically ill patient if
54:04
they're under sedated.
54:06
They're expected to sort of function semi-independently more like you would almost practice as a nurse
54:10
practitioner in some cases.
54:13
My RTs are doing a lot of non-respiratory tasks in addition to being responsible for
54:19
suction, commonly responsible for lots of equipment, assisting with a whole host of
54:25
tasks.
54:26
They're sort of like scrub tech light in some ways right or OR nurse light where they will
54:33
gather supplies for things.
54:34
They'll find the drugs they'll mix or they'll hang a bag of fluids, crystalloids and basic
54:40
things like that.
54:42
And so it's trying to teach people how to work in that environment.
54:46
Like okay this is what's fair to ask and this is a way for you as a doc to communicate better
54:53
with your nurse or as a team.
54:56
And so that's a common area that we kind of focus on.
55:01
So watch the video and look and see when you asked your nurse to do these five things,
55:09
look at the nurse and look at their face.
55:11
I could see their face in the simulation.
55:13
They got a little bit confused and didn't know where to start because nobody can do
55:19
five tasks at once.
55:21
Or you asked them to do three things while they were trying to calculate how to mix a
55:26
bag of LevaFed.
55:27
The LevaFed didn't come from the pharmacy.
55:29
Your nurse literally had to find a vial in the med box, find a bag of crystalloid, draw
55:34
it up and mix it on their own.
55:36
So their tasks saturated.
55:38
Don't ask your nurse for a flush when they're doing math.
55:42
It's not fair, right?
55:44
It's just not fair.
55:46
And so it's little things like that that we can sort of coach and help with.
55:50
And some of us just practice.
55:51
So I was just giving people the confidence to just keep going and keep trying and you'll
55:56
get there.
55:58
That makes a lot of sense and I appreciate you sharing your experience as an instructor
56:02
over there too.
56:05
Sort of summing up, I wonder how you would describe your military experience in terms
56:12
of is this what you thought you were going to do with your life?
56:15
Is this something that you're glad that you've done with your life?
56:18
Can you reflect on that for me?
56:21
Wow.
56:22
So you got me at an interesting point in my career.
56:25
I was just selected for promotion to full colonel.
56:29
Congratulations.
56:30
Thank you.
56:31
It comes with a lot, a lot.
56:34
There's a lot associated with that and it pushes a career in a different direction.
56:39
And so I've had a lot of opportunities to sort of reflect on my career lately.
56:44
And I had no idea about so many of these things.
56:50
I think by the time I was nearing the end of college, I wasn't even sure I was going
56:52
to med school anymore.
56:55
And found the right thing with USU and that went well.
56:59
And I thought I wanted to be an orthopedic surgeon and I did a year of surgery and sort
57:05
of figured out, no, no, no, no, anesthesia is where I want to be.
57:10
But when you switch directions, it takes time.
57:16
And so I ended up doing having this amazing tour with Air Force Special Operations.
57:21
Like things there that I did, I had no idea.
57:27
I had no idea how much fun, how interesting, how wild some of these things could be.
57:33
You know, defensive driving courses, racing cars through the woods at night on NVGs blacked
57:39
out.
57:43
Did you know that that's what we do in the forests of Northern Florida?
57:46
No, me neither.
57:48
I did not.
57:49
So I got there, I had no idea.
57:52
It was wild.
57:53
It's a ton of fun.
57:55
I had no idea.
57:56
And then the opportunity I got to go to the University of Pennsylvania for my residency
58:01
and my fellowship, like I am convinced that that is a function of the experiences that
58:07
the Air Force gave me.
58:08
It was not based on my academic record.
58:11
My scores, my board scores and this and that were never great.
58:17
But I learned so much practicing as a GMO flight doc and learning how to work with teams,
58:27
learning how to work with nurses, learning how to talk to patients.
58:33
And I guess that came through in the interview.
58:35
And I got to go one of the top programs in the country.
58:38
Like I was way out of my league and it was amazing.
58:42
And they took good care of me and taught me a million things.
58:44
And I'm super fortunate for that.
58:46
And then this job here is a dream job in the Air Force.
58:49
It's an absolute dream job.
58:50
You get to work at a high volume trauma center and still get to do like some really cool
58:58
military stuff from the perspective of Seacat.
59:01
That's really a gem in the Air Force's crown, if you think about it.
59:05
Like the ability to fly a sick patient anywhere in the world, no matter what, that's what
59:11
we do.
59:12
Lastly, I wonder if you could share with us, going back to the title of the podcast, some
59:18
of your style points that you've picked up along the way.
59:23
I think that learning about nursing and how to work with nurses is probably the single
59:31
biggest style point that I absolutely did not have and made heinous mistakes at the
59:38
beginning of my career and is absolutely one of my greatest strengths and helps me so much
59:45
now.
59:47
Throughout my career, I've learned by making numerous mistakes.
59:50
I don't think most of them came at the expense of patience.
59:54
I think it came at the expense of peace and collaboration and happiness and kindness.
1:00:01
Many of those things suffered and that's where I made mistakes.
1:00:04
And so I wish I hadn't learned all those things the hard way, but having learned them and
1:00:11
having learned sort of what nurses do and how to work professionally with nurses has
1:00:17
made me so much better at my job.
1:00:20
Being at Seacat, where we're on a three-person team, yeah, I'm a doc.
1:00:25
Yes, they're a nurse.
1:00:27
Yes, this one's a respiratory therapist, but we're all doctors.
1:00:31
We're all nurses and we're all respiratory therapists on the plane.
1:00:35
And learning so much about what they do and how to work better with them has made me a
1:00:40
much better physician, a much better advocate for my patients, much better at coordinating
1:00:46
care in the ICU.
1:00:50
I think that's the style point is learning how to work with the people, the support staff,
1:00:56
the doctor, and really understand what they do and as a doc, learning how to work with
1:01:01
nurses is huge.
1:01:04
It's huge.
1:01:06
Jesse, thank you so much for your service and thank you so much for joining us today.
1:01:12
Thank you.
1:01:13
This was awesome.
1:01:14
This was a lot of fun.
1:01:15
Thank you.
1:01:17
That wraps it up for this month's episode of Style Points.
1:01:20
This year, I only asked Santa for one thing.
1:01:23
It was for listeners of this podcast to take just a second and give me a five star review.
1:01:29
Why you ask?
1:01:30
Well, it's what helps other people find the podcast.
1:01:32
The more ratings I get, the more likely it is to show up in someone else's suggestions.
1:01:37
If you're enjoying it, chances are that somebody else might enjoy it too.
1:01:42
If you've got an idea for the podcast, feel free to email me at stylepointspodcast.gmail.com.
1:01:49
I'd love to hear it.
1:01:51
As always, thanks for listening.
1:01:53
Take a deep breath.
1:01:55
Open your eyes.
1:01:56
We're all done.